Moral injury symptoms and related problems among service members and Veterans: A network analysis

LAY SUMMARYBoth moral injury (MI) and posttraumatic stress disorder (PTSD) can result from adverse experiences (potentially morally injurious events [PMIEs] for the former and Criterion A events for the latter) and may lead to similar symptoms. Thus, debate is ongoing as to whether MI and PTSD are distinct. Depressive symptoms can also follow these events and may also overlap with symptoms of MI and PTSD. This study investigated how distinct MI is from PTSD and depression by examining networks composed of MI-related outcomes (trust violation, shame, functioning), PTSD symptom clusters, and depression for participants who reported experiencing a PMIE and those who did not. This study is the first of its kind to use MI outcomes with PTSD and depression in a network analysis. The results suggest that MI, PTSD, and depression are distinct but related phenomena, with more connections between these phenomena present particularly among those who experienced a PMIE. Moreover, the negative alterations in cognition and mood cluster of PTSD and MI-related functioning appears to explain some of the co-occurrence among constructs. Introduction: Whether moral injury (MI) is distinct from posttraumatic stress disorder (PTSD) has been debated. Both result from events that often definitionally overlap (a potentially morally injurious event [PMIE] for MI, a Criterion A event for PTSD) and may promote similar dysfunctional experiences. Depressive symptoms may also follow such events and include outcomes common to both MI and PTSD. This study investigated the ways in which MI may be distinct from, and related to, PTSD and depression by examining networks consisting of MI-related outcomes (trust violation, shame, functioning), PTSD symptom clusters, and depression among those who reported experiencing a PMIE and those who did not. Methods: Two networks were estimated, consisting of PTSD symptoms, MI-shame-related outcomes, MI-trust-related outcomes, MI-related functioning, and depression in a sample of military personnel who did (n = 508) and did not (n = 123) experience a PMIE. Results: In both PMIE and non-PMIE networks, stronger connections existed within, versus across, constructs. The PMIE network was denser than the non-PMIE network and driven by more connections across constructs. Negative alterations in cognitions and mood (NACM) clusters of PTSD and MI-related functioning were strong bridges connecting PTSD, MI, and depression. Discussion: MI, PTSD, and depression appear to be distinct but related clinical phenomena. NACM and MI-related functioning partially explain the co-occurrence in these constructs and thus may be important treatment targets. The greater connections across constructs in the PMIE network supports the hypothesis that experiencing a PMIE may trigger dynamic interactions among PTSD, MI-related outcomes, and depression.