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. Author manuscript; available in PMC: 2024 Oct 1.
Published in final edited form as: J Trauma Dissociation. 2023 Jun 30;24(5):692–711. doi: 10.1080/15299732.2023.2231010

Moral Injury Appraisals and Dissociation: Associations in a Sample of Trauma-Exposed Community Members

Emma C Lathan 1, Ifrah S Sheikh 2, Alfonsina Guelfo 1, Khaled C Choucair 1, Travis Fulton 3, Jacob Julian 2, Yara Mekawi 4, Joseph M Currier 5, Abigail Powers 1, Negar Fani 1
PMCID: PMC10771817  NIHMSID: NIHMS1913837  PMID: 37387238

Abstract

Appraisal of trauma is a critical factor in the development of impairing post-traumatic stress symptoms, such as dissociation. Individuals may appraise trauma as morally injurious (i.e., moral injury exposure [MIE]) and experience subsequent moral distress related to this exposure (i.e., moral injury distress [MID]). To date, however, investigation into the relations between moral injury appraisals and dissociation has been limited, particularly among community populations. This study investigated MIE and MID in relation to six facets of dissociation (disengagement, depersonalization, derealization, memory disturbances, emotional constriction, identity dissociation) in a sample of trauma-exposed community members (n=177, 58.2% Black, 89.3% female) recruited from a public hospital and/or community advertisements. Participants completed measures assessing trauma exposure, MIE, MID, dissociation, and posttraumatic stress disorder (PTSD) symptoms. Partial correlation analyses revealed that after controlling for PTSD symptoms, MIE was correlated with disengagement, r=.23, p≤.025, and depersonalization, r=.25, p≤.001, and MID was correlated with depersonalization, r=.19, p≤.025. Sex moderated each association, with stronger associations observed for female participants. Findings provide evidence that moral injury appraisals are linked with severity of dissociative symptoms among female civilians, and as such, may need to be specifically targeted in empirically supported treatments.

Keywords: moral injury, dissociation, sex, PTSD, civilians

Moral injury, or a sense of one’s moral or ethical code being violated, may occur after witnessing, perpetrating, or failing to prevent stressful or traumatic events that transgress core values and moral beliefs (i.e., potentially morally injurious events, PMIEs; McEwen, Alisic, & Jobson, 2021). Preliminary evidence suggests that civilians exposed to a PMIE may appraise it as morally injurious (i.e., moral injury exposure [MIE]) and/or experience distress related to this appraisal (i.e., moral injury distress [MID]; Fani et al., 2021). Although a unanimous definition has not yet been reached, researchers generally agree that moral injury involves particular psychological symptoms, such as feelings of guilt, shame, self-blame, disgust, and betrayal and spiritual/existential issues (i.e., MID), that can arise when an individual appraises a stressful event as “morally injurious,” or conflicting with their deeply held moral beliefs about themselves, others, and the world (i.e., MIE; Litz et al., 2009). Importantly, MIE and MID are related to an array of adverse health outcomes among civilians, including attempted suicide, posttraumatic stress disorder (PTSD), anxiety, depression, burnout, and autonomic dysregulation (Currier, Holland, Rojas-Flores, Herrera, & Foy, 2015; Fani et al., 2021; Hoffman, Liddell, Bryant, & Nickerson, 2018; Lathan et al., 2022; Nickerson et al., 2018).

Traumas that represent betrayals or elicit feelings of shame tend to lead to persistent dissociation (Platt & Freyd, 2015; Platt, Luoma, & Freyd, 2017), a transdiagnostic phenomenon that involves disruptions in the integration of memory, awareness, and body sensations and often contributes to feelings of disconnection from one’s internal and external reality (American Psychiatric Association [APA], 2013). Dissociation is frequently associated with emotional numbing, analgesia, heightened parasympathetic tone, and tonic immobility (Lloyd et al., 2019). These responses can be adaptive in the face of life-threatening events or prolonged, repeated traumas, especially those in which escape may be impossible or highly risky, such as repeated childhood sexual abuse (CSA; Bailey & Brand, 2017).

Dissociation commonly occurs within chronically trauma-exposed populations (Schimmenti, 2018), especially among those who experience trauma-related appraisals of betrayal, alienation, shame, or self-blame (DePrince, Huntjens, & Dorahy, 2015). For instance, DePrince and colleagues (2010) found that participants with betrayal, self-blame, and fear appraisals tended to have higher dissociation symptoms. Dissociation is also more likely among individuals who report higher PTSD severity, an early life and/or sexual trauma history, and female sex (Wolf, Lunney, et al., 2012; Wolf, Miller et al., 2012). Persistent dissociation has been linked to increased severity, chronicity, and comorbidity of psychiatric disorders (Lebois et al., 2022) and reduced treatment engagement and success (Boyer, Caplan, & Edwards, 2022). Thus, it is imperative to determine the various mechanisms through which dissociation is developed and maintained, including moral injury appraisals.

