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Neuropsychiatric researchers at Brown University and the Providence VA Medical Center recently have published on a trauma-related condition that is found in Veterans, which differs from posttraumatic stress disorder, and for which a pill cure does not exist, that is, Moral Injury (MI). By the end of their service, a significant number of combat soldiers have had at least one morally injurious experience (MIE); that is, they have perpetrated, failed to prevent, bore witness to, or learned about at least one act that transgressed “deeply held moral beliefs and expectations”. For example, being pressured into attacking nonhostile targets could qualify as a MIE. Stein et al. found that when asked about their “most currently distressing warzone experience”, 34% of service members referenced a MIE.

Morally injurious experiences are divided between those involving personal responsibility and those involving others’ responsibility. Oftentimes, negative internally directed emotions (e.g., guilt, shame, spiritual conflict) result from MIEs involving personal responsibility, while externally directed emotions (e.g., anger, trust issues) come from MIEs involving the responsibility of others. In comparison with other traumatic events, MIEs may not be associated with fear.

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Some Veterans who have been exposed to traumatic events develop psychogenic nonepileptic seizures (PNES), a conversion disorder that manifests as seizures, but no epileptiform neuronal firing occurs during the ictus. The PNES literature is replete with information on comorbidities; however, MI has not been addressed. We aimed to identify the presence of MIEs in a sample of Veterans with documented PNES and to examine possible differences in those with and without MIEs. We hypothesized that Veterans with PNES and MIEs would endorse more guilt than those without MIEs.

We conducted a retrospective cross-sectional study of 82 male and female Veterans with video-electroencephalography (EEG)-confirmed PNES consecutively seen in a Veterans Administration neuropsychiatry clinic. Identification of MIEs (witnessed or experienced events that conflict with one’s moral compass) was made based by an independent observer using a survey of MIEs. Comorbidities, trauma history, and symptom scales were compared among those with and without MIEs.

Of the 82 Veterans included in the analysis, MIE endorsement was present in 12 participants (14.6%). The Veterans with a MIE were an average of 9 years younger than those without MI. No significant differences were found for the other demographic variables in the study. Additionally, we found that there were no significant differences for categorical PTSD, or depression DSM-5 diagnoses, rates of substance abuse, suicidal ideation severity, or history of traumatic experiences (physical, emotional, verbal, and sexual). This may suggest that MI has its own symptomatic and historical exposure criteria.

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There was a significant difference in the total depression (BDI-II) symptom scores, with those with a MIE having an average of 10 points higher than those without a MIE, but not in categorical depression diagnoses. MI is not a specific psychiatric diagnosis; as one author wrote, MI is “a deep soul wound that pierces a person’s identity, sense of morality and relationship to society”. Future research could examine the relationship between seizures, psychiatric comorbidity symptoms (e.g., depression/PTSD), MI, sense of self, and the soul, approaching the condition from a biopsychosociospiritual (BPSS) perspective.

Likewise, feelings of guilt were significantly higher in Veterans with PNES and MIE than those with PNES and no MIE. Guilt is defined as feeling regretful about an act or behavior. The hypothesis for the study was confirmed, building on prior work, as many MIEs are described as guilt-provoking by those who witness or participate in them. Those with MIEs believe that their core values have been transgressed. Some of the Veterans who report MIEs describe a sense of spiritual death, with one Veteran who endorsed a personal faith prior to deployment recalling MIEs where child noncombatants were killed.

This is the first study that describes MIEs in Veterans with PNES. Identifying moral-spiritual conflicts, and addressing interventions such as forgiveness may be an approach to address MI. An increased understanding of this condition may aid in the development of diagnostic screenings and therapy options for those with PNES.

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W. Curt LaFrance Jr., MD, MPH, is Director of Neuropsychiatry and Behavioral Neurology at Rhode Island Hospital (RIH) and Professor of Psychiatry and Neurology at Alpert Medical School, Brown University. He studied at Wake Forest University (BA in psychology), Medical College of Georgia (MD) and Brown University (MPH). He trained in Brown’s combined neurology/psychiatry residency and is double boarded. His research is in neuropsychiatric aspects of epilepsy, somatoform / conversion disorders and TBI. He is co-editor of Nonepileptic Seizures and co-author of Taking Control of Your Seizures: Workbook and the Therapist Guide.

Dr. Nathan Stein began his career in psychology at the National Center for PTSD in the VA Boston Healthcare System (VABHS). As a Health Science Specialist for the VABHS, he managed projects and grants related to the treatment of PTSD. Additionally, he authored and co-authored several papers, including the seminal article on moral injury. From 2012 until February 2019, he served as the Staff Psychologist at the Community-Based Outpatient Center in Middletown, RI. Currently, he is a Suicide Prevention Coordinator at the Providence VA Medical Center.