April 2013 Volume 8 Issue 4 Inside In This Issue 2 Moral Injury: An Emerging Concept in Combat Trauma George Loeffler, M.D. 4 Methoxetamine: The Rise of a Ketamine Analogue “Legal High” Cassandra Craig, B.Sc. George Loeffler, M.D. 6 Depression, Suicide, and Ketamine John Burger, M.D. George Loeffler, M.D. 9 Use of “Bath Salts” Among Members of the United States Military: A Case Report With Discussion Daniel G. Allen, M.D. Wander S. Segura, M.D. Rebecca R. Burson, D.O. 11 Deployment Stress, Dextro­ This issue of the Residents’ Journal focuses on the theme of military psychiatry. The methorphan, Ketamine, and issue begins with an article by the Guest Section Editor, George Loeffler, M.D., on the Pharmacologic Interactions: emerging concept of moral injury. In a case report, Daniel G. Allen, M.D., Wander S. A Multifactorial Presentation Segura M.D., and Rebecca R. Burson, D.O., describe the effects of methylenedioxypy- of Mania rovalerone use in an active-duty service member, as well as the unique challenges use Philip Y.T. Liu, M.D. of this substance presents to both service members and military health care providers. Rebecca R. Burson, D.O. Philip Y.T. Liu, M.D., and Dr. Burson present a case report of first-episode sub- stance-induced mania with psychotic features in a decorated soldier evacuated from a 13 Virtual Reality Exposure combat-stressed environment. Ryan Richmond, B.S., discusses virtual reality exposure Therapy for the Treatment of therapy for treatment of combat posttraumatic stress disorder. Last, Nicole Garber, Combat Posttraumatic Stress M.D., presents data on the effects of military deployment on children. Disorder Ryan Richmond, B.S. Editor-in-Chief Guest Section Editor Monifa Seawell, M.D. George Loeffler, M.D. 15 Effects of Military Senior Editor Editors Emeriti Deployment on Children Sarah M. Fayad, M.D. Sarah B. Johnson, M.D. Molly McVoy, M.D. Nicole Garber, M.D. Associate Editor Arshya Vahabzadeh, M.D. Joseph M. Cerimele, M.D. 16 Editor’s Note Staff Editor Angela Moore Moral Injury: An Emerging Concept in Combat Trauma George Loeffler, M.D. Since antiquity, it has been recognized that ories of trauma. Their hypothesis was imagined conversation with a benevolent military combat can result in psychological most heavily drawn from social cogni- moral authority or fellow junior service damage. In his landmark book Achilles in tive theories of PTSD. According to this member who is similarly “stuck.” The goal Vietnam, Jonathan Shay (1) powerfully ar- theory, PTSD is a result of a traumatic is to “get service members and veterans to gues that the Iliad can be read as just such event conflicting with an individual’s be- articulate ideas about the capacity to do an account. In his book’s subtitle, “Combat liefs, such as “the world is benevolent,” good, talk about being forgiven and the Trauma and the Undoing of Character,” “the world is meaningful,” and “the self need for self-forgiveness, even if they don’t Shay intimates the profound way the war is worthy.” Moral injury fits this mold. initially accept these ideas.” fighter’s experiences shape him or her. The psychological difficulties result from He introduces the phrase “moral injury” a combat experience conflicting with an Description of Adaptive Disclosure to describe how “the moral dimension of individual’s ethical beliefs. Adaptive disclosure is a manualized trauma destroys virtue, undoes good char- intervention consisting of six 90-min- acter,” considering it “an essential part of The Moral Injury Construct ute sessions designed specifically to any combat trauma that leads to a lifelong treat active-duty service members with Drescher et al. (3) assumed the task of psychological injury” (1, p. 20) combat-related PTSD. Details of this beginning to operationalize and clinically approach are described elsewhere (2, 4, Training in a military hospital, I have situate the concept of moral injury. With 5). Acknowledging the challenges active- seen that the consequences of combat are the goal of exploring “professional opin- duty service members face participating ubiquitous. In my own clinical experience, ion as to the presence, the utility, and the in protracted courses of treatment, the I have found that neither the diagnosis phenomenology of the construct of moral goal of this brief intervention is explicitly of posttraumatic stress disorder (PTSD) injury,” they conducted semistructured identified as “initiat[ing] a process experi- nor the current trauma-focused psycho- interviews of 23 experts in mental health entially rather than expecting full system therapies adequately address the ethical and chaplaincy. remission, in effect ‘planting seeds’” (5). dimension of combat trauma. These ethi- Experts were unanimous in the expressed cal and existential concerns are the focus The first session consists of an intro- need for the concept of moral injury. This of moral injury. duction to adaptive disclosure and extended to the belief that the current identification of the index event. The next Emergence of the Moral conception