Defining conceptual boundaries of moral injury and post-traumatic stress disorder in military population: A systematic review

Larysa Zasiekina; Oleg Kokun; Iryna Hlova; Martha Bojko

doi:10.29038/eejpl.2023.10.1.zas

Authors

Larysa Zasiekina * Lesya Ukrainka Volyn National University, Ukraine; University of Cambridge, UK
Oleg Kokun Hryhorii Kostiuk Institute of Psychology, Ukraine
Iryna Hlova Lesya Ukrainka Volyn National University, Ukraine
Martha Bojko American Councils Title VIII Research Scholar to Ukraine & Poland (2021-23), USA; Medical University of Gdansk, Poland

DOI:

https://doi.org/10.29038/eejpl.2023.10.1.zas

Keywords:

moral injury, post-traumatic stress disorder, military personnel, conceptual boundaries

Abstract

Moral injury is one of the main emotional distress in military personnel. Findings suggest that in wartime there are an endless number of potentially morally injurious events, which determine maladaptive cognitions, moral emotions of guilt and shame, and inefficient behaviour. Notwithstanding the strong association between moral injury and post-traumatic stress disorder (PTSD) recognized in the number of studies, there is still a gap of accurate data aligned with identifying the differences between moral injury and PTSD in terms of treatment and healing. This study aims to establish conceptual boundaries of moral injury, post-traumatic stress disorder and systematically review the empirical literature on them in military personnel. Specifically, we explored and summarized co-occurrence of moral injury and PTSD in military personnel and evaluated the association between moral injury and PTSD, as well with other emotional distress. An intensive bibliography search screening, extraction and report focusing in moral injury and PTSD was conducted following the PRISMA recommendations. The results indicate that the key aspects of comparison of moral injury and PTSD include definition and symptomology, measurement, neural underpinning, and treatment. Considering the consequences of poor social well-being, emotional sufferings and inefficient behavioral patterns, treatments focusing on moral injury separately from PTSD-focused models are much needed.

Acknowledgements

This study is a part of the Moral Injury and Healing of Combatants: Neuropsychological Correlates and Psychological Interventions project funded by the Ministry of Education and Science of Ukraine (2022-2023).

Disclosure Statement

No potential conflict of interest was reported by the authors.

* Corresponding author: Larysa Zasiekina,

0000-0001-8456-0774

zasyekina.larisa@vnu.edu.ua

Downloads

Download data is not yet available.

References

Aldridge, V., Scott, H., & Paskell, R. (2019). Investigating the relationship between guilt and shame proneness and moral injury in veterans that have experienced active deployment. Military Behavioral Health, 7(1), 83-91.

American Psychiatric Association, DSM-5 Task Force. (2013). (5th ed.). American Psychiatric Publishing, Inc.. https://doi.org/10.1176/appi.books.9780890425596

Ames, D., Erickson, Z., Youssef, N. A., Arnold, I., Adamson, C. S., Sones, A. C., ... & Koenig, H. G. (2019). Moral injury, religiosity, and suicide risk in US veterans and active duty military with PTSD symptoms. Military Medicine, 184(3-4), e271-e278. https://doi.org/10.1093/milmed/usy148

Bomyea, J., Risbrough, V., & Lang, A. J. (2012). A consideration of select pre-trauma factors as key vulnerabilities in PTSD. Clinical Psychology Review, 32(7), 630–641. https://doi.org/10.1016/j.cpr.2012.06.008

Boska, R. L., & Capron, D. W. (2021). Exploring the maladaptive cognitions of moral injury within a primarily combat-trauma military sample. Psychological trauma: theory, research, practice, and policy, 13 (8), 861-868 https://doi.org/10.1037/tra0001071

Braitman, A. L., Battles, A. R., Kelley, M. L., Hamrick, H. C., Cramer, R. J., Ehlke, S., & Bravo, A. J. (2018). Psychometric properties of a Modified Moral Injury Questionnaire in a military population. Traumatology, 24(4), 301. https://doi.org/10.1037/trm0000158

Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 36–45. https://doi.org/10.1037/tra0000290

Browne, T., Hull, L., Horn, O., Jones, M., Murphy, D., Fear, N. T., Rona, R. J., Wessely, S., & Hotopf, M. (2007). Explanations for the increase in mental health problems in UK reserve forces who have served in Iraq. British Journal of Psychiatry, 190(6), 484–489. https://doi.org/10.1192/bjp.bp.106.030544

