The Effects of Type III Traumatic Stressors of the Protracted Conflict and Prolonged COVID-19 on Syrians Internally Displaced
A Validation Study of Type III Continuous Traumatic Stressors and Their Impact
Abstract
Abstract. This study aimed to validate the Type III continuous traumatic stress model assumptions and use it to assess the effect of intersected traumas of civil war and COVID-19 stressors on internally displaced Syrian people. We recruited 891 Syrians from camps (46.5% females, aged 18–90 years [M = 30.81, SD = 12.04]). We measured COVID-19 stressors, posttraumatic stress disorder (PTSD), complex PTSD (CPTSD), depression, anxiety, and executive functions to assess the variables related to peri-post Type III mental health syndrome. We measured Type I, II, and III traumas and Type III trauma subtypes. To explore the significance of differences between correlation sizes and the comparative severity of each trauma type, we calculated Fisher z scores. We performed path analysis with trauma Types III and II as correlated independent variables and COVID-19 stressors' impact on peri-post Type III trauma mental health syndrome to check their proliferation and impact. Of the sample, COVID-19 had infected 45.9%, 33.1% fit the diagnostic criteria for CPTSD, and 13.9% fit the diagnostic criteria for PTSD. All trauma types were associated with mental health, cognitive deficits, and COVID-19 severity, with a significantly higher association with trauma Type III. Type III-a subtype (intersected discrimination) had the highest associations with each variable. Type III was bidirectionally correlated with Type II and proliferated to Type I traumas (single past events) and COVID-19 stressors, with Type III having a larger effect size on peri-post Type III trauma mental health syndrome. The clinical and conceptual implications of the findings are discussed.
Impact and Implications.
This study helps understand the intersection between intergroup conflicts and intersected discrimination with COVID-19 pandemic stressors that amplifies its impact on mental health and cognitive functioning in Syrian internally displaced people. This study addresses the United Nations sustainable development goals of empowering and promoting the social, economic, and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic, or other status by unpacking some of the powerful mechanisms behind intergroup conflicts and intersected discrimination interfaced with COVID-19. This study validates the continuous stress Type III trauma framework and proposes corrective and treatment strategies that address inequalities and discrimination and their impact.
Traumatic events are the acute stressor within a dynamic field of acute, nonacute, and chronic stressors that impact mental health, health, cognitive functioning, and life-span development. Yet, the fields of study concerned with stress and trauma have taken dissociated trajectories that hinder a clear understanding of their global dynamics. Recent advances in stress and trauma research have attempted to reintegrate trauma and stress disciplines (Boonstra, 2103; Kira, 2022). The development-based trauma framework (DBTF, Kira, 2001, 2021, 2022) proposes an integrated approach which may help refocus the field on the managing dynamics and system's operating mechanisms. Such integration is consistent with real-time, real-life experiences and the phenomena under study. Real-life dynamics are embedded in a matrix of processes in which traumatic events (acute stressors) and chronic stressors (e.g., traumas) are triggered in chains of cause and effect, in which the effects of a cause may become a cause (e.g., trauma as effect of a traumatic event) that has a consequential impact. Dynamics and mechanism-based analysis (e.g., cumulative trauma and trauma proliferation dynamics) would be enhanced if causal chains and structures were brought to the analytical forefront (Gross, 2018).
One of the novelties that emerged from the integration of stress and trauma research is the expanded heuristics of Type III stressors or the continuous traumatic stress (CTS) paradigm. The conceptualization, heuristics, and empirical research on the impacts of continuous experience of stressors (traumatic and chronic) inclusive of past, present, and anticipated future is an emerging field that promises a paradigm shift. It contrasts with the focus on specific single trauma events which has dominated the trauma literature (Eagle & Kaminer, 2013; Kira, 2001, 2021, 2022; Kira, Ashby et al., 2013; Straker, 1987). The CTS paradigm distinguishes between three types of chronic and acute stressors: Types I, II, and III. Type I trauma is a consequence of a distinct past acute stressor with a short time scale and usually low density. Type II trauma results from a sequence of repeated mostly past acute stressors that stopped and have a relatively short to medium density and time scale. Type III traumas emerge from stressors that may still be ongoing and have a prolonged time scale and potentially higher density (Kira, 2001, 2021, 2022; Kira, Ashby et al., 2013; Solomon & Heide, 1999; Terr, 1995). There is empirical support for the severity gradients of trauma types, with Type III being the most severe vis-à-vis their association with more negative health, mental health, and cognitive functioning (Kira, 2021). CTS trauma Type III has at least five variants or subtypes that vary in their protracted time scales, fluctuations, and densities which determine their potential impact severity. The five subtypes may overlap and intensify each other's potential total effect when they co-occur. Various discriminations and intersected discrimination (resulting in trauma Type III-a) can continue through the life course with high density and thus have the lengthiest time scale and the worst potential impact on health, mental health, and cognition (e.g., Kira, Ashby et al., 2013; Kira, Omidy et al., 2015; Potluri & Patel, 2021). Intersected discrimination, especially, has not only a life-long time scale but is also denser and could include multiple bases of discrimination. It forces individuals and groups through their life course into a minority status that triggers serious harmful mechanisms (e.g., internalized inferiority, lower self-esteem, stereotype threat that may impair competence or limit performance, multiple disadvantages in accessing resources and opportunities) that negatively affect health and mental health, and cognitive functioning and behavior.
