Escalation during continuous traumatic stress: the psychological impact of wartime flare-up

ABSTRACT

Background: In June 2025, after nearly two years of fighting on Israel’s northern and Gaza borders, direct conflict between Israel and Iran exposed the Israeli homefront to hundreds of rockets and drones targeting urban centres.

Objective: This study was designed to assess the continuous traumatic stress response (CTSR) following a period of escalation and acute threat on the homefront and the relationship with unique war variables compared to recognized individual and social factors.

Method: An online questionnaire was sent to a longitudinal sample of adults living on the homefront during the Israel-Hamas war, a week following a significant escalation where rocket and missile fire was exchanged between Iran and Israel. The sample included 287 Israeli civilians (87.3% female; age 19–76) who reported psychological distress post-escalation, which was studied in relation to war-related exposures, peritraumatic dissociation during the conflict, and perceived social support and trust.

Results: Participants evacuated experienced higher levels of CTSR, depression, and anxiety. Importantly, peritraumatic dissociation was identified as the strongest predictor of psychological distress across outcomes, surpassing the impact of objective war-related experiences. Different forms of social support had varying effects on distress, while trust in government institutions uniquely influenced psychological outcomes.

Conclusions: The findings suggest that internal psychological responses during threats might be more indicative of distress than actual exposure and highlight the need for targeted interventions for displaced populations. Interventions that address dissociative experiences may be especially valuable during periods of heightened threat.

HIGHLIGHTS

• In an overall well-educated population living in the urban centre of a country at war, contrary to predictions, war-related variables such as damage in the locality or variation in shelter proximity did not predict elevated psychological distress following the cessation of the escalation.

• Being evacuated, either by choice or due to damage, predicted a higher continuous traumatic stress response.

• The most significant predictor of a continuous traumatic stress response (including hopelessness and emotional exhaustion) was the level of dissociation during the exposure to war escalation.

• People who felt detached from the experience together with people who felt the least support and trust in the government were most at risk for prolonged distress following the escalation.

1. Introduction

When traumatic exposure is ongoing rather than a past event, conventional trauma frameworks struggle, particularly when post-traumatic stress disorder (PTSD) symptoms, like hyperarousal, are adaptive responses to continuous threats. The concept of Continuous Traumatic Stress (CTS), developed in the context of political violence in South Africa (Straker, 1987), addresses this reality by highlighting a chronic cycle of normalcy and danger, where threats are anticipated rather than remembered. Under CTS, individuals exhibit a CTS Response (CTSR), characterized by exhaustion, anger, and helplessness, which may be adaptive rather than pathological (Goral et al., 2021). Since 7 October 2023, the Israeli civilian population has lived under difficult conditions, with coping patterns linked to the severity of CTSR, which rose over 6 months before stabilizing (Harwood-Gross et al., in submission). While PTSD levels have declined across Israel, variations exist among different populations and risk groups (Amsalem et al., 2025; Levi-Belz et al., 2025).

This study focuses on a significant escalatory event during the ongoing war: a 12-day confrontation with Iran in June 2025, during which Israel faced unprecedented aerial threats, including 550 missiles and 1,000 drones, resulting in 28 deaths, 3,000 injuries, and extensive property damage (Fabian, 2025). One week after this escalation, we assessed its psychological impact on the homefront population, providing insight into experiences of chronic trauma exposure during heightened risk periods.

Much of the CTS literature in Israel focuses on residents of border communities facing rocket fire (Gelkopf et al., 2012; Greene et al., 2018) and evacuees experiencing repeated displacement (Hochman & Nuttman-Shwartz, 2025), with less emphasis on the homefront, except in Ukraine (Zasiekina et al., 2024) and during the COVID-19 pandemic (Lahav, 2020). Shalev et al. (2006) found that groups directly and indirectly exposed to terror reported similar PTSD rates, with disruption of daily routines linked to psychological distress. This raises the question: do war-related disruptions independently cause psychological distress, or do they operate through internal processes and the availability of social and institutional support?

