Psychological Distress and Trauma Response Among War-Exposed Young Adults in Gaza

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In this study, we measured anxiety, depression, and post-traumatic stress disorder (PTSD) and examined their associations with displacement, accommodation, and war-related traumatic events among young adults from Gaza. A cross-sectional online survey conducted between October and December 2024 included 604 participants (mean age 21.4 ± 1.6 years) who lived through the war, using validated measures for anxiety, depression, PTSD, and a war-traumatic events checklist. Clinically significant symptoms were highly prevalent, with abnormal anxiety in 60.8% of participants, abnormal depression in 18.2% (plus 41.7% borderline), and probable PTSD in 76.5%. High trauma exposure (≥ 10 events) affected 37.1% of respondents, and displacement as well as residence in shelters were associated with greater overall distress. Cumulative trauma correlated positively with depression severity but inversely with self-reported PTSD and anxiety scores, and depression was linked to specific trauma types such as being besieged and witnessing the prevention of an ambulance from providing aid. These findings indicate a severe and complex mental-health crisis among Gaza’s young adults, in which repeated exposure appears to shift symptom expression toward depressive and morally injurious presentations and away from fear-based arousal. The results underscore the need for culturally sensitive, targeted mental-health interventions. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Biological sciences/Psychology Social science/Psychology Health sciences/Risk factors Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Armed conflicts are increasingly recognised as global public health emergencies, with devastating consequences for both physical and psychological well-being, often surpassing the burden of many major diseases. 1 – 4 Beyond immediate mortality and disability, wars profoundly disrupt social structures, leading to poverty, displacement, overcrowding, and insecurity, all of which heighten vulnerability to mental health conditions. Extensive research consistently identifies depression, anxiety, and post-traumatic stress disorder (PTSD) as predominant psychiatric sequelae among survivors of armed conflicts. 5–7 It is estimated that approximately 10% of individuals exposed to traumatic events during conflicts will develop severe mental health problems, while an additional 10% will present with functional impairments that hinder daily life. 1 , 4 , 8 , 9 Other reports suggest that up to one in five people in conflict-affected populations experience a spectrum of mental health symptoms, with prevalence rates of anxiety, depression, and PTSD being two- to three-fold higher compared to non-exposed populations 1 , 10 . Importantly, the intensity and frequency of trauma exposure are closely associated with the severity of psychiatric comorbidities. 5 , 11 , 12 Such enduring psychological harm extends beyond individuals, impairing social functioning, heightening the risk of substance abuse, and ultimately contributing significantly to the global burden of disease if left untreated. 6,9 The Gaza Strip, a small area in Palestine, has been a site of protracted conflict. The latest war, which began on October 7, 2023, is ongoing at the time of this research. 13 , 14 According to recent reports, more than 60,000 people have been killed. 15 Since the war's inception, residents of Gaza have lost access to water, electricity, food, and their homes, with families frequently displaced. These challenging conditions are expected to profoundly affect the population's mental health. 2 , 16 The recent assault on Gaza has resulted in severe and long-lasting psychological consequences for its population. The collapse of health and mental health systems has left people to endure trauma, grief, and fear without adequate support. 13 , 14 Widespread destruction and displacement have created significant challenges for psychosocial well-being, leading to high rates of depression, anxiety, and stress that disrupt family and community life. 17 Alarmingly high rates of depression, anxiety, and stress have been reported in Gaza, particularly among families repeatedly forced to change their shelter, underscoring the urgent need for effective interventions 17 However, the interplay between different trauma-related exposures and their psychological consequences remains poorly characterised. This study used a large sample of war-exposed university students to i) quantify the prevalence and overlap of anxiety, depression, PTSD, and trauma; ii) test displacement and accommodation effects; and iii) disentangle how trauma severity and event types map onto symptom clusters beyond aggregate point estimates. By combining validated self-report instruments with both cumulative and item-level trauma analyses, the work aims to clarify psychopathological patterns related to different degrees and types of trauma and to inform culturally sensitive screening and intervention priorities under protracted conflict. Methods Study Design and Participants This descriptive, cross-sectional online study was conducted between October and December 2024 among Palestinians directly affected by the ongoing war in Gaza. Participants were recruited from Medical students studying at Al-Azhar University and the Islamic University in Gaza. Individuals were excluded if they were younger than 18 years or if they had a previously diagnosed psychiatric or neurological condition. A total of 604 participants were recruited. All participants provided informed consent for participating, and data were collected in accordance with local guidelines set out by the Palestinian Ministry of Health. The study was approved by the Palestinian Health Research Council Helsinki Committee (Reference Number: PHRC/HC/1187/24). Psychological Measures Data were collected using a self-administered, anonymous online questionnaire designed in Google Forms. The survey link was distributed through social media platforms and student groups to maximise reach among the target population. Convenience sampling was used, and participation was voluntary and open to all eligible participants. The questionnaire collected demographic data, including age, gender, study year, university, place of residence (Gaza, West Bank, abroad), and accommodation type in Gaza (house, tent, shelter centre, or student accommodation). In addition, the survey included the following standardised instruments: the Hospital Anxiety and Depression Scale (HADS), 18 the PTSD Checklist for DSM-5 (PCL-5), 19 and the War-Traumatic Events Checklist (W-TECh) (Table S1). 20 HADS consists of 14 items (7 assessing anxiety and 7 assessing depression), each scored on a scale of 0–21. It classifies symptoms into three categories: Normal (0–7, probable absence), Borderline (8–10, possible presence), and Abnormal (11–21, probable presence) of anxiety and/or depression. The PCL-5 includes 20 items corresponding to DSM-5 criteria, with a total symptom severity score ranging from 0 to 80; a cutoff score of 31–33 indicates probable PTSD. The W-TECh consists of 19 questions with a total score range of 0–19, classifying traumatic exposure as low (< 5), moderate (5–9), or high (≥ 10). It was adopted from a longer list of questions previously used to examine trauma in children. Statistical Analysis Data analysis and visualisation were conducted in R (v4.4.1) and MATLAB (v2024b). Multiple linear regression models using the fitlm function in MATLAB were used to examine the effect of trauma exposure, gender, residence, and accommodation on anxiety, depression, and PTSD. A similar model was used to examine the effect of demographic variables on trauma exposure scores. The relationship between trauma exposure level and psychological outcomes was visualised using a sliding window approach with fixed trauma-quantile widths moved along the score distribution (using a 20% Gaussian kernel code: conditionalPlot.m available: https://osf.io/vmabg/ ). To qualitatively determine how different types of trauma correlate with psychological morbidity, each item of the W-TECh list was correlated with depression, anxiety and PTSD score, controlling for total trauma exposure score and correcting for multiple comparisons. Multiple correlation testing was performed using the regress function in MATLAB and corrected for multiple comparisons using the FDR method. Results Demographics The study included 604 participants ( mean age 21.4 ± 1.6 years, 47.7% females). 