Moral injury events, pain intensity, and functional mobility in post-9/11 U.S. combat veterans

Moral injury-functionally impairing alterations in one's sense of self and relatedness to others that results from high magnitude events involving perceived wrongdoing or betrayal-is associated with worse psychological and functional outcomes. The association between moral injury and chronic pain, however, is under-investigated as are the ways moral injury might contribute to pain and psychosocial functioning following combat. To address this gap, we assessed the association of self-reported wrongdoing and betrayal with pain and functional mobility. We hypothesized that wrongdoing and betrayal would be positively associated with pain intensity and, through pain intensity, functional mobility difficulties in a Bayesian latent variable model. We also hypothesized that combat exposure would affect the rates of endorsement of wrongdoing, betrayal, pain, and mobility difficulties. We conducted secondary data analysis in a sample of 323 post-9/11 U.S. combat veterans (70% male, 33.6% Black/African American). In the latent variable model, pain intensity (0.38, 95%CI: 0.23-0.55) was related to decreased functional mobility. Betrayal, but not wrongdoing, was associated with pain intensity (0.20,95%CI:0.05-0.36). Betrayal also had an indirect impact on mobility through pain intensity (indirect effect: 0.09,95%CI: 0.03-0.16). Increasing levels of combat exposure were associated with increasing endorsement of betrayal, pain, and mobility difficulties. Overall, betrayal was more strongly associated with pain intensity and functional mobility than wrongdoing. Results suggest that betrayal experiences may have more physical and functional impacts than experiences of wrongdoing, and that biopsychosocial interventions for pain may benefit from targeting comorbid moral injury. PERSPECTIVE: This article explores how potentially morally injurious betrayal and wrongdoing, chronic pain, and functional mobility are related in U.S. combat veterans. Results suggest that experiences of betrayal are associated with chronic pain and mobility. Betrayal experiences may be important to assess among U.S. combat veterans receiving chronic pain interventions.