Moral Dimensions of Anxiety and Its Treatment

In 2025, the American Psychiatric Association (APA) approved a new DSM 5-TR Z Code for Moral Problems, defined as experiences that “disrupt one’s understanding of right and wrong, or sense of goodness of oneself, others or institutions” – i.e., of one’s moral identity. While related literature has focused primarily on moral injury, moral distress and moral dilemmas, other conditions such as demoralization, depression and addiction can have an important moral dimension. Limited attention has been devoted to the moral concerns of individuals with anxiety disorders, who may feel blameworthy or ashamed. It can be helpful for clinicians to recognize four contexts in which such concerns arise - when anxiety is driven by a threat to core values, triggered by separation or invalidating encounters, activated by a negative identity, or centered on shame over needs and/or limitations. Attention to the moral concerns of patients in these contexts can lead to interventions that extend beyond standard treatment directed toward avoidance, worry and hypervigilance. These include recognizing and validating moral concerns, adopting a flexible stance to foster a sense of goodness, helping to stabilize demoralizing symptoms and behavior, and exploring obstacles to accessing resources. Moral concerns may be symptoms of anxiety, but may also be driving them, cause significant distress and benefit from being explored and addressed in their own right.