65.6% of the participants lived in Southern Gaza, 12.3% in Northern Gaza, 20.9% abroad, and 1.3% in the West Bank. Accommodation types varied, with most students residing in houses (58.4%), followed by tents (26.0%), student accommodation (9.9%), and shelter centres (5.6%) (Table 1 ). Table 1 Sample Demographics. Variable Category Count Mean ± SD Percentage Age 604 21.4 ± 1.6 Gender Male 246 40.7% Female 358 59.3% Residence South Gaza 396 65.6% North Gaza 74 12.3% Abroad: International 126 20.9% Abroad: West Bank 8 1.3% Accommodation House 353 58.4% Tent 157 26.0% Shelter Center 34 5.6% Other 60 9.9% High levels of psychological distress in young adults in Gaza Trauma exposure levels varied among participants, with 37.1% experiencing high exposure, 50.7% moderate exposure, and 12.3% low exposure ( Fig. 1 A ). Regarding depression, 18.2% of participants were classified as abnormal, 41.7% as borderline, and 40.1% as normal. For anxiety, 60.8% of students were classified as abnormal, 23.3% as borderline, and 15.9% as normal. PTSD symptoms were prevalent, with 76.5% categorised as having Probable PTSD and 23.5% showing minimal or no symptoms. A significant overlap was observed among these psychological categories, as visualised in the Venn Diagram in Fig. 1 . Higher Trauma Levels in Externally Displaced We next investigated the effect of displacement on psychological outcomes and trauma reports. There was no significant difference in Anxiety, depression or PTSD reports between individuals who completed the questionnaires while in Gaza or after leaving abroad (Fig. 2 ). However, participants who left Gaza reported significantly higher trauma exposure compared to individuals who stayed in Gaza ( β = 0.18, IRR = 1.20, 95% CI [1.10, 1.30], p < 0.001; Table S2). These results did not change when reanalysing the data after exclusion of questions about displacement (WTEC9) from the W-TECh questionnaire. Individuals living in tents ( β = − 0.12, IRR = 0.89, 95% CI [0.83, 0.95], p < 0.001) or shelters ( β = − 0.18, IRR = 0.84, 95% CI [0.74, 0.96], p = 0.008) reported lower trauma exposure compared to people living in houses. In contrast, PTSD severity was significantly higher among shelter residents compared to those living in houses ( β = 7.51, 95% CI [2.06, 12.97], p = 0.007). There were no significant differences in anxiety or depression between house residents and participants in other accommodation types (all p > 0.05). Higher trauma exposure is associated with emotional blunting Participants with higher trauma exposure showed higher severity of depression ( r = 0.13, p corr = 0.0023, Fig. 3 A–B). In contrast, both PTSD and anxiety severity were lower with higher trauma scores ( r = − 0.35, p corr < 0.001; r = − 0.23, p corr < 0.001, respectively). These patterns were consistent across gender groups, with no significant interaction between gender and trauma exposure (Fig. 3 B). Notably, Female participants had higher levels of anxiety ( β = 1.95, 95% CI [1.32, 2.58], p < 0.001) and PTSD ( β = 5.64, 95% CI [3.10, 8.18], p < 0.001) compared to males, who reported higher levels of depression ( β = − 0.63, 95% CI [–1.07, − 0.20], p = 0.004) (Fig. 2 B, Table S3). Effect of different trauma types on psychological outcomes While multiple traumatic events correlated with both anxiety and PTSD (13 out of 19 event types; Fig. 4 , Table S4), only three trauma types were significantly associated with depression. The strongest correlation was observed for witnessing ambulance prevented from saving people (WTEC15) ( r = 0.15, 95% CI [0.08, 0.23], p FDR < 0.001), followed by witnessing body parts (WTEC15) ( r = 0.13, 95% CI [0.05, 0.21], p FDR = 0.0037), and being trapped or besieged (WTEC16) ( r = 0.12, 95% CI [0.04, 0.20], p FDR = 0.006). In contrast, anxiety and PTSD showed consistent negative associations with a wide range of traumatic exposures, with the strongest effects observed for events such as witnessing family members injured (WTEC7)(Anxiety: r = − 0.19, p FDR < 0.001; PTSD: r = − 0.25, p FDR < 0.001) and witnessing shooting (WTEC12) (Anxiety: r = − 0.15, p FDR = 0.001; PTSD: r = − 0.23, p FDR < 0.001). Discussion This study reports extremely high levels of psychological distress in a sample of young adults surveyed during October–December 2024. More than three-quarters (76.5%) met a PCL-5 threshold consistent with probable PTSD, and over 60% scored in the “abnormal” range for anxiety; figures that exceed pooled prevalence estimates reported for many conflict-affected populations and indicate a severe, concentrated burden in this cohort. 8 Depression was also common: 18.2% scored as abnormal and an additional 41.7% as borderline on the HADS depression subscale. These results align with other recent surveys in the region showing elevated rates of depression and PTSD during the ongoing crisis. 5 , 13 , 14 , 17 Two sets of findings require careful interpretation. First, students who had left Gaza reported higher cumulative trauma exposure than those who remained; second, higher cumulative trauma exposure was positively associated with depressive symptoms but negatively associated with PTSD and anxiety severity. The first finding is plausible: those who left Gaza may have been compelled to endure extreme events (for example, evacuation under fire, interrupted access to medical care, family separation), and therefore, those who left Gaza may have incurred a larger burden of trauma before reaching relative safety. This pattern is consistent with evidence that forcibly displaced populations frequently report high cumulative and repeated traumatic exposures and elevated psychiatric morbidity. 21 , 22 The second finding (the inverse correlations between trauma exposure and measured PTSD/anxiety) seems counterintuitive at face value; however, several non-mutually exclusive explanations could account for it. One possibility is emotional numbing/dissociation and adaptive (but could be maladaptive long-term) affect-regulation strategies that can result from repeated or prolonged trauma exposure. 23 , 24 PTSD as a psychological construct includes symptoms of numbing and avoidance; repeated trauma can produce blunted subjective arousal or dissociative responses that attenuate symptom expression on self-report measures while functional impairment remains high. 25 , 26 Neurobiological and clinical models note that both hyperarousal and restricted affect can co-exist in trauma survivors, and emotion-transition studies suggest rapid shifts between neutral and negative states that complicate cross-sectional measurement. 27 , 28 Thus, lower self-reported anxiety or re-experiencing in the context of high cumulative exposure may reflect genuine numbing or dissociation rather than reduced psychopathology. A second explanation is measurement artefact or construct misalignment. Instruments like the PCL-5 and HADS have good psychometric properties in many settings, but their sensitivity and specificity can change across cultures and in populations experiencing chronic and repeated exposure. The W-TECh captures type and number of war-related events, but simple counts of events do not measure subjective appraisal, timing, peritraumatic reactions, or chronicity — all of which could moderate symptom expression. Repeated exposures can also change how items are interpreted (for example, somatic symptoms may be normalised or reclassified), producing apparent inverse associations. Cross-cultural validation work cautions that cut-offs and item interpretations may shift in non-Western or heavily traumatised populations. 29 , 30 More locally adapted tools or diagnostic interviews with mixed methods may yield different prevalence estimates or associations. Such work is an important avenue for future research and investigation. Third, selection and sampling biases inherent in a convenience, online sample of medical students may distort associations: participants who left Gaza may differ systematically (for example, in mobility, internet access, or willingness to report distress) from those who remained, and the most severely affected individuals may have been unable to participate (survivorship/attrition bias). 5 , 31 Finally, the negative correlations could represent a genuine but complex clinical pattern: repeated trauma may shift the dominant syndrome from fear-based re-experiencing to low-mood presentations dominated by hopelessness and anhedonia, or different exposures may preferentially precipitate depressive rather than anxious symptom clusters depending on individual and contextual moderators.32,33 It is crucial to highlight that such an association still occurs in the psychological spectrum of clinically significant anxiety and PTSD. In other words, higher depression and lower anxiety and PTSD with higher trauma does not imply that participants at relatively lower trauma scores do not express significant anxiety and PTSD. An additional, and clinically informative, possibility is that a small subset of event-types drives this pattern because of their particular psychological qualities. Specifically, entrapment or siege (WTECh4), events in which ambulances or lifesaving care are prevented (WTECh15) and direct exposure to mutilation or body parts (WTECh16) share mechanisms that preferentially precipitate depressive symptomatology. Perceived defeat/entrapment might foster hopelessness and behavioural withdrawal; exposure to events that thwart lifesaving efforts can constitute potentially morally injurious events that generate guilt, shame and social-moral distress; and intensely graphic sensory exposures produce high peritraumatic distress and intrusive imagery that, over time, may evolve into pervasive low mood and functional impairment. 24 , 25 , 34 – 37 These mechanisms are supported by meta-analytic and theoretical work on defeat/entrapment and depression, the moral-injury literature, and empirical studies showing that graphic exposures amplify distress and that peritraumatic dissociation or numbing can alter symptom expression on self-report measures. 