PTSD and Moral Injury


Moral injury is a term mental health professionals use to describe involvement in or exposure to events that violate a person’s preexisting code of moral conduct. Current evidence indicates that the presence of moral injury can potentially increase the chances that a person will develop post-traumatic stress disorder (PTSD) in the aftermath of a seriously traumatic event. This type of psychological injury can also complicate the treatment of existing PTSD symptoms or increase the chances that an affected individual will experience a later recurrence of a treated case of PTSD.

Moral Injury Basics

Moral injury is a fairly recent mental health concept, the authors of a 2013 report and study review in Psychiatric Times explain. In addition to direct participation in morally transgressive actions, this mental state can arise as a consequence of observing other people’s transgressive behaviors, observing the after effects of transgressive behavior or making an unsuccessful attempt to prevent the perpetration of morally transgressive acts. Typically, the acts that trigger moral injury deeply violate a person’s central belief structure, rather than merely approaching the border of unacceptability. The population groups most likely to develop some sort of moral injury are servicemen and servicewomen deployed in active theaters of combat.

Moral injury is not a diagnosable mental disorder according to the criteria established by the American Psychiatric Association. Instead, it functions as a contributor to a person’s overall state of mind, and also potentially contributes to a person’s risks for developing a diagnosable mental condition. Any given individual may experience effects of moral injury that range in intensity from nonexistent to severe. Specific potential effects include extreme feelings of guilt or shame, participation in self-limiting or self-sabotaging behaviors, participation in self-harming behaviors and self-condemnation based on one’s particular moral and religious beliefs.

PTSD Basics

PTSD is a mental disorder that arises in some people one month or more after exposure to events that pose an immediate threat to continued survival, make a person reasonably fear for his or her continued survival, or threaten the lives of other nearby people. Characteristic symptoms of the disorder include a stressful state of hypervigilance, nightmares or flashbacks that resemble or recreate a life-threatening situation, a disruptive increase in negative emotional states, and a strong tendency to shy away from real-life situations that could retrigger a traumatic response. Known influences on a person’s chances of developing PTSD include the strength of an initial traumatic reaction, the severity of the initial traumatic event, the length of one’s trauma exposure, the personal consequences of a traumatic event (e.g., injury or the death of loved ones) and the availability of guidance or counseling in the aftermath of a trauma-inducing event.

Relationship to PTSD

Some of the symptoms that appear in people with PTSD can strongly resemble the mental and behavioral effects of moral injury, according to the authors of a report published in 2012 in the National Center for PTSD’s PTSD Research Quarterly. However, not all people affected by moral injury develop PTSD, and not all people with PTSD experience moral injury. Critically, while people with PTSD go through experiences that make them fear for their own lives or the lives of others, moral injury can occur when there is no immediate threat to the self or to other people.

Effects on PTSD

In some cases, feelings of empathy (compassion and self-recognition) in people with moral injury can potentially act as a risk factor for the onset of PTSD, the authors of report and review in Psychiatric Times note. In addition, in people already affected by post-traumatic stress disorder, later exposure to events that trigger a sense of moral injury can lead to a relapse of their symptoms, even if they were previously responding well to their established regimens of PTSD treatment.

The most highly regarded treatment for PTSD is a form of psychotherapy called prolonged exposure therapy, which requires affected individuals to purposefully face the situations that set off their trauma-related symptoms. The presence of moral injury can potentially interfere with the effectiveness of prolonged exposure therapy and significantly decrease the chances that a person going through the therapy will receive any real treatment benefit. In some cases, morally injured people who take part in prolonged exposure may actually experience a worsening of their PTSD symptoms. Individuals especially likely to have problems with the treatment have moral injuries that stem from direct participation in the killing of others.

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