Experiencing extended childhood adversities (e.g., children in foster care) represents the trauma Type III-b subtype (e.g., Ford & Delker, 2020; Hailes et al., 2019; Landers et al., 2021). Intergroup conflicts such as the Palestinian–Israeli conflict and civil Syrian war give rise to the trauma Type III-c subtype (e.g., Greene et al., 2018; Pat-Horenczyk & Schiff, 2019; Stein et al., 2018). Living in chronic community violence is an example of events which lead to the trauma Type III-d subtype (e.g., Straker, 1987). Chronic life-threatening health disorders (e.g., HIV; Quinn et al., 2020) and the infection or stressors related to COVID-19 (e.g., Alpay et al., 2021; Kira, 2021, 2022; Kira, Shuwiekh, Alhuwailah, Ashby et al., 2021; Kira, Shuwiekh, Ashby, Elwakeel et al., 2021; Lahav, 2020) relate to the trauma type III-e subtype. All Type III trauma variants are potentially severe with different time scales and densities of their underlying events determining their potential differential intensities. Additionally, Type III trauma subtypes may intersect and may initiate each other. For example, trauma arising from intergroup conflict may initiate torture and discrimination and vice versa. They may proliferate to other contingent trauma of Type II and I (e.g., Kira et al., 2018). Discrimination may result in serious business or job loss, restricted opportunities, or even death in the case of hate crimes.
Prolonged childhood adversity, such as that experienced by children in foster care, and attachment trauma can proliferate into adult trauma through different mechanisms (Kira, Fawzi et al., 2021). Torture can lead to contracting life-threatening illnesses such as HIV during sexual torture.
The COVID-19 pandemic causes continuous prolonged stressors, associated with trauma Type III-e characterized by uncontrollability until the vaccine's discovery. It is global and multilayered, including stressors such as a fear of infection, lockdown, economic hardships, and the potential grief from losing loved ones (Kira, Shuwiekh, Ashby, Rice et al., 2021; Kira, Shuwiekh, Rice et al., 2021). There is compelling replicated support for the severe impact of COVID-19 on health, mental health, and cognitive functions (e.g., Kira, Alpay, Ayna et al., 2021; Liu et al., 2021; Prati & Mancini, 2021). The stressors of COVID-19 accounted for substantial unique variance in posttraumatic stress disorder (PTSD) after accounting for the variance explained by all prior cumulative stressors and traumas (Ashby et al., 2022; Kira, Shuwiekh, Ashby, Elwakeel et al., 2021). There is compelling support for the effects of CTS or Type III trauma on PTSD (e.g., Nuttman-Shwartz & Shoval-Zuckerman, 2016). There is also compelling evidence of the impact of intersected discrimination, childhood adversities, and other subtypes of Type III trauma on complex PTSD (CPTSD; Guo et al., 2021; Kira, 2022).
CTS triggers realistic, mostly automatic, and inevitable anticipation of constant danger as the threat is real in the present and the future and is continuous and substantive, thus creating a state of permanent emergency (Alpay et al., 2021; Amram-Vaknin et al., 2022; Eagle & Kaminer, 2013; Kira, Alpay, Ayna et al., 2021; Kira, Ashby et al., 2013; Lahav, 2020; Matthies-Boon, 2018). There is evidence that CTS caused by the COVID-19 pandemic (as an example of Type III-e trauma) may erode coping strategies of social support, the will-to-live and survive and resilience; and possibly increase suicidality and poor physical and mental health (Kira, Shuwiekh, Alhuwailah, & Balaghi, 2022).