38 – 40 Taken together, these pathways make it plausible that WTEC4, WTEC15 and WTEC16 would show stronger and more specific associations with depression than with conventional self-reported indices of re-experiencing or anxiety. In summary, this study highlights significant trauma-related psychopathology among young adults in Gaza, characterised by complex patterns including high rates of probable PTSD and anxiety alongside a dissociation between cumulative trauma and self-reported distress, with depression increasing while anxiety and PTSD symptoms decrease at higher trauma levels. These findings underscore the need for clinical assessments that go beyond standard screening, inform the design of targeted interventions addressing apathy and emotional numbing, and advance scientific understanding of trauma response heterogeneity in protracted conflict. Declarations Competing interests The authors declare no competing interests. Funding Declaration B.A. is supported by an NIHR academic clinical lectureship. Author Contribution T.A. and S.A. are co-first authors and contributed equally to this work.T.A. contributed to writing the Introduction and Methods sections.S.A. conducted the data analysis and contributed to the Introduction, Methods, and Discussion sections.R.A. contributed to writing the Results section.H.A. contributed to writing the Introduction section.S.T. performed the data analysis.N.G. contributed to writing the Results section.M.G.A. wrote the Abstract and Conclusion.M.J. supervised the study.M.Z. supervised the study.B.A. contributed to writing the Abstract, Results and Conclusion, prepared all figures and graphics, and also supervised the study. Data Availability The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request. References Charlson, F. et al. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. Lancet Lond. Engl. 394 , 240–248 (2019). MURTHY, R. S. & LAKSHMINARAYANA, R. Mental health consequences of war: a brief review of research findings. World Psychiatry . 5 , 25–30 (2006). Riad, A. et al. Mental Health Burden of the Russian–Ukrainian War 2022 (RUW-22): Anxiety and Depression Levels among Young Adults in Central Europe. Int. J. Environ. Res. Public. Health . 19 , 8418 (2022). Vesco, P. et al. The impacts of armed conflict on human development: A review of the literature. World Dev. 187 , 106806 (2025). Aldabbour, B. et al. Psychological impacts of the Gaza war on Palestinian young adults: a cross-sectional study of depression, anxiety, stress, and PTSD symptoms. BMC Psychol. 12 , 696 (2024). Levi-Belz, Y., Groweiss, Y., Blank, C. & Neria, Y. PTSD, depression, and anxiety after the October 7, 2023 attack in Israel: a nationwide prospective study. eClinicalMedicine 68 , (2024). Murray, C. J. L., King, G., Lopez, A. D., Tomijima, N. & Krug, E. G. Armed conflict as a public health problem. BMJ 324 , 346–349 (2002). Lim, I. C. Z. Y. et al. Prevalence of depression, anxiety and post-traumatic stress in war- and conflict-afflicted areas: A meta-analysis. Front. Psychiatry . 13 , 978703 (2022). Morina, N., Stam, K., Pollet, T. V. & Priebe, S. Prevalence of depression and posttraumatic stress disorder in adult civilian survivors of war who stay in war-afflicted regions. A systematic review and meta-analysis of epidemiological studies. J. Affect. Disord . 239 , 328–338 (2018). Ahmed, S. H. et al. Prevalence of post-traumatic stress disorder and depressive symptoms among civilians residing in armed conflict-affected regions: a systematic review and meta-analysis. Gen Psychiatry 37 , (2024). Amsalem, D. et al. The effects of war-related experiences on mental health symptoms of individuals living in conflict zones: a longitudinal study. Sci. Rep. 15 , 889 (2025). Østergaard, M. L. D. et al. Vulnerability factors in conflict-related mental health. Med. Confl. Surviv. (2022). https://www.tandfonline.com/doi/abs/10.1080/13623699 .2156232 (2023). Aldabbour, B. et al. The Psychological Toll of War and Forced Displacement in Gaza: A Study on Anxiety, PTSD, and Depression. Chronic Stress . 9 , 24705470251334943 (2025). Zughbur, M. R. et al. Prevalence and correlates of anxiety, depression, and symptoms of trauma among Palestinian adults in Gaza after a year of war: a cross-sectional study. Confl. Health . 19 , 43 (2025). Jamaluddine, Z., Abukmail, H., Aly, S., Campbell, O. M. R. & Checchi, F. Traumatic injury mortality in the Gaza Strip from Oct 7, 2023, to June 30, 2024: a capture–recapture analysis. Lancet 405 , 469–477 (2025). Javed, A. & Wars Conflicts & Mental Health. Pak J. Med. Sci. 40 , 797–799 (2024). Albelbeisi, A. H., Hajizadeh, A., Al-Zeer, A. M., Saeidpour, J. & Kakemam, E. Prevalence and associated factors of mental health disorders among internally displaced persons in Gaza. East. Mediterr. Health J. Rev. Sante Mediterr. Orient. Al-Majallah Al-Sihhiyah Li-Sharq Al-Mutawassit . 31 , 81–88 (2025). Zigmond, A. S. & Snaith, R. P. The hospital anxiety and depression scale. Acta Psychiatr Scand. 67 , 361–370 (1983). Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K. & Domino, J. L. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. J. Trauma. Stress . 28 , 489–498 (2015). Veronese, G., Mahamid, F., Bdier, D., Obaid, H. & Cavazzoni, F. The development and validation of the Palestinian children’s traumatic events checklist in a war-torn environment. BMC Psychiatry . 24 , 254 (2024). Nickerson, A. et al. Trauma and Mental Health in Forcibly Displaced Populations: An International Society for Traumatic Stress Studies Briefing Paper. (2017). https://research.regionh.dk/en/publications/trauma-and-mental-health-in-forcibly-displaced-populations-an-int Stevenson, K. et al. The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis. Lancet Public. Health . 8 , e203–e216 (2023). Thompson-Hollands, J., Marx, B. P., Lee, D. J. & Sloan, D. M. Longitudinal Change in Self-Reported Peritraumatic Dissociation During and After a Course of Posttraumatic Stress Disorder Treatment: Contributions of Symptom Severity and Time. Psychol. Trauma. Theory Res. Pract. Policy . 13 , 665–672 (2021). Werner, K. B. & Griffin, M. G. Peritraumatic and Persistent Dissociation as Predictors of PTSD Symptoms in a Female Cohort. J. Trauma. Stress . 25 , 401–407 (2012). Litz, B. T., Litz, B. T. & Gray, M. J. Emotional Numbing in Posttraumatic Stress Disorder: Current and Future Research Directions. Aust N Z. J. Psychiatry . 36 , 198–204 (2002). Bryant, R. A. Post-traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. World Psychiatry . 18 , 259–269 (2019). Bryant, R. A. A critical review of mechanisms of adaptation to trauma: Implications for early interventions for posttraumatic stress disorder. Clin. Psychol. Rev. 85 , 101981 (2021). Bowen, A. M., Calder, R., Neale, J., Meynen, T. & Gilchrist, G. Emotion Regulation in the Association Between Posttraumatic Stress Disorder and Substance Use: A Systematic Review With Narrative Synthesis. Trauma. Violence Abuse . 15248380241306362 10.1177/15248380241306362 (2024). Alhalaiqa, F. et al. Psychometric Properties of the Posttraumatic Stress Disorder Checklist among the Lebanese Population Exposed to the Beirut Explosion: A Cross-Sectional Study during the COVID-19 Pandemic. Behav. Neurol. 9286562 (2023). (2023). Hoffman, J. et al. Mapping the availability of translated versions of posttraumatic stress disorder screening questionnaires for adults: A scoping review. Eur J. Psychotraumatology 13 , 2143019 . Vukčević Marković, M., Bobić, A. & Živanović, M. The effects of traumatic experiences during transit and pushback on the mental health of refugees, asylum seekers, and migrants. Eur. J. Psychotraumatology . 14 , 2163064 (2023). Ahmadi, F., Goodarzi, M. A., Taghavi, M. R. & Imani, M. Modeling the structural relationships between trauma exposure with substance use tendency, depression symptoms, and suicidal thoughts in individuals with earthquake trauma experience: the mediatory role of peritraumatic dissociation and experiential avoidance. BMC Psychiatry . 24 , 171 (2024). Maier, S. F. & Seligman, M. E. P. Learned Helplessness at Fifty: Insights from Neuroscience. Psychol. Rev. 123 , 349–367 (2016). Bunnell, B. E., Davidson, T. M., Anton, M. T., Crookes, B. A. & Ruggiero, K. J. Peritraumatic distress predicts depression in traumatically injured patients admitted to a Level I trauma center. Gen. Hosp. Psychiatry . 54 , 57–59 (2018). Gilbert, P. & Allan, S. The role of defeat and entrapment (arrested flight) in depression: an exploration of an evolutionary view. Psychol. Med. 28 , 585–598 (1998). Choi, H., Shin, H. & Entrapment Hopelessness, and Cognitive Control: A Moderated Mediation Model of Depression. Healthcare 11 , 1065 (2023). Brunet, A. et al. The Peritraumatic Distress Inventory: a proposed measure of PTSD criterion A2. Am. J. Psychiatry . 158 , 1480–1485 (2001). Holman, E. A., Garfin, D. R. & Silver, R. C. It matters what you see: Graphic media images of war and terror may amplify distress. Proc. Natl. Acad. Sci. U. S. A. 121, e2318465121. Litz, B. T. et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin. Psychol. Rev. 29 , 695–706 (2009). Siddaway, A. P., Taylor, P. J., Wood, A. M. & Schulz, J. A meta-analysis of perceptions of defeat and entrapment in depression, anxiety problems, posttraumatic stress disorder, and suicidality. J. Affect. Disord . 184 , 149–159 (2015). Additional Declarations No competing interests reported. Supplementary Files SupplementaryInformation.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 May, 2026 Reviewers agreed at journal 15 May, 2026 Reviewers agreed at journal 15 May, 2026 Reviews received at journal 13 Mar, 2026 Reviewers agreed at journal 07 Mar, 2026 Reviewers invited by journal 14 Jan, 2026 Editor assigned by journal 14 Jan, 2026 Editor invited by journal 02 Jan, 2026 Submission checks completed at journal 28 Dec, 2025 First submitted to journal 28 Dec, 2025 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. 