Appraisal of trauma has been linked to the severity of dissociative symptoms that persist beyond acute threat. Of note, there is a particularly strong effect for appraisals that include betrayal, shame, and self-blame (DePrince, Chu, & Pineda, 2011; Martin, Cromer, DePrince, & Freyd, 2013), which are aspects of moral injury. Further, emerging evidence suggests that moral injury is tied to complex PTSD (Currier, Foster, Karatzias, & Murphy, 2021), central features of which include disturbances in self-organization and dissociation (van der Hart, Nijenhuis, & Steele 2005). Because dissociation is closely connected to several aspects of moral injury (i.e., betrayal, shame, and self-blame appraisals) and complex PTSD, a trauma-related disorder linked to moral injury, dissociation may also be related to MIE and MID.

To date, however, empirical investigation into the relations between moral injury appraisals and dissociation, particularly among community members, has been limited. The few existing studies indicate that moral injury appraisals are associated with dissociation in public service and military personnel. For instance, Roth et al. (2022) found that adverse childhood experiences were indirectly associated with dissociation in adulthood via moral injury symptoms among public service personnel. Another study exploring exposure to moral injury (assessed via the Moral Injury Events Scale; Nash et al., 2013) and dissociation among active-duty Marines exposed to combat found small to moderate correlations between perpetration- and betrayal-based and dissociation (Jordan et al., 2017), although this study examined MIE in relation to peritraumatic as opposed to posttraumatic dissociation. To our knowledge, no prior study has explored the relations between moral injury appraisals, specifically MIE and MID, and dissociation among civilians.

Further, MIE and MID require careful examination in relation to the various facets of dissociation. Decades of research support dissociation as a multidimensional construct (i.e., disengagement, depersonalization, derealization, identity dissociation, emotional constriction, memory disturbances; Briere, Weathers, & Runtz, 2005), with greater cumulative trauma associated with increased dissociative complexity (Briere, Dietrich, & Semple, 2016). Depersonalization and derealization are the two components of dissociation that comprise the dissociative subtype of PTSD (APA, 2013). Considering the well-documented relationship between moral injury and PTSD (Barnes, Hurley, & Taber, 2019), depersonalization and derealization may be particularly salient correlates of MIE and MID. However, a wealth of studies suggest that PTSD is often accompanied by other types of dissociation as well, including identity dissociation (Schiavone, Frewen, McKinnon, & Lanius, 2018). Moral injury may be related to other facets of dissociation with psychological mechanisms different from those of depersonalization and derealization but similarly adverse health consequences (Brown, 2006).

In addition, researchers have posited that individuals with marginalized sex identities are more likely to experience the types of PMIEs with more deleterious consequences (i.e., betrayal-based events, such as military sexual trauma; Maguen et al., 2020), contributing to greater moral injury levels and adverse outcomes among those who report female sex (Borges, Desai, Barnes, & Johnson, 2022). Whether moral injury confers greater risk for dissociation among female civilians remains unknown. Similar to dissociation, MIE and MID are more likely to occur among community members with greater PTSD severity (Fani et al., 2021) and sexual violence histories (Lathan et al., 2022), two factors whose rates considerably differ by sex (Ponomareva & Ressler, 2021). Because female sex is related to increased vulnerability to negative trauma appraisals and trauma-related outcomes (Kucharska, 2017), it may also exacerbate the association between moral injury appraisals and dissociation, even when accounting for PTSD symptoms and sexual violence history. Taken together, noted links warrant further examination of the associations among moral injury appraisals (i.e., MIE, MID), the six facets of dissociation, and sex while accounting for PTSD symptoms and sexual violence histories among trauma-exposed community members.

The Current Study

This study investigated moral injury appraisals in relation to facets of dissociation in a sample of trauma-exposed community members as well as potential sex differences in these associations. We hypothesized the following: (H1a) greater MIE and MID will be associated with more dissociative symptoms, specifically depersonalization and derealization; (H1b) these associations will remain statistically significant even when controlling for PTSD symptoms; and (H2) the associations between moral injury and dissociative symptoms will be moderated by sex when accounting for sexual violence history and PTSD symptoms, such that the association between moral injury and dissociative symptoms will be stronger for female as compared to male community members.

Method

Participants and Procedure

Participants (n=178; Mage=36.1 years; SDage=13.9 years) were majority Black (58.1%, n = 104), female (88.8%, n=159), and experiencing significant economic disadvantage (53.9%, n=96; i.e., <$2,000 monthly household income; Table 1). Participants were recruited from community advertisements and a large, publicly funded healthcare system in Atlanta, Georgia for involvement in an ongoing study of trauma and PTSD in underserved communities. As part of the parent study, trained interns approached patients in the emergency department and medical clinics regarding potential participation. During COVID-19, hospital patients were invited to participate via telephone. Informed consent was obtained from participants after study procedures were explained. Self-report measures assessing trauma history and symptoms, MIE and MID, and dissociation were verbally administered to consenting individuals. Data collection and study procedures were approved by Emory University’s Institutional Review Board and the Grady Research Oversight Committee.