Through the introduction of Type III trauma, the CTS paradigm specified various forms of CTS and expanded the trauma perspective to the dynamics of traumatization. The single past trauma static paradigm defined PTSD as arising from A trauma and thus dissociates one triggering event from previous and consequent lifetime strains or supports. The new paradigm conceptualizes traumatization as a process in which different trauma types interact in a dynamic system of proliferation, accumulation, and amplification mechanisms, and feedback and feedforward loops and circuits, especially in the multiply traumatized. There are primary advances toward this dynamic perspective starting to emerge, for example, in the study of polyvictimization (e.g., Finkelhor et al., 2007), intersectionality (Cho et al., 2013), cumulative trauma (Cloitre et al., 2009; Kira, Barger et al., 2020; Kira et al., 2014; 2019; Kira, Fawzi, & Fawzi, 2013; Kira, Fawzi et al., 2021), stress generation, and trauma and stress proliferation (Conway et al., 2012; Kira et al., 2016, 2018; Kira, Fawzi, & Fawzi, 2013; Kira, Fawzi et al., 2021; LeBlanc et al., 2015; Li, 2016). However, empirically identifying the detailed dynamics and profiles of the interaction between different trauma types and subtypes that lead to different proliferation pathways and trajectories is a challenge. The current study aimed to validate some assumptions and heuristics of the CTS dynamics paradigm and proliferation pathways empirically.
Generally, most research separated the impact of traumatization on mental health from its impact on cognitive functioning. Yet, various stressors, cognitive functioning, and mental health are entangled together in one dynamic system. Cognitive functioning and mental health reciprocally affect each other, responding to different adversities and stressors (e.g., Fabio et al., 2021; Kira et al., 2012; Kira, Shuweikh, Al-Huwailiah et al., 2022; Marin et al., 2011; Scott et al., 2015; Shields et al., 2016). It is essential to disentangle this link and understand these dynamics to devise more effective interventions to enhance cognitive function or attenuate the cognitive decline.
Furthermore, trauma must be considered within a culture because it is the cultural context that shapes the appraisal of traumatic experience. Furthermore, and in more explicit terms, culture may be a product of the trauma profiles of the community. The research and clinical literature on trauma have focused largely, if not exclusively, on interpersonal traumas which are more salient in the trauma profiles of majority group members and in individualistic cultures. It has neglected to explore intergroup traumas which may be more salient in minority groups, such as internally displaced people (IDP) and refugees. Traditional notions of traumatic stress, shaped largely by middle-class European and North American interpersonal trauma profiles may not capture the collectivistic culture in which intergroup conflict, oppression, and discrimination might be more salient than interpersonal traumas. Trauma profiles are thus probably different in collectivistic than in individualistic cultures. A more collectivistic culture may be enabled by the dominant intergroup stressors in people exposed to more intergroup stressors.
The continuous exposure to adversities in the Syrian civil war, especially for IDP, provides an extreme example that may help understand the suffering of this population and the dynamics of their continuous adversities. Syria has the most IDP worldwide, with more than half of its population (over 6.3 million) having been displaced since the civil war started in 2011 (Akbarzada & Mackey, 2017; the United Nations Office for the Coordination of Humanitarian Affairs, 2017). Most IDP inside Syria live in provisional camps with inadequate access to resources. Most camps are located in opposition-controlled areas. These living conditions contributed to an increase in mortality and morbidity. There is empirical evidence that Syrian IDP have higher PTSD than their fellow Syrian refugees in Turkey, while refugees have more depressive disorders (Tekeli-Yesil et al., 2018). Syrian civil war has persisted for over 11 years, making it a source of Type III-c trauma due to its prolonged time scale.
Additionally, for many internally displaced Syrians, Type III-c trauma intersects with stressors caused by COVID-19 (related to Type III-e trauma), in addition to the other Type I and II traumas that people may be or may have suffered, as these are high in this population (e.g., Al Ibraheem et al., 2017; Douedari et al., 2020; Guha-Sapir et al., 2018; Kira, Al Ibrahim et al., 2022). The current study explores the dynamics of traumatization in this population using the Type III continuous trauma framework. The goal is to understand the traumatization dynamics of Type III traumas and their intersected subtypes in this population.
Hypotheses
The type III traumas arising from exposure to continuous civil war and stressors arising from the COVID-19 pandemic have a greater effect on mental health and cognitive deficits than Type II and I traumas.
Type III trauma interacts with Type II trauma and proliferates to Type I trauma and its negative impact on mental health and cognitive functions.
All Type III trauma subtypes affect mental health and executive function deficits, with Type III-a traumas (intersected discrimination) having the highest impact.
Stressors arising from the COVID-19 pandemic intersect with other trauma types to negatively affect mental health and cognitive functioning among internally displaced Syrians.