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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-8245113","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":574686813,"identity":"046d6036-8651-42d6-af86-479e18bb1d5b","order_by":0,"name":"Tayef Al-Dirawi","email":"","orcid":"","institution":"Al-Azhar University – Gaza","correspondingAuthor":false,"prefix":"","firstName":"Tayef","middleName":"","lastName":"Al-Dirawi","suffix":""},{"id":574686814,"identity":"3da66a55-9f7a-423d-b27c-b1c79fca2ccf","order_by":1,"name":"Siham Al-Shawamreh","email":"","orcid":"","institution":"Al-Azhar University – 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Gaza","correspondingAuthor":false,"prefix":"","firstName":"Muayad","middleName":"","lastName":"Jouda","suffix":""},{"id":574686826,"identity":"5087ebc5-9383-4654-84f4-a5593beef01f","order_by":8,"name":"Mohamed R Zughbur","email":"","orcid":"","institution":"Al-Azhar University – Gaza","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"R","lastName":"Zughbur","suffix":""},{"id":574686829,"identity":"5592947c-e77c-4fd5-ba5c-becee46a3467","order_by":9,"name":"Bahaaeddin Attaallah","email":"data:image/png;base64,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","orcid":"","institution":"Imperial College London","correspondingAuthor":true,"prefix":"","firstName":"Bahaaeddin","middleName":"","lastName":"Attaallah","suffix":""}],"badges":[],"createdAt":"2025-12-01 01:53:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8245113/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8245113/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100595684,"identity":"7d25485a-274f-4708-afa2-5646073d1d46","added_by":"auto","created_at":"2026-01-19 13:49:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1883703,"visible":true,"origin":"","legend":"","description":"","filename":"finalManuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/436dbc3e607c140c0773981b.docx"},{"id":100574491,"identity":"f99a9a52-08c3-4655-a5be-1f590628f772","added_by":"auto","created_at":"2026-01-19 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10:10:30","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122223,"visible":true,"origin":"","legend":"","description":"","filename":"3a728bc80e0548638ccfece3d4b409ae1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/4873e07bbff2f33a945c2761.xml"},{"id":100595348,"identity":"bb7aac1c-7be9-4f98-97da-fd978d3bc1e8","added_by":"auto","created_at":"2026-01-19 13:48:17","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":137590,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/48663584f04c296cc5fb1351.html"},{"id":100574488,"identity":"070b8b3b-87d7-4aba-9f68-55aa0b5d2671","added_by":"auto","created_at":"2026-01-19 10:10:30","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":169221,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrevalence and co-occurrence of anxiety, depression, PTSD, and trauma exposure.\u003c/strong\u003e \u003cstrong\u003eA. \u003c/strong\u003eSymptom severity distribution showing frequency of anxiety, depression, PTSD, and trauma exposure at different levels. \u003cstrong\u003eB. \u003c/strong\u003eComorbidity: co-occurrence of high-risk category.\u003c/p\u003e","description":"","filename":"image1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/9a15a3821b0bb8da289e0316.jpg"},{"id":100595384,"identity":"dbe1abaf-36fd-48db-a22b-22f2403b541f","added_by":"auto","created_at":"2026-01-19 13:48:21","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":202244,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEffect of residence and accommodation on psychological outcomes and trauma levels. \u003c/strong\u003eNo effect of residence or accommodation on anxiety or depression. Higher PTSD was noted in participants living in shelters compared to houses or tents, despite reporting lower trauma levels in shelters. Participants remaining in Gaza reported overall higher traumatic experiences.\u003c/p\u003e","description":"","filename":"image2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/5aa18749c8f7770f87b16ba8.jpg"},{"id":100596027,"identity":"13bbb81d-ccf0-4ce1-a348-8e2a6c70f9a9","added_by":"auto","created_at":"2026-01-19 13:50:23","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":79610,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation between trauma exposure and psychological outcomes. A.\u003c/strong\u003eMultiple correlation shows a positive correlation between depression and the level of trauma exposure. However, higher trauma levels were associated with lower PTSD and anxiety scores, despite the sample overall showing significant PTSD and anxiety. \u003cstrong\u003eB. \u003c/strong\u003eConditional plots showing anxiety, depression, and PTSD scores as a function of different trauma scores. The bar plot shows the average score for males (blue) and females (orange). Error bars show 95% CI.\u003c/p\u003e","description":"","filename":"image3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/996bc845c704fd5a827fbdc8.jpg"},{"id":100574492,"identity":"66f934d0-378e-464c-8407-494527335f98","added_by":"auto","created_at":"2026-01-19 10:10:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":86342,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEffect of different trauma experiences on depression, anxiety, and PTSD. A.\u003c/strong\u003e Heatmap showing the significant item correlation with these mental health measures. \u003cstrong\u003eB.\u003c/strong\u003e Prevalence of different traumatic events in the sample. \u003cstrong\u003eC-E:\u003c/strong\u003e Forest plot showing correlation coefficients with 95%CI and highlighting significant item correlation for each of the psychological measures. \u003cem\u003ep\u003c/em\u003e\u003csub\u003eFDR\u003c/sub\u003e * \u0026lt;0.05, ** \u0026lt;0.01, ***\u0026lt;0.001.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/1acb1d334dc0d4f9c43a2af3.png"},{"id":100597456,"identity":"e30e1c10-5164-4d9b-b4d1-43560298fa04","added_by":"auto","created_at":"2026-01-19 14:17:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1370778,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/a3660b8d-cab9-473b-aeb0-18ece23a90e7.pdf"},{"id":100595727,"identity":"d102cd9a-e3ae-4c65-bdaf-fb6b2a15f2aa","added_by":"auto","created_at":"2026-01-19 13:49:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25206,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-8245113/v1/6ed28e576ea84bb9c7716b5c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological Distress and Trauma Response Among War-Exposed Young Adults in Gaza","fulltext":[{"header":"Introduction","content":"\u003cp\u003eArmed conflicts are increasingly recognised as global public health emergencies, with devastating consequences for both physical and psychological well-being, often surpassing the burden of many major diseases.\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Beyond immediate mortality and disability, wars profoundly disrupt social structures, leading to poverty, displacement, overcrowding, and insecurity, all of which heighten vulnerability to mental health conditions.\u003c/p\u003e \u003cp\u003eExtensive research consistently identifies depression, anxiety, and post-traumatic stress disorder (PTSD) as predominant psychiatric sequelae among survivors of armed conflicts. \u003csup\u003e5\u0026ndash;7\u003c/sup\u003e It is estimated that approximately 10% of individuals exposed to traumatic events during conflicts will develop severe mental health problems, while an additional 10% will present with functional impairments that hinder daily life.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Other reports suggest that up to one in five people in conflict-affected populations experience a spectrum of mental health symptoms, with prevalence rates of anxiety, depression, and PTSD being two- to three-fold higher compared to non-exposed populations \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eImportantly, the intensity and frequency of trauma exposure are closely associated with the severity of psychiatric comorbidities.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Such enduring psychological harm extends beyond individuals, impairing social functioning, heightening the risk of substance abuse, and ultimately contributing significantly to the global burden of disease if left untreated. \u003csup\u003e6,9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe Gaza Strip, a small area in Palestine, has been a site of protracted conflict. The latest war, which began on October 7, 2023, is ongoing at the time of this research.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e According to recent reports, more than 60,000 people have been killed.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Since the war's inception, residents of Gaza have lost access to water, electricity, food, and their homes, with families frequently displaced. These challenging conditions are expected to profoundly affect the population's mental health.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe recent assault on Gaza has resulted in severe and long-lasting psychological consequences for its population. The collapse of health and mental health systems has left people to endure trauma, grief, and fear without adequate support.