Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events.

Objective: We investigated whether potentially morally injurious events (PMIEs) during a combat deployment may lead to PTSD through distinct pathways from danger-based events. We also examined the prevalence of perpetration-based PMIEs, during which service members behaved in ways that violated their own moral values, and betrayal-based PMIEs, during which personal moral expectations were violated by trusted others. Method: Using a sample of 867 active duty Marines from a single infantry battalion that engaged in heavy ground combat while deployed to Afghanistan, a structural equation model was built to examine the relationships between perpetration-and betrayal-based PMIEs, combat experiences, and peritraumatic dissociation reported at 1 month postdeployment, and guilt/shame, anger, and PTSD symptoms reported at 8 months postdeployment. Results: The relationship between betrayal-based PMIEs and PTSD was mediated by anger (beta = .14). There was marginal evidence of mediation of the relationship between perpetration-based PMIEs and PTSD by shame and guilt (beta = .09), and of the relationship between danger-based combat events and PTSD by peritraumatic dissociation (beta = .08). No significant direct relationships were found between any of these 3 types of events and subsequent PTSD. Perceived perpetration and betrayal accounted for PTSD symptoms above and beyond combat exposure. Over a third of the sample reported experiencing perpetration-or betrayal-based PMIEs. Conclusions: The associations of perpetration and betrayal with PTSD, controlling for danger-based combat events, highlight the limitations of conceptualizations and treatments of PTSD based on fear or helplessness as sole etiologic factors.