Methods
Sampling and Participants
Snowball sampling was used to recruit a total sample of 891 Syrian adults. Age varied from 18 to 90 years (M = 30.81, SD = 12.04). 53.5% classified themselves as males, 53% as married, 20.5% as single, 0.9% as widowed, 12.7% as divorced, and 4.8% described another marital status. Of the total sample, 45.1% reported their economic status as very poor, 43% as poor, and 11.9% saw themselves as middle class. For religion, 86% reported being Muslims and 14% being Christian. In terms of education, 27.9% of the sample possessed good writing and reading abilities, 28.2% possessed a high school diploma, 27% a college-level education, and 16.8% had obtained professional or graduate education.
Procedure
This study was the first phase of a longitudinal study on the impact of COVID-19 on internally displaced Syrian people. The field research was conducted in October 2021. The data were gathered from camps for internally displaced Syrians located in Idlib and Aleppo governorates close to the Syrian–Turkish borders. Additional data were collected in villages around the urban areas of Aleppo and Idlib, where internally displaced lived. Most participants (75%) completed the Arabic questionnaire directly on an iPad, and the remaining participants required minimal help. Data were collected by five data collectors who possessed graduate degrees and resided in the area. The team had received a virtual 1-day training on survey administration. Staff of international aid organizations and refugee camp workers assisted the research team to gain access to participants and with data collection. A financial incentive (1 American $ in local currency) was provided to each participant. Each participant had to sign an informed consent form before starting the survey. Of those approached, 98% accepted to participate. The Institutional Review Board of Fayoum University, Egypt, had authorized the research protocol.
Measures
COVID-19 Cumulative Traumatic Stressors Scale
The COVID-19 cumulative traumatic stressors scale (Kira, Shuwiekh, Ashby, Rice et al., 2021; Kira, Shuwiekh, Rice et al., 2021) consists of 17 items. It includes four subscales, economic stressors (4 items), lockdown stressors (3 items), grieving for lost loved ones to COVID stressors (5 items), and threat/fear of near or future infection and death (5 items). Every item is scored on a 5-point Likert scale, with 5 indicating very much and 1 denoting not at all. An example of an item is, “How concerned are you that you will be infected with the coronavirus?” The scale had robust psychometric properties in Kira et al.’s research (Kira, Shuwiekh, Ashby, Rice et al., 2021).
Cumulative Stressors and Traumas Measure-Short Form (CST-S-36 items)
The Cumulative Stressors and Traumas Measure-Short Form-36 (Kira et al. 2008) was devised to assess the stressors and traumas proposed by the DBTF that proposed an integrated taxonomy of stressors and traumas, in which trauma, once developed, is considered an acute stressor which affects the response to future traumatic events (e.g., Kira, 2001, 2019, 2021, 2022). It measures six trauma categories. The six traumas include attachment traumas (e.g., abandonment by caregivers), personal identity trauma (e.g., traumas due to sexual and physical abuse and rape), collective or social identity traumas (e.g., due to oppression and intersected discrimination), role identity or status achievement trauma (e.g., arisen from dropping out of school, being fired, or failed business), and physical survival traumas (e.g., triggered through the experience of natural disasters and car accidents). They also include secondary or indirect trauma (i.e., due to trauma-impacted significant others). Several specific trauma measures were derived from these six main types; for example, gender discrimination and intersected discrimination measures are derived from the collective identity trauma main category.
Furthermore, the trauma severity is identified by three general types of traumas: Traumas Type 1 (6 traumas) which were caused by single events, traumas Type II (9 traumas) which follow from cascades or sequences of events that were sustained in the past for a rather short time scale, and traumas Type III (14 traumas) which are triggered by events that continued for prolonged times. Type III trauma, the most critical, has five variants and subtypes, as discussed in the Introduction. There is strong support for the validity of the model, as Type III trauma, compared to trauma Types II and I, predicted more severe symptoms in Kira’s (2021) research.
The investigator can estimate the parameters of each event regarding its occurrence (happened or not), frequency (number of occurrences), category (e.g., attachment), appraisals of the event’s impact, and the actual age at which exposure took place. In this study, participants were only requested to indicate for each event, if they had endured the stressor on a 5-point Likert-type scale (4 = many times, 0 = never). The measure has been found to possess adequate test–retest stability (.95 over 4 weeks; Kira, Barger et al., 2020) and internal consistency (α = .85; Kira et al., 2008). Studies conducted in different countries and languages (e.g., Spanish, Polish, Arabic, Turkish, Burmese, Yoruba, and Korean) replicated the scale’s convergent, divergent, and predictive validity (e.g., Kira, Barger et al., 2020; Kira et al., 2011; 2018; 2019; Kira, Fawzi, & Fawzi, 2013). In the current research, we used the subscales for traumas of Type I, II, and III and the five subtypes of Type III trauma.
