Psychology
2013. Vol.4, No.4, 396-409
Published Online April 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.44057
396
Advances in Continuous Traumatic Stress Theory: Traumatogenic
Dynamics and Consequences of Intergroup Conflict: The
Palestinian Adolescents Case
Ibrahim A. Kira1*, Jeffrey S. Ashby2, Linda Lewandowski3,
Abdul Wahhab Nasser Alawneh4, Jamal Mohanesh5, Lydia Odenat6
1Center for Cumulative Trauma Studies, Stone Mountain, USA
2Georgia State University, Atlanta, USA
3University of Massachusetts, Amherst, USA
4Arab and Middle East Resource Center, Dearborn, USA
5ACCESS Community Health and Research Center, Dearborn, USA
6Emory University, Atlanta, USA
Received January 21st, 2013; revised February 25th, 2013; accepted March 21st, 2013
Copyright © 2013 Ibrahim A. Kira et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
The goal of this paper is to advance the theory of chronic and traumatic stressors that have been identified
as type III traumas in the trauma developmentally-based framework (DBTF) and use it to investigate the
mental and physical health effects of such traumas on impacted individuals and groups. Participants were
438 Palestinian adolescents from the West Bank who had been exposed to a number of types of trauma
including chronic intergroup violence. The age of participants in the sample ranged from 12 to 19 with a
mean of 15.66 and SD of 1.43. The sample included 54.6% males, 52.3% resided in cities, 44.4% resided
in villages, while 3.2% resided in refugee camps. The study utilized a measure for cumulative traumas
that is based on the DBTF and measures of post-traumatic stress disorder (PTSD), cumulative trauma re-
lated disorders (CTD), depression, anxiety, collective annihilation anxiety (AA), identity salience, and
fear of death. The results of partial correlation and path analyses indicated that continuous traumatic stress
was a significant predictor of mental health. The analyses also indicated that poverty predicted identity
salience and AA that mediated their negative effects on physical and mental health of Palestinian adoles-
cents. The relevance of these results to peace, social and clinical psychology was discussed.
Keywords: DBTF Trauma Framework; Type III trauma; Stress Generation; Stress Proliferation;
Collective Annihilation Anxiety
Toward a Theory of Continuous Traumatic
Stress
Researchers and theorists (e.g., Turner, Wheaton, & Lloyd,
1995) typically identify three types of stressors: traumatic stress,
life events or “ordinary stress”, and chronic stress. Typically
the focus of clinical, social and political psychology is more on
stressors that have the potential of generating psychological and
social pathology and inter-group conflicts rather than the more
inconsequential ordinary life stressors. While the literature ge-
nerally identifies stressors in these ways, there is a rift in the
theory and study of stress. There are two competing but related
paradigms including the stress, appraisal, and coping theory
that originated initially from the physiological and sociological
literature (e.g. Selye, 1956; Lazarus, 1999; Lazarus & Folkman,
1984; Everly & Lating, 2002) and the theory of traumatic stress
that originated mostly from psychiatric, psychological, and psy-
cho-political literature (e.g., van der Kolk, Weisaeth, & van der
Hart, 1996; Cassidy & Shaver, 1999; Freyd, DePrince, & Glea-
ves, 2007; Herman, 1992; Bryant-Davis & Ocampo, 2005).
Further, within the theory of traumatic stress there is a divide
between three major paradigms in studying traumatic processes:
the psychiatric paradigm that focused mostly on the physical
survival types of traumatic stress that threaten the “physical
integrity”, or risk of serious injury or death, to self or others,
and on the resulted post-traumatic stress disorder (PTSD) sym-
ptoms (e.g., Green, 1995; Rothschild, 2000), the psychoanalytic,
and developmental paradigms that focused more on studying
the effects of abandonment, child maltreatment and other betra-
yal traumas in early childhood (e.g., Bowlby, 1988; Cassidy &
Shaver, 1999; Freyd, DePrince, & Gleaves, 2007), and the inter-
group paradigm as evidenced in studying discrimination, geno-
cide, holocaust, torture and other shared politically motivated
micro and macro aggressions (e.g., Bryant-Davis & Ocampo,
2005; Sue, 2010; for analysis of discrimination as a trauma, see
Helms, Nicolas, & Green, 2010, for meta-analysis of the effects
of discrimination , see Pascoe & Richman, 2009).
There are at least three potential problems with the current
status of trauma theory and research. The first is its fragmenta-
*Corresponding author.

