Can gut problems cause anxiety?

Yes, research strongly suggests a significant link between gut problems and anxiety. An imbalance in gut bacteria (dysbiosis), increased gut permeability (“leaky gut”), and inflammation in the gut can all impact the brain and contribute to anxiety symptoms. The gut-brain axis is a bidirectional communication network, meaning that problems in the gut can send signals to the brain that influence mood, anxiety levels, and even cognitive function. The vagus nerve, the gut microbiome, neurotransmitters, and the immune system all play roles in this complex interaction.

What are the best foods for gut health and mental health?

The best foods for gut health and mental health are those that are rich in fibre, prebiotics, and probiotics, and that support a diverse and balanced gut microbiome. These include a wide variety of fruits (especially berries, apples with skin, and bananas), vegetables (especially leafy greens, broccoli, artichokes, and asparagus), legumes (lentils, chickpeas, beans), whole grains (oats, brown rice, quinoa, whole-wheat bread), nuts and seeds (almonds, chia seeds, flaxseeds), and fermented foods (yogurt with live cultures, kefir, sauerkraut, kimchi, kombucha, tempeh, miso). It’s also important to limit processed foods, added sugar, unhealthy fats, and excessive alcohol consumption, as these can negatively impact gut health.

Should I take probiotics for my mental health?

While some research shows promise for using specific strains of probiotics to improve certain mental health symptoms (particularly anxiety and depression), the research is still evolving, and it’s not a one-size-fits-all solution. It’s essential to talk to your doctor or a registered dietitian/nutritionist before taking probiotic supplements. They can help you determine if probiotics are appropriate for you, considering your individual needs, medical history, and current medications. They can also recommend specific strains and dosages that are supported by scientific evidence for your particular concerns. Probiotics are generally most effective when combined with a healthy, gut-friendly diet and lifestyle.

What is the vagus nerve, and how does it relate to the gut-brain connection?

The vagus nerve is a major cranial nerve (the longest one) that connects your brainstem to many organs in your body, including your gut. It’s a crucial component of the gut-brain axis, acting as a bidirectional communication highway. This means it transmits signals from the gut to the brain, and from the brain to the gut. Information about the state of your gut (e.g., inflammation, nutrient levels, the presence of certain bacteria) is relayed to the brain via the vagus nerve, influencing mood, anxiety, and even cognitive function. Conversely, signals from the brain can influence gut motility, secretion, and the composition of the gut microbiome. Stimulating the vagus nerve (through techniques like deep breathing, meditation, or even cold exposure) can have calming effects and may improve gut health.

What is dysbiosis, and how does it affect mental health?

Dysbiosis refers to an imbalance in the composition and/or function of the gut microbiome. This can involve a decrease in the abundance and diversity of beneficial bacteria, an overgrowth of potentially harmful bacteria, or a loss of overall microbial balance. Gut dysbiosis has been linked to a wide range of health problems, including mental health conditions like anxiety and depression. The mechanisms by which dysbiosis affects mental health are complex and involve the gut-brain axis, including altered neurotransmitter production, increased gut permeability (“leaky gut”), inflammation, and altered immune function.

What is “leaky gut,” and how does it relate to mental health?

“Leaky gut,” also known as increased intestinal permeability, refers to a condition in which the lining of the gut becomes more porous than it should be. This allows undigested food particles, bacteria, and bacterial byproducts (like lipopolysaccharide or LPS) to “leak” from the gut into the bloodstream. This can trigger an immune response and inflammation, which can then affect the brain and contribute to mental health issues like anxiety and depression. Factors that can contribute to leaky gut include gut dysbiosis, chronic stress, a poor diet (high in processed foods, sugar, and unhealthy fats), excessive alcohol consumption, and certain medications (like NSAIDs).

Moral Injury: From Hidden Wound to Clinical Recognition 2025

The Evolution of Understanding Moral Injury

Five years ago, as the COVID-19 pandemic began overwhelming healthcare systems worldwide, a term once confined to military psychology began appearing in mainstream medical discussions: moral injury. Today, in late 2025, we stand at a transformative moment. The inclusion of moral problems in the DSM-5-TR represents not just diagnostic evolution, but validation of experiences that healthcare workers, veterans, and first responders have long struggled to name.