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Widespread destruction and displacement have created significant challenges for psychosocial well-being, leading to high rates of depression, anxiety, and stress that disrupt family and community life.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Alarmingly high rates of depression, anxiety, and stress have been reported in Gaza, particularly among families repeatedly forced to change their shelter, underscoring the urgent need for effective interventions \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, the interplay between different trauma-related exposures and their psychological consequences remains poorly characterised. This study used a large sample of war-exposed university students to i) quantify the prevalence and overlap of anxiety, depression, PTSD, and trauma; ii) test displacement and accommodation effects; and iii) disentangle how trauma severity and event types map onto symptom clusters beyond aggregate point estimates. By combining validated self-report instruments with both cumulative and item-level trauma analyses, the work aims to clarify psychopathological patterns related to different degrees and types of trauma and to inform culturally sensitive screening and intervention priorities under protracted conflict.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eThis descriptive, cross-sectional online study was conducted between October and December 2024 among Palestinians directly affected by the ongoing war in Gaza. Participants were recruited from Medical students studying at Al-Azhar University and the Islamic University in Gaza.\u003c/p\u003e \u003cp\u003eIndividuals were excluded if they were younger than 18 years or if they had a previously diagnosed psychiatric or neurological condition. A total of 604 participants were recruited. All participants provided informed consent for participating, and data were collected in accordance with local guidelines set out by the Palestinian Ministry of Health. The study was approved by the Palestinian Health Research Council Helsinki Committee (Reference Number: PHRC/HC/1187/24).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePsychological Measures\u003c/h3\u003e\n\u003cp\u003eData were collected using a self-administered, anonymous online questionnaire designed in Google Forms. The survey link was distributed through social media platforms and student groups to maximise reach among the target population. Convenience sampling was used, and participation was voluntary and open to all eligible participants.\u003c/p\u003e \u003cp\u003eThe questionnaire collected demographic data, including age, gender, study year, university, place of residence (Gaza, West Bank, abroad), and accommodation type in Gaza (house, tent, shelter centre, or student accommodation). In addition, the survey included the following standardised instruments: the Hospital Anxiety and Depression Scale (HADS),\u003csup\u003e18\u003c/sup\u003e the PTSD Checklist for DSM-5 (PCL-5),\u003csup\u003e19\u003c/sup\u003e and the War-Traumatic Events Checklist (W-TECh) (Table S1).\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHADS consists of 14 items (7 assessing anxiety and 7 assessing depression), each scored on a scale of 0\u0026ndash;21. It classifies symptoms into three categories: Normal (0\u0026ndash;7, probable absence), Borderline (8\u0026ndash;10, possible presence), and Abnormal (11\u0026ndash;21, probable presence) of anxiety and/or depression.\u003c/p\u003e \u003cp\u003eThe PCL-5 includes 20 items corresponding to DSM-5 criteria, with a total symptom severity score ranging from 0 to 80; a cutoff score of 31\u0026ndash;33 indicates probable PTSD.\u003c/p\u003e \u003cp\u003eThe W-TECh consists of 19 questions with a total score range of 0\u0026ndash;19, classifying traumatic exposure as low (\u0026lt;\u0026thinsp;5), moderate (5\u0026ndash;9), or high (\u0026ge;\u0026thinsp;10). It was adopted from a longer list of questions previously used to examine trauma in children.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData analysis and visualisation were conducted in R (v4.4.1) and MATLAB (v2024b). Multiple linear regression models using the fitlm function in MATLAB were used to examine the effect of trauma exposure, gender, residence, and accommodation on anxiety, depression, and PTSD. A similar model was used to examine the effect of demographic variables on trauma exposure scores. The relationship between trauma exposure level and psychological outcomes was visualised using a sliding window approach with fixed trauma-quantile widths moved along the score distribution (using a 20% Gaussian kernel code: conditionalPlot.m available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/vmabg/\u003c/span\u003e\u003cspan address=\"https://osf.io/vmabg/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo qualitatively determine how different types of trauma correlate with psychological morbidity, each item of the W-TECh list was correlated with depression, anxiety and PTSD score, controlling for total trauma exposure score and correcting for multiple comparisons. Multiple correlation testing was performed using the regress function in MATLAB and corrected for multiple comparisons using the FDR method.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eThe study included 604 participants ( mean age 21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 years, 47.7% females). 65.6% of the participants lived in Southern Gaza, 12.3% in Northern Gaza, 20.9% abroad, and 1.3% in the West Bank. Accommodation types varied, with most students residing in houses (58.4%), followed by tents (26.0%), student accommodation (9.9%), and shelter centres (5.6%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eSample Demographics.\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=\"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=\"char\" char=\"\u0026plusmn;\" 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\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e604\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e59.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Gaza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e396\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e65.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth Gaza\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbroad: International\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbroad: West Bank\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccommodation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHouse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e58.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShelter Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHigh levels of psychological distress in young adults in Gaza\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTrauma exposure levels varied among participants, with 37.1% experiencing high exposure, 50.7% moderate exposure, and 12.3% low exposure (\u003c/span\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e). Regarding depression, 18.2% of participants were classified as abnormal, 41.7% as borderline, and 40.1% as normal. For anxiety, 60.8% of students were classified as abnormal, 23.3% as borderline, and 15.9% as normal. PTSD symptoms were prevalent, with 76.5% categorised as having\u003c/span\u003e Probable \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePTSD and 23.5% showing minimal or no symptoms. A significant overlap was observed among these psychological categories, as visualised in the Venn Diagram in\u003c/span\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHigher Trauma Levels in Externally Displaced\u003c/h3\u003e\n\u003cp\u003eWe next investigated the effect of displacement on psychological outcomes and trauma reports. There was no significant difference in Anxiety, depression or PTSD reports between individuals who completed the questionnaires while in Gaza or after leaving abroad (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, participants who left Gaza reported significantly higher trauma exposure compared to individuals who stayed in Gaza (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.18, IRR\u0026thinsp;=\u0026thinsp;1.20, 95% CI [1.10, 1.30], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Table S2). These results did not change when reanalysing the data after exclusion of questions about displacement (WTEC9) from the W-TECh questionnaire.