Table 1.

Sample Characteristics (n=177)

Variable % (n or SD)
Sex
 Female 89.3% (n=158)
 Male 10.1% (n=18)
 Missing 0.6% (n=1)
Female Male
Race/Ethnicity
 Black/African American 58.2% (n=103) 57.0% (n = 90) 66.7% (n = 12)
 White 29.9% (n=53) 31.6% (n = 50) 16.7% (n = 3)
 Hispanic/Latinx 5.1% (n=9) 4.4% (n = 7) 11.1% (n = 2)
 Multiracial 2.3% (n=4) 2.5% (n = 4) ---
 Asian 2.3% (n=4) 2.5% (n = 4) ---
 Other 2.3% (n=4) 1.9% (n = 3) ---
Education Level
 Some college/technical school 33.9% (n=60) 32.3% (n = 51) 44.4% (n = 8)
 College/technical school graduate 25.4% (n=45) 26.6% (n = 42) 16.7% (n = 3)
 High school graduate/equivalent 20.4% (n=36) 20.3% (n = 32) 22.2% (n = 4)
 Graduate school 13.0% (n=23) 13.3% (n = 21) 11.1% (n = 2)
 Less than 12th grade 7.3% (n=13) 7.6% (n = 12) 5.6% (n = 1)
Current Employment Status
 Unemployed 49.2% (n=87) 46.2% (n = 73) 77.8% (n = 14)
 Employed 50.3% (n=89) 53.2% (n = 84) 22.2% (n = 4)
 Missing 0.6% (n=1) 0.6% (n = 1) ---
Household Monthly Income
 ≥ $2,000 40.7% (n=72) 41.8% (n = 66) 33.3% (n = 6)
 $1,000 – 1,999 20.9% (n=37) 20.3% (n = 32) 27.8% (n = 5)
 $500 – 999 17.5% (n=31) 16.5% (n = 26) 22.2% (n = 4)
 $0 – 249 8.5% (n=15) 8.9% (n = 14) 5.6% (n = 1)
 $250 – 499 7.3% (n=13) 7.6% (n = 12) 5.6% (n = 1)
 Missing 5.1% (n=9) 5.1% (n = 8) 5.6% (n = 1)
Mean Age 36.12 years (SD=13.9) 35.9 years (SD=13.8) 22.9 years (SD=4.68)
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Note: Female participants (n = 150–158), Male participants (n = 17–18)

Measures

Moral Injury.

The Moral Injury Exposure and Symptom Scale–Civilian (MIESS-C; Fani et al., 2021) is a 10-item questionnaire measuring moral injury across two, 5-item subscales: MIE (e.g., “I saw things that were morally wrong”) and MID (e.g., “I am troubled because I violated my morals by failing to do something that I felt I should have done”). The MIESS-C was adapted from the MIES (Nash et al., 2013) to assess moral injury within civilian populations. Responses ranged from 1 (strongly disagree) to 6 (strongly agree). Internal consistency of the MIESS-C was good (α=.83). Like other studies of MIE and MID (Fani et al., 2021; Lathan et al., 2022), internal consistencies of the MIESS-C subscales were acceptable but lower than expected (MIE, α=.65; MID, α=.70).

Dissociation.

The Multiscale Dissociation Inventory (MDI; Briere et al., 2005), a 30-item self-report measure, was used to assess the frequency of dissociative experiences across six, 5-item subscales: disengagement, depersonalization, derealization, identity dissociation, emotional constriction, and memory disturbances. Responses ranged from 1 (never) to 5 (very often). In the current study, mean subscale scores were used, and internal consistencies ranged from good (α=.77, disengagement) to excellent (α=.89, emotional constriction).

Sex.

Self-reported sex was assessed using the following question: “What is your sex?” Response options included Male (0) and Female (1).

PTSD Symptoms.

Both the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) and the Modified PTSD Symptom Scale (mPSS; Coffey, Dansky, Falsetti, Saladin, & Brady, 1998) were used to assess self-reported PTSD symptoms given data availability (PCL-5, 88.2%, n=157; mPSS, 11.8%, n=21). The PCL-5 and mPSS are well-validated measures; the PCL-5 is a 20-item questionnaire based on The Diagnostic and Statistical Manual-Fifth Edition (DSM-5) criteria (APA, 2013), and the mPSS is an 18-item measure based on DSM-IV-TR (APA, 2000) criteria. Cronbach’s alphas of the PCL-5 and mPSS were in the good to excellent range (α=.92 and α=.74, respectively). Z-scores were generated for each scale to facilitate data pooling across measures (Fischer & Milfont, 2010).