As we’ve explored in our previous examination of moral injury during the pandemic, what began as crisis recognition has evolved into systematic clinical understanding. This comprehensive guide synthesises the latest research, assessment tools, and treatment approaches, offering both professionals and those experiencing moral injury a complete resource for understanding and addressing this complex condition.

What causes moral injury infographic mind health psychologists sydney parramatta — What causes moral injury?

Understanding Moral Injury: Core Definitions and Concepts

What Is Moral Injury?

According to the Moral Injury Project at Syracuse University, moral injury is damage done to the soul of the individual. It occurs when someone perpetrates, witnesses, or fails to prevent acts that transgress deeply held moral beliefs and expectations. Unlike physical wounds or even psychological trauma rooted in fear, moral injury strikes at the core of one’s identity as a moral being.

integrated model of traumatic stress injuries moral injury — Integrated Model of Traumatic Stress Injuries

The Ethics Centre of Australia emphasises that moral injury involves a betrayal of what is right, either by oneself or by someone in a position of legitimate authority, in a high-stakes situation. This betrayal leads to profound psychological, social, and spiritual suffering that extends beyond traditional mental health categories.

The DSM-5-TR Recognition: A Historic Milestone

In September 2025, the American Psychiatric Association published a groundbreaking update to the DSM-5-TR, formally recognising moral problems under code Z65.8: “Moral, Religious, or Spiritual Problem.”¹ This classification acknowledges that moral problems “include experiences that disrupt one’s understanding of right and wrong, or sense of goodness of oneself, others or institutions.”

This recognition matters because it:

Legitimises the distinct nature of moral suffering
Enables specific clinical documentation and treatment planning
Facilitates insurance coverage for specialised interventions
Promotes research through standardised classification

As detailed in The Lancet Psychiatry, moral injury differs fundamentally from other psychological conditions:²

Moral Injury vs PTSD:

PTSD stems from life-threat and fear
Moral injury arises from moral violations
PTSD involves hypervigilance and avoidance of triggers
Moral injury involves shame, guilt, and spiritual crisis

Moral Injury vs Burnout:

Burnout results from chronic workplace stress
Moral injury stems from specific moral violations
Burnout causes exhaustion and cynicism
Moral injury causes deep shame and loss of meaning

Moral Injury vs Depression:

Depression involves persistent low mood and anhedonia
Moral injury specifically relates to moral transgressions
Depression may occur without precipitating events
Moral injury always links to identifiable moral conflicts

The Australian Landscape: Current State of Moral Injury

Healthcare Worker Moral Injury Post-Pandemic

According to the Department of Veterans’ Affairs comprehensive assessment, Australian healthcare workers continue experiencing significant moral injury from pandemic-related decisions and ongoing system pressures.³

Key findings include:

60% of healthcare workers report ongoing moral distress
45% of nurses experience higher rates than other professionals
1 in 9 nurses leaving the profession cite moral injury factors
Systemic issues persist beyond pandemic acute phase

Research published in BMC Psychiatry identifies specific ongoing triggers:⁴

Chronic understaffing forcing compromised care
Resource allocation decisions
Institutional policies conflicting with patient needs
Inability to provide culturally appropriate care

Veterans and Military Personnel

Open Arms reports that Australian veterans experience moral injury from:⁵

Witnessing civilian casualties
Following orders conflicting with personal values
Inability to help local populations
Perceived betrayal by leadership or government
Transition challenges to civilian life

The DVA’s rapid evidence assessment highlights that military moral injury often co-occurs with PTSD but requires distinct treatment approaches focusing on:

Values reconciliation
Meaning-making
Spiritual repair
Community reintegration

First Responders: The Overlooked Population

Recent Australian research reveals first responders face unique moral injury risks:

Police: Use of force decisions, witnessing preventable tragedies
Paramedics: Triage decisions, resource limitations
Firefighters: Inability to save lives despite best efforts

For more on supporting these populations, see our guide on First Responder Mental Health.