Capone, C., Norman, S. B., Haller, M., Davis, B., Shea, M. T., Browne, K., ... & Westendorf, L. (2021). Trauma Informed Guilt Reduction (TrIGR) therapy for guilt, shame, and moral injury resulting from trauma: Rationale, design, and methodology of a two-site randomized controlled trial. Contemporary clinical trials, 101. https://doi.org/10.1016/j.cct.2020.106251

Campbell-Sills, L., Flynn, P. J., Choi, K. W., Ng, T., Aliaga, P. A., Broshek, C., Jain, S., Kessler, R. C., Stein, M. B., Ursano, R. J., & Bliese, P. D. (2022). Unit cohesion during deployment and post-deployment mental health: is cohesion an individual- or unit-level buffer for combat-exposed soldiers? Psychological Medicine, 52(1), 121–131. https://doi.org/10.1017/S0033291720001786

Cesur, R., Sabia, J. J., & Tekin, E. (2012). The psychological costs of war: military combat and mental health. Journal of Health Economics, 32(1). 51–65. https://doi.org/10.1016/j.jhealeco.2012.09.001

Chesnut, R. P., Richardson, C. B., Morgan, N. R., Bleser, J. A., Perkins, D. F., Vogt, D., ... & Finley, E. (2020). Moral injury and social wellbeing: a growth curve analysis. Journal of traumatic stress, 33(4), 587-597. https://doi.org/10.1002/jts.22567

Corona, C. D., Van Orden, K. A., Wisco, B. E., & Pietrzak, R. H. (2019). Meaning in life moderates the association between morally injurious experiences and suicide ideation among US combat veterans: Results from the National Health and Resilience in Veterans Study. Psychological Trauma: Theory, Research, Practice, and Policy, 11(6), 614. https://doi.org/10.1037/tra0000475

Currier, J. M., Farnsworth, J. K., Drescher, K. D., McDermott, R. C., Sims, B. M., & Albright, D. L. (2018). Development and evaluation of the Expressions of Moral Injury Scale—Military Version. Clinical Psychology & Psychotherapy, 25(3), 474-488. https://doi.org/10.1002/cpp.2170

Currier, J. M., McDermott, R. C., Farnsworth, J. K., & Borges, L. M. (2019). Temporal associations between moral injury and posttraumatic stress disorder symptom clusters in military veterans. Journal of Traumatic Stress, 32(3), 382-392. https://doi.org/10.1002/jts.22367

Currier, J. M., Isaak, S. L., & McDermott, R. C. (2020). Validation of the Expressions of Moral Injury Scale‐Military version‐short form. Clinical psychology & psychotherapy, 27(1), 61-68. https://doi.org/10.1002/cpp.2407

Currier, J. M., Foster, J. D., Karatzias, T., & Murphy, D. (2021). Moral injury and ICD-11 complex PTSD (CPTSD) symptoms among treatment-seeking veterans in the United Kingdom. Psychological Trauma: Theory, Research, Practice, and Policy, 13(4), 417. https://doi.org/10.1037/tra0000921

Dami, B. E., James, A., Zubairu, D., Karick, H., & Dakwak, S. (2018). Combat exposure and PTSD among military combatants in North East Nigeria. Journal of Psychology & Clinical Psychiatry, 9(4), 400–404. https://doi.org/10.15406/jpcpy.2018.09.00558

Dekel, S., Mamon, D., Solomon, Z., Lanman, O., & Dishy, G. (2016). Can guilt lead to psychological growth following trauma exposure?. Psychiatry Research, 236, 196-198. https://doi.org/10.1016/j.psychres.2016.01.011

Dennis, P. A., Dennis, N. M., Van Voorhees, E. E., Calhoun, P. S., Dennis, M. F., & Beckham, J. C. (2017). Moral transgression during the Vietnam War: A path analysis of the psychological impact of veterans’ involvement in wartime atrocities. Anxiety, Stress, & Coping, 30(2), 188-201. https://doi.org/10.1080/10615806.2016.1230669

Fajarito, C. D. C., & Guzman, R. G. D. (2017). Understanding combat-related PTSD symptom expression through index trauma and military culture: case studies of Filipino soldiers. Military Medicine, 182(5/6), 1665–1671. https://doi.org/10.7205/MILMED-D-16-00216

Farnsworth, J. K., Drescher, K. D., Nieuwsma, J. A., Walser, R. B., & Currier, J. M. (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249-262. https://doi.org/10.1037/gpr0000018

