Morally damaging betrayal associated with chronic pain in female veterans

When we think of war, we tend to think of the physical carnage it causes, but what about its moral effects? A study published in Journal of Psychiatric Research investigates whether acting against morals while serving may be associated with pain intensity in veterans.

War is a very traumatic event, and it’s no secret that many veterans struggle with PTSD as a result. Another less commonly considered outcome after war is moral damage, which is the result of experiences that conflict with deeply held beliefs or morals.

This could include anything from committing violence to witnessing something wrong and not being able to prevent it. Moral injury is thought to be related to chronic pain for veterans, but research has been scarce. This study seeks to bridge this gap in the literature.

For their study, Rachel M. Ranney and her colleagues used data from 11,871 US veterans from the Comparative Health Assessment Interview Research Study. Data for this study were collected in 2018 online and/or by telephone. Participants completed measures analyzing demographic information, trauma events, PTSD criteria, combat exposure, adverse childhood experiences, joint and muscle pain, and pain intensity. Moral harm has three subscales: witnessing, perpetrating, and betraying.

The results showed that PTSD symptoms were associated with increased joint and muscle pain, as well as higher levels of pain intensity. Witnessing and perpetrating morally damaging events was not found to be related to pain, but feelings of betrayal were associated with higher pain intensity even when all other variables were controlled.

Upon further analyses, this relationship only existed for female veterans. Betrayal (such as intimate partner sexual assault) differs from witnessing and perpetrating because it causes harm to the person experiencing it, which may explain why it is the only factor associated with physical pain. This is consistent with previous research that traumas involving high levels of betrayal lead to more negative health outcomes.

This study made important strides in better understanding moral injury in veterans. However, there are limitations that should be noted. One such limitation is that this study is cross-sectional, not longitudinal, and investigating temporal relationships would be very useful in this case. Furthermore, the types of pain assessed were very limited. future research could include more common sources of pain, such as headaches.

“This is the first study we know of to investigate the relationships between different types [potentially morally injurious events] and chronic pain. Our application of population weights increases confidence in the generalizability of the results to the national population of post-9/11 veterans,” the researchers concluded.

“We found that betrayal (but not witnessing or perpetrating) was associated with pain intensity, even when controlling for PTSD and other relevant factors. Regarding gender differences, we found that among women, betrayal was associated with joint pain and pain intensity, but among men, betrayal was not associated with pain outcome. Thus, it may be important to assess betrayal when treating patients—particularly female patients—with PTSD and/or chronic pain.”

“The psychological effects of betrayal may play a role in the development and maintenance of chronic pain as well as PTSD,” Ranney and colleagues wrote. “Providers treating patients for pain who may also have a history of pain trauma should be aware of psychological therapies, such as evidence-based psychotherapies for PTSD, that target psychological factors that may maintain and worsen pain.”

The study, “Moral Injury and Chronic Pain in Veterans,” was authored by Rachel M. Ranney, Shira Maguen, Paul A. Bernhard, Nicholas Holder, Dawne Vogt, John R. Blosnich and Aaron I. Schneiderman.

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