Recognising Moral Injury: Presentation, Symptoms, and Assessment

Moral Injury Presentation

Moral injury does not usually look like a single symptom; it appears as a pattern across emotions, relationships, and the body.

At its core is a rupture between what a person believes is right and what they were compelled to do, witness, or endure. This “fractured inner compass” can leave people feeling internally divided — torn between their values and their lived reality — which then ripples outward into how they feel, connect with others, and function day to day.

Emotionally, moral injury often presents as anger, shame, grief, or anxiety — sometimes shifting rapidly between them. Relationally, people may withdraw or feel alienated from others, as trust in themselves or institutions has been damaged. Physically and psychologically, disrupted sleep, nightmares, and a self-reinforcing cycle of low mood, guilt, and withdrawal can emerge.

Importantly, these responses are not signs of weakness or personal failing; they are understandable reactions to experiences that have violated deeply held moral beliefs.

How moral injury presents Mind Health infographic — How moral injury presents

Core Symptoms and Experiences

The Moral Injury Project identifies key symptom clusters:⁶

Emotional Symptoms:

Intense guilt and shame
Anger at self, others, or institutions
Profound sadness and grief
Emotional numbing or disconnection

Cognitive Symptoms:

Persistent negative self-judgments (“I’m unforgivable”)
Loss of trust in authority and institutions
Questioning previously held beliefs
Intrusive thoughts about the morally injurious event

Behavioural Symptoms:

Social isolation and withdrawal
Self-punishing behaviours
Substance use as coping
Difficulty in relationships

Spiritual/Existential Symptoms:

Loss of meaning and purpose
Questioning faith or spiritual beliefs
Feeling condemned or unworthy of forgiveness
Existential despair

Social Symptoms:

Difficulty trusting others
Alienation from previously important communities
Inability to share experiences
Feeling fundamentally different from others

The Phenomenology: What Moral Injury Feels Like

what does moral injury feel like — What does moral injury feel like?

Drawing from lived experience research, moral injury manifests as:

Immediate Impact:

Moral Pollution: Feeling contaminated or dirty
Moral Betrayal: Shock at violations of trust
Moral Transgression: Horror at one’s actions
Traumatic Loss: Grief over lost innocence

Enduring Impact:

Isolation: “No one could understand”
Preoccupation: Constant rumination
Obligation: Compulsive need to atone
Incompleteness: Sense of unfinished business

Assessment Tools and Measures

The Moral Injury and Distress Scale (MIDS)

The MIDS, released in 2023, provides:⁷

Event-specific assessment
Validated cut-points for clinical significance
Cross-population validity
Free availability for clinicians

The Moral Injury Outcome Scale (MIOS)

Developed through international collaboration, the MIOS offers:⁸

14-item assessment
Two factors: Shame-Related and Trust-Violation-Related outcomes
Cross-cultural validity
Integration with treatment planning

Clinical Interview Considerations

When assessing moral injury, clinicians should:

Create a non-judgmental space
Ask about specific events violating values
Explore role (perpetrator, witness, betrayed)
Assess spiritual/existential impact
Document using DSM-5-TR Z65.8 code
Screen for co-occurring conditions

Evidence-Based Treatment Approaches

Established Adaptations of Trauma Therapies

Cognitive Processing Therapy (CPT) for Moral Injury

Recent trials demonstrate CPT effectiveness when adapted for moral injury:⁹

Focus on moral assumptions rather than just danger assumptions
Extended work on contextual factors
Integration of self-forgiveness modules
Attention to values clarification

Key Modifications:

Challenging moral absolutism
Exploring contextual constraints
Addressing hindsight bias
Reconstructing moral identity

Prolonged Exposure (PE) with Values Integration

PE adaptations for moral injury include:¹⁰

Imaginal exposure to morally injurious events
In-vivo exercises reconnecting with values
Behavioural activation targeting moral repair
Community reengagement activities

Specialised Moral Injury Interventions

Acceptance and Commitment Therapy for Moral Injury (ACT-MI)