Feingold, D., Zerach, G., & Levi-Belz, Y. (2019). The association between moral injury and substance use among Israeli combat veterans: The mediating role of distress and perceived social support. International Journal of Mental Health and Addiction, 17(2), 217-233. https://doi.org/10.1007/s11469-018-0012-8

Ferrajão, P. C., & Oliveira, R. A. (2015). Attachment patterns as mediators of the link between combat exposure and posttraumatic symptoms: A study among Portuguese war veterans. Military Psychology, 27(3), 185–195. https://doi.org/10.1037/mil0000075

Fischer, I., Shanahan, M., Hirsh, A., Stewart, J., & Rand, K. (2020). The relationship between meaning in life and post-traumatic stress symptoms in US military personnel: A meta-analysis. Journal of Affective Disorders, 277, 658–670. https://doi.org/10.1016/j.jad.2020.08.063.

Fleming, W. H. (2021). Moral injury and the absurd: The suffering of moral paradox. Journal of Religion and Health, 60(5), 3012–3033. https://doi.org/10.1007/s10943-021-01227-4

Frankfurt, S., & Frazier, P. (2016). A review of research on moral injury in combat veterans. Military psychology, 28(5), 318-330. https://doi.org/10.1037/mil0000132

Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., Elbogen E., & Beckham, J. C. (2015). The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98–107. https://doi.org/10.1016/j.janxdis.2015.02.003

Gates, M. A., Holowka, D. W., Vasterling, J. J., Keane, T. M., Marx, B. P., & Rosen, R. C. (2012). Posttraumatic stress disorder in veterans and military personnel: Epidemiology, screening, and case recognition. Psychological Services, 9(4), 361–382. https://doi.org/10.1037/a0027649

Graham, J., Legarreta, M., North, L., DiMuzio, J., McGlade, E., & Yurgelun-Todd, D. (2016). A preliminary study of DSM–5 PTSD symptom patterns in veterans by trauma type. Military Psychology, 28(2), 115–122. https://doi.org/10.1037/mil0000092

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., ... & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350-362. https://doi.org/10.1002/jts.22362

Guyker, W. M., Donnelly, K. T., Donnelly, J. P., Dunnam, M., Warner, G. C., Kittleson, J., Bradshaw, C. B., Alt, M., & Meier, S. T. (2013). Dimensionality, reliability, and validity of the combat experiences scale. Military Medicine, 178(4), 377-384. https://doi.org/10.7205/MILMED-D-12-00223

Hashemi Dezaki, Z., Eyni, S., & Ebadi Kasbakhi, M. (2021). Life satisfaction of veterans with post-traumatic stress disorder: The predictive role of cognitive flexibility and alexithymia. Annales Médico-Psychologiques, Revue Psychiatrique, 179(10), 901–906. https://doi.org/10.1016/j.amp.2021.02.007

Held, P., Klassen, B. J., Steigerwald, V. L., Smith, D. L., Bravo, K., Rozek, D. C., ... & Zalta, A. (2021). Do morally injurious experiences and index events negatively impact intensive PTSD treatment outcomes among combat veterans?. European Journal of Psychotraumatology, 12(1), https://doi.org/10.1080/20008198.2021.1877026

Hines, L. A., Sundin, J., Rona, R. J., Wessely, S., & Fear, N.T. (2014). Posttraumatic stress disorder post Iraq and Afghanistan: Prevalence among military subgroups. The Canadian Journal of Psychiatry, 59(9), 468−479. https://10.1177/070674371405900903

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13–22. https://doi.org/10.1056/NEJMoa040603

Houle, S. A., Vincent, C., Jetly, R., & Ashbaugh, A. R. (2020). A qualitative analysis of the impact of potentially morally injurious experiences in the Canadian Armed Forces. Journal of Military, Veteran and Family Health, 6(1), 67-69.

Hruby, A., Lieberman, H. R., & Smith, T. J. (2021). Symptoms of depression, anxiety, and post-traumatic stress disorder and their relationship to health-related behaviors in over 12,000 US military personnel: Bi-directional associations. Journal of Affective Disorders, 283, 84–93. https://doi.org/10.1016/j.jad.2021.01.029

Jakupcak, M., Cook, J., Imel, Z., Fontana, A., Rosenheck, R., & McFall, M. (2009). Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. Journal of Traumatic Stress, 22(4), 303-306. https://doi.org/10.1002/jts.20423