I. A. KIRA ET AL.
tion that may allow for the focused study of specific trauma but
does not allow for a comprehensive trauma assessment that
considers the whole picture of traumatic exposure that the indi-
vidual may has endured. Second, current theory and research is
more focused on past traumatic events, commonly ignoring the
present ongoing and potentially continuous traumatic stressors
that may not stop across the lifespan. For example, the psychi-
atric paradigm is limited to “physical survival types of trau-
matic stress” which focus on a “single trauma type” ignoring
the considerable literature addressing the impact of ongoing
traumas, as well as systemic traumas, not all of which involve
threats to life (although they may involve harm and serious
threats to personal or collective identity). Third, current re-
search and theory has an individualistic bias that tends to ignore
the traumatogenic dynamics of intergroup conflict and of struc-
tural, institutional, and ecological traumas. These may include
extreme poverty, caste systems, dangerous neighborhoods, hos-
tile schools, uprootedness and exclusion from social support
networks, disadvantaged social location, and accelerated glob-
alization that increase trauma transmission and proliferation,
which are key factors in predicting heightened risk for psycho-
logical and social pathology. The application of the existing
trauma frameworks to contexts of ongoing threat and danger is
problematic. Their exclusive focus on past traumas is problem-
atic because it tends to obscure the dynamics of the ongoing
traumatic events that have unique effects that may modulate,
add to, or amplify the effects of past traumas and increase vul-
nerability to future traumas.
A relatively new, bidimensional, developmentally based stress
and trauma framework (DBTF) of stress and trauma attempts to
integrate and synthesize the disparate parts of current theory
and research. DBTF integrates the factors of chronic stress
along with the three main streams of trauma theories in a uni-
fied development-based stress and trauma paradigm that in-
cludes the previously missing temporal dimensions of chro-
nicity and severity by including the impact of ongoing chronic
stress and continuous traumatic stressors. DBTF offers a dual
lens paradigm through which stress and traumas can be mapped
in an individual’s life. DBTF also presents a template to apprise
stress and trauma as magnifying or attenuating the effects of
exposure to such chronic and traumatic stress (e.g., Kira, 2001,
2004, 2010; Kira et al., 2008a; Kira et al., 2010a, 2010b; Kira et
al., 2006; Kira et al., 2012c; Kira, Fawzi, & Fawzi, 2012).
The focus of DBTF is on both the individual and group’s
traumatization. DBTF defines traumatization as a process that
can be triggered by stressors with different levels of intensity
that range from chronic hassles to severe traumatic complex
stressors, such as the Hiroshima bombing and the holocaust.
These identified stressors have the potential to trigger post-
trauma spectrum disorders, and/or post-trauma spectrum com-
petencies and growth. The synergistic trans-theoretical DBTF
offers a wider lens and a defined conceptualization of the trau-
matization process and its cumulative dynamics.
Based on the general framework of human development and
attachment theory (e.g., Bowlby, 1988; Erikson, 1968; Gilbert,
1989), the first dimension of DBTF is development-based and
includes attachment traumas, identity traumas that constitute
violation of the identities that were developed through the indi-
viduation process and emerged in adolescence and adulthood.
Identity traumas include four sub-kinds: personal identity trau-
mas, collective, social or group identity trauma, and role iden-
tity or self-actualization trauma, and physical identity (physical
survival) traumas. The source of physical trauma can be either
internal, or external. Additionally, interdependence dynamics
that are one of the landmarks of adolescent and adult develop-
ment may yield socially-made traumas. Socially-made traumas
may be perpetuated, directly or indirectly, by institutions, inter-
group conflict, and social-structural violence and through glob-
alization dynamics. Indirect socially-made traumas can be tran-
smitted through secondary and tertiary dynamics (e.g., Figley,
1995; Kira, 2004; Kira, Fawzi, & Fawzi, 2012). Some traumas
reverberate continuously horizontally and/or vertically in the
fabric of social networks to spread activation of waves of sec-
ondary and tertiary trauma and can continue cross-generation-
ally. Trauma proliferation theory (Pearlin, Aneshensel, & Leb-
lanc, 1997) highlights a class of traumas that spills over to more
subsequent traumas. Proliferation refers to the tendency for
stressors to beget stressors. For example, job loss can trigger
the emergence of a cascade of subsequent serious stressors (e.g.,
home foreclosure or divorce resulting from job loss). Three
important mechanisms of traumatic stress proliferation may be
involved. First, chronic stressors and continuous traumatic stress,
as well as other non-chronic traumatic stressors, may initiate
more subsequent traumas, such as job loss due to discrimina-
tion. Second, they may make the individual more vulnerable
and susceptible to victimization. This potentially vulnerability
is consistent with the stress generation theory. Stress generation
theory distinguishes between dependent and independent stres-
sors. Independent stressors (stressors out of the individual con-
trol, e.g., childhood abuse), tend to generate dependent stressors
that the individual controls (e.g., those related to interpersonal
relationship, for example. divorce, domestic violence). Stress
generation theory proposes that independent life stressors in-
crease an individual’s susceptibility to dysfunctional cognitions,
attitudes, and behavioral patterns that persist and are, in turn,
associated with greater likelihood of subsequent dependent
stressors (e.g., domestic violence) (Hammen, 2006; Uliaszek et
al., 2012; for a review see Liu, 2013). Integrative models of
multiple risk factors that may mediate the relationship between
independent and subsequent dependent stressors provide the
opportunity for a more comprehensive understanding of stress
generation (Liu, 2013).
