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What do we know about exposure to trauma, sense of threat and stress symptoms?

There is much evidence in the scientific literature to a direct link between the sense of threat a person feels during and immediately after experiencing a traumatic event, and their subsequent level of posttraumatic stress symptoms. We also know that the more severe the exposure to trauma, the higher is the level of symptoms. Yet, we still do not fully understand the interrelationships between exposure, sense of threat, and symptoms, particularly when the traumatic situation is ongoing, i.e., during the peritraumatic period. In addition, female gender and a history of severe mental illness are prominent risk factors, and thus, for these populations, it is important to further clarify the relationship between exposure, sense of threat, and symptoms.

Why is it important to measure peritraumatic reactions in-vivo?

To date, studies investigating peritraumatic stress reactions used cross-sectional retroactive methods, i.e., requesting subjects to recall their experiences during the traumatic event after it happened. This approach is subject to a number of biases, including recall bias and mood at the time of recall. Instead, the current study uses Experience Sampling Methodology (ESM), which involves reporting momentary emotions, behaviors, symptoms, and environmental conditions, repeatedly and in real-time. Thus, we minimized biases and improved accuracy and context sensitivity.

What did the current study reveal?

A 30-day twice-daily smartphone-based intensive assessment of exposure to sirens, sense of threat, and peritraumatic stress symptoms was performed during the 2014 Israel-Gaza conflict. 182 highly-exposed individuals with or without severe mental illness (SMI) participated. We found that exposure affected the level of peritraumatic stress symptoms both directly, and indirectly through sense of threat, i.e., sense of threat acted as a mediator. In addition, the effect of sense of threat on stress symptoms was larger among people with severe mental illness. Gender did not play a significant role in the relationship between exposure, sense of threat, and symptoms.

What is the role of sense of threat in symptom development during war?

As our results show, sense of threat has a key role in symptom development during wartime. Symptom development during ongoing traumatic exposure depends not only on the severity of exposure, but – more importantly – on the degree to which the person feels threatened. Various theoretical models of posttraumatic stress disorder (e.g., the cognitive model, emotional processing) include an element of threat appraisal during the posttraumatic period. Current results open the door for including peritraumatic sense of threat and other peritraumatic factors in trauma-related models, as important factors in explaining symptom development.

How do people with severe mental illness react differently during war?

We found that sense of threat had a stronger effect on peritraumatic stress symptoms for people with severe mental illness (SMI) compared to the general population, i.e., sense of threat is more likely to lead to symptomatology. Interestingly, no stronger effect was found for exposure on symptoms in the SMI population compared to the general population, and a previous analysis of our data showed no heightened sense of threat in this population. In other words, rather than having an elevated sense of threat (as expected from previous studies), people with SMI are more affected by sense of threat than the general population. It should be noted that the current study did not differentiate between diagnoses, and future studies may increase sample size in order to enable comparison between different diagnoses.

What are the practical implications?

These findings emphasize the need to address people’s sense of threat, and to do this while trauma exposure is ongoing. Attempts should be made to reduce perceived threat and promote a sense of safety among individuals in high-exposure areas or who show increased sense of threat or symptomatology, as well as in the population at large. Additionally, the current study highlights the need to provide individuals with severe mental illness with resources and skills not only to reduce symptomatology but also to reduce perceived threat during the peritraumatic period, as this may lead to symptomatology.


Lapid Pickman, L., Greene, T., & Gelkopf, M. (2017). Sense of threat as a mediator of peritraumatic stress symptom development during wartime: An experience sampling study. Journal of Traumatic Stress (early view). https://doi.org/10.1002/jts.22207

Author Biography

Liron Lapid Pickman is a Ph.D. candidate at the department of Community Mental Health, University of Haifa, as well as the research coordinator at NATAL – Israel trauma center for victims of terror and war. Her research interests include peri- and posttraumatic reactions, psychiatric rehabilitation, and experience sampling methodology.

Talya Greene is a lecturer at the department of Community Mental Health, University of Haifa. Her focuses on the impact of trauma exposure, the assessment of psychiatric symptoms in daily life, network approaches to psychopathology, and resilience and growth.

Marc Gelkopf is the head of the department of Community Mental Health, University of Haifa, and the director of the research department at NATAL – Israel trauma center for victims of terror and war. His research interests include peri- and posttraumatic reactions, resilience, psychiatric rehabilitation, substance abuse, as well as experience sampling methodology, and conceptualization of mental illness as a network of symptoms