Moral problem(s) added to DSM-5-TR : But what does this mean for research and the Armed Forces Community?
Across the Armed Forces sector the term ‘moral injury’ is likely a familiar one, especially when thinking about ex-service personnel’ mental health. While moral injury is not a mental health diagnosis, it’s role in the psychological wellbeing of ex-Service personnel has become a highly discussed topic, with 20 research papers being published about ex-Service personnel and moral injury since January 2025[1].
In the past week, moral problem(s) was added as a term in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). But what are moral problems, is this the same as a moral injury, and what does this addition to DSM-5-TR mean for research and the Armed Forces Community?
We spoke to one of our Governance Advisors, Professor Neil Greenberg, a consultant psychiatrist who used to serve in the Royal Navy, about it.
Here’s what Neil said:
Moral injury (MI) is characterised by persistent psychological distress following events that violate moral beliefs. There has been a lot of interest in moral injury particularly over recent years given our increasing knowledge that MI is linked with adverse mental health outcomes including PTSD (post-traumatic stress disorder), depression, and suicidality. Whilst we know that potentially morally injurious events (PMIEs) can cause moral injury, there is no agreed definition of what a PMIE is. Often discussions on this topic suggest that PMIEs should be ‘high stakes’ events although there is no agreed threshold as to what events are high stakes and what events are not.
Another important consideration is that MI is not a formal diagnosis in the way that PTSD or depression are. Rather it is a ‘useful concept’ which helps explain why people exposed to PMIEs may experience negative impacts such as anger, shame, guilt, or disgust and changes in the way they think, behave, and indeed their physical health. PMIEs are often categorised into acts of commission (things that people do which they should not have done), omission (situations where people should have done something but failed to do so), or betrayal (where people are let down by others who should have been looking out for them). However, it is fair to say that respected authorities on MI also debate which sorts of events should be categorised as PMIEs.
All in all, whilst the concepts of PMIEs and MI are helpful for our thinking, the field remains a bit muddled and non-specific. However, DSM-5, which is one of the two well accepted diagnostic texts [with the other one being the ICD-11] has recently been updated and now includes ‘a mention’ of moral problems.
This mention is part of what are called Z codes which are not formal diagnosis, rather they are used to “identify psychosocial and environmental factors that are relevant to a person's mental health but are not mental disorders themselves”. They fall under the category of "other conditions that may be a focus of clinical attention".
Previously Z65.8 [in DSM-5] described what were termed a ‘Religious, or Spiritual Problem’, but the recent update of DSM-5-TR (TR simply means text revision) now states that the category “Moral, Religious, or Spiritual Problem” is “may be used when the focus of clinical attention is a moral, religious, or spiritual problem. Moral problems include experiences that disrupt one’s understanding of right and wrong, or sense of goodness of oneself, others or institutions. Examples of religious or spiritual problems include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution.”
So moral injury is still not a formal diagnosis, but the formal recognition of ‘moral problems’ within the DSM-5 will hopefully stimulate scientists and clinicians to do more work on firming up exactly what PMIEs and MI are. Watch this space!
For more information and evidence about moral injury visit the KCMHR moral injury webpage - Moral Injury
Thank you to Professor Neil Greenberg for providing these insights for this News Feature.