Trauma Exposure History.

The Traumatic Events Inventory (TEI; Gillespie et al, 2009) was used to measure participants’ self-reported exposure to various traumatic events. Three items were used to determine participants’ exposure to and frequency of CSA (i.e., “Between the ages of 0 and 13, how many times did an adult or older teenager sexually abuse you or have any type of sexual contact with you?”), teenage sexual abuse (i.e., “Between the ages of 14 and 17, how many times did an adult or older teenager sexually abuse you or have any type of sexual contact with you?”), and adulthood sexual assault (i.e., “After the age of 17, how many times has someone raped you or sexually assaulted you?”). Possible responses to each item ranged from 0 to (never) to 8 (>20 times). Item responses were summed to generate a total lifetime sexual violence score.

Data Analyses

One-hundred and eighty participants completed one or more measures of interest (i.e., MIEES-C, MDI) between February 2020 and May 2022. Three participants were removed due to failure to endorse trauma exposure on the TEI, leaving the final sample at n = 177. Missing MIE (2.8%, n=5), MID (2.8%, n=5), and dissociation (11.3%, n=20) data were handled via mean imputation. One participant declined to report their sex (0.6%), and five had missing lifetime sexual violence data (2.8%); listwise deletion was used in respective moderation analyses. None of the PTSD symptom scores were missing. See Table 2 for exposure to various trauma types and Tables 3 and 4 for descriptive statistics.

Table 2.

Exposure to Various Trauma Types

Variable % (n or SD)
Overall (n=171–177) Female (n = 152–158) Male (n = 17–18)
Natural disaster 37.9% (n = 67) 37.3% (n = 59) 38.9% (n = 7)
Experienced serious accident or injury 57.6% (n = 102) 56.3% (n = 89) 72.2% (n = 13)
Witnessed serious accident or injury 56.5% (n = 100) 55.1% (n = 87) 66.7% (n = 12)
Experienced a sudden life-threatening illness 29.4% (n = 52) 27.2% (n = 43) 44.4% (n = 8)
Military combat or service in a war zone 0.0 (n = 0) 0.0% (n = 0) 0.0% (n = 0)
Confronted with murder of family member 45.2% (n = 80) 42.4% (n = 67) 66.7% (n = 12)
Witness murder of family member or friend 11.3% (n = 20) 9.5% (n = 15) 27.8% (n = 5)
Attacked with a weapon by an intimate partner 22.0% (n = 39) 21.5% (n = 34) 27.8% (n = 5)
Attacked with a weapon by a non-intimate partner 27.1% (n = 48) 24.7% (n = 39) 50.0% (n = 9)
Witnessed a family member or friend being attacked with a weapon 35.0% (n = 62) 32.9% (n = 52) 55.6% (n = 10)
Witnessed someone other than a family member or friend being attacked with a weapon 32.2% (n = 57) 27.8% (n = 44) 66.7% (n = 12)
Attacked without a weapon by an intimate partner 39.0% (n = 69) 37.3% (n = 59) 55.6% (n = 10)
Attacked without a weapon by a non-intimate partner 42.9% (n = 76) 37.3% (n = 59) 83.3% (n = 15)
Witnessed a family member or friend being attacked without a weapon 50.8% (n = 90) 48.1% (n = 76) 72.2% (n = 13)
Witnessed someone other than a family member or friend being attacked without a weapon 41.8% (n = 74) 38.0% (n = 60) 77.8% (n = 14)
Witnessed caregiver violence (0–18 years) 43.5% (n = 77) 42.4% (n = 67) 50.0% (n = 9)
Child physical abuse 44.6% (n = 79) 41.8% (n = 66) 66.7% (n = 12)
Child sexual abuse (0–13 years) 39.5% (n = 70) 41.1% (n = 65) 27.8% (n = 5)
Teenage sexual abuse (14–17 years) 35.0% (n = 60) 37.3% (n = 59) 5.6% (n = 1)
Adulthood sexual assault (≥18 years) 36.7% (n = 65) 40.5% (n = 64) 5.6% (n = 1)
Other trauma 45.8% (n = 81) 46.8% (n = 74) 39.9% (n = 7)
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Table 3.