of PTSD has failed to ade- four sessions delve into this event. The Injury Construct quately capture this dimension of combat event is described in significant detail trauma. so as to emotionally engage the patient. Litz et al. (2) wrote an article, published Treating Moral Injury Following this, based on the nature of in 2009, on the understanding and treat- the event and the patient’s reaction, the ment of combat trauma. Using the phrase therapist guides the patient in addressing Theoretical Considerations “moral injury,” the authors postulated a one of three experiences: life threat, loss, Litz et al. (2) outlined an approach de- distinct syndrome arising from the com- or moral injury. signed to treat moral injuries. They bat experience. They defined moral injury identified two routes to healing moral To address moral injury, the therapist uses as “perpetrating, failing to prevent, bear- injury: the psychological and emotional the empty chair technique in guiding the ing witness to, or learning about acts processing of the memory and meaning of patient through an imagined conversa- that transgress deeply held moral be- the moral transgression and corrective life tion with a benevolent authority figure. liefs and expectations.” They also stated experience. Focusing on the first, Litz et al. The patient describes his or her guilt and that, “moral injury requires an act of drew from a number of psychotherapeutic shame and then offers what the authority transgression that severely and abruptly interventions. From exposure therapy, they figure might say in turn. The therapist is contradicts an individual’s personal or suggested a raw and emotional reliving of encouraged to be highly directive in elic- shared expectation about the rules or the the morally transgressive experience, fol- iting “forgiveness-related content. code of conduct, either during the event lowed by a critical examination of implicit In the sixth and final session, the patient or at some point afterward.” appraisals. Recognizing the rigidity and is instructed to reflect on gains and to Litz et al. situated the notion of moral resistance to disconfirmation of these neg- prepare for future struggles. injury within a number of current the- ative appraisals, the authors proposed an The Residents’ Journal 2 Open Trial of Adaptive Disclosure that it contains some measure of univer- While it has long been known that not Gray et al. (5) described the initial proof sality that binds or compels an individual. all combat wounds are physical, the moral of concept trial of adaptive disclosure, The Golden Rule appeals to a special set of dimension of psychological injury re- which was conducted at the Marine beliefs that bind both oneself and others mains largely unexplored, at least within Corps Base Camp Pendleton in San with a special force. While these ethical mainstream mental health. The work Diego and funded by the Navy Bureau beliefs are embedded in the particular done to understand and treat moral in- of Medicine and Surgery. This was an history and psychology of an individual, jury, while preliminary, provides hope for uncontrolled open-clinical trial of 44 ac- at the same time they originate and apply those suffering from these unseen scars tive-duty Marines. All participants met beyond the individual. I do not feel that and those charged with helping them. criteria for PTSD from deployment ex- these elements of moral injury have thus Dr. Loeffler is a fourth-year psychiatry periences in Iraq or Afghanistan. far been sufficiently addressed. resident at the Naval Medical Center San Results of this brief intervention were To adequately do so would be part of a Diego. He is also an active-duty Lieutenant encouraging. The primary outcome mea- larger project to draw together insights in the United States Navy. sure, PTSD symptoms as measured by from many different fields. Within psy- The author thanks Eileen Delaney for her the PTSD Checklist–Military version, chology, in addition to the cognitive, support and guidance. The author also thanks revealed that there was nearly a 10-point behavioral, and gestalt schools, I would Eric Baker, Marc Capobianco, Warren Klam, improvement in symptoms, represent- include existential psychotherapy, affect George Loeffler, Sr., Robert McLay, David ing an effect size of 0.79 (Cohen’s d) in theory, moral psychology, and psycho- Oliver, Christopher Streeter, and Sarah Yas- the large range. Improvement of depres- dynamics, particularly as it relates to utake for their assistance with this article. sive symptoms was also in the large effect object-relations and super-ego function- size range (Cohen’s d=0.71, p=0.001). Of ing, to name just a few. As my mentor The views presented in this article are solely note, these results were for all three arms Christopher Streeter once pointed out, that of the author’s and do not necessar- of the intervention pooled and not exclu- developmental theories, such as Erik- ily reflect the official policy or position of the sively for the moral injury intervention.