Mediating pathways from potentially morally injurious events to PTSD: A longitudinal cohort study of U.S. post-9/11 veterans.

In the military, potentially morally injurious events (PMIEs) are experiences that violate a service member's moral values and have been linked to psychological distress, including posttraumatic stress disorder (PTSD). However, debate persists over how to best conceptualize PMIEs: as a unitary exposure or as role-specific appraisals of perpetration, witnessing, or betrayal. Guided by the Dual Process Model of moral injury, this study examines whether anger, loneliness, and trauma-related guilt mediate the relationship between PMIEs and PTSD symptoms, and whether different PMIE conceptualizations offer distinct explanatory value. Data were drawn from a longitudinal study of 1230 post-9/11 U.S. veterans. Three mediation models were estimated using: (1) a one-factor model, (2) a two-factor model combining perpetration/witnessing and betrayal, and (3) a three-factor model separating perpetration, witnessing, and betrayal. Across models, anger and loneliness consistently mediated the link between PMIEs and PTSD, while trauma-related guilt did not. Both the two-factor and three-factor models revealed that perpetration and betrayal predicted anger and loneliness, whereas witnessing did not significantly predict any process. These findings suggest that anger and loneliness may serve as robust treatment targets following PMIE exposure, regardless of the specific moral transgression. Results support a shift toward process-based models of PMIE-related distress and highlight the need for refined measurement of moral injury exposures.