Moral injury occurs when an event or situation transgresses or violates an individual’s core moral values, resulting in—feelings of guilt, shame, self-condemnation, trust issues, loss of meaning and spiritual struggles.

Post-traumatic stress disorder (PTSD) is a mental health disorder that develops after a traumatic event. It can completely disrupt an individual’s life, making it hard to sleep, relax, concentrate and function. According to the U.S. Department of Veterans Affairs, the number of veterans with PTSD varies by service era. In any given year, PTSD is reported in between 11-and-20 percent of veterans who served in Operations Iraqi Freedom or Enduring Freedom and about 12 percent of those who served in the Gulf War have PTSD. Approximately 30 percent of Vietnam veterans are estimated to have had PTSD in their lifetime.

Veterans and active duty military personnel with post-traumatic stress disorder (PTSD) often experience moral injury. Although there are similarities between moral injury and PTSD, they are not the same.

Moral injury and PTSD

According to research published in the Journal of Neuropsychiatry and Clinical Neurosciences, between 25 percent and 34 percent of index events for combat-related PTSD result in moral injuries. Co-occurring moral injury and PTSD is associated with more severe symptoms as well as greater likelihood of suicidal intent and behaviors.

Similarities

Both PTSD and moral injury may lead to lasting behavioral, social, psychological and spiritual effects, such as anger, substance use and depression. The following symptoms can be present in both moral injury and PTSD:

•   Guilt
•   Shame
•   Betrayal
•   Reliving past events
•   Loss of trust
•   Loss of faith

Learn more about the signs and symptoms of moral injury here. [link to blog: What is Moral Injury]

It’s important to note that experiencing a potentially morally injurious event does not necessarily mean that you will develop moral injury. Similarly, experiencing trauma does not inevitably lead to the development of PTSD.

PTSD is fear-based

While moral injury is based on moral judgment and conscience, PTSD is a fear-based disorder. Treatment modalities for PTSD that are aimed at defusing fear, such as reliving the traumatic incident in a safe environment, can sometimes aggravate moral injury and make it more difficult to address.

Moral injury is not a medical disorder

Unlike PTSD, moral injury is not a mental health disorder. While people with PTSD often suffer from moral injury as well, they cannot be medically diagnosed with moral injury. As such, moral injury has no diagnostic criteria or treatment protocols. It is possible to have moral injury and not meet the diagnostic criteria for PTSD.

Morally injurious vs. traumatic events

During war and combat, military service members are often exposed to traumatic events, such as:

•   Life-threatening situations
•   Injuries and accidents
•   Violence
•   Terrorism
•   Military sexual trauma

While moral injury may occur in the context of traumatic events, situations that put individuals at risk of moral injury are not necessarily life-threatening or traumatic. Instead, morally injurious events threaten an individual’s deeply held moral values, conscience or beliefs. Morally injurious events may include:

•   Something you have done or failed to do
•   Something someone else has done or failed to do
•   Witnessing actions that contradict your moral values
•   Learning about something that violates your moral values after it has happened

Learn more about exposures that may lead to moral injury here.

Different symptoms

Compared to the fear-based reactions associated with traumatic events, the effects of morally injurious events may lead to different signs and symptoms. PTSD also includes symptoms that are not seen in cases of moral injury.

According to the U.S. Department of Veterans Affairs, studies have shown that morally injurious events in which the individual perpetrated an act that violated their own moral values were associated with more intense re-experiencing, guilt, self-blame, and suicidal ideation than life-threatening traumatic events.

PTSD stemming from life-threatening traumatic events has neurological effects that are distinct from what is observed in the brains of individuals with moral injury, such as hyperarousal.

Get help today

Moral injury is distinct from PTSD, despite their overlapping symptoms and frequent co-occurrence in veterans and active duty military personnel. It’s important to understand the differences between PTSD and moral injury to ensure treatment approaches appropriately address moral injury or fear-based trauma, or both if applicable.

Read more about recovery from moral injury here or contact Pyramid Military Therapy to learn more about our programs.