The study explores the link between wartime variables and psychological distress, emphasizing individual and social conditions during periods of heightened distress. While social support is generally protective during conflict (Gelkopf et al., 2012), its impact varies by source, with community solidarity and trust in authorities being more significant for resilient communities. Additionally, peritraumatic dissociation – detachment during acute threat – emerges as a strong predictor of posttraumatic stress, often surpassing factors like prior trauma, prior psychological adjustment, and social support (Breh & Seidler, 2007; Lensvelt-Mulders et al., 2008; Ozer et al., 2003). Previous research predominantly focuses on discrete events, but Gil et al. (2016) found that, in prolonged threat contexts, dissociative symptoms were significant predictors of PTSD severity among Israeli civilians, unlike proximity and social support.

The current study will assess which war-related variables were related to increased psychological distress and, in turn, whether war-related variables, peritraumatic dissociation, or social and societal support predicted psychological distress following a period of elevated trauma exposure during a prolonged period of war.

2. Methods

2.1. Sample and procedure

The sample included 287 participants, mostly females (87.3%), aged 19 to 76 years (M = 42.33, SD = 11.88). Most were highly educated (28% had an undergraduate degree, 55.8% held a master's degree, and 9.9% had a doctorate). The education level was somewhat representative of the homefront population, primarily residing in the Tel Aviv-Jerusalem corridor (68.9%) (Tel Aviv Municipality, 2022), and the gender bias represented the initial sample, which was recruited at a time of mass conscription of males to reserve duty. Participants had previously taken part in a study on the effects of the Hamas incursion on 7 October 2023 (see Harwood-Gross et al., 2025) and were approached a week after the Israel-Iran war in June 2025 to ask about their experiences during this period. The research was approved by the Ariel University ethics committee (AU-SOC-RA-20240316).

2.2. Measures

Demographic and war-related background. Participants were asked to report background information across several domains relevant to their circumstances during the war with Iran period (see Table 1).

Table 1.

Means, SDs, and ANOVA for group comparisons or war-related changes.

War functioning	Group	N	CTSR Mean (SD)	F (df)	Depression-Anxiety Mean (SD)	F (df)
Evacuation	Forced or choice evacuation	36	15.08 (6.47)	9.30 *** (2,277)	9.86 (3.47)	4.49 ** (2,276)
	Moved home during the period	7	15 (8.54)		9.14 (3.02)
	Did not move	224	10.6 (5.64)		8.32 (2.82)
Damage	Home or next to home	12	12.17 (3.27)	1.91 (2,275)	8.75 (1.91)	1.47 (2,275)
	Locality	61	12.56 (6.24)		9.11 (2.95)
	None	194	10.89 (6.08)		8.39 (2.99)
Work	Unemployed	34	11.55 (7.5)	1.15 (4,268)	8.64 (3.31)	.68 (4,267)
	Worked as normal	39	10.46 (6.73)		8.05 (3.42)
	Worked less hours	32	9.81 (4.65)		8.12 (2.08)
	Worked from home, regular hours	54	11.11 (5.57)		8.91 (3.17)
	Worked from home, less hours	108	12.11 (5.87)		8.61 (2.74)
Shelter	Within home	156	11.28 (6.00)	.63 (4,271)	8.64 (2.98)	.99 (4,270)
	Within building	54	11.54 (6.01)		8.70 (2.92)
	Next to the building/home	18	11.33 (4.13)		8.06 (2.52)
	On same street	30	10.00 (4.13)		7.77 (2.81)
	No specific (i.e. Stairwell or inner room)	17	12.82 (7.08)		9.29 (3.67)

Note: * = p < .05, ** = p < .01, *** = p < .001.

Social support was evaluated using 5 items assessing the current level of perceived support. This approach was based on Ben-Zur's (2008) scale. Participants were asked for their level of agreement to the statement: ‘At the moment my family/friends/community/government/military are a source of security, trust and support’. They rated agreement on a scale from ‘1' (no agreement) to ‘5’ (strong agreement).

