Progressive worsening of posttraumatic stress symptoms in Syrian and Iraqi refugees associated with cumulative and victimization trauma: A longitudinal study

Abstract

Background: War and forced migration expose refugees to trauma and ongoing stress, often contributing to long-term psychological consequences. Typically, trauma exposure is assessed cumulatively; yet, trauma type may better predict psychological outcomes. This study examined the differential impact of cumulative trauma and trauma subtypes (victimization, death threat, accidental/injury) on postmigration trajectories of posttraumatic stress and anxiety in refugees.

Method: Seventy-seven Syrian (88.3%) and Iraqi (9.1%) adult refugees self-reported prior trauma exposure and psychological symptoms at time of arrival in the United States and 2 years post. Linear mixed-effects modeling was performed to assess for associations between trauma variables and symptom trajectories. Models using cumulative trauma as a predictor were compared to models including the three trauma subtype variables as predictors, using pseudo-R² values to compare variance explained between the two methods of trauma measurement.

Results: Linear mixed-effects modeling indicated that prior exposure to victimization predicted progressively worsening posttraumatic stress disorder (PTSD) symptoms over time postmigration (b = .97, SE = .45, t = 2.14, p = .036). Cumulative trauma also predicted increasing PTSD symptoms (b = .124, SE = .06, t = 2.09, p = .041), but explained less variance than victimization (9% vs. 18.1%). Direct effects of cumulative trauma (p = .009) and victimization (p = .002) on anxiety severity emerged; however, anxiety symptoms did not change over time depending on prior trauma exposure. Accidents/injuries and death threats did not predict PTSD or anxiety.

Conclusions: These findings can be leveraged toward focused identification of those at highest risk for progressive illness postmigration, thus providing empirical guidance for allocation of interventions and resources for refugees. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Figure 1.

Visual representation of PTSD symptoms over time at each number of total traumatic events endorsed on the LEC-5. Higher cumulative trauma scores on the LEC-5 were significantly associated with increasing PTSD symptom severity over time. Time 1 refers to time of arrival in the U.S., with Time 2 referring to two years post-arrival. Y-axis represents PTSD symptoms using PCL-5 scores. PCL-C scores at Time 1 were converted to PCL-5 scores using protocol from Moshier et al. (2019).

Figure 2.

Exposure to victimization on the LEC-5 was significantly associated with increasing PTSD symptom severity over time, as compared to those not reporting victimization. Time 1 refers to time of arrival in the U.S., with Time 2 referring to two years post-arrival. Y-axis represents PTSD symptoms using PCL-5 scores. PCL-C scores at Time 1 were converted to PCL-5 scores using protocol from Moshier et al. (2019). A cut-off score of 35 on the PCL-5 is recommended for a probable PTSD diagnosis (Mat et al., 2020).