Jeffrey, M., Collado, F., Kibler, J., DeLucia, C., Messer, S., Klimas, N., & Craddock, T. (2021). Post-traumatic stress impact on health outcomes in Gulf War Illness. BMC Psychology, 9(1), e57. https://doi.org/10.1186/s40359-021-00561-2

Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & Litz, B. T. (2017). Distinguishing war-related PTSD resulting from perpetration-and betrayal-based morally injurious events. Psychological Trauma: Theory, Research, Practice, and Policy, 9(6), 627. https://doi.org/10.1037/tra0000249

Kamphuis, W., Delahaij, R., Duel, J., Geuze, E., & Vermetten, E. (2021). The relationship between resilience resources and long-term deployment-related PTSD symptoms: a longitudinal study in Dutch veterans. Military Behavioral Health, 9(3), 267–274. https://doi.org/10.1080/21635781.2020.1864528

Kang, H. K., Natelson, B. H., Mahan, C. M., Lee, K. Y., & Murphy, F. M. (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: A population-based survey of 30,000 Veterans. American Journal of Epidemiology, 157(2), 141–148. https://doi.org/10.1093/aje/kwf187

King, D. W., King, L. A., Gudanowski, D. M., & Vreven, D. L. (1995). Alternative representations of war zone stressors: Relationships to posttraumatic stress disorder in male and female Vietnam veterans. Journal of Abnormal Psychology, 104, 184–196. https://doi.org/10.1037/0021-843X.104.1.184.

Kinney, A. R., Gerber, H. R., Hostetter, T. A., Brenner, L. A., Forster, J. E., & Stephenson, R. O. (2022). Morally injurious combat events as an indirect risk factor for postconcussive symptoms among veterans: The mediating role of posttraumatic stress. Psychological Trauma: Theory, Research, Practice, and Policy. https://doi.org/10.1037/tra0001213

Koenig, H. G., Wang, Z., Al Zaben, F., & Adi, A. (2015). Belief into Action Scale: A comprehensive and sensitive measure of religious involvement. Religions, 6(3), 1006-1016. https://doi.org/10.3390/rel6031006

Koenig, H. G., Boucher, N. A., Oliver, R. J. P., Youssef, N., Mooney, S. R., Currier, J. M., & Pearce, M. (2017). Rationale for spiritually oriented cognitive processing therapy for moral injury in active duty military and veterans with posttraumatic stress disorder. The Journal of Nervous and Mental Disease, 205(2), 147-153. https://doi.org/10.1097/NMD.0000000000000554

Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., ... & Pearce, M. (2018). The moral injury symptom scale-military version. Journal of Religion and Health, 57(1), 249-265.

Koenig, H. G., Youssef, N. A., Ames, D., Oliver, J. P., Teng, E. J., Haynes, K., ... & Pearce, M. (2018). Moral injury and religiosity in US veterans with posttraumatic stress disorder symptoms. The Journal of Nervous and Mental Disease, 206(5), 325-331.

Koenig, H. G., Youssef, N. A., Ames, D., Teng, E. J., & Hill, T. D. (2020). Examining the overlap between moral injury and PTSD in US veterans and active duty military. The Journal of nervous and mental disease, 208(1), 7-12. https://doi.org/10.1097/NMD.0000000000000798

Kokun, O., Agayev, N,. Pischko, I., & Stasiuk, V. (2020). Characteristic impacts of combat stressors on posttraumatic stress disorder in Ukrainian military personnel who participated in the armed conflict in Eastern Ukraine. International Journal of Psychology & Psychological Therapy, 20(3), 315–326. https://www.ijpsy.com/volumen20/num3/554.html

Koven, S. G. (2018). Veteran treatments: PTSD interventions. Healthcare, 6(3), e94. https://doi.org/10.3390/healthcare6030094

Lapierre, C. B., Schwegler, A. F., & Labauve, B. J. (2007). Posttraumatic stress and depression symptoms in soldiers returning from combat operations in Iraq and Afghanistan. Journal of Traumatic Stress, 20(6), 933-943. https://doi.org/10.1002/jts.20278.

Levi-Belz, Y., Greene, T., & Zerach, G. (2020). Associations between moral injury, PTSD clusters, and depression among Israeli veterans: A network approach. European Journal of Psychotraumatology, 11(1), 1736411. https://doi.org/10.1016/j.psychres.2018.08.105

Levi-Belz, Y., & Zerach, G. (2018). Moral injury, suicide ideation, and behavior among combat veterans: The mediating roles of entrapment and depression. Psychiatry Research, 269, 508-516. https://doi.org/10.1016/j.psychres.2018.08.105.

