Morally Injurious Combat Events as an Indirect Risk Factor for Postconcussive Symptoms Among Veterans: The Mediating Role of Posttraumatic Stress

Abstract

Objective: Psychosocial factors, including combat-related distress (e.g., posttraumatic stress disorder [PTSD]), contribute to postconcussive symptoms (PCS) among veterans with mild traumatic brain injury (mTBI). However, research on risk factors for PCS has focused solely on life-threatening combat experiences, neglecting the morally injurious dimension of combat-related trauma and associated implications for treatment. Morally injurious events (MIEs) are associated with PTSD symptoms among veterans, a robust risk factor of PCS. Nonetheless, the interplay between MIEs, PTSD symptoms, and PCS remains poorly understood. We sought to investigate MIEs as an indirect risk factor for PCS among Veterans with mTBI. Method: This cross-sectional study of 145 veterans with mTBI used path analysis to investigate whether PTSD symptoms mediated the relationship between MIEs (transgressions and betrayals) and PCS (mood-behavioral, vestibular-sensory, and cognitive domains) among 145 veterans with mTBI. We used the Moral Injury Event Scale, PTSD Checklist—Civilian Version, and Neurobehavioral Symptom Inventory to measure MIEs, PTSD, and PCS, respectively. Results: Perceived transgressions were indirectly associated with mood-behavioral (β =.21, p =.005), vestibular-sensory (β =.17, p =.005), and cognitive PCS (β =.20, p =.005), as mediated by PTSD. Greater transgressions were associated with more severe PTSD (β =.27, p =.003), and greater PTSD was associated with more severe mood-behavioral (β =.79, p