Moral injury is a particular type of trauma characterized by guilt, existential crisis, and loss of trust that may develop following a perceived moral violation. The present article reviews phenomenological descriptions, incidence, etiology, and symptoms of moral injury, with a view toward providing an updated conceptual definition. Moral injury's existing definition (Litz et al., 2009) is updated to emphasize its empirically and theoretically recognized symptoms. Guilt, shame, spiritual/existential conflict, and loss of trust are identified as core symptoms. Depression, anxiety, anger, reexperiencing, self-harm, and social problems are identified as secondary symptoms. Based upon the updated syndrome definition, recommendations are given for quantitative assessment of moral injury, which involves assessing both event history and symptoms. The updated definition and assessment strategy will aid providers in recognizing moral injury and allow for quantitative moral injury research.

Potentially morally injurious experiences (PMIEs) are events that may violate deeply held values or belief systems. Combat engagement places service members at a heightened risk for PMIE exposure. Exposure to PMIEs may elicit internal conflict between moral beliefs and experiences and, if unresolved, conflict may manifest as feelings of guilt, shame, and spiritual or existential crisis. Further, distress caused by these experiences may promote harmful behaviors (e.g., excessive alcohol use), which may serve as attempts to cope with PMIEs veterans have witnessed or participated in. The present study examined a sequential mediation model in which combat exposure was associated with alcohol use (i.e., alcohol consumption, dependence symptoms, and alcohol‐related problems) via PMIE exposure and spiritual injury (e.g., alienation from and/or anger towards respective higher power) in a community sample of 380 recent‐era combat veterans. Multiple‐group sequential mediation was then used to examine whether the model fit similarly across men and women. Exposure to PMIEs and spiritual injury sequentially mediated the association between combat and alcohol; higher levels of PMIE exposure and spiritual injury were associated with increased alcohol use, R2 = .17, f2 = 0.07. The multiple‐group model showed that these associations significantly varied between genders such that the mediation was only significant among men. The results indicated that PMIEs and spiritual injury were associated with increased alcohol use, but these associations differed as a function of gender. Future research is needed to refine our understanding of moral and spiritual injury and explore possible risk and protective factors.

Moral injury is a unique type of trauma characterized by guilt and shame that may develop after acting inconsistently with one's moral values or observing moral violations by trusted individuals. According to the moral injury syndrome model, exposure to potentially morally injurious events (pMIEs-e.g., killing combatants or civilians) statistically predicts the development of proposed moral injury symptoms. Moral injury's core symptoms (e.g., guilt and loss of meaning) are further hypothesized to mediate relationships between pMIEs and secondary symptoms (e.g., depression, anxiety, and posttraumatic stress disorder symptoms). To empirically evaluate these propositions, the relationships between exposure to pMIEs, core symptoms, and secondary symptoms were examined in a community sample of combat veterans (N ϭ 72). pMIE exposure was statistically associated with all proposed moral injury symptoms. Furthermore, the relationships between pMIE exposure and secondary symptoms were all mediated by core symptoms. Results highlight guilt's centrality in moral injury.

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