International Trauma Questionnaire
The International Trauma Questionnaire (ITQ; Cloitre et al., 2018) measures and diagnoses CPTSD and PTSD according to the ICD-11 criteria. The ITQ comprises 18 items that assess avoidance, re-experiencing, the sense of presented threat, and disturbances in self-organization clusters that were unique to CPTSD. Additionally, the scale includes two questions that ask the participant to identify their main trauma(s). ITQ employs algorithms that help reach the potential diagnosis of CPTSD or PTSD. The measure also provides the scoring for CPTSD and PTSD that displays symptom severity. Various studies showed that the measure has robust psychometric properties (e.g., Karatzias et al., 2017). The Arabic version of the measure showed adequate psychometric properties in Arabic populations (Vallières et al., 2018).
Generalized Anxiety Disorder-7
The Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006) is a 7-item scale that measures generalized anxiety. Each statement is scored on a 4-point Likert scale with 3 meaning a presented condition exists nearly every day and 0 meaning the condition does not exist. Scores 15 and above on the scale indicate clinical anxiety. In Spitzer et al.’s (2006) research, the scale had a specificity of 82% and a sensitivity of 89%. Elevated scores on the scale were highly associated with functional impairment. The scale’s Arabic version has shown robust psychometric properties (Sawaya et al., 2016).
Patient Health Questionnaire-9
This 9-item scale (Kroenke et al., 2001) assesses the severity of depression. Each item is scored on a 4-point Likert scale with 3 indicating a symptom exists nearly every day and 0 indicating that the condition does not exist. Scores between 15 and 19 indicate moderate to severe depression. A score of 20+ indicates severe depression. The Arabic adaptation of the measure had robust psychometrics (Sawaya et al., 2016).
The Adult Executive Functioning Inventory (ADEXI)
The scale comprises 14 questions that assess executive functioning deficits in adults (Holst & Thorell, 2018). It assesses working memory (9 items) and inhibition deficits (5 items). An example of an item that evaluates working memory deficits is “I have difficulty remembering lengthy instructions.” An example of the statements that evaluate inhibition deficits is “I tend to do things without first thinking about what could happen.” Each statement is evaluated on a range from 1 to 5, with 5 indicating it is definitely true, and 1 indicating that it is definitely not true. The greater the score, the higher the deficits. The scale was able to successfully differentiate between ADHD adult patients and controls (Holst & Thorell, 2018) and had adequate psychometric properties in Arabic populations (Kira, Shuweikh, Al-Huwailiah et al., 2022).
Statistical Analysis
We followed Cohen’s (1992, p. 158) recommended criteria to decide the sample size needed to obtain a medium effect size for correlations (.30) at power = .80 for α = .05 considering the number of variables. We utilized IBM-SPSS (Statistical Package for Social Sciences) and AMOS 22 (analysis of a moment structures) software in data analysis. Due to the survey being planned to give the participant the option either to answer an item or to opt out of the study, there were no missing data and the number of drop-outs was negligible. We determined descriptive statistics and the significance of correlation coefficients between the frequency with which events related to CTS Type III trauma and its five variants had been experienced. We utilized Lee and Preacher's (2013) formulae to calculate the Fisher z score to verify the significance of the differences between correlation sizes (see also Steiger, 1980). We used Cohen's suggestions (1988) for determining effect sizes in correlational research. Accordingly, an effect size of .10 (or less) can be judged as small; an effect size of .30 can be judged as medium, while an effect size of .50 or more can be determined as large.
We performed SEM analysis with trauma types III and II as correlated independent variables, and stressors related to COVID-19 and mental health syndrome (latent variable) as the dependent variables. We calculated the standardized regression coefficients of direct, indirect, and total effects. Good model fit criteria (Byrne, 2012) were a nonsignificant chi-square (χ2), the χ2 to degrees of freedom ratio (χ2/df > 5), comparative fit index (CFI) values > 0.90, and root-mean-square error of approximation (RMSEA) values < 0.08. We conducted bootstrapping with 10,000 bootstrap samples to evaluate the significance of indirect, direct, and total effects and their 95% bias-corrected confidence intervals (95% CI) for each variable.
Results
Scale Reliability
All scales had adequate reliabilities (see Table 1 for Cronbach α values).