Descriptive Statistics

Variable Female Male
M SD Min - Max M SD Min - Max M SD Min - Max
Moral Injury
 Exposure 21.02 5.43 5.00 – 30.00 20.80 5.50 5.00–30.00 22.89 4.68 15.00–30.00
 Distress 19.40 5.93 5.00 – 30.00 19.42 5.93 5.00–30.00 19.50 6.14 10.00–29.00
Dissociation
 Disengagement 2.69 .80 1.00 – 5.00 2.65 .81 1.00–4.80 2.95 .71 2.20–5.00
 Depersonalization 1.88 .81 1.00 – 4.80 1.84 .79 1.00–4.80 2.23 .86 1.00–3.80
 Derealization 2.03 .80 1.00 – 4.40 1.98 .77 1.00–4.40 2.46 .97 1.00–4.40
 Emotional Constriction 2.38 .91 1.00 – 5.00 2.36 .93 1.00–5.00 2.52 .72 1.00–3.80
 Memory Disturbance 1.85 .77 1.00 – 4.60 1.79 .73 1.00–4.40 2.28 1.00 1.00–4.60
 Identity Dissociation 1.23 .54 1.00 – 4.60 1.18 .42 1.00–4.60 1.71 1.05 1.00–4.60
Trauma Symptoms and Sexual Violence History
 PTSD Symptoms (z-score) −.01 .98 −2.46 – 1.92 −.04 .99 −2.46–1.92 .27 .89 −1.38–1.80
 Sexual Violence History 3.60 5.14 .00 – 24.00 3.90 5.31 .00–24.00 1.12 1.96 .00–6.00
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Note: Female participants (n = 154–158), Male participants (n = 17–18)

Table 4.

MIESS-C Item-Level Descriptive Statistics

Variable Female Male
M SD M SD
I saw things that were morally wrong 5.15 1.37 5.61 .70
I am troubled by having witnessed others’ immoral acts 4.29 1.59 4.06 1.73
I acted in ways that violated my own moral code or values 3.22 1.84 4.11 1.64
I am troubled by having acted in ways that violated my own moral code or values 3.27 1.92 4.00 1.64
I violated my own morals by failing to do something that I felt I should have done 3.40 1.86 4.00 1.71
I am troubled because I violated my morals by failing to do something that I felt like I should have done 3.33 1.77 3.28 1.84
I feel betrayed by specific people who I once trusted 4.67 1.69 4.39 1.94
I am troubled by this betrayal by specific people 4.39 1.73 3.83 1.95
I feel betrayed by the institutions that I am supposed to trust (e.g., police, church, schools, governmental workers) 4.35 1.78 4.78 1.63
I am troubled by this betrayal by the institutions that I am supposed to trust 4.14 1.90 4.33 1.71
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Note: Female participants (n = 153), Min-Max = 1.00 – 6.00 for all items; Male participants (n = 18), Min-Max = 1.00 – 6.00 for all items

Pearson’s correlations were conducted to assess bivariate associations among MIE, MID, and the MDI’s six dissociation facets (H1a), examined as different families of tests. Bonferroni correction was applied to correct for error due to multiple comparisons; statistical significance was set at p≤.008. Where significant findings were observed, partial correlations were conducted to determine whether these associations remained significant after controlling for PTSD symptoms (H1b); Bonferroni correction was also applied in these analyses.

To address (H2), we conducted moderation models using Hayes’ PROCESS Macro on associations that emerged following testing for (H1b). In each model, sex was entered as the moderator, and PTSD symptoms and lifetime sexual violence history were entered as covariates. Continuous variables were mean centered. Statistical significance was defined as p<.05.

Results

In support of (H1a), both MIE and MID appraisals were significantly associated with symptoms of dissociation, after correcting for multiple comparisons (Table 5). Namely, MIE and MID were positively associated with disengagement (MIE, r(177)=.32, p<.001; MID, r(177)=.22, p=.004) and depersonalization (MIE, r(177)=.33, p<.001; MID, r(177)=.28, p<.001). MIE was also positively associated with memory disturbance, r(177)=.20, p≤.008, and the relationships between MIE and emotional constriction, r(177)=.19, p=.02, and MIE and derealization, r(177)=.18, p=.02, were trending towards significance. Neither MIE nor MID were significantly related to identity dissociation.

Table 5.

Bivariate Correlations

Variable 2 3 4 5 6 7 8
1. MIE .83*** .32*** .33*** .18 .19 .20** .05
2. MID -- .22** .28*** .13 .11 .16 .02
3. Disengagement -- -- .56*** .58*** .42*** .66*** .17
4. Depersonalization -- -- -- .71*** .48*** .50*** .34***
5. Derealization -- -- -- -- .42*** .63*** .44***
6. Emotional constriction -- -- -- -- -- .35*** .20
7. Memory disturbance -- -- -- -- -- -- .37***
8. Identity dissociation -- -- -- -- -- -- --
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n=177

**

p≤.008

***

p≤.001

Partial correlation matrices were generated to examine the relations between moral injury and dissociation, while accounting for PTSD symptoms (H1b). Bonferroni correction was applied, and statistical significance was set at p<.025. After controlling for PTSD symptoms and correcting for multiple comparisons, MIE was positively associated with disengagement, r(174)=.23, p=.002, and depersonalization, r(174)=.25, p≤.001, and MID was positively associated with depersonalization, r(174)=.19, p=.011. However, the associations between MIE and memory disturbance, r(174)=.07, p=.34, as well as between MID and disengagement, r(174)=.11, p=.14, did not remain statistically significant when including PTSD symptoms in analyses (Table 6).

