The longitudinal relationship between social support and post- traumatic stress disorder among Chinese adolescents following a flood: The serial mediating roles of intolerance of uncertainty and Internet gaming disorder

The longitudinal relationship between social support and post- traumatic stress disorder among Chinese adolescents following a flood: The serial mediating roles of intolerance of uncertainty and Internet gaming disorder | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The longitudinal relationship between social support and post- traumatic stress disorder among Chinese adolescents following a flood: The serial mediating roles of intolerance of uncertainty and Internet gaming disorder Xu Ding, Shuang Su, Wenqing Liu, Jinyu Wang, Kaiqi Wang, Xiangtao Si, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9009204/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Floods severely disrupt the daily lives of adolescents and pose a significant threat to their mental health. Understanding the mechanisms underlying the maintenance of post-traumatic stress disorder (PTSD) is crucial for its prevention and intervention. This study aimed to examine the reciprocal relationship between social support (SS) and PTSD among Chinese adolescents following a flood, specifically exploring the mediating roles of intolerance of uncertainty (IU) and Internet gaming disorder (IGD). It was hypothesized that SS would have a direct effect on PTSD as well as being mediated by IU and IGD. Methods A total of 403 junior high school students (Mean age = 12.32 years, SD age = 0.52; 50.5% female) were recruited using whole-group sampling and followed up across two waves with a one-year interval. Time 1 (T1) data were collected 2 months after the flood, and Time 2 (T2) data were collected 14 months after the flood. Participants completed self-report questionnaires regarding SS, PTSD, IU, and IGD. Structural equation modeling was used to examine the relationships among the four variables. Results (1) a bidirectional relationship exists between SS and PTSD; (2) IU mediates the association between SS and PTSD; (3) IU and IGD play a serial mediating role in the link between SS and subsequent PTSD symptoms. Conclusions the results of the present study underscore the importance of enhancing SS, reducing IU, and addressing IGD to mitigate PTSD risk among adolescents exposed to natural disasters. Adolescents Social support Post-traumatic stress disorder Intolerance of uncertainty Internet gaming disorder Figures Figure 1 Figure 2 Figure 3 Figure 4 1 Introduction In China, floods are one of the most common and severe forms of natural disasters. In August 2021, a catastrophic flood struck Sichuan Province, China. This disaster had multifaceted impacts on individuals' lives, causing not only direct economic losses but also negative effects on the physical and mental health of the victims. Research indicates that post-traumatic stress disorder (PTSD) is the most common adverse psychological response among disaster survivors[ 1 ]. Frequently comorbid with depression and anxiety, PTSD severely impedes post-disaster recovery and persistently impairs daily functioning[ 2 , 3 ]. Notably, adolescents are more susceptible to psychological problems after a disaster[ 4 , 5 ], such as depression and PTSD. This is because adolescence involves significant biological, social, and cognitive changes, such as establishing a stable self-identity, developing intimate relationships with peers, and achieving relative independence from parents[ 6 ]. These changes may bring additional stress, thereby increasing sensitivity to traumatic events and further raising the risk of PTSD. Although some influencing factors of PTSD (such as age and gender) have been identified[ 7 ], many of these factors are fixed and unchangeable[ 8 ]. Therefore, it is crucial to identify and understand factors that are highly malleable and amenable to intervention. This is essential for elucidating the mechanisms of PTSD and developing effective prevention strategies, holding significant theoretical and practical value. The association between social support (SS) and PTSD has garnered significant scholarly attention. Extensive research has investigated this relationship[ 9 – 11 ], aiming to clarify the causal mechanisms and pathways of influence. Specifically, many researchers have focused on whether SS is eroded by PTSD or SS serves as a buffer against PTSD's development[ 12 ]. The social causation model posits that SS exerts a protective effect against PTSD[ 13 – 16 ]. This framework suggests that when post-trauma interpersonal relationships are repaired and strengthened, individuals are better equipped to cope with traumatic experiences, thereby facilitating psychological restoration[ 17 ]. Consequently, we hypothesized that SS would negatively predict subsequent PTSD (Hypothesis 1). Conversely, the social selection model proposes that elevated psychological distress undermines SS levels[ 18 ]. Individuals suffering from PTSD often exhibit social withdrawal, irritability, and alienation, rendering them less amenable to accepting support[ 12 ]. Furthermore, their impaired social functioning can overburden those around them, who may eventually withdraw[ 19 ], leading to a gradual reduction in available SS. Therefore, we hypothesized that PTSD would negatively predict subsequent SS (Hypothesis 2). However, the relationship between SS and PTSD may be bidirectional. Over time, SS influences the risk and severity of psychiatric conditions and may subsequently impair an individual's level of SS. This occurs through increased withdrawal tendencies, diminished interest in interpersonal activities, and potential alienating or aggressive behaviors[ 20 ]. Thus, we hypothesized a reciprocal relationship wherein SS and PTSD mutually and negatively predict each other (Hypothesis 3). Intolerance of uncertainty (IU) is defined as a cognitive bias that affects how a person perceives, interprets, and responds to uncertain situations at the cognitive, emotional, and behavioral levels[ 21 ]. This bias predisposes individuals to perceive uncertain situations as negative and something to be avoided[ 22 ]. Empirical evidence demonstrates an inverse correlation between SS and IU[ 23 , 24 ]. Following trauma exposure, individuals with elevated IU often experience heightened threat perception and stress, leading to pronounced avoidance behaviors[ 25 , 26 ]. SS can provide both practical help and emotional comfort. This enhances optimistic attitudes in adversity, improves stress coping, and reduces levels of IU[ 24 , 27 ]. Furthermore, current research suggests that high IU may convey unique risk for heightened PTSD symptomatology[ 28 ]. Specifically, to reduce uncertainty regarding potential future exposure to a trauma-related cue or stressor, individuals with high IU may adopt more cognitive or behavioral avoidance strategies after trauma[ 29 ], thereby worsening PTSD symptoms[ 30 ]. Based on the aforementioned associations between SS, IU, and PTSD, we hypothesized that IU may play a key mediating role in the relationship between SS and PTSD (Hypothesis 4). Internet gaming disorder (IGD), as an important subtype of internet addiction, refers to individuals who cannot control, excessively, or compulsively play online games. This behavior causes impairments in their physiological, psychological, and social functions[ 31 ]. Gaming is often used as a coping strategy against distressing emotions and/or realistic problems[ 32 ]. Individuals lacking adequate SS may seek compensatory gratification through gaming, leading to excessive use[ 33 ], which may develop into IGD[ 34 ]. Furthermore, prolonged internet use may also trigger issues such as academic failure, which brings additional frustration[ 35 ]. Consequently, individuals with internet addiction exhibit heightened avoidance behaviors, negative cognitions, and negative emotions[ 36 ], which may further contribute to the development of PTSD. Previous research has established IGD as a mediator between SS and psychological pathologies like anxiety and depression[ 37 ]. Therefore, we hypothesized that IGD would similarly mediate the association between SS and PTSD (Hypothesis 5). To effectively address PTSD, it is essential to extend research beyond the direct relationship between SS and PTSD by exploring the underlying mechanisms. Therefore, this study examines the serial mediating roles of IU and IGD. The Interaction of Person-Affect-Cognition-Execution (I-PACE) model provides an integrative framework for internet-related disorders[ 38 ]. It posits that an individual's core characteristics, which include social cognition (e.g., perceived SS), cognitive reactions in response to a situation (e.g., IU), constitute etiological factors involved in the development, maintenance, and relapse of various types of internet use disorders (e.g., excessive video gaming). Specifically, individuals with insufficient SS may exhibit higher levels of IU when confronting trauma-related stimuli. Such individuals may worry excessively about threats under uncertainty, while also underestimating their ability to handle these threats. This may result in them experiencing negative emotions more easily and adopting passive coping strategies, such as using online games to escape negative experiences brought about by uncertainty. This can lead to the consequences of IGD[ 39 ]. Furthermore, as a maladaptive coping strategy, IGD may interfere with effective coping with stressful events, ultimately leading to the onset of PTSD. Therefore, we hypothesized that SS may indirectly influence PTSD through the serial mediation of IU and IGD (Hypothesis 6). The present study investigates the longitudinal reciprocal associations between SS and PTSD among Chinese adolescents exposed to flood disasters. A cross-lagged model was constructed using data collected at two time points to analyze these dynamics (see Fig. 1 ). Furthermore, extending this longitudinal framework, a serial mediation model was specified to examine the mediating roles of IU and IGD in the pathway from initial SS to subsequent PTSD (see Fig. 2 ). 2 Methods 2.1 Participants The present study was conducted in a junior high school in Sichuan Province, China. Using a whole-group sampling method, students from 10 classes in Grade 7 were recruited as participants. Data collection occurred in two waves over a one-year period. At Time 1 (T1: October 2021), two months post-flood, 494 questionnaires were distributed and retrieved. One year later, at Time 2 (T2: October 2022), 478 questionnaires were distributed, with 403 valid responses collected. Both rounds of questionnaire surveys were completed under the guidance of mental health teachers. Some baseline participants did not participate in the follow-up survey due to reasons such as absence and school transfer. Participants who completed less than 90% of all the scales measured were excluded. Additionally, those suspected of not responding sincerely (i.e., all the answers were the same), or who missed one or more surveys were also excluded from the study. Finally, answers from 403 participants were included for further statistical analyses. The baseline age of the subjects was 12.32 ± 0.52 years, ranging from 11 to 14 years old. Among them, 240 (48.50%) were male and 254 (51.50%) were female. 