ACT-MI represents a paradigm shift in moral injury treatment:¹¹

Duration: 15 sessions (individual and group hybrid)
Focus: Living according to values despite moral pain
Core Processes:
- Acceptance of moral emotions without avoidance
- Cognitive defusion from self-condemning thoughts
- Values clarification and commitment
- Mindful awareness of present-moment experience
- Self-as-context work for identity flexibility

Adaptive Disclosure

Originally developed for military populations, now expanded:¹²

12-session protocol
Imaginal conversations with compassionate moral authority
Empty chair techniques for forgiveness
Letters to self, others, or deceased
Integration of meaning-making

Impact of Killing (IOK)

Specifically for killing-related moral injury:¹³

10 sessions post-PTSD treatment
Focus on forgiveness planning
Letter writing exercises
Values honour ceremonies

Building Spiritual Strength

Addressing spiritual dimensions:¹⁴

8-session group format
Chaplain involvement
Exploration of forgiveness
Restoration of spiritual connections

Emerging and Innovative Approaches

Trauma-Informed Guilt Reduction (TrIGR)

Brief intervention showing promise:¹⁵

6 sessions focusing on guilt and shame
Cognitive reappraisal of responsibility
Values identification and action planning
Behavioural experiments testing beliefs

Community-Based Interventions

The Moral Engagement Group (MEG) model emphasises:¹⁶

Collective healing approaches
Public testimony and witness
Community service as moral repair
Peer support networks

Integrative Approaches

Combining modalities for comprehensive care:

Individual therapy for symptom management
Group therapy for connection and normalisation
Spiritual care for existential concerns
Peer support for shared understanding
Family therapy for relational healing

→ For more on trauma treatments, see our guide to Evidence-Based Trauma Treatments.

Systemic and Organisational Interventions

Healthcare System Reforms

Addressing root causes requires systemic change:¹⁷

Immediate Interventions:

Ethics consultation services
Moral distress rounds
Peer support programmes
Leadership communication protocols

Long-term Reforms:

Adequate staffing ratios
Resource allocation transparency
Values-based decision frameworks
Culture change initiatives

Professional Development:

Moral injury education in training
Continuing education requirements
Supervision models addressing moral dimensions
Self-care as professional responsibility

Military and Veteran Support Systems

The DVA recommends:¹⁸

Pre-deployment moral injury education
In-theatre support systems
Transition programmes addressing moral injuries
Long-term follow-up protocols

First Responder Initiatives

Emerging best practices include:

Critical incident debriefing with moral focus
Peer support trained in moral injury
Chaplaincy and spiritual care access
Organisational culture addressing moral stress

Special Considerations and Populations

Cultural and Spiritual Dimensions

Moral injury intersects with cultural values:¹⁹

Indigenous concepts of spiritual wounds
Cultural variations in guilt and shame
Religious frameworks for forgiveness
Community-based healing traditions

Gender Considerations

Research reveals gender differences:

Women report higher guilt, men higher anger
Different coping strategies
Varying help-seeking behaviours
Distinct treatment preferences

Developmental Perspectives

Age and development influence moral injury:

Young adults: Identity formation disruption
Mid-life: Values reassessment
Older adults: Life review complications

Recovery and Post-Traumatic Growth

The Recovery Journey

Recovery from moral injury is non-linear:²⁰

Acknowledgment: Recognising moral injury
Expression: Sharing the experience
Processing: Working through emotions
Integration: Incorporating into life narrative
Transformation: Finding new meaning
Service: Using experience to help others

Facilitating Post-Traumatic Growth

Some individuals experience growth through:

Clarified values and priorities
Deepened compassion and empathy
Renewed sense of purpose
Spiritual development
Commitment to preventing others’ moral injuries

Peer Support and Lived Experience

The power of shared experience:²¹

Reduces isolation and shame
Provides hope through modelling
Offers practical coping strategies
Creates meaning through service

Future Directions and Research

Priority Research Areas

The field requires investigation into:²²

Biomarkers distinguishing moral injury from PTSD
Cultural adaptations of interventions
Prevention strategies for high-risk professions
Long-term outcomes and trajectories
Intergenerational transmission