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695-706. https://doi.org/10.1016/j.cpr.2009.07.003

Maguen, S., Griffin, B. J., Copeland, L. A., Perkins, D. F., Richardson, C. B., Finley, E. P., & Vogt, D. (2020). Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression. Psychological Medicine, 1-10.

Marmar, C. R., Schlenger, W., Henn-Haase, C., Qian, M., Purchia, E., Li, M., Corry, N., Williams, C.S., Ho, C. L., Horesh, D., Karstoft, K. I., Shalev, A., & Kulka, R. A. (2015). Course of posttraumatic stress disorder 40 years after the Vietnam War. JAMA psychiatry, 72(9), 875–881. https://doi.org/10.1001/jamapsychiatry.2015.0803

Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652. https://doi.org/10.7205/MILMED-D-13-00017

Nichter, B., Norman, S. B., Maguen, S., & Pietrzak, R. H. (2021). Moral injury and suicidal behavior among US combat veterans: Results from the 2019–2020 National Health and Resilience in Veterans Study. Depression and Anxiety, 38(6), 606-614. https://doi.org/10.1002/da.23145

Nieuwsma, J. A., Brancu, M., Wortmann, J., Smigelsky, M. A., King, H. A., VISN 6 MIRECC Workgroup, & Meador, K. G. (2021). Screening for moral injury and comparatively evaluating moral injury measures in relation to mental illness symptomatology and diagnosis. Clinical Psychology & Psychotherapy, 28(1), 239-250. https://doi.org/10.1002/cpp.2503

Nillni, Y. I., Shayani, D. R., Finley, E., Copeland, L. A., Perkins, D. F., & Vogt, D. S. (2020). The impact of posttraumatic stress disorder and moral injury on women veterans’ perinatal outcomes following separation from military service. Journal of Traumatic Stress, 33(3), 248-256. https://doi.org/10.1002/jts.22509

Okulate, G. T., Akinsanmi, M. A., Oguntuase, R. A., & Majebi, M. A. (2021). Moral injury among Nigerian soldiers following combat: case reports and a review of the literature. Military Medicine, 186(9-10), e1048-e1052. https://doi.org/10.1093/milmed/usaa373

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., ... & Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. International Journal of Surgery, 88, 105906. https://doi-org.ezp.lib.cam.ac.uk/10.1016/j.ijsu.2021.105906

Paige, L., Renshaw, K. D., Allen, E. S., & Litz B. T. (2019). Deployment trauma and seeking treatment for PTSD in US soldiers. Military Psychology, 31(1), 26–34. https://doi.org/10.1080/08995605.2018.1525219

Pietrzak, R. H., Whealin, J. M., Stotzer, R. L., Goldstein, M. B., & Southwick, S. M. (2011). An examination of the relation between combat experiences and combat-related posttraumatic stress disorder in a sample of Connecticut OEF–OIF Veterans. Journal of Psychiatric Research, 45(12), 1579–1584. https://doi.org/10.1016/j.jpsychires.2011.07.010

Plouffe, R. A., Easterbrook, B., Liu, A., McKinnon, M. C., Richardson, J. D., & Nazarov, A. (2021). Psychometric Evaluation of the Moral Injury Events Scale in Two Canadian Armed Forces Samples. Assessment, 10731911211044198. https://doi.org/10.1177/10731911211044198

Rahman, N., & Brown, A. D. (2021). Mental time travel in post-traumatic stress disorder: current gaps and future directions. Frontiers in Psychology, 12, e624707. https://doi.org/10.3389/fpsyg.2021.624707

Rauch, S. A. M., Favorite, T., Giardino, N., Porcari, C., Defever, E., & Liberzon, I. (2010). Relationship between anxiety, depression, and health satisfaction among Veterans with PTSD. Journal of Affective Disorders, 121(1-2), 165–168. https://doi.org/10.1016/j.jad.2009.05.026

Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C .R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. American Journal of Public Health, 99(9), 1651–1658. https://doi.org/10.2105/AJPH.2008.150284

Shastry, N., Sultana, E., Jeffrey, M., Collado, F., Kibler, J., DeLucia, C., Fletcher, M. A., Klimas, N., & Craddock, T. (2022). The impact of post-traumatic stress on quality of life and fatigue in women with Gulf War Illness. BMC Psychology, 10(1), e42. https://doi.org/10.1186/s40359-022-00752-5