2.2 Measures 2.2.1 Social support The SS was assessed via the Chinese version of the Multidimensional Scale of Perceived Social Support (MSPSS)[ 40 ]. The MSPSS includes 12 items with responses ranging from 1 (very strongly disagree) to 7 (very strongly agree)[ 41 ]. The MSPSS estimates SS quality from three sources: family, friends, and significant others[ 42 ]. All item scores were added up and then divided by 12. Mean scores ranging from 1 to 2.99 were classified as low, 3 to 5 as medium, and 5.01 to 7 as high perceived support levels, respectively. In this sample, confirmatory factor analysis (CFA) was conducted on the scale using T1 data. The results indicated good structural validity: the normed chi-square ( χ 2 /df) = 2.792, comparative fit index (CFI) = 0.969, Tucker-Lewis index (TLI) = 0.957, root mean squared error of approximation (RMSEA) = 0.067. Additionally, The scale demonstrated good internal reliability, with Cronbach’s α coefficients of 0.915 and 0.947 at the two time points . 2.2.2 Post-traumatic stress disorder PTSD was assessed using the PTSD Checklist for DSM-5 (PCL-5)[ 43 ]. The PCL-5 is a self-report measure consisting of 20 items. It covers the symptoms of PTSD, such as re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal. Each item reflects the severity of a particular symptom, which was rated on a five-point Likert scale from 0 (not at all) to 4 (extremely) during the previous month. A total symptom severity score (range 0–80) can be obtained by summing the scores for each of the 20 items. The higher the total score, the more severe the PTSD level. This scale has been previously identified as being applicable to adolescents following a natural disaster[ 44 ]. CFA was performed on the scale using T2 data. The results showed that the scale had good structural validity in this study ( χ 2 /df = 2.884, CFI = 0.922, TLI = 0.910, RMSEA = 0.068). The scale also demonstrated good reliability, with Cronbach’s α coefficients of 0.920 and 0.929 at the two time points. 2.2.3 Intolerance of uncertainty IU was measured using the Chinese version of the Intolerance of Uncertainty Scale (IUS)[ 45 , 46 ]. The scale comprises 12 items. Responses were given on a 5-point Likert scale, ranging from 1 (completely inconsistent) to 5 (completely in conformity). Total scores range from 12 to 60, with higher scores indicating higher levels of IU. CFA was performed on the scale using T1 data. The analysis in this study yielded favorable results ( χ 2 /df = 2.374, CFI = 0.967, TLI = 0.954, RMSEA = 0.058), supporting the good construct validity of the IUS. The scale exhibited good reliability, with Cronbach’s α coefficients of 0.887 and 0.915 at the two time points. 2.2.4 Internet gaming disorder The severity of IGD symptoms was assessed using the Chinese version of Internet Gaming Disorder Scale-Short Form (IGDS9-SF)[ 47 – 49 ]. The Chinese version of IGDS-SF9 has good psychometric properties[ 50 , 51 ]. It is a 9-item scale developed from the core symptoms of IGD proposed by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. It assesses excessive gaming behavior and its adverse effects in the past 12 months. All items are rated on a 5-point Likert scale (1 = never, 5 = very often). Total scores of this scale range from 9 to 45. Higher scores represent more severe IGD symptoms. In this study, CFA was conducted on the scale using T2 data. The results showed that the scale had good structural validity ( χ 2 /df = 2.893, CFI = 0.980, TLI = 0.968, RMSEA = 0.069). Cronbach’s α coefficients were 0.898 and 0.911 at the two time points, indicating reliable consistency. 2.3 Procedure Prior to the assessment, consent was obtained from the head teachers. The survey was administered uniformly in classrooms by mental health teachers on a class-by-class basis. The teachers read aloud the informed consent form and instructions in a unified manner. The total administration duration was approximately 30 minutes. Questionnaires were collected on the spot, and small gifts were presented to participants immediately as compensation. The study strictly adhered to the ethical guidelines of the Helsinki Declaration and was approved by the Academic Committee of Leshan Normal University (Approval No.: LNU-20210831P). 2.4 Statistical analysis The data were first analyzed using SPSS 27.0 for descriptive statistics and correlation analysis. Additionally, Harman's single-factor test was used to evaluate the common method bias derived from self-reported data[ 52 ]. Subsequently, Amos 24.0 was employed to construct a cross-lagged model to examine the relationship between SS and PTSD at two time points. This cross-lagged model was further extended to incorporate IU and IGD, enabling the analysis of the serial mediating effect between SS and PTSD. Thresholds were considered as follows: for CFI and TLI excellent fit > 0.95 and moderate fit > 0.90[ 53 ]; for RMSEA excellent fit < 0.05 and moderate fit < 0.08[ 54 ]. A total of 5000 bootstrap samples were used to estimate the 95% confidence intervals. The mediating effects were considered to be significant when the 95% CI did not include zero. All results were standardized. Additionally, age and gender were controlled as covariates in the serial mediation analysis. 3 Results 3.1 Testing for common method bias Harman's single-factor test extracted 21 factors with eigenvalues greater than 1. The first factor explained 22.38% of the total variances, which is below the threshold of 40%[ 52 ]. Therefore, the data used in this study do not exhibit any discernible common method bias. 3.2 Descriptive statistics and correlation analysis Table 1 shows the means, standard deviations, and correlations among the main variables in the current study. All the variables at T1 and T2 demonstrated significant correlations with one another. Correlation analysis indicated that at T1, SS was negatively correlated with IU ( r = -0.136, p < 0.01), IGD ( r = -0.242, p < 0.01) and PTSD ( r = -0.288, p < 0.01). IU was positively correlated with IGD ( r = 0.448, p < 0.01) and PTSD ( r = 0.539, p < 0.01). IGD was positively correlated with PTSD ( r = 0.374, p < 0.01). At T2, SS was negatively correlated with IU ( r = -0.250, p < 0.01), IGD ( r = -0.344, p < 0.01) and PTSD ( r = -0.258, p < 0.01). IU was positively correlated with IGD ( r = 0.404, p < 0.01) and PTSD ( r = 0.501, p < 0.01). IGD was positively correlated with PTSD ( r = 0.288, p < 0.01). Table 1 Descriptive statistics and correlations among the main variables (N = 403). 1.SS(T1) M ± SD 1 2 3 4 5 6 7 8 43(31,53) 1 2.SS(T2) 41(25,52) 0.555** 1 3.IU(T1) 29(22,38) -0.136** -0.126* 1 4.IU(T2) 29(,22,37) -0.108* -0.250** 0.621** 1 5.IGD(T1) 15(10,22) -0.242** -0.216** 0.448** 0.283** 1 6.IGD(T2) 16(11,23) -0.167** -0.344** 0.309** 0.404** 0.693** 1 7.PTSD(T1) 13(7,22) -0.288** -0.246** 0.539** 0.418** 0.374** 0.298** 1 8.PTSD(T2) 14(6,24) -0.282** -0.258** 0.371** 0.501** 0.272** 0.288** 0.692** 1 Note: PTSD = Post-traumatic stress disorder; IGD = Internet gaming disorder; IU = Intolerance of uncertainty; SS = Social support. ** p < 0.01, * p < 0.05. 3.3 Cross-Lagged relationship between social support and PTSD Based on the correlation analysis, a cross-lagged model was conducted to explore the longitudinal relationship between SS and PTSD. The results showed that the model fit the data well ( χ 2 /df = 2.401, CFI = 0.996, TLI = 0.978, RMSEA = 0.059). As shown in Fig. 3 , SS at T1 significantly negatively predicted PTSD at T2 ( β = -0.14, SE = 0.034, p < 0.05). PTSD at T1 significantly negatively predicted SS at T2 ( β = -0.09, SE = 0.058, p < 0.01). Figure 3 3.4 Mediating effects of Internet gaming disorder and intolerance of uncertainty between social support and PTSD After controlling for age and gender, we tested the serial mediation model. The model fit the data well: ( χ 2 /df = 1.771, CFI = 0.906, TLI = 0.900, RMSEA = 0.044. Figure 4 displays the standardized path coefficients for the direct effects in the model. SS (T1) was significantly negatively associated with IU (T1) ( β = -0.20, p < 0.05), which in turn was significantly positively associated with PTSD (T2) ( β = 0.28, p < 0.01). Furthermore, SS (T1) was significantly negatively associated with PTSD (T2) ( β = -0.20, p < 0.001). Moreover, IGD (T2) was significantly positively associated with PTSD (T2) ( β = 0.33, p 0.05). Finally, IU (T1) was significantly positively associated with IGD (T2) ( β = 0.38, p < 0.01). Figure 4 In addition, to test the significance of each mediating effect, 95% confidence intervals (CI) were estimated using the bootstrapping method. If the resulting CI does not contain zero, it indicates a significant mediating effect. As shown in Table 2 , the results showed the mediating effects. The total effect of SS on PTSD was significant (effect = -0.297, 95% CI = [-0.394, -0.119]). Furthermore, SS had a significant indirect effect on PTSD through IU (effect = -0.057, 95% CI = [-0.102, -0.026]), accounting for 19.2% of the total effect; however, the indirect effect of SS on PTSD through IGD was not significant (effect = -0.013, 95% CI = [-0.051,0.021]). The serial mediation effect was significant (effect = -0.026, 95% CI = [-0.049, -0.010]), accounting for 8.8% of the total effect. Table 2 The serial mediation effects of model (N = 403) Model pathways effects Boot SE 95% confidence interval Boot LLCI Boot ULCI SS(T1)→IU(T1)→PTSD(T2) -0.057 0.019 -0.102 -0.026 SS(T1)→IGD(T2)→PTSD(T2) -0.013 0.018 -0.051 0.021 SS(T1)→IU(T1)→IGD(T2)→PTSD(T2) -0.026 0.010 -0.049 -0.010 Total effect -0.297 0.050 -0.394 -0.199 Direct effect -0.202 0.046 -0.291 -0.112 Total indirect effect -0.096 0.029 -0.158 -0.043 Note: SS = Social support; IU = Intolerance of uncertainty; IGD = Internet gaming disorder; PTSD = Post-traumatic stress disorder. Boot SE, Boot LLCI, and Boot ULCI refer to the standard errors and the upper and lower bounds of the 95% confidence intervals of the indirect effects estimated by the bootstrap method, respectively. 4 Discussion The present study employed a cross-lagged model to investigate the reciprocal relationships between SS and PTSD among adolescents exposed to a flood disaster. Based on this, a serial mediation model involving IU and IGD was constructed to investigate the mediating mechanisms through which SS influences PTSD. The study found a significant bidirectional relationship between SS and PTSD, and that IU and IGD played a serial mediating role in this relationship. 