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J Relig Health. 2018 Feb;57(1):249-265. doi: 10.1007/s10943-017-0531-9.

The Moral Injury Symptom Scale-Military Version.

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Duke University Medical Center, Box 3400, Durham, NC, 27710, USA.
King Abdulaziz University, Jeddah, Saudi Arabia.
Ningxia Medical University, Yinchuan, People's Republic of China.
David Geffen School of Medicine at UCLA, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
Medical College of Georgia, Augusta University, Charlie Norwood VA Medical Center, Augusta, GA, USA.
Durham Veterans Affairs Medical Center, Durham, NC, USA.
Department of Counselor Education and Family Studies, School of Behavioral Sciences, Liberty University, Lynchburg, VA, USA.
Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX, USA.
South Texas Veterans Healthcare System, San Antonio, TX, USA.
VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
Psychology Department, Duke University Medical Center, Durham, NC, USA.
Department of Family and Community Medicine, Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.


The purpose of this study was to develop a multi-dimensional measure of moral injury symptoms that can be used as a primary outcome measure in intervention studies that target moral injury (MI) in Veterans and Active Duty Military with PTSD. This was a multi-center study of 427 Veterans and Active Duty Military with PTSD symptoms recruited from VA Medical Centers in Augusta, Los Angeles, Durham, Houston, and San Antonio, and from Liberty University in Lynchburg. Internal reliability of the Moral Injury Symptom Scale-Military Version (MISS-M) was examined along with factor analytic, discriminant, and convergent validity. Participants were randomly split into two equal samples, with exploratory factor analysis conducted in the first sample and confirmatory factor analysis in the second. Test-retest reliability was assessed in a subsample of 64 Veterans. The 45-item MISS-M consists of 10 theoretically grounded subscales assessing guilt, shame, moral concerns, religious struggles, loss of religious faith/hope, loss of meaning/purpose, difficulty forgiving, loss of trust, and self-condemnation. The Cronbach's alpha of the overall scale was .92 and of individual subscales ranged from .56 to .91. The test-retest reliability was .91 for the total scale and ranged from .78 to .90 for subscales. Discriminant validity was demonstrated by relatively weak correlations with other psychosocial, religious, and physical health constructs, and convergent validity was indicated by strong correlations with PTSD, depression, and anxiety symptoms. The MISS-M is a reliable and valid multi-dimensional symptom measure of moral injury that can be used in studies targeting MI in Veterans and Active Duty Military with PTSD symptoms and may also be used by clinicians to identify those at risk.


Active Duty Military; Internal conflict; Moral injury; Post-traumatic stress disorder; Veterans


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