The New Z Code for Moral Problems: What Can it Add?
John Peteet, MD, Harvard Medical School

Moral injury was first studied in military populations, later in healthcare workers, and since in other populations who experience potentially morally injurious events (sexual abuse victims and perpetrators, prisoners, etc.). In 2025, the American Psychiatric Association revised the Diagnostic and Statistical Manual’s Z code for Religious or Spiritual Problem to include Moral Problems, that “include experiences that disrupt one’s understanding of right and wrong, or sense of goodness of oneself, others or institutions.” (APA, 2025)The revision proposal cited the clinical relevance of moral injury, moral distress and moral dilemmas, but other conditions such as depression, demoralization, personality disorders and addiction may have important moral dimensions. With respect to treatment, a consensus is emerging that clinicians should address not only psychological aspects of morally injurious experiences, but disturbances in value and character domains, e.g. “through reflection, self-forgiveness, repentance and restoration” (Barr et al., 2022). Here we review the development of the Z code for Moral Problem and use a case example to consider what it can contribute to the care of the whole patient.
APA (2025). September 2025 Updates to the DSM-5-TR. https://www.psychiatry.org/getmedia/b68a5776-f88c-45c7-9535-fd219d7aa5cb/APA-DSM5TR-Update-September-2025.pdf
Barr N, Atuel H, Saba S, Castro CA. Toward a dual process model of moral injury and traumatic illness. Front Psychiatry. 2022 Aug 24;13:883338.