4.1 Reciprocal relationship between social support and PTSD Results indicated significant correlations between SS and PTSD at both T1 and T2. This correlation had cross-temporal stability. Cross-lagged analysis revealed that SS at T1 significantly and negatively predicted PTSD at T2. This finding supports Hypothesis 1, aligning with the social causation model[ 13 – 16 ]. Specifically, adequate SS functions as a crucial protective factor that effectively alleviates individuals' negative emotions following trauma. It also promotes the adoption of positive coping strategies and enhances psychological resilience. This process helps prevent and reduce the incidence of PTSD. Simultaneously, PTSD at T1 significantly and negatively predicted SS at T2, supporting Hypothesis 2. This finding aligns with the social selection model, which posits that psychological distress may decrease SS levels[ 18 ]. Specifically, trauma may distort an individual's perception of available support, rendering them less receptive to assistance from others. Alternatively, PTSD symptoms (e.g., withdrawal, angry outburst, avoiding, negative cognition and emotions) may lead individuals to alienate others in their social networks[ 12 , 17 ], while also reducing their willingness to seek SS. Furthermore, the relatives and friends of individuals with psychiatric disorders may accumulate stress and reduce supportive behaviors when living with or caring for them. This may further weaken the patients' SS[ 19 ]. Collectively, the current findings corroborate a robust bidirectional relationship between SS and PTSD, supporting Hypothesis 3, indicating that the two can influence each other over time. This conclusion is consistent with the results of two previous meta-analyses[ 17 , 55 ], which documented a bidirectional relationship between PTSD and SS. Specifically, while SS influences the risk and severity of PTSD over time, the disorder subsequently erodes an individual's level of SS. 4.2 The mediating role of intolerance of uncertainty Our findings demonstrated that IU significantly mediated the relationship between SS and PTSD, supporting Hypothesis 4. The first path of this mediating effect showed that SS significantly and negatively predicted IU. This aligns with previous research indicating that individuals with more SS exhibit lower levels of IU[ 23 , 24 ]. When individuals perceive more SS, they tend to display greater confidence in their ability to cope with uncertain environments. This enhanced sense of control can effectively diminish IU[ 56 , 57 ]. Additionally, the second path of the mediating effect revealed that IU significantly and positively predicted PTSD. This is consistent with prior studies identifying IU as a significant and robust predictor of PTSD symptoms[ 28 ]. Existing studies suggests that individuals with elevated levels of IU may develop an exaggerated perception of threat following trauma. This leads to heightened avoidance behaviors due to uncertainty.[ 46 , 58 , 59 ]. Moreover, IU, as a tendency to respond negatively to uncertain situations and events, essentially reflects the worry about the uncertainty in the future[ 60 ]. The repeated experience of these sensations can contribute to the development of PTSD[ 61 ]. Overall, these mechanisms elucidate how SS indirectly influences PTSD via an individual's IU levels. When facing an insufficient SS, individuals may struggle to access necessary psychological resources during recovery from a traumatic event. This may exacerbate their feelings of ambiguity and loss of control over potential future threats, thereby elevating their IU levels. This negative response tendency can keep individuals in a state of avoidance, ultimately reinforcing the core symptoms of PTSD. 4.3 The mediating role of Internet gaming disorder In the current study, the independent mediating role of IGD in the relationship between SS and PTSD was not significant, thus, Hypothesis 5 was not supported. Specifically, the predictive effect of SS on IGD lacked statistical significance. Although previous research has documented a significant negative association between SS and IGD[ 34 , 37 ], this finding was not replicated in our sample. One plausible explanation is that some individuals may develop online relationships through gaming, thereby acquiring support from their online friends. This online social reward might inadvertently reinforce, rather than mitigate, IGD tendencies[ 62 ]. The present study did not evaluate online and offline SS separately, which may have confounded the overall results. Future research should delineate the distinct impacts of virtual versus real-world support on IGD. Alternatively, the mechanism linking SS to PTSD may be more complex, necessitating additional variables. Therefore, the single IGD pathway alone is insufficient to fully capture this relationship. 4.4 The serial mediating role of intolerance of uncertainty and Internet gaming disorder Our findings further demonstrated that SS influences PTSD through the serial mediation of IU and IGD, supporting Hypothesis 6. Consistent with the I-PACE model, individuals with insufficient SS may be more susceptible to intense emotional distress when confronting uncertainty. Consequently, they exhibit elevated levels of IU. To mitigate the distress and anxiety induced by this uncertainty, these individuals often turn to online gaming. This maladaptive coping strategy allows them to divert attention from perceived threats. Simultaneously, it delivers a level of satisfaction often unattainable in the offline world[ 63 ]. Over time, individuals with high IU may become increasingly reliant on internet games to escape uncertainty, ultimately culminating in IGD. Subsequently, individuals with IGD symptoms habitually utilize video games as a temporary distraction from negative trauma-related experiences and emotions[ 62 ]. This behavior further compromises their mental health, ultimately precipitating the development or exacerbation of PTSD. 4.5 Implications This study offers several vital theoretical implications. First, it elucidates a significant bidirectional relationship between SS and PTSD among adolescents experiencing natural disaster. This finding corroborates both the social causation and social selection models, enhancing our comprehension of the intricate relationship between SS and PTSD. Second, our findings indicate that adolescents' SS can indirectly influence PTSD through the serial mediation of IU and IGD. Consequently, addressing cognitive vulnerabilities (IU) and maladaptive behaviors (IGD) linked to SS deficits is crucial. This perspective provides a novel theoretical framework for early PTSD interventions. Furthermore, these findings yield substantial clinical implications for the prevention and treatment of PTSD. To effectively mitigate post-traumatic cognitive biases and problematic behaviors in adolescents, future therapeutic practices should specifically target IU and IGD. Considering the beneficial effects of mindfulness training on both IU and IGD[ 64 , 65 ], future mindfulness intervention programs could incorporate content targeting these factors. For instance, mindfulness-based strategies can be employed to mitigate avoidant gaming behavior. This approach serves as a valuable adjunctive pathway for managing PTSD symptoms. 4.6 Limitations and future directions Several limitations of the current study should be acknowledged. First, the reliance on only two waves of measurement with a one-year interval limits the ability to ascertain the long-term stability of the observed effects. To address this, multi-wave longitudinal designs with more frequent follow-ups should be employed in future research. Second, PTSD was assessed using a self-report symptom checklist rather than a clinical diagnostic measure. Future studies could incorporate objective physiological indicators of PTSD risk, such as cortisol levels, heart rate, and blood pressure[ 66 ]. Finally, the sample was restricted to seventh-grade students, which constrains the generalizability of the findings to adolescents of other age groups. Subsequent research should encompass more diverse adolescent cohorts across various grade levels. 5 Conclusions The present study yields the following main conclusions: (1) SS serves as a crucial protective factor against PTSD among adolescents experiencing a flood disaster. (2) A significant bidirectional relationship exists between SS and PTSD, indicating that they reciprocally influence each other over time. (3) SS indirectly affects PTSD through the serial mediation of IU and subsequent IGD. Declarations Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Xu Ding, and Shuang Su contribute equally to this work and joint first authors. Yan Cao, and Ru Tao contribute equally to supervise this work and joint corresponding authors. Competing interests The authors declare no competing interests. Ethics approval and consent to participate The study strictly adhered to the ethical guidelines of the Helsinki Declaration and was approved by the Academic Committee of Leshan Normal University (Approval No.: LNU-20210831P). Informed consent was obtained from all participants. Consent for publication Not applicable. Funding This study was supported by the the Natural Science Foundation of Shandong Province (Grant. ZR2025QC2044Z). Author Contribution XD designed the study. SS processed the data. XD and SS wrote original draft. WQL, JYW, KQW and XTS collected the data and performed the data analysis and its interpretation.RT and YC completed review and revised the manuscript. All authors reviewed and approved the final version of the manuscript. Acknowledgement The authors would like to thank all participants for their involvement in this study. Data Availability The data set used and analyzed during the current study is available from the corresponding author on reasonable request. References Zhang W, Duan G, Xu Q, Jia Z, Bai Z, Liu W, et al. A Cross-sectional Study on Posttraumatic Stress Disorder and General Psychiatric Morbidity Among Adult Survivors 3 Years After the Wenchuan Earthquake, China. Asia Pac J Public Health. 2015;27(8):860–70. Pan X, Liu W, Deng G, Liu T, Yan J, Tang Y, et al. Symptoms of posttraumatic stress disorder, depression, and anxiety among junior high school students in worst-hit areas 3 years after the Wenchuan earthquake in China. Asia Pac J Public Health. 2015;27(2):Np1985–94. 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A vacation from your mind: Problematic online gaming is a stress response. Comput Hum Behav. 2014;38:248–60. Davis RA. A cognitive-behavioral model of pathological Internet use. Comput Hum Behav. 2001;17(2):187–95. Wartberg L, Kriston L, Kammerl R. Associations of Social Support, Friends Only Known Through the Internet, and Health-Related Quality of Life with Internet Gaming Disorder in Adolescence. Cyberpsychology Behav social Netw. 2017;20(7):436–41. Chu XY, Li Y, Wang PC, Zeng P, Lei L. Social support and cyberbullying for university students: The mediating role of internet addiction and the moderating role of stress. Curr Psychol. 