Complexity of exposure to mass-casualty conflict and terror stress: A population study following a major civilian targeted event

Objectives The October 7, 2023 events exposed both Israelis, Palestinians, and the entire middle east to unprecedented complex trauma. Guided by theoretical considerations and expert panel discussions, we identified seven distinct exposure domains: missile attacks, physical violence, evacuation, combat participation, hostage involvement, media exposure, and group-based marginalization. We examined actual exposure, that of self and significant others, to these domains alongside subjective stress and major stressful life events. Outcomes included PTSD, depression, anxiety, and somatic symptoms. Methods A representative sample of Israeli-Jewish adults ( N = 928) surveyed for political stress prior to the October 7th 23 events were assessed again in December 2023. They completed a newly developed measure capturing the above seven exposure domains, a measure of major stressful events, and measures of the above outcomes. Hierarchical Regression Analysis was employed to identify both linear and curvilinear effects of exposure, moderated by life stress. Results Self and significant others' exposure were unrelated to subjective stress ( r s: 0.09 and 0.14, ns) but differentially predicted all symptom types. Subjective stress was the strongest predictor of outcomes overall (βs: 0.18–0.35). Curvilinear effects and interactions between trauma exposure and major life stress were documented, although the latter interactions were substantially trimmed by sensitivity analyses. Conclusions A comprehensive conceptualization and assessment mass-casualty armed conflict is essential for identifying stress–distress profiles and guiding personalized care and preventive interventions worldwide.