Betrayal as consequence and catalyst: Longitudinal and reciprocal relations with PTSD and depression during ongoing...

Ongoing armed conflicts expose civilian populations to sustained psychological trauma. While PTSD and depression are well documented, evidence suggests that civilians may also experience moral injury, particularly through a sense of potential moral injuries, events of betrayal (PMIE-Betrayal) by leaders or institutions. This betrayal can manifest as feelings of abandonment, unfulfilled promises of safety, or perceived neglect. Despite known links to distress, betrayal's evolving relationship with PTSD and depression during ongoing trauma is less known.

685 adults residing in conflict-affected areas in Israel, completed assessments at three time points in three months (baseline, 30-day, and 90-day assessments), reporting PTSD symptoms, depressive symptoms, betrayal-related moral injury, and war-related stressors. Structural equation modeling and multi-group analyses examined reciprocal (bi-directional) associations, comparing individuals with higher versus lower levels of war-related trauma exposure.

High rates of PTSD (16-17%), depression (9-11%), and comorbid PTSD-depression (20-24%) persisted across time. Longitudinal cross-lagged analysis revealed novel bi-directional associations between PTSD and depression, with a sense of betrayal predicting later symptom severity and being shaped by earlier distress. Among highly exposed individuals, betrayal was more strongly linked to PTSD, while among those with lower exposure, it was more closely related to depression.

Betrayal plays a central role in the development and maintenance of PTSD and depression, acting as both a consequence and a driver of psychological distress. A heightened sensitivity to perceived betrayal may increase vulnerability for potentially morally injurious experiences (PMIEs), reinforcing the need for trauma-informed care that addresses moral injury and institutional trust in civilian populations facing ongoing threats.