\u003c/p\u003e \u003cp\u003eIndividuals living in tents (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.12, IRR\u0026thinsp;=\u0026thinsp;0.89, 95% CI [0.83, 0.95], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) or shelters (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.18, IRR\u0026thinsp;=\u0026thinsp;0.84, 95% CI [0.74, 0.96], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008) reported lower trauma exposure compared to people living in houses. In contrast, PTSD severity was significantly higher among shelter residents compared to those living in houses (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.51, 95% CI [2.06, 12.97], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007). There were no significant differences in anxiety or depression between house residents and participants in other accommodation types (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eHigher trauma exposure is associated with emotional blunting\u003c/h3\u003e\n\u003cp\u003eParticipants with higher trauma exposure showed higher severity of depression (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.13, \u003cem\u003ep\u003c/em\u003e\u003csub\u003e\u003cem\u003ecorr\u003c/em\u003e\u003c/sub\u003e = 0.0023, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA\u0026ndash;B). In contrast, both PTSD and anxiety severity were lower with higher trauma scores (\u003cem\u003er\u003c/em\u003e = \u0026minus;\u0026thinsp;0.35, \u003cem\u003ep\u003c/em\u003e\u003csub\u003e\u003cem\u003ecorr\u003c/em\u003e\u003c/sub\u003e \u0026lt; 0.001; \u003cem\u003er\u003c/em\u003e = \u0026minus;\u0026thinsp;0.23, \u003cem\u003ep\u003c/em\u003e\u003csub\u003e\u003cem\u003ecorr\u003c/em\u003e\u003c/sub\u003e \u0026lt; 0.001, respectively). These patterns were consistent across gender groups, with no significant interaction between gender and trauma exposure (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). Notably, Female participants had higher levels of anxiety (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.95, 95% CI [1.32, 2.58], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and PTSD (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.64, 95% CI [3.10, 8.18], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to males, who reported higher levels of depression (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;0.63, 95% CI [\u0026ndash;1.07, \u0026minus;\u0026thinsp;0.20], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, Table S3).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEffect of different trauma types on psychological outcomes\u003c/h2\u003e \u003cp\u003eWhile multiple traumatic events correlated with both anxiety and PTSD (13 out of 19 event types; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Table S4), only three trauma types were significantly associated with depression. The strongest correlation was observed for \u003cem\u003ewitnessing ambulance prevented from saving people\u003c/em\u003e (WTEC15) (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.15, 95% CI [0.08, 0.23], \u003cem\u003ep\u003c/em\u003e\u003csub\u003eFDR\u003c/sub\u003e \u0026lt; 0.001), followed by \u003cem\u003ewitnessing body parts\u003c/em\u003e (WTEC15) ( \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.13, 95% CI [0.05, 0.21], \u003cem\u003ep\u003c/em\u003e\u003csub\u003eFDR\u003c/sub\u003e = 0.0037), and \u003cem\u003ebeing trapped or besieged\u003c/em\u003e (WTEC16) ( \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.12, 95% CI [0.04, 0.20], \u003cem\u003ep\u003c/em\u003e\u003csub\u003eFDR\u003c/sub\u003e = 0.006). In contrast, anxiety and PTSD showed consistent negative associations with a wide range of traumatic exposures, with the strongest effects observed for events such as \u003cem\u003ewitnessing family members injured\u003c/em\u003e (WTEC7)(Anxiety: \u003cem\u003er\u003c/em\u003e = \u0026minus;\u0026thinsp;0.19, \u003cem\u003ep\u003c/em\u003e\u003csub\u003eFDR\u003c/sub\u003e \u0026lt; 0.001; PTSD: \u003cem\u003er\u003c/em\u003e = \u0026minus;\u0026thinsp;0.25, \u003cem\u003ep\u003c/em\u003e\u003csub\u003eFDR\u003c/sub\u003e \u0026lt; 0.001) and \u003cem\u003ewitnessing shooting (WTEC12)\u003c/em\u003e (Anxiety: \u003cem\u003er\u003c/em\u003e = \u0026minus;\u0026thinsp;0.15, \u003cem\u003ep\u003c/em\u003e\u003csub\u003eFDR\u003c/sub\u003e = 0.001; PTSD: \u003cem\u003er\u003c/em\u003e = \u0026minus;\u0026thinsp;0.23, \u003cem\u003ep\u003c/em\u003e\u003csub\u003eFDR\u003c/sub\u003e \u0026lt; 0.001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reports extremely high levels of psychological distress in a sample of young adults surveyed during October\u0026ndash;December 2024. More than three-quarters (76.5%) met a PCL-5 threshold consistent with probable PTSD, and over 60% scored in the \u0026ldquo;abnormal\u0026rdquo; range for anxiety; figures that exceed pooled prevalence estimates reported for many conflict-affected populations and indicate a severe, concentrated burden in this cohort.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Depression was also common: 18.2% scored as abnormal and an additional 41.7% as borderline on the HADS depression subscale. These results align with other recent surveys in the region showing elevated rates of depression and PTSD during the ongoing crisis.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTwo sets of findings require careful interpretation. First, students who had left Gaza reported higher cumulative trauma exposure than those who remained; second, higher cumulative trauma exposure was positively associated with depressive symptoms but negatively associated with PTSD and anxiety severity. The first finding is plausible: those who left Gaza may have been compelled to endure extreme events (for example, evacuation under fire, interrupted access to medical care, family separation), and therefore, those who left Gaza may have incurred a larger burden of trauma before reaching relative safety. This pattern is consistent with evidence that forcibly displaced populations frequently report high cumulative and repeated traumatic exposures and elevated psychiatric morbidity.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe second finding (the inverse correlations between trauma exposure and measured PTSD/anxiety) seems counterintuitive at face value; however, several non-mutually exclusive explanations could account for it. One possibility is emotional numbing/dissociation and adaptive (but could be maladaptive long-term) affect-regulation strategies that can result from repeated or prolonged trauma exposure.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e PTSD as a psychological construct includes symptoms of numbing and avoidance; repeated trauma can produce blunted subjective arousal or dissociative responses that attenuate symptom expression on self-report measures while functional impairment remains high.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Neurobiological and clinical models note that both hyperarousal and restricted affect can co-exist in trauma survivors, and emotion-transition studies suggest rapid shifts between neutral and negative states that complicate cross-sectional measurement.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Thus, lower self-reported anxiety or re-experiencing in the context of high cumulative exposure may reflect genuine numbing or dissociation rather than reduced psychopathology.\u003c/p\u003e \u003cp\u003eA second explanation is measurement artefact or construct misalignment. Instruments like the PCL-5 and HADS have good psychometric properties in many settings, but their sensitivity and specificity can change across cultures and in populations experiencing chronic and repeated exposure. The W-TECh captures type and number of war-related events, but simple counts of events do not measure subjective appraisal, timing, peritraumatic reactions, or chronicity \u0026mdash; all of which could moderate symptom expression. Repeated exposures can also change how items are interpreted (for example, somatic symptoms may be normalised or reclassified), producing apparent inverse associations. Cross-cultural validation work cautions that cut-offs and item interpretations may shift in non-Western or heavily traumatised populations.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e More locally adapted tools or diagnostic interviews with mixed methods may yield different prevalence estimates or associations. Such work is an important avenue for future research and investigation.\u003c/p\u003e \u003cp\u003eThird, selection and sampling biases inherent in a convenience, online sample of medical students may distort associations: participants who left Gaza may differ systematically (for example, in mobility, internet access, or willingness to report distress) from those who remained, and the most severely affected individuals may have been unable to participate (survivorship/attrition bias).\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Finally, the negative correlations could represent a genuine but complex clinical pattern: repeated trauma may shift the dominant syndrome from fear-based re-experiencing to low-mood presentations dominated by hopelessness and anhedonia, or different exposures may preferentially precipitate depressive rather than anxious symptom clusters depending on individual and contextual moderators.32,33 It is crucial to highlight that such an association still occurs in the psychological spectrum of clinically significant anxiety and PTSD. In other words, higher depression and lower anxiety and PTSD with higher trauma does not imply that participants at relatively lower trauma scores do not express significant anxiety and PTSD.\u003c/p\u003e \u003cp\u003eAn additional, and clinically informative, possibility is that a small subset of event-types drives this pattern because of their particular psychological qualities. Specifically, entrapment or siege (WTECh4), events in which ambulances or lifesaving care are prevented (WTECh15) and direct exposure to mutilation or body parts (WTECh16) share mechanisms that preferentially precipitate depressive symptomatology. Perceived defeat/entrapment might foster hopelessness and behavioural withdrawal; exposure to events that thwart lifesaving efforts can constitute potentially morally injurious events that generate guilt, shame and social-moral distress; and intensely graphic sensory exposures produce high peritraumatic distress and intrusive imagery that, over time, may evolve into pervasive low mood and functional impairment.