The Dual Impact of Moral Injury: Links to PTSD Symptoms and Disinhibited Externalizing in U.S. Combat Veterans

Moral injury is an experience of psychological distress that occurs when a person’s morals are violated by themselves or others, including institutions and organizations. Such violations of morality can be impairing and have high rates of comorbidity with internalizing disorders (posttraumatic stress, depression, anxiety, suicidality), which may indicate that moral injury is a transdiagnostic construct. This study had four aims, which were accomplished using from a nationally representative, probability-based sample of 1,353 US military veterans. In the first aim, we created structural models of moral injury using the Moral Injury Events Scale (for which a bifactor structure with a specific factor of perceived betrayals fit best) and posttraumatic stress using the PTSD checklist for DSM-5 (for which a seven correlated factors model fit best). The second aim created a bifactor structural model of disinhibited externalizing with symptoms of alcohol use, drug use, and gambling disorders as markers of the general factor alone, with a specific second-order normal-range inhibitory personality factor comprising traits of conscientiousness, cognitive impulsivity, and grit. In the third aim, we found that the general factor of moral injury was associated with the unique variance in the reexperiencing factor of PTSD along with disinhibited personality traits and drug and gambling use disorder symptoms.The perceived betrayals factor was associated with the unique variance in the anhedonia factor of PTSD. In the fourth aim, we verified that these relationships remained after adjusting for lifetime trauma and combat exposure. These results highlight the importance of examining these constructs at multiple levels to understand their relationships and formulate treatments targeted at the appropriate level of symptom presentation.