2023;42(3):2014–22. Longstreet P, Brooks S, Gonzalez ES. Internet addiction: When the positive emotions are not so positive. Technol Soc. 2019;57:76–85. Malak MZ, Shuhaiber AH, Alsswey A, Tarawneh A. Social support as the mediator for the relationship between internet gaming disorder and psychological problems among university students. J Psychiatr Res. 2023;164:243–50. Brand M, Young KS, Laier C, Wölfling K, Potenza MN. Integrating psychological and neurobiological considerations regarding the development and maintenance of specific Internet-use disorders: An Interaction of Person-Affect-Cognition-Execution (I-PACE) model. Neurosci Biobehav Rev. 2016;71:252–66. Yuan Z, Xu F, Liu Q. Nature Connectedness Reduces Internet Gaming Disorder: The Chain Mediating Role of Intolerance of Uncertainty and Desire Thinking. Behav Sci (Basel). 2024;14(9). Jiang Q. Perceived social support scale. Chin J Behav Med. 2001;10(10):41–3. Altman DG, Bland JM. Statistics Notes - Interaction revisited: the difference between two estimates. BMJ-British Med J. 2003;326(7382):219. Osman A, Lamis DA, Freedenthal S, Gutierrez PM, McNaughton-Cassill M. The Multidimensional Scale of Perceived Social Support: Analyses of Internal Reliability, Measurement Invariance, and Correlates Across Gender. J Pers Assess. 2014;96(1):103–12. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. J Trauma Stress. 2015;28(6):489–98. Wang L, Zhang L, Armour C, Cao C, Qing Y, Zhang J, et al. Assessing the underlying dimensionality of DSM-5 PTSD symptoms in Chinese adolescents surviving the 2008 Wenchuan earthquake. J Anxiety Disord. 2015;31:90–7. Wu L, Wang J, Qi X. Validity and reliability of the Intolerance of Uncertainty Scale-12 in middle school students. Chin Mental Health J. 2016;30(9):700–5. Carleton RN, Norton MA, Asmundson GJ. Fearing the unknown: a short version of the Intolerance of Uncertainty Scale. J Anxiety Disord. 2007;21(1):105–17. Pontes HM, Griffiths MD. Measuring DSM-5 internet gaming disorder: Development and validation of a short psychometric scale. Comput Hum Behav. 2015;45:137–43. Poon LYJ, Tsang HWH, Chan TYJ, Man SWT, Ng LY, Wong YLE, et al. Psychometric Properties of the Internet Gaming Disorder Scale-Short-Form (IGDS9-SF): Systematic Review. J Med Internet Res. 2021;23(10):16. Yam C-W, Pakpour AH, Griffiths MD, Yau W-Y, Lo C-LM, Ng JMT, et al. Psychometric Testing of Three Chinese Online-Related Addictive Behavior Instruments among Hong Kong University Students. Psychiatr Q. 2019;90(1):117–28. Chen IH, Ahorsu DK, Pakpour AH, Griffiths MD, Lin CY, Chen CY. Psychometric Properties of Three Simplified Chinese Online-Related Addictive Behavior Instruments Among Mainland Chinese Primary School Students. Front Psychiatry. 2020;11:8. Leung H, Pakpour AH, Strong C, Lin YC, Tsai MC, Griffiths MD, et al. Measurement invariance across young adults from Hong Kong and Taiwan among three internet-related addiction scales: Bergen Social Media Addiction for Scale (BSMAS), Smartphone Application-Based Addiction Scale (SAGAS), and Internet Gaming Disorder Scale-Short Form (IGDS-SF9) (Study Part A). Addict Behav. 2020;101:9. Podsakoff PM, MacKenzie SB, Lee JY, Podsakoff NP. Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol. 2003;88(5):879–903. Browne MW, Cudeck R. Alternative ways of assessing model fit. Sociol methods Res. 1992;21(2):230–58. Hu L-t, Bentler PM. Cutoff Criteria for Fit Indexes in Covariance Structure Analysis: Conventional Criteria Versus New Alternatives. Structural Equation Modeling-a. Multidisciplinary J. 1999;6(1):1–55. Zalta AK, Tirone V, Orlowska D, Blais RK, Lofgreen A, Klassen B, et al. Examining moderators of the relationship between social support and self-reported PTSD symptoms: A meta-analysis. Psychol Bull. 2021;147(1):33–54. van der Wal SJ, Geuze E, Vermetten E. Long-term risk for mental health symptoms in Dutch ISAF veterans: the role of perceived social support. Psychol Med. 2023;53(8):3355–65. Wilson JM, Weiss A, Shook NJ. Mindfulness, self-compassion, and savoring: Factors that explain the relation between perceived social support and well-being. Pers Indiv Differ. 2020;152:109568. Fetzner MG, Horswill SC, Boelen PA, Carleton RN. Intolerance of Uncertainty and PTSD Symptoms: Exploring the Construct Relationship in a Community Sample with a Heterogeneous Trauma History. Cogn Therapy Res. 2013;37(4):725–34. Oglesby ME, Gibby BA, Mathes BM, Short NA, Schmidt NB. Intolerance of uncertainty and post-traumatic stress symptoms: An investigation within a treatment seeking trauma-exposed sample. Compr Psychiatry. 2017;72:34–40. Dugas MJ, Schwartz A, Francis K. Intolerance of uncertainty, worry, and depression. Cogn Therapy Res. 2004;28(6):835–42. Bardeen JR, Fergus TA, Wu KD. The Interactive Effect of Worry and Intolerance of Uncertainty on Posttraumatic Stress Symptoms. Cogn Therapy Res. 2013;37(4):742–51. King DL, Delfabbro PH. The cognitive psychology of Internet gaming disorder. Clin Psychol Rev. 2014;34(4):298–308. King DL, Delfabbro PH, Perales JC, Deleuze J, Király O, Krossbakken E, et al. Maladaptive player-game relationships in problematic gaming and gaming disorder: A systematic review. Clin Psychol Rev. 2019;73:101777. Jiang XC, Zhang AB, Zhang Q. The effects of mindfulness-based intervention on social anxiety, mindfulness, intolerance of uncertainty and emotion dysregulation–a serial multiple mediating structural equation model. Curr Psychol. 2025. Sanacora G, Johnson MR, Khan A, Atkinson SD, Riesenberg RR, Schronen JP, et al. Adjunctive Lanicemine (AZD6765) in Patients with Major Depressive Disorder and History of Inadequate Response to Antidepressants: A Randomized, Placebo-Controlled Study. Neuropsychopharmacology: official publication Am Coll Neuropsychopharmacol. 2017;42(4):844–53. Morris MC, Hellman N, Abelson JL, Rao U. Cortisol, heart rate, and blood pressure as early markers of PTSD risk: A systematic review and meta-analysis. Clin Psychol Rev. 2016;49:79–91. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 12 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers invited by journal 28 Apr, 2026 Editor invited by journal 10 Mar, 2026 Editor assigned by journal 06 Mar, 2026 Submission checks completed at journal 06 Mar, 2026 First submitted to journal 02 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9009204","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635252767,"identity":"34e79e80-935f-464d-b786-738b888b1e05","order_by":0,"name":"Xu Ding","email":"","orcid":"","institution":"Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Ding","suffix":""},{"id":635252768,"identity":"7c424602-5bbd-4dcd-9141-03cafe42af57","order_by":1,"name":"Shuang Su","email":"","orcid":"","institution":"Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shuang","middleName":"","lastName":"Su","suffix":""},{"id":635252769,"identity":"5d36e1ac-01ab-45f5-97e4-c6abc217e29a","order_by":2,"name":"Wenqing Liu","email":"","orcid":"","institution":"Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wenqing","middleName":"","lastName":"Liu","suffix":""},{"id":635252775,"identity":"a7747adb-e887-4d9c-9937-898ccce1857d","order_by":3,"name":"Jinyu Wang","email":"","orcid":"","institution":"Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jinyu","middleName":"","lastName":"Wang","suffix":""},{"id":635252778,"identity":"a69b54b4-a3b3-4a3a-b7f1-c30961d9eb64","order_by":4,"name":"Kaiqi Wang","email":"","orcid":"","institution":"Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Kaiqi","middleName":"","lastName":"Wang","suffix":""},{"id":635252780,"identity":"c0f173af-f52a-4647-9362-52ae0c5e65f4","order_by":5,"name":"Xiangtao Si","email":"","orcid":"","institution":"Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiangtao","middleName":"","lastName":"Si","suffix":""},{"id":635252781,"identity":"0d1d4834-ab2a-4e42-8e8a-ed1411fa61c2","order_by":6,"name":"Yan Cao","email":"","orcid":"","institution":"The Second Affiliated Hospital of Shandong First Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Cao","suffix":""},{"id":635252782,"identity":"9db7f0a1-e5a2-4114-938f-d016661810dc","order_by":7,"name":"Ru Tao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYBAC+2bGxgcfKmp42NgbiNRiwM7cbDjjzDEZPp4DxGrhZ2+T5m1htpGTSCBSizkzY7PhzAY2HjbJxxtvMNTYRBPUYgnyy8cdMjxs0mnFFgzH0nIbCOo5DLLlDNAW6RwzCcaGw0RpAfqljRnosDNEajGAa5HgIVKLZDMjOJB52HiAfkkgxi/8/McfgqLSXr798MYbH2psiPALsiOJjhokLaTqGAWjYBSMgpEBALtBOp6gN51iAAAAAElFTkSuQmCC","orcid":"","institution":"Shandong First Medical University","correspondingAuthor":true,"prefix":"","firstName":"Ru","middleName":"","lastName":"Tao","suffix":""}],"badges":[],"createdAt":"2026-03-02 10:54:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9009204/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9009204/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108950588,"identity":"58816869-38e9-469e-9fb4-5b2b5385c9ec","added_by":"auto","created_at":"2026-05-11 07:06:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47332,"visible":true,"origin":"","legend":"\u003cp\u003eThe conceptual model of cross-lagged model.\u003c/p\u003e\n\u003cp\u003eNote: SS = Social support; PTSD = Post-traumatic stress disorder.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9009204/v1/d7cc16df062beefa802429ac.png"},{"id":108950586,"identity":"d28939ca-2069-4542-a87b-e436d712cecf","added_by":"auto","created_at":"2026-05-11 07:06:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":47576,"visible":true,"origin":"","legend":"\u003cp\u003eThe conceptual model of mediation model.\u003c/p\u003e\n\u003cp\u003eNote: SS = Social support; IU = Intolerance of uncertainty; IGD = Internet gaming disorder; PTSD = Post-traumatic stress disorder.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9009204/v1/b14f9bcb3b501ae5eeab7c4c.png"},{"id":108950585,"identity":"8b640ccd-54ef-4e7e-9d56-665934d9f4fe","added_by":"auto","created_at":"2026-05-11 07:06:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":45525,"visible":true,"origin":"","legend":"\u003cp\u003eCross-lagged model of SS and PTSD with standardized estimates.