Table 6.

Partial Correlations Controlling for PTSD Symptoms

Variable 2 3 4 5 6 7 8
1. MIE .80*** .23** .25*** .05 .07 .07 −.02
2. MID -- .11 .19** −.01 −.02 .03 −.05
3. Disengagement -- -- .51*** .52*** .35*** .62*** .12
4. Depersonalization -- -- -- .68*** .43*** .44*** .31***
5. Derealization -- -- -- -- .33*** .57*** .41***
6. Emotional constriction -- -- -- -- -- .25*** .14
7. Memory disturbance -- -- -- -- -- -- .34***
8. Identity dissociation -- -- -- -- -- -- --
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n=174

**

p≤.025

***

p≤.001

To address (H2), three moderation models were conducted on associations that emerged via (H1b) (Table 7). In the first model, MIE served as the predictor, disengagement as the outcome, and PTSD symptoms and lifetime sexual violence as covariates. MIE and sex significantly interacted to predict disengagement when controlling for PTSD symptoms and lifetime sexual violence, B=.12, SD=.04, p=.004 (Figure 1). Specifically, there was a positive relationship between MIE and disengagement for participants who reported female sex (t=3.39, p<.001) and a negative relationship for those who reported male sex (t=−2.01, p=.047).

Table 7.

Summary of Moderation Analyses for Moral Injury Predicting Dissociative Symptoms by Sex

B SE B t LLCI-ULCI F df R 2
Disengagement 8.52*** 5,165 .21
 Constant 3.08 .19 15.96*** 2.70–3.46
 MIE −.08 .04 −2.00* −.15-.00
 Sex −.46 .20 −2.26* −.87- −.06
 MIE X Sex Interaction .12 .04 2.92** .04-.19
 Lifetime Sexual Violence .01 .01 1.11 −.01-.04
 PTSD symptoms .17 .06 2.67** .04-.29
Depersonalization 7.16*** 5,165 .18
 Constant 2.28 .19 12.10*** 1.91–2.65
 MIE -.08 .04 −2.08* −.15-.00
 Sex −.45 .20 −2.22* −.84- −.05
 MIE X Sex Interaction .12 .04 3.13** .05-.20
 Lifetime Sexual Violence −.00 .01 −.28 −.03-.02
 PTSD symptoms .12 .06 2.00* .00-.24
Depersonalization 6.71*** 5,165 .17
 Constant 2.13 .18 12.13*** 1.78–2.47
 MID −.07 .03 −2.36* −.13- −.01
 Sex −.30 .19 −1.57 −.67-.08
 MID X Sex Interaction .10 .03 3.41*** .04-.16
 Lifetime Sexual Violence .00 .01 −.38 −.03-.02
 PTSD symptoms .15 .06 2.44* .03-.27
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n=171

*

p<.05

**

p<.01

***

p≤.001

Figure 1.

Figure 1

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Relationship Between MIE and Disengagement by Sex

In the second model, MIE was entered as the predictor, depersonalization as the outcome, and PTSD symptoms and lifetime sexual violence as covariates. A significant interaction of MIE and sex on depersonalization was observed when controlling for PTSD symptoms and lifetime sexual violence, B=.12, SD=.04, p=.002 (Figure 2). For participants who reported their sex as female, MIE increased as depersonalization increased (t=3.84, p < .001); conversely, among participants who reported their sex as male, MIE increased as depersonalization decreased (t=−2.08, p=.039).

Figure 2.

Figure 2

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Relationship Between MIE and Depersonalization by Sex

In the third model, MID served as the predictor, depersonalization as the outcome, and PTSD symptoms and lifetime sexual violence as covariates. MID and sex significantly interacted to predict depersonalization when controlling for PTSD symptoms and lifetime sexual violence, B=.10, SD=.03, p<.001 (Figure 3). Again, results indicated a positive association between MID and depersonalization for female participants (t=3.34, p=.001) and a negative relationship for male participants (t=−2.36, p=.019).

Figure 3.