Descriptive Results
Most participants identified their main traumatic events as uprootedness and related to COVID-19. The results indicated an extremely high trauma load (number of traumatic events: M = 19.60, SD = 13.02 with frequencies M = 43.24, SD = 32.59). Over 77% of the sample experienced traumatic events related to Type III traumas, more than 45% had been infected with COVID-19, and over 85% scored above the midpoint on the COVID-19 stressors scale. Also, 13.9% met the criteria for PTSD and 33.1% met the criteria for CPTSD. Almost every tenth participant (9.9%) met the criteria of clinical anxiety with a score of 15 or above on the GAD-7 scale, and 33.6% scored on or above the cutoff score for moderate to severe depression on the Patient Health Questionnaire-9 (PHQ-9). Additionally, 51.9% were torture survivors and 37.9% presented as suicidal based on the suicidality item in PHQ-9.
Correlations
All types of stressors were associated significantly with depression, anxiety, PTSD, CPTSD, severity of COVID-19 stressors, working memory, and inhibition deficits. However, the degree of association generally increased from traumatic events related to Type I to events associated with Type III trauma. For working memory and inhibition deficits, the trend was not evident between trauma Types I and II. The severity of COVID-19 stressors was significantly associated with all variables, with its highest association with CPTSD and depression. Working memory deficits had the highest association with all mental health variables, especially with CPTSD (.65). Inhibition deficits showed similar associations with its highest association also with CPTSD (.59). For ease of reading, the “frequency of events associated with trauma type” will be abbreviated as trauma type. For example, the frequency of events related to Type 1 trauma will be described simply as “Type 1 trauma.” The differences in correlation between Types I and III traumas and severity of COVID-19 stressors were significant (z score = −3.40, p[two-tailed] = .002), while the relative increase in the association with severity of COVID-19 stressors between trauma Types I and II and between Types II and III was not significant.
For the association between trauma types and working memory, the change between trauma Types I and II in working memory deficits was not significant. However, the increase in the association of working memory deficits with trauma Types II and III was significant (z score = −4.99, p[two-tailed] = .001) as was the increase in the association between working memory deficits and trauma between trauma Types I and III (z score = −2.63, p[two-tailed] = .01). For the association between trauma types and inhibition deficits, the change between trauma Types I and II, again, was not significant. However, the increase in the association between trauma Types II and III was significant (z score = −4.87, p[two-tailed] = .001), as well as the increase in inhibition deficits between trauma Types I and III (z score = −2.56, p[two-tailed] = .01).
For the association between trauma types and depression, the increase in the size of the association between trauma Types I and II in depression was significant (z score = −2.01, p[two-tailed] = .04), and between trauma Types II and III (z score = −2.68, p[two-tailed] = .001).
For the association between trauma types and anxiety, the increase in the size of the association between trauma Types I and II in anxiety was not significant. However, the size of the increase in anxiety between trauma Types II and III in anxiety was significant (z score = −2.52, p[two-tailed] = .01).
For the association between trauma types and PTSD, the increase in the size of the association between trauma Types I and II in PTSD was not significant. However, the increase in the size of the association between trauma Types II and III in PTSD was significant (z score = −2.07, p[two-tailed] = .03), as was the increased size of the association between trauma Types I and III in PTSD (z score = −3.10, p[two-tailed] = .001).
For the association between trauma types and CPTSD, the increase in the size of the association between trauma Types I and II in CPTSD was significant (z score = −2.10, p[two-tailed] = .03), as well as the increase in the size of the association between trauma Types II and III in CPTSD (z score = −2.68, p[two-tailed] = .01). Table 1 details these associations.
Furthermore, we compared the associations of the five trauma III subtypes and mental health and executive function deficits using the same procedure. The correlations between the frequency with which traumatic events related to the five subtypes of Type III and all mental health and executive function deficits were significant and ranged between moderate to high. The frequency with which events associated with the Type III-a subtype were experienced (intersected discrimination) had the highest associations with mental health and executive function deficits, followed by the frequency of events related to Type III-b (adverse childhood trauma). The difference in the strength of this relationship between Types III-a and III-b was significant in all variables except for depression. The correlations between Type III-b and mental health and cognitive variables were significantly stronger than those with Type III-c (intergroup conflict). The strength of the correlations between mental health and cognitive variables and Type III-c (intergroup conflict) was not significantly different from those between the mental health and cognitive variables and Type III-d (community violence) traumas, except for executive function deficits. The same applied to the strengths in correlations between Type III-d and mental health and cognitive variables and the same correlations with Type III-e (chronic, life-threatening medical conditions). All differences in correlations were insignificant except for the correlations between the trauma type and executive function deficits. Table 2 details the correlations between variables, while Table 3 details the z scores for the significance of the difference in correlation sizes between the frequency of events related to the subtypes of Type III traumas and the main variables in this study.
