Evaluating the association between potentially morally injurious events (PMIEs) and types of psychological distress. A systematic review.

TL;DR

This systematic review of 15 studies (N≈21,700) examined associations between three types of potentially morally injurious events (PMIEs)—betrayal, commission, and omission—and psychological distress outcomes. Betrayal-type PMIEs showed the strongest and most consistent associations with PTSD, depression, and anxiety, while commission-type events were particularly linked to suicidality, and omission-type associations were more variable.

Key findings

• Betrayal by trusted persons emerged as the most consistently associated PMIE subtype with PTSD, depression, and anxiety across multiple studies
• Commission-type PMIEs (one's own transgressive actions) showed variable associations with PTSD, depression, and notably with suicidality
• Omission-type PMIEs (failing to prevent or witnessing wrongdoing) demonstrated less consistent patterns of association with measured psychological outcomes
• Different PMIE subtypes may confer distinct risk profiles for specific psychological distress outcomes, supporting differentiated assessment approaches

Why this matters at the bedside

Understanding PMIE subtypes could inform targeted assessment and treatment approaches in military, veteran, and healthcare populations where moral injury is prevalent. Distinguishing betrayal-related distress from other PMIE patterns may guide differential intervention strategies.