title: Distinguishing war-related PTSD resulting from perpetration- and betrayal-based morally injurious events.
abstract: OBJECTIVE
  We investigated whether potentially morally injurious events (PMIEs) during a combat deployment may lead to PTSD through distinct pathways from danger-based events. We also examined the prevalence of perpetration-based PMIEs, during which service members behaved in ways that violated their own moral values, and betrayal-based PMIEs, during which personal moral expectations were violated by trusted others.
  
  
  METHODS
  Using a sample of 867 active duty Marines from a single infantry battalion that engaged in heavy ground combat while deployed to Afghanistan, a structural equation model was built to examine the relationships between perpetration- and betrayal-based PMIEs, combat experiences, and peritraumatic dissociation reported at 1 month postdeployment, and guilt/shame, anger, and PTSD symptoms reported at 8 months postdeployment.
  
  
  RESULTS
  The relationship between betrayal-based PMIEs and PTSD was mediated by anger (β = .14). There was marginal evidence of mediation of the relationship between perpetration-based PMIEs and PTSD by shame and guilt (β = .09), and of the relationship between danger-based combat events and PTSD by peritraumatic dissociation (β = .08). No significant direct relationships were found between any of these 3 types of events and subsequent PTSD. Perceived perpetration and betrayal accounted for PTSD symptoms above and beyond combat exposure. Over a third of the sample reported experiencing perpetration- or betrayal-based PMIEs.
  
  
  CONCLUSIONS
  The associations of perpetration and betrayal with PTSD, controlling for danger-based combat events, highlight the limitations of conceptualizations and treatments of PTSD based on fear or helplessness as sole etiologic factors. (PsycINFO Database Record
authors.affiliation: Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System.
authors.forename: Alexander H
authors.initials: AH
authors.lastname: Jordan
authors.affiliation: VA Long Beach Healthcare System.
authors.forename: Ethan
authors.initials: E
authors.lastname: Eisen
authors.affiliation: Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System.
authors.forename: Elisa
authors.initials: E
authors.lastname: Bolton
authors.affiliation: United States Marine Corps.
authors.forename: William P
authors.initials: WP
authors.lastname: Nash
authors.affiliation: Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System.
authors.forename: Brett T
authors.identifier: 0000-0002-0479-8887
authors.initials: BT
authors.lastname: Litz
mesh_terms: D055826:Afghan Campaign 2001-; D000786:Anger; D003130:Combat Disorders / Q000175:diagnosis* / Q000209:etiology*; D006801:Humans; D008889:Military Personnel / Q000523:psychology; D009014:Morals; D011446:Prospective Studies; D011569:Psychiatric Status Rating Scales; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis* / Q000209:etiology*; D000067453:War Exposure