Degree Date

8-2026

Document Type

Dissertation - Public Access

Degree Name

Psy.D. Doctor of Clinical Psychology

Academic Discipline

Clinical Psychology

First Advisor

Dr. Sandra Zakowski

Second Advisor

Dr. Brad Olson

Third Advisor

Dr. John Bair

Abstract

This pilot study examined associations between self-reported moral distress, state distress, combat exposure, deployment history, and maximum pupil reactivity among veterans diagnosed with PTSD. Participants viewed neutral and morally relevant images while pupil responses were recorded using eye-tracking technology. Self-report measures included moral distress severity, exposure to potentially morally injurious events, Subjective Units of Distress Scale (SUDS) ratings, total deployments, number of combat deployments, and Combat Exposure Scale scores. Maximum pupil reactivity was calculated by subtracting the mean z-scored maximum pupil response during neutral image presentations from the mean z-scored maximum pupil response during morally relevant image presentations. This variable reflected differences between image conditions rather than differences between maximum and minimum pupil values. Results indicated that mean SUDS ratings during morally relevant images were significantly positively associated with maximum pupil reactivity, suggesting that in-the-moment distress was related to pupil-based responding. MIDS moral distress and Combat Exposure Scale scores were not significantly associated with maximum pupil reactivity. In contrast, the number of combat deployments was significantly negatively associated with maximum pupil reactivity, suggesting a more constrained pupil-response pattern among participants with more combat deployments. Total deployments were also negatively associated with maximum pupil reactivity, although combat deployments showed a stronger association. Findings should be interpreted with caution due to the study's pilot nature and small sample size of 18. Overall, the results provide preliminary support for the feasibility and potential usefulness of pupil-based eye-tracking measures in future research on moral injury.

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