Stress generation theory can be extended to include not only
being a victim, but also being a perpetrator which may involve
a different set of dependent stressors. For example, committing
violence can be dependent on other independent stressors, like be-
ing abused as a child, being exposed to killing in combat, or to
discrimination and oppression. Perpetrating is a dependent stres-
sor that may be a stress generator as well (e.g., McNair, 2002;
Hecker et al., 2013). Perpetration-induced trauma is a self-
stressor that can generate further stressors related to severe stress-
sful consequences, for example, jail, divorce, and social exclu-
sion. Even committing violence against self, for example self-
cutting, hair bulling, and suicide is a dependent stressor within
the causal chain of stress generation that can be a stress gen-
erator to self and or others. The third mechanism of traumatic
stress proliferation occurs when secondary (indirect) and terti-
ary (across individuals and generations) traumas that reverber-
ate in the targeted social network and is a third trauma prolifera-
tion mechanism (e.g., Kira, 2004; Kira, Fawzi, & Fawzi, 2012).
The second dimension in DBTF is more vertical in terms of
changing degree or level of chronicity and severity, with sever-
ity being dependent on both chronicity and intensity of events.
Traumatic events may include, at this level, at least two kinds:

I. A. KIRA ET AL.
398
single episode (type I) (e.g., car accident) and complex traumas.
Complex traumas, in terms of chronicity, include two kinds:
type II (repeated similar traumatic episodes that have ceased,
for example sexual abuse) (see Terr, 1991), and type III (con-
tinuous, repeated and ongoing events, e.g., racism). Examples of
continuous chronic personal identity traumas are prostitution
and trafficking. Examples of continuous collective identity trau-
mas include protracted conflict and related terrorism and other
forms of intergroup violence. Another kind of chronic traumatic
stressor is social structure-based violence and includes such
conditions as extreme poverty and relative deprivation, caste
system, and slavery (e.g., Cassiman, 2005; Kira, 2001, 2004;
Kira et al., 2008a). Type IV traumas, in this taxonomy, is cu-
mulative trauma (CT) across the life time and includes events in
the past and ongoing chronic traumas. CT has different cumula-
tive dynamics. Table 1 illustrates some of the elements of this
model, (see also tables and diagrams published in Kira, 2001;
Kira, 2004; Kira et al., 2008a; Kira et al., 2012c, Kira, Fawzi, &
Fawzi, 2012e).
The etiology of mental health symptoms, social pathology,
and intergroup conflict is one of the main focuses of clinical,
social, political, and peace psychology. While chronic non-
traumatic stressors (e.g., hassles) found to have negative effects
on health were the initial focus of stress theory (e.g., DeLongis,
Folkman, & Lazarus; 1988; Lazarus, 2000), traumatology fo-
cuses much more on chronic traumatic stress. Type III traumas
that are continuous and do not stop, as contrasted to types I and
II that occurred but have now stopped, may be considered as
having the most serious negative effects on individuals and
groups, especially if they have an added intensity. Chronic tra-
umatic stress, based on DBTF frame work can include chronic
attachment traumas like children separated from parents, chro-
nic personal identity trauma like the case in prostitution and
human trafficking, chronic collective identity trauma like the
case in oppression and discrimination, chronic survival traumas
like terrorism and protracted intergroup conflict, and chronic
secondary traumas often transmitted through media and other
means of secondary continuous exposure. All of the above pro-
duce different cumulative trauma profiles that may yield com-
plex post-traumatic stress disorder (Ford, 1999; Herman, 1992),
continuous traumatic stress syndrome (Straker et al., 1987), and
different types of cumulative trauma disorders (Kira, 2001,
2010; Kira et al., 2012b, 2012e) that include different profiles
of mental and physical health comorbid disorders.
