Shame on the brain: Neural correlates of moral injury event recall in posttraumatic stress disorder
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BACKGROUND: Moral injury (MI) is consistently associated with adverse mental health outcomes, including the development of posttraumatic stress disorder (PTSD) and suicidality. METHODS: We investigated neural activation patterns associated with MI event recall using functional magnetic resonance imaging in participants with military and public safety-related PTSD, relative to civilian MI-exposed controls. RESULTS: MI recall in the PTSD as compared to control group was associated with increased neural activation among salience network nodes involved in viscerosensory processing and hyperarousal (right posterior insula, dorsal anterior cingulate cortex; dACC), regions involved in defensive responding (left postcentral gyrus), and areas responsible for top-down cognitive control of emotions (left dorsolateral prefrontal cortex; dlPFC). Within the PTSD group, measures of state and trait shame correlated negatively with activity among default mode network regions associated with self-related processing and moral cognition (dorsomedial prefrontal cortex; dmPFC) and salience network regions associated with viscerosensory processing (left posterior insula), respectively. CONCLUSIONS: These findings suggest that MI event processing is altered in military and public safety-related PTSD, relative to MI-exposed controls. Here, it appears probable that as individuals with PTSD recall their MI event, they experience a surge of blame-related processing of bodily sensations within salience network regions, including the right posterior insula and the dACC, which in turn, prompt regulatory strategies at the level of the left dlPFC aimed at increasing cognitive control and inhibiting emotional affect. These results are consistent with previous findings showing enhanced sensory processing and altered top-down control in PTSD samples during autobiographical memory recall.
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Investigations of morally salient autobiographical recall report atypical posterior DMN activation, altered connectivity with sensorimotor and midbrain regions, and associations between shame intensity and dorsomedial prefrontal activity.
“Investigations of morally salient autobiographical recall report atypical posterior DMN activation, altered connectivity with sensorimotor and midbrain regions, and associations between shame intensity and dorsomedial prefrontal activity—patterns broadly consistent with intensified moral self-focus and difficulties integrating emotionally charged experiences into coherent narratives (40, 41, 52).”
From The therapeutic role of self-transcendence in moral injury recovery: theory, mechanisms, and clinical implications (2026) · cites this paper as [40]
The Discussion (§4) and neural-correlates-of-shame section (§4.2) report that greater shame during morally injurious event recall was associated with reduced activity in a dorsomedial prefrontal region among participants with PTSD. The Neuroimaging Results (§3.2) describe only a trending, not statistically significant, interaction in the posterior cingulate cortex. The paper does not report altered connectivity with sensorimotor and midbrain regions during this recall task. (LLM, conf=0.88)
Experimental — accuracy not yet measuredEmerging studies associate moral injury with altered activity in large-scale brain networks supporting self-referential thought, particularly the Default Mode Network.
“Emerging studies associate moral injury with altered activity in large-scale brain networks supporting self-referential thought, particularly the Default Mode Network (DMN) (40, 41, 51, 52).”
From The therapeutic role of self-transcendence in moral injury recovery: theory, mechanisms, and clinical implications (2026) · cites this paper as [40]
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Self-citationLevinstein, Y., Zerach, G., Levi‐Belz, Y., & Bonanno, G. A. (2024) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2024.07.025 · Cited by 12 · see citing works
Enhancing Conceptual Clarity regarding the Construct of Moral Injury
O'Brien, S. F., Baptista, I., & Szeszko, P. R. (2024) · Psychotherapy and Psychosomatics · doi:10.1159/000540030 · Cited by 8 · see citing works
Lathan, E. C., Sheikh, I. S., Guelfo, A., Choucair, K. C., Fulton, T. M., Julian, J., Mekawi, Y., Currier, J. M., Powers, A. D., & Fani, N. (2023) · Journal of Trauma & Dissociation · doi:10.1080/15299732.2023.2231010 · Cited by 9 · see citing works
James, K. E., McKimmie, B. M., & Maccallum, F. (2024) · Anxiety Stress & Coping · doi:10.1080/10615806.2024.2387607 · Cited by 7 · see citing works
Spiritually Integrated Cognitive Processing Therapy for Moral Injury in the Setting of PTSD
O’Garo, K.-G. N., & Koenig, H. G. (2023) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001686 · Cited by 7 · see citing works
