Does a moral injury framework enhance our understanding of OCD?

Obsessive-compulsive disorder (OCD) is characterized by intrusive thoughts that are appraised as signalling harm, evoking distress and efforts to reduce distress and/or prevent harm. It has long been observed that obsessions often reflect moral themes and that many people with OCD experience strong moral emotions, particularly guilt and shame.

Drawing on social functionalist models of moral emotions and the literature on moral injury (MI), we propose that in some people with OCD, symptoms can be conceptualized as an MI.

We reviewed leading theoretical models of OCD, moral emotions, and MI, and identified areas of overlap in phenomenology, development, and persistence.

When an obsessional thought is itself a moral transgression, and/or failure to resolve the obsessional concern via the compulsion is viewed as a moral transgression, it evokes moral emotions and threatens social standing, reputation, and trust. This increases the stake in avoiding the obsession and in ensuring the compulsion is done properly.

The integration of moral injury concepts with established cognitive behavioral models may enhance case formulation, reduce treatment ambivalence, and support recovery processes that extend beyond symptom reduction to restoration of moral coherence and self-trust. Clinical implications are discussed.