\u003c/p\u003e\n\u003cp\u003eNote: SS = Social support; PTSD = Post-traumatic stress disorder. ***\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001, **\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01, *\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9009204/v1/dd1c9d97402a40a228979cc7.png"},{"id":108950587,"identity":"a9c031cf-2301-4304-89c5-7591b1a7e68b","added_by":"auto","created_at":"2026-05-11 07:06:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":54160,"visible":true,"origin":"","legend":"\u003cp\u003eSerial mediation model from SS (T1) to PTSD (T2). Values shown are standardized path coefficients\u003c/p\u003e\n\u003cp\u003eNote: SS = Social support; IU = Intolerance of uncertainty; IGD = Internet gaming disorder; PTSD = Post-traumatic stress disorder. ***\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001, **\u003cem\u003ep\u003c/em\u003e\u0026lt; 0.01, *\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9009204/v1/7ad1baab09aa2caf67fe4fc9.png"},{"id":108978145,"identity":"0b5a5df3-0b74-4b42-b7a3-603d3b88c90e","added_by":"auto","created_at":"2026-05-11 11:34:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":483925,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9009204/v1/d1d8b245-860a-4f92-a354-2ed7c72d8eae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The longitudinal relationship between social support and post- traumatic stress disorder among Chinese adolescents following a flood: The serial mediating roles of intolerance of uncertainty and Internet gaming disorder","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eIn China, floods are one of the most common and severe forms of natural disasters. In August 2021, a catastrophic flood struck Sichuan Province, China. This disaster had multifaceted impacts on individuals' lives, causing not only direct economic losses but also negative effects on the physical and mental health of the victims. Research indicates that post-traumatic stress disorder (PTSD) is the most common adverse psychological response among disaster survivors[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Frequently comorbid with depression and anxiety, PTSD severely impedes post-disaster recovery and persistently impairs daily functioning[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Notably, adolescents are more susceptible to psychological problems after a disaster[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], such as depression and PTSD. This is because adolescence involves significant biological, social, and cognitive changes, such as establishing a stable self-identity, developing intimate relationships with peers, and achieving relative independence from parents[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These changes may bring additional stress, thereby increasing sensitivity to traumatic events and further raising the risk of PTSD. Although some influencing factors of PTSD (such as age and gender) have been identified[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], many of these factors are fixed and unchangeable[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, it is crucial to identify and understand factors that are highly malleable and amenable to intervention. This is essential for elucidating the mechanisms of PTSD and developing effective prevention strategies, holding significant theoretical and practical value.\u003c/p\u003e \u003cp\u003eThe association between social support (SS) and PTSD has garnered significant scholarly attention. Extensive research has investigated this relationship[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], aiming to clarify the causal mechanisms and pathways of influence. Specifically, many researchers have focused on whether SS is eroded by PTSD or SS serves as a buffer against PTSD's development[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The social causation model posits that SS exerts a protective effect against PTSD[\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This framework suggests that when post-trauma interpersonal relationships are repaired and strengthened, individuals are better equipped to cope with traumatic experiences, thereby facilitating psychological restoration[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Consequently, we hypothesized that SS would negatively predict subsequent PTSD (Hypothesis 1).\u003c/p\u003e \u003cp\u003eConversely, the social selection model proposes that elevated psychological distress undermines SS levels[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Individuals suffering from PTSD often exhibit social withdrawal, irritability, and alienation, rendering them less amenable to accepting support[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, their impaired social functioning can overburden those around them, who may eventually withdraw[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], leading to a gradual reduction in available SS. Therefore, we hypothesized that PTSD would negatively predict subsequent SS (Hypothesis 2).\u003c/p\u003e \u003cp\u003eHowever, the relationship between SS and PTSD may be bidirectional. Over time, SS influences the risk and severity of psychiatric conditions and may subsequently impair an individual's level of SS. This occurs through increased withdrawal tendencies, diminished interest in interpersonal activities, and potential alienating or aggressive behaviors[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Thus, we hypothesized a reciprocal relationship wherein SS and PTSD mutually and negatively predict each other (Hypothesis 3).\u003c/p\u003e \u003cp\u003eIntolerance of uncertainty (IU) is defined as a cognitive bias that affects how a person perceives, interprets, and responds to uncertain situations at the cognitive, emotional, and behavioral levels[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This bias predisposes individuals to perceive uncertain situations as negative and something to be avoided[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Empirical evidence demonstrates an inverse correlation between SS and IU[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Following trauma exposure, individuals with elevated IU often experience heightened threat perception and stress, leading to pronounced avoidance behaviors[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. SS can provide both practical help and emotional comfort. This enhances optimistic attitudes in adversity, improves stress coping, and reduces levels of IU[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Furthermore, current research suggests that high IU may convey unique risk for heightened PTSD symptomatology[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Specifically, to reduce uncertainty regarding potential future exposure to a trauma-related cue or stressor, individuals with high IU may adopt more cognitive or behavioral avoidance strategies after trauma[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], thereby worsening PTSD symptoms[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on the aforementioned associations between SS, IU, and PTSD, we hypothesized that IU may play a key mediating role in the relationship between SS and PTSD (Hypothesis 4).\u003c/p\u003e \u003cp\u003eInternet gaming disorder (IGD), as an important subtype of internet addiction, refers to individuals who cannot control, excessively, or compulsively play online games. This behavior causes impairments in their physiological, psychological, and social functions[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Gaming is often used as a coping strategy against distressing emotions and/or realistic problems[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Individuals lacking adequate SS may seek compensatory gratification through gaming, leading to excessive use[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], which may develop into IGD[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Furthermore, prolonged internet use may also trigger issues such as academic failure, which brings additional frustration[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Consequently, individuals with internet addiction exhibit heightened avoidance behaviors, negative cognitions, and negative emotions[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], which may further contribute to the development of PTSD. Previous research has established IGD as a mediator between SS and psychological pathologies like anxiety and depression[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Therefore, we hypothesized that IGD would similarly mediate the association between SS and PTSD (Hypothesis 5).\u003c/p\u003e \u003cp\u003eTo effectively address PTSD, it is essential to extend research beyond the direct relationship between SS and PTSD by exploring the underlying mechanisms. Therefore, this study examines the serial mediating roles of IU and IGD. The Interaction of Person-Affect-Cognition-Execution (I-PACE) model provides an integrative framework for internet-related disorders[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. It posits that an individual's core characteristics, which include social cognition (e.g., perceived SS), cognitive reactions in response to a situation (e.g., IU), constitute etiological factors involved in the development, maintenance, and relapse of various types of internet use disorders (e.g., excessive video gaming). Specifically, individuals with insufficient SS may exhibit higher levels of IU when confronting trauma-related stimuli. Such individuals may worry excessively about threats under uncertainty, while also underestimating their ability to handle these threats. This may result in them experiencing negative emotions more easily and adopting passive coping strategies, such as using online games to escape negative experiences brought about by uncertainty. This can lead to the consequences of IGD[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Furthermore, as a maladaptive coping strategy, IGD may interfere with effective coping with stressful events, ultimately leading to the onset of PTSD. Therefore, we hypothesized that SS may indirectly influence PTSD through the serial mediation of IU and IGD (Hypothesis 6).\u003c/p\u003e \u003cp\u003eThe present study investigates the longitudinal reciprocal associations between SS and PTSD among Chinese adolescents exposed to flood disasters. A cross-lagged model was constructed using data collected at two time points to analyze these dynamics (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Furthermore, extending this longitudinal framework, a serial mediation model was specified to examine the mediating roles of IU and IGD in the pathway from initial SS to subsequent PTSD (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e "},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Participants\u003c/h2\u003e \u003cp\u003eThe present study was conducted in a junior high school in Sichuan Province, China. Using a whole-group sampling method, students from 10 classes in Grade 7 were recruited as participants. Data collection occurred in two waves over a one-year period. At Time 1 (T1: October 2021), two months post-flood, 494 questionnaires were distributed and retrieved. One year later, at Time 2 (T2: October 2022), 478 questionnaires were distributed, with 403 valid responses collected. Both rounds of questionnaire surveys were completed under the guidance of mental health teachers. Some baseline participants did not participate in the follow-up survey due to reasons such as absence and school transfer. Participants who completed less than 90% of all the scales measured were excluded. Additionally, those suspected of not responding sincerely (i.e., all the answers were the same), or who missed one or more surveys were also excluded from the study. Finally, answers from 403 participants were included for further statistical analyses. The baseline age of the subjects was 12.