Studying continuous traumatic stress provides one way of
researching the psychological impact of living in community
conditions where there is a realistic threat of continuous present
and future danger, rather than only experiences of past trau-
matic dangers and threats. Type III trauma model provides a
theoretical basis to study not only past traumas but also differ-
ent types of continuous traumatic stress that is still ongoing
(e.g., continuous structural violence within group dynamics), as
well as other continuous present traumas like chronic extreme
poverty, gender or ethnic discrimination and oppression, com-
munity violence, human trafficking, prostitution, homelessness,
poverty, caste systems, and other ongoing traumas. Such tra-
uma types pose endemic limitations on occupational and edu-
cational opportunities, and produce marginalization and suf-
fering.
Structural violence has been recognized as a subtle form of
serious complex trauma (Galtung, 1969; Winter & Leighton,
2001). In a type III trauma model structural traumatic violence
is triggered by the dynamics of systemic intergroup conflict and
related interpersonal macro and micro aggressions. Macro ag-
gressions may take a variety of forms including targeted hate
crimes, oppression by dominant powerful actors in the form of
occupation, insurgency, counter-insurgency, and slavery (pre-
sent, past or even those historical or cross-generationally trans-
mitted) and reverberate through interdependent structures and
networks to produce traumatogenic dynamics for those who
Table 1.
Taxonomy of severe stressors.
Physical Traumas Attachment TraumasIndividuation Traumas Interdependence Traumas
Salience Mortality Connection, IntimacyIdentity, Annihilation Group Elimination, Subjugation
and Dominance
Developmental
Task Safety Security Individuation
Affiliation and Interdependence (Belonging,
Inclusion and Exclusion Dynamics)
Internal ExternalChild Adult Personal IdentityCollective
Identity Role IdentitySecondary Tertiary+ Systemic Violence
Type I Severe Pain Car
Accident
Parental
Neglect
Failed
Relationships Rape
Pearl
Harbor
Attack
Serious
Failure
(School,
Business)
Witnessing
Murder
Multiply
Transited -
Type II
Life
Threatening
Illness,
Reproductive
Trauma
Combat Parental
Neglect
Failed
Relationships
Sexual Abuse,
Perpetration-
Induced Trauma
September
11, 2001,
War on
Terror
Dropping Out
of School,
Bankruptcy
Domestic
Violence
(Child),
Vicarious
Trauma
(Therapist)
- Genocide
Type III HIV
Protracted
Violent
Conflict
Terrorism
Foster
Care
Failed
Relationships
Prostitution
Human
Trafficking
Oppression,
Racism,
Slavery
Homelessness
Violence Media
Exposure
Globalization
Historical
Trauma,
Cross-Generation
Extreme
Poverty,
Caste
System
Type IV Multilateral Continuous Traumatic Stress—Cumulative Traumatic and Non-Traumatic Stress (Chronic Stress) across Life Span*.
N
ote: *Multilateral traumas are those that involve the overlap of two or more of these basic severe stress elements.

I. A. KIRA ET AL.
belong, identify with, or empathize with the targeted groups.
Some identity focused type III traumas are may be internal-
ized or resisted by some. Internalization of inferiority can cause
diminished self-capacity and efficacy and inferiority feelings
that may be associated with poor physical, mental and quality
of life. Resistance, especially if unsuccessful, can cause sys-
temic social conflict or intensify individual distress and social
suffering. For example, in discrimination, as a process of chro-
nic traumatization, while micro aggressions (e.g., Sue, 2010),
demean or exclude the targeted persons, they act as reminders
of the overwhelming macro aggressions and the implicit and
explicit threats and stereotypes of dominant actors or their rep-
resentatives. These reminders may trigger feelings of existential
annihilation/subjugation/oppression anxieties, feelings of socie-
tal betrayal, stereotype threats that result in decreased self-es-
teem, and suppressed self-efficacy. Because such trauma types
(collective and personal identity traumas) threaten the core and
identity salience of the individual, they can be associated with
specific feeling of self-annihilation or subjugation threats and
cause annihilation anxiety (e.g., Kira et al., 2012a; Hurvith).
