The prominent impact of pre-deployment aggression on moral injury outcomes post-discharge: a six-year longitudinal study of former Israeli combatants

Background: Moral injury (MI) is a potential clinical problem associated with distress following exposure to potentially morally injurious events (PMIEs). While previous studies have linked PMIEs to MI outcomes such as shame and trust violation, few have examined the role of pre-enlistment personality traits in predicting MI. This study investigates whether pre-deployment aggression contributes to MI outcomes among recently discharged Israeli combat veterans, both directly and indirectly, through exposure to PMIEs. Design: A six-year longitudinal study. Methods: 169 Israeli combat veterans were assessed at four time points: pre-enlistment (T1), pre-deployment (T2), post-deployment (T3), and post-discharge (T4) with validated self-report questionnaires. Results: Structural equation modeling results showed pre-deployment aggression (T2) significantly predicted post-discharge MI outcomes of shame and trust violation (T4), above and beyond combat exposure and negative life events. Additionally, PMIE-betrayal (T3) emerged as a key mediator linking aggression (T2) to MI outcomes (T4). Conclusions: Pre-enlistment aggression is a significant risk factor for MI, primarily through its association with betrayal-based PMIEs. These findings highlight the importance of early screening for aggression traits, and the need for targeted interventions to address MI, particularly interventions focused on betrayal-related distress and self-directed moral emotions.