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52 years, ranging from 11 to 14 years old. Among them, 240 (48.50%) were male and 254 (51.50%) were female.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Measures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Social support\u003c/h2\u003e \u003cp\u003eThe SS was assessed via the Chinese version of the Multidimensional Scale of Perceived Social Support (MSPSS)[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. The MSPSS includes 12 items with responses ranging from 1 (very strongly disagree) to 7 (very strongly agree)[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The MSPSS estimates SS quality from three sources: family, friends, and significant others[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. All item scores were added up and then divided by 12. Mean scores ranging from 1 to 2.99 were classified as low, 3 to 5 as medium, and 5.01 to 7 as high perceived support levels, respectively. In this sample, confirmatory factor analysis (CFA) was conducted on the scale using T1 data. The results indicated good structural validity: the normed chi-square (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e/df)\u0026thinsp;=\u0026thinsp;2.792, comparative fit index (CFI)\u0026thinsp;=\u0026thinsp;0.969, Tucker-Lewis index (TLI)\u0026thinsp;=\u0026thinsp;0.957, root mean squared error of approximation (RMSEA)\u0026thinsp;=\u0026thinsp;0.067. Additionally, The scale demonstrated good internal reliability, with Cronbach\u0026rsquo;s α coefficients of 0.915 and 0.947 at the two time points .\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Post-traumatic stress disorder\u003c/h2\u003e \u003cp\u003ePTSD was assessed using the PTSD Checklist for DSM-5 (PCL-5)[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The PCL-5 is a self-report measure consisting of 20 items. It covers the symptoms of PTSD, such as re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal. Each item reflects the severity of a particular symptom, which was rated on a five-point Likert scale from 0 (not at all) to 4 (extremely) during the previous month. A total symptom severity score (range 0\u0026ndash;80) can be obtained by summing the scores for each of the 20 items. The higher the total score, the more severe the PTSD level. This scale has been previously identified as being applicable to adolescents following a natural disaster[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. CFA was performed on the scale using T2 data. The results showed that the scale had good structural validity in this study (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;2.884, CFI\u0026thinsp;=\u0026thinsp;0.922, TLI\u0026thinsp;=\u0026thinsp;0.910, RMSEA\u0026thinsp;=\u0026thinsp;0.068). The scale also demonstrated good reliability, with Cronbach\u0026rsquo;s α coefficients of 0.920 and 0.929 at the two time points.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Intolerance of uncertainty\u003c/h2\u003e \u003cp\u003eIU was measured using the Chinese version of the Intolerance of Uncertainty Scale (IUS)[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The scale comprises 12 items. Responses were given on a 5-point Likert scale, ranging from 1 (completely inconsistent) to 5 (completely in conformity). Total scores range from 12 to 60, with higher scores indicating higher levels of IU. CFA was performed on the scale using T1 data. The analysis in this study yielded favorable results (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;2.374, CFI\u0026thinsp;=\u0026thinsp;0.967, TLI\u0026thinsp;=\u0026thinsp;0.954, RMSEA\u0026thinsp;=\u0026thinsp;0.058), supporting the good construct validity of the IUS. The scale exhibited good reliability, with Cronbach\u0026rsquo;s α coefficients of 0.887 and 0.915 at the two time points.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4 Internet gaming disorder\u003c/h2\u003e \u003cp\u003eThe severity of IGD symptoms was assessed using the Chinese version of Internet Gaming Disorder Scale-Short Form (IGDS9-SF)[\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. The Chinese version of IGDS-SF9 has good psychometric properties[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. It is a 9-item scale developed from the core symptoms of IGD proposed by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. It assesses excessive gaming behavior and its adverse effects in the past 12 months. All items are rated on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;never, 5\u0026thinsp;=\u0026thinsp;very often). Total scores of this scale range from 9 to 45. Higher scores represent more severe IGD symptoms. In this study, CFA was conducted on the scale using T2 data. The results showed that the scale had good structural validity (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;2.893, CFI\u0026thinsp;=\u0026thinsp;0.980, TLI\u0026thinsp;=\u0026thinsp;0.968, RMSEA\u0026thinsp;=\u0026thinsp;0.069). Cronbach\u0026rsquo;s α coefficients were 0.898 and 0.911 at the two time points, indicating reliable consistency.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Procedure\u003c/h2\u003e \u003cp\u003ePrior to the assessment, consent was obtained from the head teachers. The survey was administered uniformly in classrooms by mental health teachers on a class-by-class basis. The teachers read aloud the informed consent form and instructions in a unified manner. The total administration duration was approximately 30 minutes. Questionnaires were collected on the spot, and small gifts were presented to participants immediately as compensation. The study strictly adhered to the ethical guidelines of the Helsinki Declaration and was approved by the Academic Committee of Leshan Normal University (Approval No.: LNU-20210831P).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e \u003cp\u003eThe data were first analyzed using SPSS 27.0 for descriptive statistics and correlation analysis. Additionally, Harman's single-factor test was used to evaluate the common method bias derived from self-reported data[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Subsequently, Amos 24.0 was employed to construct a cross-lagged model to examine the relationship between SS and PTSD at two time points. This cross-lagged model was further extended to incorporate IU and IGD, enabling the analysis of the serial mediating effect between SS and PTSD. Thresholds were considered as follows: for CFI and TLI excellent fit\u0026thinsp;\u0026gt;\u0026thinsp;0.95 and moderate fit\u0026thinsp;\u0026gt;\u0026thinsp;0.90[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]; for RMSEA excellent fit\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and moderate fit\u0026thinsp;\u0026lt;\u0026thinsp;0.08[\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. A total of 5000 bootstrap samples were used to estimate the 95% confidence intervals. The mediating effects were considered to be significant when the 95% CI did not include zero. All results were standardized. Additionally, age and gender were controlled as covariates in the serial mediation analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Testing for common method bias\u003c/h2\u003e \u003cp\u003eHarman's single-factor test extracted 21 factors with eigenvalues greater than 1. The first factor explained 22.38% of the total variances, which is below the threshold of 40%[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Therefore, the data used in this study do not exhibit any discernible common method bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Descriptive statistics and correlation analysis\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the means, standard deviations, and correlations among the main variables in the current study. All the variables at T1 and T2 demonstrated significant correlations with one another. Correlation analysis indicated that at T1, SS was negatively correlated with IU (\u003cem\u003er\u003c/em\u003e = -0.136, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), IGD (\u003cem\u003er\u003c/em\u003e = -0.242, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and PTSD (\u003cem\u003er\u003c/em\u003e = -0.288, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). IU was positively correlated with IGD (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.448, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and PTSD (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.539, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). IGD was positively correlated with PTSD (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.374, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). At T2, SS was negatively correlated with IU (\u003cem\u003er\u003c/em\u003e = -0.250, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), IGD (\u003cem\u003er\u003c/em\u003e = -0.344, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and PTSD (\u003cem\u003er\u003c/em\u003e = -0.258, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). IU was positively correlated with IGD (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.404, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and PTSD (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.501, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). IGD was positively correlated with PTSD (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.288, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics and correlations among the main variables (N\u0026thinsp;=\u0026thinsp;403).