Figure 3

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Relationship Between MID and Depersonalization by Sex

Given the racial distribution of the current sample and extant literature supporting racial differences in dissociative symptoms (Douglas et al., 2009), we conducted three additional moderation analyses examining the associations of MIE and MID with emotional disengagement and depersonalization by race. Only those who reported female sex were included in these analyses (n = 158). In each model (n = 143), race (White or Black) was entered as the moderator, and lifetime sexual violence history and PTSD symptoms were entered as covariates. In the first model, MIE served as the predictor and disengagement as the outcome. MIE and race significantly interacted to predict disengagement when controlling for PTSD symptoms and lifetime sexual violence, B=−.06, SD=.03, p=.02 (Figure 4). Results indicated a weaker association between MIE and depersonalization for Black participants (t=2.07, p=.04) than White participants (t=3.75, p<.001). MIE was entered as the predictor and depersonalization as the outcome in the next moderation model. The association between MIE and depersonalization was not moderated by race, B=−.02, SD=.03, p=.51. In the third model, MID was entered as the predictor and depersonalization as the outcome. Again, the association between MID and depersonalization was not moderated by race, B=−.01, SD=.02, p=.56.

Figure 4.

Figure 4

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Relationship Between MIE and Emotional Disengagement by Race

Discussion

The present study examined moral injury appraisals in relation to multiple facets of dissociation and potential sex differences in these associations in a sample of trauma-exposed community members. Results suggest moral injury appraisals are associated with greater dissociation even when accounting for PTSD symptoms and point to MIE and MID as potential targets in the treatment of disengagement and depersonalization among female civilians.

(H1a) was partially supported, in that both MIE and MID were positively correlated with disengagement and depersonalization, and MIE was positively correlated with memory disturbances. Findings suggest that higher MIE and/or MID are related to stronger experiential avoidance (i.e., disengagement), feelings of disconnection from one’s body (i.e., depersonalization), and dissociative amnesia (i.e., memory disturbance). Moral injury appraisals seem to be related to dissociative symptoms concerning individuals’ internal experience, including their relationships with their emotions and bodies. A recent study of the neural correlates of moral injury found heightened viscerosensory information processing, described as an ‘internal gnawing,’ during moral injury event recall; moreover, as moral injury-related shame increased, activity in the right superior frontal gyrus (SFG), a region that plays a role in self-referential processing, decreased among those with PTSD (Lloyd et al., 2021). Although yet to be explored, reduced interoceptive awareness may function as a protective mechanism following moral injury.

Conversely, neither MIE nor MID was associated with derealization, a dissociative symptom often described as feeling detached from the external environment, including others or surroundings. Altogether, results suggest moral injury appraisals may be more closely related to an individuals’ internal (e.g., disengagement) as opposed to external (e.g., derealization) experience. Additional research is needed to examine the potential role of the right SFG and other brain regions implicated in moral injury outcomes in the manifestation of dissociative symptoms that are internally versus externally focused.

As expected via (H1b), the associations between MIE and disengagement, MIE and depersonalization, and MID and depersonalization remained statistically significant, even when accounting for PTSD symptoms. Findings suggest a relationship between moral injury and dissociation exists above and beyond the effects of PTSD, adding to the growing body of literature pointing to moral injury as a phenomenologically distinct construct (Sun et al., 2019). Moreover, both MIE and MID may be critical targets for individuals with impairing dissociative symptoms. Future research should expand on these findings by investigating the use of targeted treatments focused on moral injury in reducing both dissociation and PTSD symptomatology.

Results also supported (H2), which posited that the relationships discovered via (H1b) would be moderated by sex. Participants who endorsed relatively high levels of moral injury and female sex were likely to report greater dissociative symptoms, whereas those who endorsed relatively high levels of moral injury and male sex were likely to report lower dissociative symptoms. Sex-related differences in dissociative symptoms were most prominent at low levels of MIE and MID, with female participants reporting lower levels of depersonalization and disengagement than male participants. It is well-established that female sex is associated with increased likelihood of sexual violence and PTSD development, even when male individuals are exposed to the same trauma types (Ponomareva & Ressler, 2021). Yet, these factors did not account for the sex-based discrepancies observed in the association between moral injury and dissociation.

Perhaps, biological sex differences and socialization can provide insight into current findings. Biological sex differences strongly influence early gender differences in emotion expression, which are refined into gender-role-consistent patterns of behaviors via socialization (Chaplin, 2015). While boys/men often express negative emotion via anger or aggression, girls/women often internalize negative emotions; dissociative symptoms may reflect internal expression of negative emotion experienced by women with greater MIE and MID appraisals. Gender differences in perceived agency may help to explain the negative relationship found between MIE and dissociation among men (Hsu et al, 2021); men may react to a potentially morally injurious event with increasing anger given greater perceived agency, while women may be more likely to dissociate given lower perceived agency to enact change. However, in the absence of highly emotionally arousing stimuli (i.e., low MIE or MID), men may be more inclined to disengage or depersonalize, perhaps due to societal expectations regarding emotional expression by gender and documented sex differences in emotion regulation (Domes et al., 2010). While findings do reflect previous literature suggesting that trauma appraisals and trauma-related outcomes differ based on sex (Kucharska et al., 2017), it should be noted that a small proportion of our population reported male sex (10.1%), meaning caution should be applied when interpreting these data. Altogether, further study into potential explanations for observed sex differences in a representative male sample is needed before drawing conclusions.

