Moral Injury in the DSM-5-TR: Syndrome Spectrum vs. Categorical Disorder

Noteworthy advancements with respect to moral injury (MI) have occurred during the past five years. MI has now been sufficiently recognized and officially noted within the DSM-5-TR Updates under 'Religious, Spiritual and Moral Problem' Z code ("Section of Other Conditions that May Be a Focus of Clinical Attention"). Here we summarize the changes in the DSM related to MI and discuss the possibility of its future inclusion in other diagnostic nomenclature (e.g., WHO-ICD). With regard to classifying MI as a distinct diagnostic entity, criteria for MI as a disorder are reviewed based on scales assessing the severity of MI symptoms and the functional impairment that these symptoms create. We discuss problems with conceptualizing MI as a distinct diagnostic entity based on the concerns commonly encountered when categorizing mental health conditions as discrete disorders. Moral distress and injury are also discussed in terms of a dimensional or spectrum approach. This paper argues that moral injury is best conceptualized as a dimensional construct within a broader spectrum of moral trauma, with categorical diagnosis reserved for severe and persistent cases. The spectrums discussed range from 'moral dilemma/moral challenge' to 'moral distress' to 'moral injury' to 'moral injury disorder'. Finally, concerns raised by clergy and chaplains about inclusion of MI in the DSM or other diagnostic nomenclature systems are noted. MI has been increasingly recognized as a significant syndrome requiring future research to define its boundaries, identify the best treatment approaches, and determine those appropriate to be involved in the treatment of MI.