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.SS(T1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43(31,53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.SS(T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41(25,52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.555**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.IU(T1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(22,38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.136**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.126*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.IU(T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(,22,37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.108*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.250**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.621**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.IGD(T1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(10,22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.242**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.216**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.448**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.283**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.IGD(T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(11,23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.167**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.344**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.309**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.404**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.693**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.PTSD(T1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(7,22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.288**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.246**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.539**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.418**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.374**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.298**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8.PTSD(T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(6,24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.282**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.258**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.371**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.501**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.272**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.288**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.692**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eNote: PTSD\u0026thinsp;=\u0026thinsp;Post-traumatic stress disorder; IGD\u0026thinsp;=\u0026thinsp;Internet gaming disorder; IU\u0026thinsp;=\u0026thinsp;Intolerance of uncertainty; SS\u0026thinsp;=\u0026thinsp;Social support. **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Cross-Lagged relationship between social support and PTSD\u003c/h2\u003e \u003cp\u003eBased on the correlation analysis, a cross-lagged model was conducted to explore the longitudinal relationship between SS and PTSD. The results showed that the model fit the data well (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;2.401, CFI\u0026thinsp;=\u0026thinsp;0.996, TLI\u0026thinsp;=\u0026thinsp;0.978, RMSEA\u0026thinsp;=\u0026thinsp;0.059). As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, SS at T1 significantly negatively predicted PTSD at T2 (\u003cem\u003eβ\u003c/em\u003e = -0.14, SE\u0026thinsp;=\u0026thinsp;0.034, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). PTSD at T1 significantly negatively predicted SS at T2 (\u003cem\u003eβ\u003c/em\u003e = -0.09, SE\u0026thinsp;=\u0026thinsp;0.058, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Mediating effects of Internet gaming disorder and intolerance of uncertainty between social support and PTSD\u003c/h2\u003e \u003cp\u003eAfter controlling for age and gender, we tested the serial mediation model. The model fit the data well: (\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;1.771, CFI\u0026thinsp;=\u0026thinsp;0.906, TLI\u0026thinsp;=\u0026thinsp;0.900, RMSEA\u0026thinsp;=\u0026thinsp;0.044. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e displays the standardized path coefficients for the direct effects in the model. SS (T1) was significantly negatively associated with IU (T1) (\u003cem\u003eβ\u003c/em\u003e = -0.20, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), which in turn was significantly positively associated with PTSD (T2) (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.28, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Furthermore, SS (T1) was significantly negatively associated with PTSD (T2) (\u003cem\u003eβ\u003c/em\u003e = -0.20, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Moreover, IGD (T2) was significantly positively associated with PTSD (T2) (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.33, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but the association between SS (T1) and IGD (T2) was not significant (\u003cem\u003eβ\u003c/em\u003e = -0.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Finally, IU (T1) was significantly positively associated with IGD (T2) (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.38, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003c/p\u003e \u003cp\u003eIn addition, to test the significance of each mediating effect, 95% confidence intervals (CI) were estimated using the bootstrapping method. If the resulting CI does not contain zero, it indicates a significant mediating effect. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the results showed the mediating effects. The total effect of SS on PTSD was significant (effect = -0.297, 95% CI = [-0.394, -0.119]). Furthermore, SS had a significant indirect effect on PTSD through IU (effect = -0.057, 95% CI = [-0.102, -0.026]), accounting for 19.2% of the total effect; however, the indirect effect of SS on PTSD through IGD was not significant (effect = -0.013, 95% CI = [-0.051,0.021]). The serial mediation effect was significant (effect = -0.026, 95% CI = [-0.049, -0.010]), accounting for 8.8% of the total effect.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe serial mediation effects of model (N\u0026thinsp;=\u0026thinsp;403)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eModel pathways\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eeffects\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBoot SE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e95% confidence interval\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBoot LLCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBoot ULCI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSS(T1)\u0026rarr;IU(T1)\u0026rarr;PTSD(T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSS(T1)\u0026rarr;IGD(T2)\u0026rarr;PTSD(T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSS(T1)\u0026rarr;IU(T1)\u0026rarr;IGD(T2)\u0026rarr;PTSD(T2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.199\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal indirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: SS\u0026thinsp;=\u0026thinsp;Social support; IU\u0026thinsp;=\u0026thinsp;Intolerance of uncertainty; IGD\u0026thinsp;=\u0026thinsp;Internet gaming disorder; PTSD\u0026thinsp;=\u0026thinsp;Post-traumatic stress disorder. Boot SE, Boot LLCI, and Boot ULCI refer to the standard errors and the upper and lower bounds of the 95% confidence intervals of the indirect effects estimated by the bootstrap method, respectively.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"4 Discussion","content":"\u003cp\u003eThe present study employed a cross-lagged model to investigate the reciprocal relationships between SS and PTSD among adolescents exposed to a flood disaster. Based on this, a serial mediation model involving IU and IGD was constructed to investigate the mediating mechanisms through which SS influences PTSD. The study found a significant bidirectional relationship between SS and PTSD, and that IU and IGD played a serial mediating role in this relationship.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Reciprocal relationship between social support and PTSD\u003c/h2\u003e \u003cp\u003eResults indicated significant correlations between SS and PTSD at both T1 and T2. This correlation had cross-temporal stability. Cross-lagged analysis revealed that SS at T1 significantly and negatively predicted PTSD at T2. This finding supports Hypothesis 1, aligning with the social causation model[\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Specifically, adequate SS functions as a crucial protective factor that effectively alleviates individuals' negative emotions following trauma. It also promotes the adoption of positive coping strategies and enhances psychological resilience. This process helps prevent and reduce the incidence of PTSD.\u003c/p\u003e \u003cp\u003eSimultaneously, PTSD at T1 significantly and negatively predicted SS at T2, supporting Hypothesis 2. This finding aligns with the social selection model, which posits that psychological distress may decrease SS levels[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Specifically, trauma may distort an individual's perception of available support, rendering them less receptive to assistance from others. Alternatively, PTSD symptoms (e.g., withdrawal, angry outburst, avoiding, negative cognition and emotions) may lead individuals to alienate others in their social networks[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], while also reducing their willingness to seek SS. Furthermore, the relatives and friends of individuals with psychiatric disorders may accumulate stress and reduce supportive behaviors when living with or caring for them. This may further weaken the patients' SS[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCollectively, the current findings corroborate a robust bidirectional relationship between SS and PTSD, supporting Hypothesis 3, indicating that the two can influence each other over time. This conclusion is consistent with the results of two previous meta-analyses[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], which documented a bidirectional relationship between PTSD and SS. Specifically, while SS influences the risk and severity of PTSD over time, the disorder subsequently erodes an individual's level of SS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.2 The mediating role of intolerance of uncertainty\u003c/h2\u003e \u003cp\u003eOur findings demonstrated that IU significantly mediated the relationship between SS and PTSD, supporting Hypothesis 4. The first path of this mediating effect showed that SS significantly and negatively predicted IU. This aligns with previous research indicating that individuals with more SS exhibit lower levels of IU[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. When individuals perceive more SS, they tend to display greater confidence in their ability to cope with uncertain environments. This enhanced sense of control can effectively diminish IU[\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, the second path of the mediating effect revealed that IU significantly and positively predicted PTSD. This is consistent with prior studies identifying IU as a significant and robust predictor of PTSD symptoms[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Existing studies suggests that individuals with elevated levels of IU may develop an exaggerated perception of threat following trauma. This leads to heightened avoidance behaviors due to uncertainty.