SEM Analysis Results
The SEM model had acceptable fit with the data (χ2 = 39.167, df = 17, p = .002, CFI = .996, RMSEA = .038). All variables that were represented in the latent variable peri-post Type III trauma mental health syndrome loaded highly on the latent variable (above .60). In the model, the frequency of events related to Type III trauma correlated highly and bidirectionally with the frequency with which events related to Type II trauma had been experienced (.86), and both had large size direct effects on the frequency with which Type I traumatic events had been experienced, which indicated the direction of the proliferation dynamics. A greater frequency of experienced events related to Type III traumas had large direct effects on the frequency of events experienced which relate to Type I traumas (.45, p < .01). Type III trauma had direct and indirect effects on mental health syndrome. Type III trauma’s total effects on mental health syndrome were large (.56, p < .01) and accounted for 82% of the total effects. Equally so, there were direct and indirect effects on the degree to which participants were concerned about COVID-19 stressors. Type III trauma’s total effect size on COVID-19 stressors was medium to large (.35, p < .01), accounting for 60% of the total effects. The frequency with which traumatic events associated with Type III trauma had been experienced had indirect medium to large effects on depression, anxiety, executive function deficits, CPTSD, and PTSD.
Type II trauma had direct medium to large size effects on Type I trauma (.42, p < .01). It had small-sized indirect effects on COVID-19 stressors, mental health syndrome, and related variables (depression, anxiety, executive function deficits, PTSD, and CPTSD).
Type I traumas had medium-size effects on COVID-19 stressors (.32, p < .01) and small indirect effects on COVID-19 stressors, mental health syndrome, and related variables (depression, anxiety, executive function deficits, PTSD, and CPTSD).
COVID-19 stressors had direct medium-size effects on mental health syndrome (.29, p < .01). It primarily had medium-size indirect effects on all the mental health variables (depression, anxiety, executive function deficits, PTSD, and CPTSD). Table 4 presents the direct, indirect, and total effects and 95% confidence intervals for each variable. Figure 1 presents the direct standardized effects of the variables and their paths.
Conclusion and Discussion
The results supported the four hypotheses of the study providing evidence that Type III traumas of exposure to continuous civil war and stressors arising from the COVID-19 pandemic have a greater effect on mental health and cognitive deficits than Type II and I traumas. Further, Type III traumas proliferate to trauma Types II and I, and have the highest effect size on mental health and executive function deficits compared to trauma Types I and II.
This study convincingly validated the stress and trauma-gradient hypothesis, with the frequency of traumatic events leading to Type III trauma (the CTS) being most strongly associated with the peri-post Type III trauma mental health syndrome and with its five components. It further validated the stress and trauma-gradient hypotheses of the five Type III trauma variants, with the frequency of Type III-a events (intersected discrimination), followed by the frequency of events related to Type III-b trauma (childhood adversities) being most strongly related with adverse mental health and cognitive conditions. Also, the study further replicated the proliferation of the frequency of events related to Type III and II to the frequency of events related to Type I traumas (single events). The results supported the study hypotheses, a greater frequency of events related to Type III traumas, arising from prolonged civil war and greater concern about stressors related to the COVID-19 pandemic have greater negative impact on mental health and cognitive function than the frequency of events associated with trauma Types I and II. Types III and II traumatic events interact and proliferate to Type I traumatic events. All Type III traumas subtypes, including concern about stressors related to the COVID-19 pandemic have negative effects on mental health and cognition, with the frequency of experienced intersected discriminations (Type III-a trauma) having the largest relative impact in Syrian internally displaced.
Moreover, this study expanded previous findings on the impact of COVID-19 as continuous prolonged traumatic stressors on the peri-post Type III trauma mental health syndrome that included mental health and cognitive functions. This study is one of the first studies, if not the first, that explored the effects of the degree of concern about COVID-19 on CPTSD as an outcome variable. A recent study found that CPTSD mediated the effects of child abuse and COVID-19-related stressors (Tsur & Abu-Raiya, 2020). The role of CPTSD as mediating or outcome variable needs to be explored further in future studies. While we explored the effects of the frequency of such severe traumatic events on CPTSD and other mental health conditions, we did not study its effects on dissociation, suicidality, or addiction. Other research has found suicidality to be highly predicted by affective temperament types evoked by such severe trauma (e.g., Baldessarini et al., 2017; Orsolini et al., 2020) and COVID-19 to be associated with higher suicide rates (for meta-analysis, see Dubé et al., 2021). Dissociation and risk of addiction increased with the pandemic (e.g., La Rosa et al., 2021).