Innovation in Treatment

Emerging approaches under development:

Virtual reality for perspective-taking
AI-assisted values clarification
Psychedelic-assisted therapy protocols
Community healing circles
Art and narrative therapies

Policy and Advocacy

Critical policy priorities:

Insurance coverage for moral injury treatment
Workplace mental health standards
Professional education requirements
Research funding allocation
Public awareness campaigns

Practical Resources and Support

For Individuals Experiencing Moral Injury

Immediate Steps:

Recognise you’re not alone
Name the experience as moral injury
Seek professional support
Connect with peers who understand
Be patient with the healing process

Self-Care Strategies:

Journaling about values and experiences
Mindfulness and meditation practices
Creative expression through art or writing
Physical activity and nature connection
Spiritual or philosophical exploration

For Healthcare Professionals

Assessment Resources:

Download MIDS assessment tool
Access MIOS through Phoenix Australia
Use DSM-5-TR Z65.8 coding
Screen for co-occurring conditions
Document thoroughly for treatment planning

Treatment Planning:

Match intervention to individual needs
Consider group and individual modalities
Integrate spiritual care when appropriate
Address systemic factors
Monitor for risk factors

Professional Development:

Attend moral injury training workshops
Join professional interest groups
Access supervision for complex cases
Engage in self-care to prevent vicarious moral injury

For Organisations

Implementation Strategies:

Conduct organisational assessment
Develop moral injury policies
Train leadership and staff
Establish support systems
Monitor and evaluate outcomes

Creating Psychologically Safe Workplaces:

Open communication channels
Transparent decision-making
Values-aligned policies
Adequate resources
Support for staff wellbeing

Conclusion: The Path Forward

The journey from hidden wound to clinical recognition represents tremendous progress, yet much work remains. The DSM-5-TR inclusion of moral problems validates experiences long dismissed or misunderstood. For the healthcare workers who made impossible decisions during the pandemic, veterans carrying the weight of war, and first responders witnessing daily tragedies, this recognition offers hope for understanding and healing.

As we move forward, addressing moral injury requires more than individual treatment—it demands systemic change, organisational accountability, and cultural transformation. The path from moral injury to moral repair is challenging but possible. Through continued research, clinical innovation, and commitment to addressing root causes, we can support those whose service to others has come at profound personal cost.

Recovery involves not forgetting or minimising moral injuries, but integrating them into a life narrative that includes growth, meaning, and renewed purpose. As the Moral Injury Project reminds us, moral injury reflects the depth of human conscience—our capacity to care deeply about right and wrong. In acknowledging and treating moral injury, we honour both the suffering and the humanity of those affected.

The inclusion of moral injury in our clinical frameworks represents not an end but a beginning—an opportunity to transform how we understand and respond to the moral dimensions of human suffering. For all those carrying moral wounds, know that recognition, understanding, and healing are possible. The journey may be long, but you need not walk it alone.

Australian Resources and Support

Crisis Support:

Lifeline Australia: 13 11 14 (24/7)
Beyond Blue: 1300 22 4636
Suicide Call Back Service: 1300 659 467
MensLine Australia: 1300 78 99 78

Specialised Support:

Open Arms (Veterans & Families): 1800 011 046
Phoenix Australia: www.phoenixaustralia.org
Black Dog Institute: www.blackdoginstitute.org.au
Centre for Moral Injury (when established): Check Phoenix Australia for updates

Professional Resources:

Phoenix Australia Moral Injury Resources: phoenixaustralia.org/resources/moral-injury/
DVA Moral Injury Information: dva.gov.au
Australian Psychological Society: psychology.org.au
RANZCP Resources: ranzcp.org

Assessment Tools:

Education and Training:

Phoenix Australia Training: Professional development courses
University Programs: Check major universities for specialised courses
Online Learning: Coursera and FutureLearn trauma courses
Professional Workshops: Check professional associations

References

1. American Psychiatric Association. DSM-5-TR Update: Supplement to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC: American Psychiatric Association Publishing; September 2025.