[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Moreover, IU, as a tendency to respond negatively to uncertain situations and events, essentially reflects the worry about the uncertainty in the future[\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. The repeated experience of these sensations can contribute to the development of PTSD[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, these mechanisms elucidate how SS indirectly influences PTSD via an individual's IU levels. When facing an insufficient SS, individuals may struggle to access necessary psychological resources during recovery from a traumatic event. This may exacerbate their feelings of ambiguity and loss of control over potential future threats, thereby elevating their IU levels. This negative response tendency can keep individuals in a state of avoidance, ultimately reinforcing the core symptoms of PTSD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.3 The mediating role of Internet gaming disorder\u003c/h2\u003e \u003cp\u003eIn the current study, the independent mediating role of IGD in the relationship between SS and PTSD was not significant, thus, Hypothesis 5 was not supported. Specifically, the predictive effect of SS on IGD lacked statistical significance. Although previous research has documented a significant negative association between SS and IGD[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], this finding was not replicated in our sample. One plausible explanation is that some individuals may develop online relationships through gaming, thereby acquiring support from their online friends. This online social reward might inadvertently reinforce, rather than mitigate, IGD tendencies[\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. The present study did not evaluate online and offline SS separately, which may have confounded the overall results. Future research should delineate the distinct impacts of virtual versus real-world support on IGD. Alternatively, the mechanism linking SS to PTSD may be more complex, necessitating additional variables. Therefore, the single IGD pathway alone is insufficient to fully capture this relationship.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.4 The serial mediating role of intolerance of uncertainty and Internet gaming disorder\u003c/h2\u003e \u003cp\u003eOur findings further demonstrated that SS influences PTSD through the serial mediation of IU and IGD, supporting Hypothesis 6. Consistent with the I-PACE model, individuals with insufficient SS may be more susceptible to intense emotional distress when confronting uncertainty. Consequently, they exhibit elevated levels of IU. To mitigate the distress and anxiety induced by this uncertainty, these individuals often turn to online gaming. This maladaptive coping strategy allows them to divert attention from perceived threats. Simultaneously, it delivers a level of satisfaction often unattainable in the offline world[\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Over time, individuals with high IU may become increasingly reliant on internet games to escape uncertainty, ultimately culminating in IGD. Subsequently, individuals with IGD symptoms habitually utilize video games as a temporary distraction from negative trauma-related experiences and emotions[\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. This behavior further compromises their mental health, ultimately precipitating the development or exacerbation of PTSD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Implications\u003c/h2\u003e \u003cp\u003eThis study offers several vital theoretical implications. First, it elucidates a significant bidirectional relationship between SS and PTSD among adolescents experiencing natural disaster. This finding corroborates both the social causation and social selection models, enhancing our comprehension of the intricate relationship between SS and PTSD. Second, our findings indicate that adolescents' SS can indirectly influence PTSD through the serial mediation of IU and IGD. Consequently, addressing cognitive vulnerabilities (IU) and maladaptive behaviors (IGD) linked to SS deficits is crucial. This perspective provides a novel theoretical framework for early PTSD interventions.\u003c/p\u003e \u003cp\u003eFurthermore, these findings yield substantial clinical implications for the prevention and treatment of PTSD. To effectively mitigate post-traumatic cognitive biases and problematic behaviors in adolescents, future therapeutic practices should specifically target IU and IGD. Considering the beneficial effects of mindfulness training on both IU and IGD[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e], future mindfulness intervention programs could incorporate content targeting these factors. For instance, mindfulness-based strategies can be employed to mitigate avoidant gaming behavior. This approach serves as a valuable adjunctive pathway for managing PTSD symptoms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Limitations and future directions\u003c/h2\u003e \u003cp\u003eSeveral limitations of the current study should be acknowledged. First, the reliance on only two waves of measurement with a one-year interval limits the ability to ascertain the long-term stability of the observed effects. To address this, multi-wave longitudinal designs with more frequent follow-ups should be employed in future research. Second, PTSD was assessed using a self-report symptom checklist rather than a clinical diagnostic measure. Future studies could incorporate objective physiological indicators of PTSD risk, such as cortisol levels, heart rate, and blood pressure[\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Finally, the sample was restricted to seventh-grade students, which constrains the generalizability of the findings to adolescents of other age groups. Subsequent research should encompass more diverse adolescent cohorts across various grade levels.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eThe present study yields the following main conclusions: (1) SS serves as a crucial protective factor against PTSD among adolescents experiencing a flood disaster. (2) A significant bidirectional relationship exists between SS and PTSD, indicating that they reciprocally influence each other over time. (3) SS indirectly affects PTSD through the serial mediation of IU and subsequent IGD.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFootnotes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePublisher\u0026rsquo;s note\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\u003c/p\u003e\n\u003cp\u003eXu Ding, and Shuang Su contribute equally to this work and joint first authors.\u003c/p\u003e\n\u003cp\u003eYan Cao, and Ru Tao contribute equally to supervise this work and joint corresponding authors.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe study strictly adhered to the ethical guidelines of the Helsinki Declaration and was approved by the Academic Committee of Leshan Normal University (Approval No.: LNU-20210831P). Informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was supported by the the Natural Science Foundation of Shandong Province (Grant. ZR2025QC2044Z).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eXD designed the study. SS processed the data. XD and SS wrote original draft. WQL, JYW, KQW and XTS collected the data and performed the data analysis and its interpretation.RT and YC completed review and revised the manuscript. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank all participants for their involvement in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data set used and analyzed during the current study is available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhang W, Duan G, Xu Q, Jia Z, Bai Z, Liu W, et al. A Cross-sectional Study on Posttraumatic Stress Disorder and General Psychiatric Morbidity Among Adult Survivors 3 Years After the Wenchuan Earthquake, China. Asia Pac J Public Health. 2015;27(8):860\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePan X, Liu W, Deng G, Liu T, Yan J, Tang Y, et al. 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Clin Psychol Rev. 2016;49:79\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescents, Social support, Post-traumatic stress disorder, Intolerance of uncertainty, Internet gaming disorder","lastPublishedDoi":"10.21203/rs.3.rs-9009204/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9009204/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFloods severely disrupt the daily lives of adolescents and pose a significant threat to their mental health. Understanding the mechanisms underlying the maintenance of post-traumatic stress disorder (PTSD) is crucial for its prevention and intervention. This study aimed to examine the reciprocal relationship between social support (SS) and PTSD among Chinese adolescents following a flood, specifically exploring the mediating roles of intolerance of uncertainty (IU) and Internet gaming disorder (IGD). It was hypothesized that SS would have a direct effect on PTSD as well as being mediated by IU and IGD.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 403 junior high school students (Mean\u003csub\u003eage\u003c/sub\u003e = 12.32 years, SD\u003csub\u003eage\u003c/sub\u003e = 0.52; 50.5% female) were recruited using whole-group sampling and followed up across two waves with a one-year interval. Time 1 (T1) data were collected 2 months after the flood, and Time 2 (T2) data were collected 14 months after the flood. Participants completed self-report questionnaires regarding SS, PTSD, IU, and IGD. Structural equation modeling was used to examine the relationships among the four variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e(1) a bidirectional relationship exists between SS and PTSD; (2) IU mediates the association between SS and PTSD; (3) IU and IGD play a serial mediating role in the link between SS and subsequent PTSD symptoms.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ethe results of the present study underscore the importance of enhancing SS, reducing IU, and addressing IGD to mitigate PTSD risk among adolescents exposed to natural disasters.\u003c/p\u003e","manuscriptTitle":"The longitudinal relationship between social support and post- traumatic stress disorder among Chinese adolescents following a flood: The serial mediating roles of intolerance of uncertainty and Internet gaming disorder","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 07:06:24","doi":"10.21203/rs.3.rs-9009204/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-12T14:23:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338235561336587140495426845708087952131","date":"2026-05-06T06:44:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T15:44:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-10T18:59:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-07T00:38:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-07T00:38:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-02T10:49:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"84a33111-49fc-4904-8d7e-110eb9830da7","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-12T14:23:44+00:00","index":79,"fulltext":""},{"type":"reviewerAgreed","content":"338235561336587140495426845708087952131","date":"2026-05-06T06:44:38+00:00","index":75,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T07:06:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 07:06:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9009204","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9009204","identity":"rs-9009204","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}