The findings offer several key takeaways that can improve understanding of traumatization dynamics and inform interventions related to the mental health and cognitive outcomes of Type III traumas in Syrian IDP and potentially other populations with multiple types of trauma. The findings provided compelling evidence that the frequency with which traumatic events related to Type I, II, and III traumas tend to be related to mental health and cognitive functions to varying degrees, with the frequency of events experienced that relate to Type III traumas (the CTS), having the strongest associations, especially its subtype III-a (intersected discrimination and oppression). This is in line with previous findings (Kira, 2021; Kira, Al-Noor et al., 2022; Kira, Aljakoub et al., 2022; Kira, Rice et al., 2022). This study especially validated Type III trauma’s five subtypes with the frequency of events associated with the Type III-a subtype (intersected discrimination/ oppression) being the worst in terms of its association with mental health symptoms and cognitive deficits. This is likely to be the case as discrimination has a lifelong time scale and demeans the person's identity. This may lead to internalized inferiority, lower self-esteem, and stereotype threats that affect the person's life outcome and well-being.
Path analysis results explained the dynamics through which the frequency of Type III traumatic events, which tend to lead to CTS, bidirectionally interacts with the frequency of Type II traumatic events to proliferate to the frequency of Type I (the single event) traumatic events to impact mental health and cognitions negatively, replicating and extending previous finding on stress and trauma proliferation (e.g., Conway et al., 2012; Kira et al., 2016; 2018; Kira, Fawzi et al., 2021; LeBlanc et al., 2015). The frequency with which Type III traumatic events are experienced have the greatest impact on mental health and cognitive variables in the path model. Additionally, the severity of concern related to COVID-19 (a variant of the subtype -e of Type III traumas) has a significant impact on mental health and cognitive functioning, replicating previous studies (e.g., Fiorenzato et al., 2021, Kira, Alpay, Ayny et al., 2021; Kira, Alpay, Turkeli et al., 2021; Lavigne-Cerván et al., 2021). Additionally, the results are the first, to our knowledge, to provide important information about the impact of the Syrian protracted civil war complicated by uncontrolled prolonged COVID-19 spread. They showed that stressors related to internal displacement and the degree of concern about COVID-19 stressors intersected with other traumatic stressors and that internally displaced Syrians displayed high rates of CPTSD, depression, PTSD, executive function deficits, and anxiety.
At a more general level, the results show that it is important to consider different trauma profiles as they relate differently to mental health and cognitive outcomes. This exposes the limitation of conceptual frameworks that are restricted to a certain trauma profile. It is important to consider integrated stress and trauma frameworks that account for all the different trauma profiles in different communities and cultures.
Furthermore, the results highlighted the potential cultural differences in trauma profiles between individualistic and collectivistic cultures. The salient traumatic events in collectivistic cultures are likely more frequently traumatic events related to intergroup trauma, which may explain, at least in part, the genesis of collectivism, while the salient traumatic events in the majorities’ cultures trauma profiles are more interpersonal traumas which may explain, at least in part, the traumatic basis of individualism (see, e.g., Kira, Rice et al., 2022).
While the current study has notable conceptual implications for stress and trauma disciplines, it also has significant implications for clinical intervention and prevention of CTS, an outcome of continuous traumatic events. It highlighted the need for innovations to address the CTS dynamics of proliferation and accumulation, even for those highly resilient. Some emerging interventions for CTS (e.g., Kira, Ashby et al., 2015; Kira & Tummala-Narra, 2015) need to be developed further and tested. Our results highlighted the significance of working memory deficits in mental health, which were highly associated with all mental health variables. The interplay between symptoms and executive functions in peri-post type III trauma MH syndrome reflected the acting integrative cognitive and emotional processes that are shaping mental health status. Any intervention strategies for individuals who experienced traumatic events associated with Type III and traumas in general, should include executive function optimization training in order for them to be more effective (e.g., Chiu et al., 2017; Karbach & Kray, 2021; Zimmer et al., 2021).
The current study, while having notable strengths, has numerous limitations. This study was conducted in a convenient sample. The measures we used in the study were based on self-reports. Self-report is subject to different biases such as social desirability. Furthermore, the self-report executive function (EF) scale may not represent the same cognitive structures measured by performance-based EF scales. Performance-based and self-report tests of EF measures were found to be complementary, but distinct and unique constructs of metacognitive mechanisms (Snyder et al., 2021). Furthermore, the current study was cross-sectional. We cannot draw definite causal inferences from the results in a cross-sectional design. Regardless of these limitations, this study provided empirical evidence that greater frequency of the validity of type III continuous stressors (acute and chronic) has the most grave effects, with greater frequency of intersected discrimination (Type III-a stressors) having the most severe impact. Syrian IDP are exposed to the most detrimental traumatic events and need urgent and innovative help.
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