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e These mechanisms are supported by meta-analytic and theoretical work on defeat/entrapment and depression, the moral-injury literature, and empirical studies showing that graphic exposures amplify distress and that peritraumatic dissociation or numbing can alter symptom expression on self-report measures.\u003csup\u003e\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e Taken together, these pathways make it plausible that WTEC4, WTEC15 and WTEC16 would show stronger and more specific associations with depression than with conventional self-reported indices of re-experiencing or anxiety.\u003c/p\u003e \u003cp\u003eIn summary, this study highlights significant trauma-related psychopathology among young adults in Gaza, characterised by complex patterns including high rates of probable PTSD and anxiety alongside a dissociation between cumulative trauma and self-reported distress, with depression increasing while anxiety and PTSD symptoms decrease at higher trauma levels. These findings underscore the need for clinical assessments that go beyond standard screening, inform the design of targeted interventions addressing apathy and emotional numbing, and advance scientific understanding of trauma response heterogeneity in protracted conflict.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003ch2\u003eFunding Declaration\u003c/h2\u003e \u003cp\u003eB.A. is supported by an NIHR academic clinical lectureship.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eT.A. and S.A. are co-first authors and contributed equally to this work.T.A. contributed to writing the Introduction and Methods sections.S.A. conducted the data analysis and contributed to the Introduction, Methods, and Discussion sections.R.A. contributed to writing the Results section.H.A. contributed to writing the Introduction section.S.T. performed the data analysis.N.G. contributed to writing the Results section.M.G.A. wrote the Abstract and Conclusion.M.J. supervised the study.M.Z. supervised the study.B.A. contributed to writing the Abstract, Results and Conclusion, prepared all figures and graphics, and also supervised the study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCharlson, F. et al. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. \u003cem\u003eLancet Lond. Engl.\u003c/em\u003e \u003cb\u003e394\u003c/b\u003e, 240\u0026ndash;248 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMURTHY, R. S. \u0026amp; LAKSHMINARAYANA, R. Mental health consequences of war: a brief review of research findings. \u003cem\u003eWorld Psychiatry\u003c/em\u003e. \u003cb\u003e5\u003c/b\u003e, 25\u0026ndash;30 (2006).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiad, A. et al. Mental Health Burden of the Russian\u0026ndash;Ukrainian War 2022 (RUW-22): Anxiety and Depression Levels among Young Adults in Central Europe. \u003cem\u003eInt. J. Environ. Res. Public. Health\u003c/em\u003e. \u003cb\u003e19\u003c/b\u003e, 8418 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVesco, P. et al. The impacts of armed conflict on human development: A review of the literature. \u003cem\u003eWorld Dev.\u003c/em\u003e \u003cb\u003e187\u003c/b\u003e, 106806 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldabbour, B. et al. Psychological impacts of the Gaza war on Palestinian young adults: a cross-sectional study of depression, anxiety, stress, and PTSD symptoms. \u003cem\u003eBMC Psychol.\u003c/em\u003e \u003cb\u003e12\u003c/b\u003e, 696 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevi-Belz, Y., Groweiss, Y., Blank, C. \u0026amp; Neria, Y. PTSD, depression, and anxiety after the October 7, 2023 attack in Israel: a nationwide prospective study. \u003cem\u003eeClinicalMedicine\u003c/em\u003e \u003cb\u003e68\u003c/b\u003e, (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray, C. J. L., King, G., Lopez, A. D., Tomijima, N. \u0026amp; Krug, E. G. Armed conflict as a public health problem. \u003cem\u003eBMJ\u003c/em\u003e \u003cb\u003e324\u003c/b\u003e, 346\u0026ndash;349 (2002).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim, I. C. Z. Y. et al. Prevalence of depression, anxiety and post-traumatic stress in war- and conflict-afflicted areas: A meta-analysis. \u003cem\u003eFront. Psychiatry\u003c/em\u003e. \u003cb\u003e13\u003c/b\u003e, 978703 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorina, N., Stam, K., Pollet, T. V. \u0026amp; Priebe, S. Prevalence of depression and posttraumatic stress disorder in adult civilian survivors of war who stay in war-afflicted regions. A systematic review and meta-analysis of epidemiological studies. \u003cem\u003eJ. Affect. Disord\u003c/em\u003e. \u003cb\u003e239\u003c/b\u003e, 328\u0026ndash;338 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed, S. H. et al. Prevalence of post-traumatic stress disorder and depressive symptoms among civilians residing in armed conflict-affected regions: a systematic review and meta-analysis. \u003cem\u003eGen Psychiatry\u003c/em\u003e \u003cb\u003e37\u003c/b\u003e, (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmsalem, D. et al. The effects of war-related experiences on mental health symptoms of individuals living in conflict zones: a longitudinal study. \u003cem\u003eSci. Rep.\u003c/em\u003e \u003cb\u003e15\u003c/b\u003e, 889 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Oslash;stergaard, M. L. D. et al. Vulnerability factors in conflict-related mental health. \u003cem\u003eMed. Confl. Surviv.\u003c/em\u003e (2022). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.tandfonline.com/doi/abs/10.1080/13623699\u003c/span\u003e\u003cspan address=\"https://www.tandfonline.com/doi/abs/10.1080/13623699\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.2156232 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldabbour, B. et al. The Psychological Toll of War and Forced Displacement in Gaza: A Study on Anxiety, PTSD, and Depression. \u003cem\u003eChronic Stress\u003c/em\u003e. \u003cb\u003e9\u003c/b\u003e, 24705470251334943 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZughbur, M. R. et al. Prevalence and correlates of anxiety, depression, and symptoms of trauma among Palestinian adults in Gaza after a year of war: a cross-sectional study. \u003cem\u003eConfl. Health\u003c/em\u003e. \u003cb\u003e19\u003c/b\u003e, 43 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJamaluddine, Z., Abukmail, H., Aly, S., Campbell, O. M. R. \u0026amp; Checchi, F. Traumatic injury mortality in the Gaza Strip from Oct 7, 2023, to June 30, 2024: a capture\u0026ndash;recapture analysis. \u003cem\u003eLancet\u003c/em\u003e \u003cb\u003e405\u003c/b\u003e, 469\u0026ndash;477 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaved, A. \u0026amp; Wars Conflicts \u0026amp; Mental Health. \u003cem\u003ePak J. Med. Sci.\u003c/em\u003e \u003cb\u003e40\u003c/b\u003e, 797\u0026ndash;799 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbelbeisi, A. H., Hajizadeh, A., Al-Zeer, A. M., Saeidpour, J. \u0026amp; Kakemam, E. Prevalence and associated factors of mental health disorders among internally displaced persons in Gaza. \u003cem\u003eEast. Mediterr. Health J. Rev. Sante Mediterr. Orient. Al-Majallah Al-Sihhiyah Li-Sharq Al-Mutawassit\u003c/em\u003e. \u003cb\u003e31\u003c/b\u003e, 81\u0026ndash;88 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZigmond, A. S. \u0026amp; Snaith, R. P. The hospital anxiety and depression scale. \u003cem\u003eActa Psychiatr Scand.\u003c/em\u003e \u003cb\u003e67\u003c/b\u003e, 361\u0026ndash;370 (1983).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K. \u0026amp; Domino, J. L. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. \u003cem\u003eJ. Trauma. Stress\u003c/em\u003e. \u003cb\u003e28\u003c/b\u003e, 489\u0026ndash;498 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeronese, G., Mahamid, F., Bdier, D., Obaid, H. \u0026amp; Cavazzoni, F. The development and validation of the Palestinian children\u0026rsquo;s traumatic events checklist in a war-torn environment. \u003cem\u003eBMC Psychiatry\u003c/em\u003e. \u003cb\u003e24\u003c/b\u003e, 254 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNickerson, A. et al. Trauma and Mental Health in Forcibly Displaced Populations: An International Society for Traumatic Stress Studies Briefing Paper. (2017). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://research.regionh.dk/en/publications/trauma-and-mental-health-in-forcibly-displaced-populations-an-int\u003c/span\u003e\u003cspan address=\"https://research.regionh.dk/en/publications/trauma-and-mental-health-in-forcibly-displaced-populations-an-int\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevenson, K. et al. The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis. \u003cem\u003eLancet Public. Health\u003c/em\u003e. \u003cb\u003e8\u003c/b\u003e, e203\u0026ndash;e216 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson-Hollands, J., Marx, B. P., Lee, D. J. \u0026amp; Sloan, D. M. Longitudinal Change in Self-Reported Peritraumatic Dissociation During and After a Course of Posttraumatic Stress Disorder Treatment: Contributions of Symptom Severity and Time. \u003cem\u003ePsychol. Trauma. Theory Res. Pract. Policy\u003c/em\u003e. \u003cb\u003e13\u003c/b\u003e, 665\u0026ndash;672 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWerner, K. B. \u0026amp; Griffin, M. G. Peritraumatic and Persistent Dissociation as Predictors of PTSD Symptoms in a Female Cohort. \u003cem\u003eJ. Trauma. Stress\u003c/em\u003e. \u003cb\u003e25\u003c/b\u003e, 401\u0026ndash;407 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLitz, B. T., Litz, B. T. \u0026amp; Gray, M. J. Emotional Numbing in Posttraumatic Stress Disorder: Current and Future Research Directions. \u003cem\u003eAust N Z. J. Psychiatry\u003c/em\u003e. \u003cb\u003e36\u003c/b\u003e, 198\u0026ndash;204 (2002).