D’Alessandro-Lowe, A. M., Scott, A. M., Patel, H., Easterbrook, B., Ritchie, K., Brown, A., Pichtikova, M., Karram, M., Sullo, E., Mirabelli, J., et al. (2024) · Journal of Traumatic Stress · doi:10.1002/jts.23122 · Cited by 7 · see citing works
Self-citationReduced cerebello-thalamo-cortical functional connectivity during traumatic memory retrieval in PTSD
Kearney, B. E., Densmore, M., Théberge, J., Jetly, R., McKinnon, M. C., Shaw, S. B., & Lanius, R. A. (2025) · Nature Mental Health · doi:10.1038/s44220-025-00476-6 · Cited by 8 · see citing works
Self-citationResting-state neural signatures of moral injury: associations with rumination
Fulton, T. M., Guelfo, A., Elbasheir, A., McDermott, T. J., Lee, J., Ahluwalia, V., Ely, T. D., Lathan, E. C., & Fani, N. (2026) · Biological Psychiatry: Cognitive Neuroscience and Neuroimaging · doi:10.1016/j.bpsc.2025.08.001 · Cited by 5 · see citing works
Moral Injury in the DSM-5-TR: Syndrome Spectrum vs. Categorical Disorder
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Perceptions of Military Experience Among Veterans Reporting Lifetime Warzone Moral Injury
Borges, L. M., Holliman, B. D., Farnsworth, J. K., & Barnes, S. M. (2023) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001676 · Cited by 3 · see citing works
Chaposhloo, M., McKinnon, M. C., Kearney, B. E., Shaw, S. B., Lanius, R. A., & Becker, S. (2025) · Neuroimage Reports · doi:10.1016/j.ynirp.2025.100279 · Cited by 2 · see citing works
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Towards an Integration of Risk Assessment, Case Formulation, and Forensic Neuroscience
Craig, L. A., & Rettenberger, M. (2022) · Springer eBooks · doi:10.1007/978-3-030-80212-7_8 · Cited by 2 · see citing works
Burke, P. J. (2022) · Journal of Contemporary Ethnography · doi:10.1177/08912416221087362 · Cited by 1 · see citing works
Shiota, S., Oura, S.-I., & MATSUMOTO, M. (2024) · Environment and Social Psychology · doi:10.59429/esp.v9i7.2079 · Cited by 1 · see citing works
Kelley, M. L., Gabelmann, J. M., Strowger, M., Hearton, J., Folivi, F., Bravo, A. J., Noh, J., Kuskye, K., Haber, W., & McGuire, A. P. (2025) · Journal of Drug Education · doi:10.1177/00472379251394435 · Cited by 3 · see citing works
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Fleming, W. H. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1701564
“Investigations of morally salient autobiographical recall report atypical posterior DMN activation, altered connectivity with sensorimotor and midbrain regions, and associations between shame intensity and dorsomedial prefrontal activity — patterns broadly consistent with intensi fi ed moral self-focus and dif fi cultie…”
InfluentialParpart, H. M., Blaß, J., Meindl, T., Blautzik, J., Michl, P., Beblo, T., Engel, R. R., Reiser, M., Falkai, P., Moeller, H., et al. (2024) · Brain Sciences · doi:10.3390/brainsci14060549 · Cited by 1 · see citing works
Posttraumatic survivor guilt is associated with white matter microstructure alterations
Rojczyk, P., Seitz‐Holland, J., Heller, C., Marcolini, S., Marshall, A. D., Sydnor, V. J., Kaufmann, E., Jung, L., Bonke, E. M., Berger, L., et al. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.06.047
Editorial: The cost of war: sociological approaches to the societal and individual wounds of combat
Grimell, J., Atuel, H. R., & Sinai, C. (2026) · Frontiers in Sociology · doi:10.3389/fsoc.2025.1767848
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- Authors
- Lloyd, C. S., Nicholson, A. A., Densmore, M., Théberge, J., Neufeld, R. W. J., Jetly, R., McKinnon, M. C., & Lanius, R. A.
- Affiliations
- Western University (CA)
- Homewood Research Institute (CA)
- Canadian Armed Forces (CA)
- Corresponding author
- Lanius, Ruth A.
- ORCID
- Venue
- Depression and Anxiety
- Publisher
- Wiley
- Published
- 2020-12-28
- Volume
- 38
- Issue
- 6
- Pages
- 596-605
- ISSN
- 1091-4269 (ISSN-L)
- 1520-6394
- OpenAlex
- W3116171990
- Cited by
- 35
- References
- 73
- Citations by year
- 2026: 6 · 2025: 5 · 2024: 9 · 2023: 7 · 2022: 7 · 2021: 1
- FWCI
- 1.50
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Depression and Anxiety (publishedVersion)
- PubMed (publishedVersion)
- Scholarship@Western (Western University) (submittedVersion, cc-by)
- Scholarship@Western (Western University) (submittedVersion)
- Funders
- Canada Foundation for Innovation (31724)
- Canadian Institutes of Health Research (148784)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Social Sciences › Arts and Humanities › Philosophy › Memory, History, Trauma, Identity
- Keywords
- moral injury, post-traumatic stress disorder, shame, event recall, autobiographical memory, salience network, default mode network, posterior insula, dorsal anterior cingulate cortex, dorsolateral prefrontal cortex, dorsomedial prefrontal cortex, hyperarousal, cognitive control, military personnel, public safety personnel, moral cognition
- MeSH terms
- Brain, Emotions, Humans, Magnetic Resonance Imaging, Mental Recall, Shame, Stress Disorders, Post-Traumatic
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