2. Williamson V, Stevelink SAM, Greenberg N. Moral injury: the effect on mental health and implications for treatment. Lancet Psychiatry. 2021;8(6):453-455.

3. Metcalf O, Phelps A, Watson L, Varker T. The current status of moral injury: A narrative review and Rapid Evidence Assessment. Phoenix Australia – Centre for Posttraumatic Mental Health; 2022.

4. Čartolovni A, Stolt M, Scott PA, Suhonen R. Moral injury in healthcare professionals: A scoping review and discussion. Nurs Ethics. 2021;28(5):590-602.

5. Open Arms – Veterans & Families Counselling. Moral Injury. Australian Government Department of Veterans’ Affairs; 2025.

6. The Moral Injury Project. What is Moral Injury. Syracuse University; 2025.

7. Norman SB, Griffin BJ, Pietrzak RH, et al. The Moral Injury and Distress Scale: psychometric evaluation and initial validation in three high-risk populations. Psychol Trauma. 2024;16(3):280-291.

8. Litz BT, Plouffe RA, Nazarov A, et al. Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium. Front Psychiatry. 2022;13:923928.

9. Held P, Klassen BJ, Brennan MB, Zalta AK. Using prolonged exposure and cognitive processing therapy to treat veterans with moral injury-based PTSD. Behav Ther. 2018;49(4):607-616.

10. Steenkamp MM, Litz BT, Hoge CW, Marmar CR. Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA. 2015;314(5):489-500.

11. Farnsworth JK, Borges LM, Walser RD, et al. Case Conceptualizing in Acceptance and Commitment Therapy for Moral Injury. Front Psychiatry. 2022;13:910414.

12. Gray MJ, Schorr Y, Nash W, et al. Adaptive disclosure: an open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries. Behav Ther. 2012;43(2):407-415.

13. Maguen S, Burkman K, Madden E, et al. Impact of killing in war: a randomized, controlled pilot trial. J Clin Psychol. 2017;73(9):997-1012.

14. Harris JI, Usset T, Voecks C, et al. Spiritually integrated care for PTSD: a randomized controlled trial of “Building Spiritual Strength.” Psychiatry Res. 2018;267:420-428.

15. Norman SB. Trauma informed guilt reduction therapy: treating guilt and shame resulting from trauma and moral injury. London: Academic Press; 2019.

16. Starnino VR, Sullivan JE, Angel CT, et al. Moral Engagement Group: A trauma-informed intervention for moral injury. Soc Work Groups. 2023;46(2):145-160.

17. Dean W, Talbot S, Dean A. Reframing clinician distress: moral injury not burnout. Fed Pract. 2019;36(9):400-402.

18. Department of Veterans’ Affairs. Framework for Moral Injury Support. Australian Government; 2023.

19. Gone JP, Hartmann WE, Pomerville A, et al. The impact of historical trauma on health outcomes for indigenous populations. Am Psychol. 2019;74(1):20-35.

20. Tedeschi RG, Calhoun LG. Posttraumatic growth: conceptual foundations and empirical evidence. Psychol Inquiry. 2004;15(1):1-18.

21. Hundt NE, Robinson A, Arney J, et al. Veterans’ perspectives on benefits and drawbacks of peer support for posttraumatic stress disorder. Mil Med. 2015;180(8):851-856.

22. Frankfurt S, Frazier P. A review of research on moral injury in combat veterans. Mil Psychol. 2016;28(5):318-330.

Expert Review: This article has been reviewed by clinical psychologists specialising in trauma and moral injury treatment.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. If you are experiencing symptoms of moral injury or other mental health concerns, please consult with a qualified mental health professional.

Bulent Ada

Bulent is the Principal Psychologist and Director of Mind Health in Parramatta, Sydney. With over 20 years of experience in psychology and mental health, he takes an integrative approach to psychotherapy, blending traditional evidence-based methods with cutting-edge techniques including CBT, ACT, EMDR, and Schema Therapy. Bulent is passionate about making psychology accessible and practical, helping clients build resilience and thrive under pressure.

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