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBryant, R. A. Post-traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. \u003cem\u003eWorld Psychiatry\u003c/em\u003e. \u003cb\u003e18\u003c/b\u003e, 259\u0026ndash;269 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBryant, R. A. A critical review of mechanisms of adaptation to trauma: Implications for early interventions for posttraumatic stress disorder. \u003cem\u003eClin. Psychol. Rev.\u003c/em\u003e \u003cb\u003e85\u003c/b\u003e, 101981 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowen, A. M., Calder, R., Neale, J., Meynen, T. \u0026amp; Gilchrist, G. Emotion Regulation in the Association Between Posttraumatic Stress Disorder and Substance Use: A Systematic Review With Narrative Synthesis. \u003cem\u003eTrauma. Violence Abuse\u003c/em\u003e. \u003cb\u003e15248380241306362\u003c/b\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/15248380241306362\u003c/span\u003e\u003cspan address=\"10.1177/15248380241306362\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhalaiqa, F. et al. Psychometric Properties of the Posttraumatic Stress Disorder Checklist among the Lebanese Population Exposed to the Beirut Explosion: A Cross-Sectional Study during the COVID-19 Pandemic. \u003cem\u003eBehav. Neurol.\u003c/em\u003e 9286562 (2023). (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoffman, J. et al. Mapping the availability of translated versions of posttraumatic stress disorder screening questionnaires for adults: A scoping review. \u003cem\u003eEur J. Psychotraumatology\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e, 2143019 .\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVukčević Marković, M., Bobić, A. \u0026amp; Živanović, M. The effects of traumatic experiences during transit and pushback on the mental health of refugees, asylum seekers, and migrants. \u003cem\u003eEur. J. Psychotraumatology\u003c/em\u003e. \u003cb\u003e14\u003c/b\u003e, 2163064 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmadi, F., Goodarzi, M. A., Taghavi, M. R. \u0026amp; Imani, M. Modeling the structural relationships between trauma exposure with substance use tendency, depression symptoms, and suicidal thoughts in individuals with earthquake trauma experience: the mediatory role of peritraumatic dissociation and experiential avoidance. \u003cem\u003eBMC Psychiatry\u003c/em\u003e. \u003cb\u003e24\u003c/b\u003e, 171 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaier, S. F. \u0026amp; Seligman, M. E. P. Learned Helplessness at Fifty: Insights from Neuroscience. \u003cem\u003ePsychol. Rev.\u003c/em\u003e \u003cb\u003e123\u003c/b\u003e, 349\u0026ndash;367 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBunnell, B. E., Davidson, T. M., Anton, M. T., Crookes, B. A. \u0026amp; Ruggiero, K. J. Peritraumatic distress predicts depression in traumatically injured patients admitted to a Level I trauma center. \u003cem\u003eGen. Hosp. Psychiatry\u003c/em\u003e. \u003cb\u003e54\u003c/b\u003e, 57\u0026ndash;59 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilbert, P. \u0026amp; Allan, S. The role of defeat and entrapment (arrested flight) in depression: an exploration of an evolutionary view. \u003cem\u003ePsychol. Med.\u003c/em\u003e \u003cb\u003e28\u003c/b\u003e, 585\u0026ndash;598 (1998).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi, H., Shin, H. \u0026amp; Entrapment Hopelessness, and Cognitive Control: A Moderated Mediation Model of Depression. \u003cem\u003eHealthcare\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e, 1065 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunet, A. et al. The Peritraumatic Distress Inventory: a proposed measure of PTSD criterion A2. \u003cem\u003eAm. J. Psychiatry\u003c/em\u003e. \u003cb\u003e158\u003c/b\u003e, 1480\u0026ndash;1485 (2001).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolman, E. A., Garfin, D. R. \u0026amp; Silver, R. C. It matters what you see: Graphic media images of war and terror may amplify distress. \u003cem\u003eProc. Natl. Acad. Sci. U. S. A.\u003c/em\u003e 121, e2318465121.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLitz, B. T. et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. \u003cem\u003eClin. Psychol. Rev.\u003c/em\u003e \u003cb\u003e29\u003c/b\u003e, 695\u0026ndash;706 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiddaway, A. P., Taylor, P. J., Wood, A. M. \u0026amp; Schulz, J. A meta-analysis of perceptions of defeat and entrapment in depression, anxiety problems, posttraumatic stress disorder, and suicidality. \u003cem\u003eJ. Affect. Disord\u003c/em\u003e. \u003cb\u003e184\u003c/b\u003e, 149\u0026ndash;159 (2015).\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":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8245113/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8245113/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe Gaza Strip has suffered massive civilian harm, widespread displacement, and near-total disruption of health services since the assault began on 7 October 2023, creating an acute humanitarian and mental-health emergency. In this study, we measured anxiety, depression, and post-traumatic stress disorder (PTSD) and examined their associations with displacement, accommodation, and war-related traumatic events among young adults from Gaza. A cross-sectional online survey conducted between October and December 2024 included 604 participants (mean age 21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 years) who lived through the war, using validated measures for anxiety, depression, PTSD, and a war-traumatic events checklist. Clinically significant symptoms were highly prevalent, with abnormal anxiety in 60.8% of participants, abnormal depression in 18.2% (plus 41.7% borderline), and probable PTSD in 76.5%. High trauma exposure (\u0026ge;\u0026thinsp;10 events) affected 37.1% of respondents, and displacement as well as residence in shelters were associated with greater overall distress. Cumulative trauma correlated positively with depression severity but inversely with self-reported PTSD and anxiety scores, and depression was linked to specific trauma types such as being besieged and witnessing the prevention of an ambulance from providing aid. These findings indicate a severe and complex mental-health crisis among Gaza\u0026rsquo;s young adults, in which repeated exposure appears to shift symptom expression toward depressive and morally injurious presentations and away from fear-based arousal. The results underscore the need for culturally sensitive, targeted mental-health interventions.\u003c/p\u003e","manuscriptTitle":"Psychological Distress and Trauma Response Among War-Exposed Young Adults in Gaza","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 10:10:25","doi":"10.21203/rs.3.rs-8245113/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"115197981544821671811645417150580062802","date":"2026-05-18T18:21:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258143233228977954894849933247790234759","date":"2026-05-15T13:18:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273340912210917995634453554345777925294","date":"2026-05-15T11:59:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-13T12:47:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200851964779836395109573170826305648561","date":"2026-03-08T02:24:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T16:33:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-14T12:32:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-02T09:20:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-29T00:02:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-12-28T23:57:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"20a4734b-b767-41b4-b564-8a70f7da4886","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"115197981544821671811645417150580062802","date":"2026-05-18T18:21:30+00:00","index":116,"fulltext":""},{"type":"reviewerAgreed","content":"258143233228977954894849933247790234759","date":"2026-05-15T13:18:24+00:00","index":111,"fulltext":""},{"type":"reviewerAgreed","content":"273340912210917995634453554345777925294","date":"2026-05-15T11:59:20+00:00","index":110,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":61153633,"name":"Health sciences/Diseases"},{"id":61153634,"name":"Health sciences/Health care"},{"id":61153635,"name":"Health sciences/Medical research"},{"id":61153636,"name":"Biological sciences/Psychology"},{"id":61153637,"name":"Social science/Psychology"},{"id":61153638,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-01-19T10:10:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-19 10:10:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8245113","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8245113","identity":"rs-8245113","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}