Two of the more important works on PTSD and moral injury are Jonathan Shay’s Achilles in Vietnam: Combat Trauma and the Undoing of Character and Odysseus in America: Combat Trauma and the Trials of Homecoming. Shay, a great proponent of the concept of Moral Injury, something I recognize in myself, explains the difference between PTSD and moral injury in this excellent piece from Public Insight Network:

Moral injury, Shay says, can happen when “there is a betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation.”

That person who’s betraying “what’s right” could be a superior — or that person could be you. Maybe it’s that you killed somebody or were ordered to kill. Or maybe it was something tragic that you could have stopped, but didn’t. Guilt and shame are at the center of moral injury. And, as Shay describes it, so is a shrinking of what he calls “the moral and social horizon.” When a person’s moral horizon shrinks, he says, so do a person’s ideals and attachments and ambitions……

….“Shay, a psychiatrist who has worked with combat vets for twenty years and authored two books about PTSD — or psychological and moral injury, as he insists it should be known — told me by phone from his Newton, Mass., office, ‘It’s titanic pain that these men live with. They don’t feel that they can get that across, in part because they feel they deserve it, and in part because they don’t feel people will understand it.’

“‘Despair, this word that’s so hard to get our arms around,’ he said. ‘It’s despair that rips people apart [who] feel they’ve become irredeemable.’

“I told Dr. Shay about Noah’s experiences in Iraq, in particular the killing, the loss of comrades, the nightmares. He sounded saddened on the phone, but unsurprised. ‘The flip side of this fellow’s despair was the murderous rages he experienced on his second tour,’ he said. ‘In combat, soldiers become each other’s mothers. The rage, need for revenge, and self-sacrificial commitment toward protecting each other when comrades are killed [are] akin to when a mother’s offspring are put in danger or killed.’

“Dr. Shay explained the nightmares and sleeplessness were one of the major issues. ‘The lack of sleep contributed directly to a loss of control of his own anger, a loss of control of things he felt morally responsible for.’”

And importantly:

“Peers are the key to recovery — I can’t emphasize that enough,” he said. “Credentialed mental health professionals like me have no place in center stage. It’s the veterans themselves, healing each other, that belong at center stage.”

Shay, demonstrating that PTSD and moral injury has been common to warriors since the creation of civilization by identifying PTSD and moral injury in the great Homerian works, also identifies PTSD and Moral Injury in William Shakespeare’s Henry IV. From Public Insight Network, again, Shay places the corresponding PTSD symptoms alongside Lady Percy’s lines from Act II, Scene 2:

O my good lord, why are you thus alone?      (Social withdrawal and isolation)
For what offense have I this fortnight been
A banished woman from my Harry’s bed? (Random, unwarranted rage at family, sexual dysfunction, no capacity for intimacy)
Tell me, sweet lord, what is ’t that takes from thee
Thy stomach, pleasure,          (Somatic disturbances, loss of ability to experience pleasure)
and thy golden sleep?            (Insomnia)
Why dost thou bend thine eyes upon the earth     (Depression)
And start so often when thou sit’st alone?          (Hyperactive startle reaction)
Why hast thou lost the fresh blood in thy cheeks      (Peripheral vasoconstriction, autonomic hyper-activity)
And given my treasures and my rights of thee
To thick-eyed musing and curst melancholy?    (Sense of the dead being more real than the living, depression)
In thy faint slumbers I by thee have watched,   (Fragmented, vigilant sleep)
And heard thee murmur tales of iron wars,
Speak terms of manage to thy bounding steed,
Cry “Courage! To the field!” And though hast talk’d
Of sallies and retires, or trenches, tents,
Of palisadoes, frontiers, parapets,
Of basilisks, of cannon, culverin,
Of prisoners’ ransom and of soldiers slain,
And all the currents of a heady fight.
Thy spirit within thee hath been so at war,
And thus hath so bestirred thee in thy sleep,   (Traumatic dreams, reliving episodes of combat, fragmented sleep)
That beads of sweat have stood upon thy brow
Like bubbles in a late-disturbed stream … (Night sweats, automatic hyperactivity)

Do you recognize this in a loved one? Do you recognize this in yourself? I wonder who in the great bard’s life inspired him to relay such pain through Lady Percy’s words. And note, that Lady Percy’s pain is as deep, tormenting and disabling as that of her husbands’. PTSD and moral injury is, in effect, contagious, and wrecks relationships and families. True now and true over five hundred years ago.

Before admitting my injury and getting help, from friends, family, peers, strangers and professionals, I would have silently and reluctantly recognized these words in myself. I would loathe myself for such recognition and would find solace in alcohol and suicidality. If this is you now, there is no shame, open up, admit your pain and get help. Your pain is as old as war and I promise you, you will find strength in others when you seek help and in that you will find strength in yourself.