Further, because most participants were Black women, findings should also be considered within the context of culturally salient factors that impact the ways Black women experience, respond to, and heal from trauma – for example, the narrative that Black women must disconnect from their emotional responses to uphold an image of strength in the face of ongoing stressors, including racism (Gómez, 2019). A consequence of this is increased detachment from the self and an erosion of ability to trust bodily sensations, which have been linked to self-devaluation and suicidal ideation (Kinkel-Ram et al., 2021). In the current study, however, race moderated the relationship between MIE and emotional disengagement; surprisingly, this association was stronger for White participants as compared to participants of Color, highlighting the importance of examining resilience and posttraumatic growth in relation to moral injury in future studies. Special attention should also be paid to moral injury’s influence on various facets of dissociation in the context of factors frequently experienced by minoritized groups, such as gendered racism and other forms of discrimination.

This study is not without limitations, two of which include reliance on clinician-administered self-report measures for trauma history and cross-sectional methodology, which bars causal conclusions. Moreover, a single self-report item was used to determine a participant’s sex at the binary level; it is unknown whether they answered based on external primary sex characteristics at birth or present or sex chromosomes, among many other ways to determine sex. In future studies, researchers should use a more standardized yet nuanced way to ascertain biological sex as well as gender identity. In addition, most of the present sample reported female sex, meaning male participants were underrepresented; thus, results regarding sex differences are preliminary and should be interpreted with caution. It is important to note that a similarly high proportion of the participants in the ongoing parent study report female sex. This is likely due to (i) several of the clinical trials or intervention studies included in the larger parent study (see Gillespie et al., 2009) having female sex or identifying as a woman as an inclusion criterion, (ii) women being more likely to seek preventive care, a main source of participant recruitment (Vaidya, Partha, & Karmakar, 2012), and (iii) women being more likely to utilize mental health services (Smith et al., 2013), such as those offered by our study. Those who identified outside of the male/female binary were not represented in the current study, highlighting an important area of future research. Although all participants denied a history of military combat exposure, it is possible that participants had prior non-combat military experience; in future research, participants should be screened for all forms of military experience. Lastly, although the internal consistency of the total scale was good (α=.83), the internal consistencies of MIE and MID were lower than expected, perhaps due to few items comprising each scale. It is important to note that these subscales were theoretically, not empirically, derived (Braitman et al., 2018; Fani et al., 2021), meaning a different factor structure, such as Nash et al. (2013), may be better suited for use among civilians. Future research should evaluate the MIESS-C’s psychometric properties, specifically the degree to which MIESS-C items overlap with betrayal, self-blame, and shame, to inform best practices regarding assessment of civilian moral injury.

Implications

The present study adds to the growing body of literature supporting the role of moral injury appraisals in psychological distress and impairment following trauma. Findings highlight moral injury appraisals as a potential mechanism through which dissociative symptoms emerge. Noted links suggest moral injury appraisals may be key targets in the treatment of dissociative symptoms, particularly among trauma-exposed, female community members. Currently, however, empirically supported psychotherapeutic treatment options for civilian moral injury are non-existent. Extant evidence-based moral injury treatments, Trauma Informed Guilt Reduction therapy (Norman, 2022) and Adaptive Disclosure (Darnell, Vannini, Grunthal, Benfer, & Litz, 2022), require evaluation for efficacy in non-military populations. Although traditional PTSD interventions, such as Cognitive Processing Therapy and Prolonged Exposure, reduce feelings of shame and guilt following trauma in civilians, the active ingredients need to be isolated to streamline treatment of civilian moral injury. Present findings call for, and may help inform, the development of evidence-based intervention strategies for concurrent moral injury appraisals and dissociative symptoms among trauma-exposed community members.

Acknowledgements:

We wish to thank Rebecca Hinrichs and other members of the Grady Trauma Project, as well as members of the Fani Affective Neuroscience Lab, for their assistance with data collection. We also thank our participants for their time and involvement in this study.

Funding Statement:

This work was primarily supported by National Institutes of Mental Health (MH101380 to NF) and the National Center for Complementary and Integrative Health (AT011267 to NF). Support was also received from the Emory Medical Care Foundation and American Psychological Association, Society for Clinical Neuropsychology.

Footnotes

Declaration of Interest Statement: The authors report no competing interest to declare.

Data Availability Statement:

The data and materials that support the results or analyses presented in this study will be made available via email to the corresponding author, EL (emma.catherine.lathan-powell@emory.edu), upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data and materials that support the results or analyses presented in this study will be made available via email to the corresponding author, EL (emma.catherine.lathan-powell@emory.edu), upon reasonable request.

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