Temporal Associations Between Moral Injury and Posttraumatic Stress Disorder Symptom Clusters in Military Veterans

Abstract

War zone veterans who experience posttraumatic stress disorder (PTSD) symptoms might struggle with co‐occurring cognitive, emotional, and behavioral expressions of suffering that align with conceptual definitions of moral injury (MI). However, given that PTSD is a multidimensional condition, disentangling the apparent interplay with MI may inform clinical practice and research. This study incorporated a cross‐lagged design to explore temporal associations between self‐ and other‐directed outcomes related to MI and severity of DSM‐5 PTSD symptom clusters while accounting for depressive symptoms. Drawing on the Expressions of Moral Injury Scale–Military Version in a community sample of 182 previously deployed veterans, MI‐related outcomes were linked with severity of PTSD symptom clusters at two assessments spaced apart by 6 months, rs = .58–.62. Of possible models for conceptualizing the temporal nature of these associations, structural equation modeling analyses revealed a cross‐lagged primary MI model best fit veterans’ responses. Within this model, veterans’ self‐directed MI at Time 1 predicted greater PTSD symptoms at the 6‐month follow‐up. However, an equivalent cross‐lagged path also emerged between Time 1 PTSD Cluster D symptoms and self‐directed MI at Time 2, suggesting the value of a reciprocal MI model for this symptom domain. In contrast, other‐directed outcomes of MI were not linked with PTSD in the presence of other variables. Overall, these findings support the prognostic value of assessing for MI‐related outcomes among veterans who might be struggling with PTSD symptomatology, particularly with respect to self‐directed problems associated with enduring moral distress.

The Role of Moral Injury in PTSD Among Law Enforcement Officers: A Brief Report

“…Yeterian et al, 2019), and differentiating both index events and outcomes associated with moral injury and post-traumatic stress disorder (PTSD; e.g. Jinkerson, 2016;Currier et al, 2019). Practically, questions remain regarding best practices for treating moral injury and the extent to which current treatments for PTSD are suitable to treat moral injury (e.g.…”

“…Regardless of the precipitant, however, the outcomes appear to share many characteristics, and the two conditions have been observed to co-occur among military samples (e.g. Jordan et al, 2017;Currier et al, 2019;Davies et al, 2019). In one study, higher levels of moral injury correlated positively with "increased history of suicide attempt, but only among those higher in PTSD severity" (Bryan et al, 2018, p. 41).…”

Moving Moral Injury Into the Future With Functional Contextualism: A Response to Nash's “Unpacking Two Models for Understanding Moral Injury” (2019)

“…Although research on morally injurious events is still in its infancy, it has been observed that not all morally injurious events meet PTSD's requirements for Criterion A traumatic events as given in the fifth edition of the DSM (i.e., DSM‐5 ; Litz & Kerig, ). Furthermore, early research suggests that although MI and PTSD are intertwined, they also appear to be distinct (Bryan, Bryan, Roberge, Leifker, & Rozek, ; Currier, McDermott, Farnsworth, & Borges, ), and that morally injurious events serve as a risk factor for a range of psychological difficulties, including suicidal ideation and behavior, depression, and substance use disorders (Battles et al., ; Bryan et al., ; Currier, Holland, & Mallot, ; Kelley et al., ; Maguen et al., ). Rather than pigeon‐holing MI to solely exist within the construct of PTSD and fear‐based biological models of posttraumatic stress, the functional contextual definition approaches MI transdiagnostically, making it applicable to a much wider range of clinical conditions.…”

Veterans’ perspectives on discussing moral injury in the context of evidence‐based psychotherapies for PTSD and other VA treatment

“…In addition to the potential impact of violations of one's moral code on functioning, MIEs have been established as a transdiagnostic risk factor for a range of psychological difficulties including posttraumatic stress disorder (PTSD), suicidal ideation and behavior, depression, and substance use (Battles et al, ; Bryan, Bryan, Roberge, Leifker, & Rosek, ; Currier, McDermott, Farnsworth, & Borges, ; Currier et al, ; Kelley, Braitman, White, & Ehlke, ; Maguen et al, ). The links between exposure to MIEs and the development of PTSD are particularly robust.…”

“…EMIS scores have been conceptualized as a proxy for moral injury. In one study, heightened moral injury as characterized by the EMIS was predictive of PTSD symptoms 6-months after initial assessment, but PTSD symptoms were not predictive of expressions of moral injury (with the exception of cluster D PTSD symptoms where the relationship was bidirectional; Currier et al, 2019). The difference between PTSD and moral injury could in part be due to the mechanisms leading to the development and maintenance of these constructs.…”