Koenig Harold G, Youssef Nagy A, Pearce Michelle
Duke University Medical Center, Durham, NC, United States.
King Abdulaziz University, Jeddah, Saudi Arabia.
Front Psychiatry. 2019 Jun 28;10:443. doi: 10.3389/fpsyt.2019.00443. eCollection 2019.
Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only. A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were "moral injury," "measuring," "screening," "Veterans," and "Active Duty Military." Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies. Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions. MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.
道德损伤（MI）涉及因违背或违反核心道德界限而产生的痛苦，伴有内疚、羞耻、自我谴责、信任丧失、意义缺失和精神挣扎等感受。道德损伤常见于患有创伤后应激障碍（PTSD）的退伍军人和现役军人。在有PTSD症状的人群中，道德损伤普遍存在，对心理健康产生不利影响，且可能增加自杀风险；然而，道德损伤常常被仅关注PTSD的心理健康专业人员忽视和忽略。本文呈现了2018年对1980年至2018年间文献的回顾，以确定用于评估道德损伤的量表。本回顾中使用的数据库有PsychInfo、PubMed（医学索引）和谷歌学术。检索词为“道德损伤”“测量”“筛查”“退伍军人”和“现役军人”。纳入标准为对道德损伤和健康结果的定量测量、退伍军人或现役军人身份以及同行评审出版物。排除的文献包括文献综述、学位论文、书籍章节、病例报告和定性研究。在识别出的730项研究中，大多数不符合纳入标准，剩余118篇全文文章接受了评审，其中42篇不符合纳入标准。在其余76项研究中，34项为重复研究，剩余42项研究，大多数发表于2013年或之后。在评估道德损伤的22项研究中，5项使用了评估多个维度的量表，17项仅评估了一两个方面（如内疚、羞耻或宽恕）。其余20项研究使用了前22项研究中报告的量表之一。在评估道德损伤多个维度的5个量表中，2个量表既评估道德损伤事件又评估症状，其余3个量表仅评估症状。除3项测试干预措施的研究外，所有研究均为横断面研究。军事环境中的道德损伤普遍存在，且与当前或以前军人的PTSD症状严重程度、焦虑、抑郁及自杀风险相关。存在多种措施来评估道德损伤的各个维度，包括5个多维量表，不过未来研究需要确定临界值和具有临床意义的变化值。3个多维测量工具仅评估道德损伤症状（而非事件），可能有助于确定针对道德损伤的治疗是否既能减轻症状，又能影响包括PTSD在内的其他心理健康结果。