Sheerin, C. M., Chowdhury, N., Lind, M. J., Kurtz, E. D., Rappaport, L. M., Berenz, E. C, Brown, R. C, Pickett, T., McDonald, S. D., Danielson, C. K., & Amstadter, A. B. (2018). Relation between coping and posttrauma cognitions on PTSD in a combat-trauma population. Military Psychology, 30(2), 98–107. https://doi.org/10.1080/08995605.2017.1420980

Shen, Y., Arkes, J. A., & Pilgrim, J. D. (2009). The effects of deployment intensity on post-traumatic stress disorder: 2002-2006. Military Medicine, 174(3), 217–223. https://doi.org/10.7205/MILMED-D-03-4307

Sipos, M. L., Bar-Haim, Y., Abend, R., Adler, A. B., & Bliese, P. D. (2014). Postdeployment threat-related attention bias interacts with combat exposure to account for PTSD and anxiety symptoms in soldiers. Depression & Anxiety, 31(2), 124–129. https://doi.org/10.1002/da.22157

Smigelsky, M. A., Malott, J. D., Veazey Morris, K., Berlin, K. S., & Neimeyer, R. A. (2019). Latent profile analysis exploring potential moral injury and posttraumatic stress disorder among military veterans. Journal of Clinical Psychology, 75(3), 499-519. https://doi.org/10.1002/jclp.22714

Smith, M., Schnurr, P.P., & Rosenheck, R.A. (2005). Employment outcomes and PTSD symptom severity. Mental Health Services Research, 7(2), 89–101. https://doi.org/10.1007/S11020-005-3780-2

Sun, D., Phillips, R. D., Mulready, H. L., Zablonski, S. T., Turner, J. A., Turner, M. D., ... & Morey, R. A. (2019). Resting‐state brain fluctuation and functional connectivity dissociate moral injury from posttraumatic stress disorder. Depression and Anxiety, 36(5), 442-452.

https://doi.org/10.1002/da.22883

Sung, E., Chang, J. H., Lee, S., & Park, S. H. (2019). The moderating effect of cognitive flexibility in the relationship between work stress and psychological symptoms in Korean Air Force Pilots. Military Psychology, 31(2), 100–106. https://doi.org/10.1080/08995605.2018.1556083

Takemoto, E., Van Oss, K., Chamany, S., Brite, J., & Brackbill, R. (2021). Post-traumatic stress disorder and the association with overweight, obesity, and weight change among individuals exposed to the World Trade Center disaster, 2003–2016. Psychological Medicine, 51(15), 2647–2656. https://doi.org/10.1017/S0033291720001208

Tanielian, T. L., & Jaycox, L. (Eds.) (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. RAND Center for Military Health Policy Research. https://www.rand.org/pubs/monographs/MG720.html

Thomassen, Å. G., Hystad, S. W., Johnsen, B. H., Johnsen, G. E., & Bartone, P. T. (2018). The effect of hardiness on PTSD symptoms: A prospective mediational approach. Military Psychology, 30(2), 142–151. https://doi.org/10.1080/08995605.2018.1425065

Volk, F., & Koenig, H. G. (2019). Moral injury and religiosity in active duty US Military with PTSD symptoms. Military Behavioral Health, 7(1), 64-72. https://doi.org/10.1080/21635781.2018.1436102

Williamson, V., Greenberg, N., & Murphy, D. (2020). Impact of moral injury on the lives of UK military veterans: a pilot study. BMJ of Military Health, 166(5), 302-306. https://doi.org/10.1136/jramc-2019-001243

Williamson, V., Murphy, D., Stevelink, S. A., Allen, S., Jones, E., & Greenberg, N. (2021). The impact of moral injury on the wellbeing of UK military veterans. BMC Psychology, 9(1), 1-7. https://doi.org/10.1186/s40359-021-00578-7

Yazici, H., Ozdemir, M., & Koca, F. (2021). Impact of posttraumatic stress disorder symptoms on posttraumatic growth. Journal of Loss and Trauma, 26(4), 389–400. https://doi.org/10.1080/15325024.2020.1801240

Zasiekina, L. (2020). Trauma, rememory and language in Holodomor survivors’ narratives. Psycholinguistics, 27(1), 80-94. https://doi.org/10.31470/2309-1797-2020-27-1-80-94

Zerach, G., & Levi‐Belz, Y. (2018). Moral injury process and its psychological consequences among Israeli combat veterans. Journal of Clinical Psychology, 74(9), 1526-1544. https://doi.org/10.1002/jclp.22598

Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361-370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x