An Examination of Moral Injury, Moral Emotions, and Adult Attachment in the Prediction of PTSD for Male Veterans



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Individuals within the U.S. military frequently experience posttraumatic stress disorder (PTSD); however, not all combat veterans develop PTSD. Attachment theory is a valuable framework for understanding potential vulnerabilities, since there is an inverse relationship between attachment security and PTSD symptom severity. Although attachment insecurity is related to PTSD severity, additional variables that explain this relationship remain unexplored. Moral injury, defined as events in combat that conflict with moral beliefs, may help to explain this relationship, as moral injury is posited to be understood using stable, internal attributions about the self and others. Litz and colleagues (2009) posited a causal model to explicate moral injury, including shame-proneness and guilt in the prediction of PTSD re-experiencing and avoidance/emotional numbing symptom severity. Their model is theoretical and has not been empirically examined. The primary objective of this study was to evaluate the interrelationships of moral injury to selected constructs and to evaluate portions of predictions within the Litz et al. model using DSM 5 criteria for PTSD. A secondary objective was to evaluate a portion of the Litz et al. model. Collectively, the linear relationships were predominantly consistent with the Litz et al. model. A few exceptions were found, including: (a) a significant relationship between moral injury and PTSD hyper-vigilance and (b) no relationship between attachment avoidance and moral injury. The proposed portion of the Litz et al. model that was tested did not fit the data. However, guided by theory and the modification indexes, an acceptable model was found. Collectively, the results indicate that models of fear-based conditioning are pertinent to the experience of moral injury. The role of attachment within the meaning making process of moral injury remains unclear and was likely temporally misspecified within the Litz et al. model. Limitations are discussed and future directions are provided, including highlighting the importance of future longitudinal research for examining moral injury, adult attachment, and post-trauma psychopathology.



Combat, Moral injury, Moral emotions, Combat-related guilt, Shame, Shame-proneness, Adult attachment, DSM 5, PTSD symptom severity


Portions of this document appear in: Bannister, Jenny A., James J. Mahoney III, and Tam K. Dao. "Combat Related Posttraumatic Stress Disorder–History, Prevalence, Etiology, Treatment, and Comorbidity." In Post traumatic stress disorders in a global context. InTech, 2012.