Peritraumatic dissociation was assessed using the Peritraumatic Dissociative Experiences Questionnaire (PDEQ; Marmar et al., 1998), which was translated into Hebrew by Shalev et al. (1997). PDEQ consists of 8 items rated on a scale from 1 (not at all true) to 5 (extremely true). Consistent with previous studies that examined uninjured populations (Dokkedahl & Lahav, 2024), one item was omitted from the current analysis. Both versions demonstrate strong psychometric properties. In this study, the internal consistency was good (α = .84).

Continuous traumatic stress was measured using the Continuous Traumatic Stress Response (CTSR) Questionnaire (Goral et al., 2021). The Questionnaire consists of 11 statements on a Likert scale from 0 (not at all) to 3 (to a great extent), with a higher total score indicating more severe CTSR symptoms. The questionnaire has been validated in residents living near the Gaza Strip (Goral et al., 2021) and has also been adapted and validated in Ukrainian populations (Zasiekina et al., 2024). In this study, the internal consistency was good (α = .87).

Depression and anxiety were measured using the Patient Health Questionnaire-4 (PHQ-4) (Löwe et al., 2010), a valid and concise tool for detecting both anxiety and depressive disorders. The PHQ-4 is a 4-item questionnaire assessing symptoms of anxiety and depression, each comprising 2 items rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). The total score is calculated by summing the scores from all four items. The PHQ-4 is a well-validated psychometric tool of psychological distress in the general population (Löwe et al., 2010). In the current study, the internal consistency was good (α = .86).

2.3. Data analysis

First, we used one-way ANOVAs to identify which war-related circumstances, evacuation status, damage to locality, shelter access, and work disruption were associated with CTSR and depression-anxiety. Second, variables with significant group differences were entered into hierarchical regression models, with their effects tested alongside demographics (Step 1), war-related factors (Step 2), peritraumatic dissociation (Step 3), and five sources of perceived support (Step 4). To ensure adequate statistical power, an a priori G*Power 3.1 analysis suggested that a linear multiple regression model with 10 predictors would require approximately 172 participants to detect a medium effect size (f² = .15) with an alpha level of .05 and power of .95. Allowing for up to 20% attrition or incomplete data, the target sample was set at 215 participants. The final sample comprised 287 participants, exceeding this target.

3. Results

3.1. Preliminary analyses

Initial group comparisons (ANOVAs) were conducted to identify war-related factors associated with psychological distress (see Table 1). Evacuation status (forced or by choice) was significantly associated with higher levels of CTSR and anxiety-depression symptoms. No other war-related variables were associated with CTSR or anxiety-depression symptoms.

3.2. Prediction of psychological distress

Two hierarchical linear regression models were conducted to predict CTSR and depression-anxiety. All models were significant (see Table 2): For CTSR, the final model accounted for 46% of the variance, F(10, 239) = 20.46, p < .001. For depression-anxiety, the final model accounted for 32% of the variance, F(10, 239) = 11.20, p < .001. Notably, being evacuated, family and community support were only significant for CTSR, and friend support played a small role in reducing depression-anxiety symptoms.

Table 2.

Hierarchical regression models for CTSR and depression-anxiety symptoms.

Predictor	CTSR (β)	Anxiety-Depression (β)
Step 1: Demographics
Age	−.29***	−.17**
Children (Dummy)	.09	.10
Step 2: War Related
Evacuated (Dummy)	.13 **	.08
Damage to Locality (Dummy)	.05	−.05
Step 3: Internal Process
Peritraumatic Dissociation	.37 ***	.39 ***
Step 4: Support Systems
Government Support	−.18 ***	−.21 **
Family Support	−.18***	−.09
Community Support	−.14**	−.11
Friends Support	−.08	−.14*
Military Support	−.07	.05
Model R²	.461	.319
ΔR²	.157***	.098*

Note: β coefficients from the final step (Step 4) are reported.

*p < .05, **p < .01, ***p < .001.

4. Discussion

The present study offers a nuanced picture of psychological distress during acute escalation under conditions of CTS. War-related exposures were not related to increased psychological distress other than evacuation (forced or by choice) which was related to increased CTSR. Peritraumatic dissociation was the strongest predictor of both CTSR and anxiety-depression symptoms as was distrust in governmental organizations.

The significance of peritraumatic dissociation is in accordance with previous research, which primarily focused on discrete traumas (Breh & Seidler, 2007; Lensvelt-Mulders et al., 2008; Ozer et al., 2003). In the context of sustained threats, like a 12-day aerial escalation, dissociative responses may function similarly to those during brief trauma. The findings suggest that dissociative fragmentation during acute escalation is a broad vulnerability factor for psychological distress, not just a trauma-specific factor.

Preliminary evidence from the 2014 Israel-Hamas conflict pointed in this direction (Gil et al., 2016); the present findings provide more robust support. From a clinical standpoint, these results underscore the importance of screening for dissociative experiences during acute flare-ups within protracted conflicts. Grounding-based interventions may be particularly indicated for individuals reporting high peritraumatic dissociation, and interventions that encourage connection to the present moment may be particularly helpful to this population, even if their long-term efficacy is questionable (Figueroa et al., 2022; Ironson et al., 2021).

A second notable pattern was the limited predictive power of concrete war-related disruptions, with only CTSR showing significant variance attributable to these factors. Evacuation persists as a unique predictor in the final model. This supports the idea of home as ontological security (Fullilove, 1996), suggesting that displacement contributes specifically to traumatic stress responses rather than broader mood or anxiety issues. This finding aligns with research in other ongoing conflict situations, most similarly in Ukraine, where the mental health of displaced persons has been demonstrated to be worse than that of those remaining on the home front (Kurapov et al., 2023). The lack of predictive ability of other war-related disruptions aligns with prior CTS research indicating weak or inconsistent relationships between exposure and distress (Greene et al., 2018; Shalev et al., 2006). The current findings underscore the psychological distress associated with war even under conditions of low direct or specific exposure. Regarding social support, trust in the government was the only source that predicted lower distress across both outcomes. This extends our earlier finding that system justification protected against CTSR (Harwood-Gross et al., 2025) and suggests that during a threat perceived as national and existential, institutional trust provides a psychological anchor that local social networks cannot fully replicate. Moreover, in wartime, believing that governing systems remain capable and protective may reduce distress by sustaining a sense that threat, although severe, is still containable within an intelligible social order (Haim-Nachum et al., 2025; Jost, 2020). This finding again relates to similar findings in Ukraine, with displacement and lack of trust in the government repeatedly reported and significant factors related to psychological distress (Kurapov et al., 2023; Timmer et al., 2025). Additionally, trust in the government as a source of support or benevolence, as opposed to level of competence, was also demonstrated to predict psychological distress during the COVID-19 pandemic (Mahat-Shamir et al., 2023).

Other support sources showed outcome-specific patterns: family and community support were protective for CTSR, friends for anxiety and depression symptoms. This differential pattern suggests that different dimensions of distress may require different social resources. One possible interpretation is that trauma-related symptoms may be especially responsive to resources that restore safety and belonging, an idea encapsulated by the term social resilience (Kimhi et al., 2025; Nuttman-Shwartz & Dekel, 2009). On the other hand, depression and anxiety may be more sensitive to peer connectedness.

Several limitations are noted. The cross-sectional design limits causal inferences regarding the relationship between distress and dissociative recall. While peritraumatic dissociation’s relevance to distress identification is significant, it was assessed retrospectively (1 week after the escalation), which may introduce recall bias (Candel & Merckelbach, 2004). Additionally, the predominantly female and well-educated sample reflects wartime demographics but limits generalizability. PTSD was not assessed due to the brief post-event interval; however, future longitudinal waves will explore if these patterns persist or evolve as the conflict continues.

In conclusion, during an acute escalation within a protracted war, internal dissociative processes and institutional support emerged as the primary predictors of psychological distress, largely superseding the concrete environmental disruptions of the conflict itself. Interventions during such periods should prioritize dissociation screening and grounding techniques alongside efforts to maintain public trust in governing institutions.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics approval

Ethics approval was granted from Ariel University ethics committee (approval number: AU-SOC-RA-20240316).

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.