This is in contrast to some of the physical identity trauma types
that are more associated with harm or death threats and may
yield fear of death or death anxiety and trigger mortality Sali-
ence (for a review of mortality salience theory, see Burke, Mar-
tens, & Faucher, 2010; see also Solomon, Greenberg, & Pyszc-
zynski, 1991).
The links between perceived oppression and discrimination,
and poor physical and mental health in adolescents and adults
are fairly well established (e.g. Kira et al., 2010a, 2010b; Pas-
coe & Richman, 2009; Pieterse, Todd, Neville, & Carter, 2011;
Williams & Mohammed, 2009). Prospective studies show that
perceived discrimination precedes poor psychological and phy-
sical health, rather than the other way around (Brody et al.,
2008; Gee & Waslemann, 2009). Similar results were found for
discrimination against Asian Americans (e.g., Gee, Spencer,
Chen, & Takeuchi, 2007), Mexican Americans (e.g., Flores,
Tschann, Dimas, Pasch, & de Groat, 2010), immigrants (e.g.,
Berg et al., 2011), refugees (e.g., Kira et al., 2010a), and female
gender (e.g., Kira, Smith, Lewandowski, & Templin, 2010b;
Kira et al., 2012d) and for discrimination against sexual minori-
ties (e.g., Gilman et al., 2001).
Traditionally, Type three traumas have often been underes-
timated or ignored and, as a result, have not been identified as
extreme traumatic stressors. However, their inclusion may be
very important for group, social peace, conflict resolution, and
clinical psychology. The lack of inclusion may be explained, in
part, by the nature and origins of the traumas. For instance,
most of these types of trauma are related to socio-politics, in
which the dominant majority or the damaged or inherited social
systems, and their governing institutions are the major actors
contributing to the continuous traumatic conditions. This makes
it difficult to objectively acknowledge their importance and, ei-
ther consciously or unconsciously, they may be minimized, dis-
couraged or silenced.
Living in such traumatic chronic contexts can have deleteri-
ous effects on the functioning of biological stress regulatory
systems across the life span and, ultimately, on health and psy-
chological well-being (Shonkoff, Boyce, & McEwen, 2009).
Recent research suggests that coping with continuous and cu-
mulative stressors elicits a cascade of biological responses that
may be functional in the short term but over time they
“weather” or damage the systems that regulate the body’s stress
response. Allostatic load (AL), a marker of chronic physiologi-
cal stress and cumulative wear and tear on the body, illustrates
the disease-promoting potential of continuous adjustment to
stress (McEwen, 2000; Seeman, McEwen, Rowe, & Singer,
2001; Sterling & Eyer, 1988). Chronic psychological stress has
been associated with the body losing its ability to regulate the
inflammatory response which promotes the development and
progression of disease (Cohen et al., 2012). Elevated continu-
ous or prolonged, chronic coping demands sets in motion a
cascade of physiological changes that contribute to the devel-
opment of chronic illnesses, including hypertension, cardiac di-
sease, diabetes, stroke, and psychiatric disorders (Seeman et al.,
2001).
The effects of type III chronic identity trauma (e.g., dis-
crimination) may be particularly detrimental to adolescents.
Adolescence is a developmental period characterized by indi-
viduation and identity development, as well as cognitive, bio-
logical, and social changes. Discrimination stressors signifi-
cantly impact youths’ development, psychosocial functioning,
and mental and physical health (e.g., Greene, Way, & Pahl,
2006; DuBois et al., 2002, Williams & Mohammed, 2009).
The Israeli Palestinian conflict and its continuous collective
identity terror and ongoing exposure to political violence (type
III trauma) have exerted a negative toll on Israeli and Palestin-
ian adolescents and adults (e.g., Kira, 2006). There is an im-
portant and rich literature on the negative mental health effects
of terrorism and continuous traumatic stress on Jews and Arabs
adolescents and adults in Israel (e.g., Hobfoll, Canetti-Nisim, &
Johnson, 2006; Hopfoll et al., 2009). There is also rich research
on the effects of different traumatic stressors on Palestinians
adolescents (e.g., Madianos, Sarhan, & Lufti, 2011; Canettti et
al., 2010; Al-Krenawi, Graham, & Kanat-Maymon, 2009). De-
mitiri (2012), in a meta-analysis of the effects of political vio-
lence on Israeli, Palestinian, Lebanese and Iraqi adolescents,
found that the prevalence of post-traumatic stress disorder in
children and adolescents was 5% - 8% in Israel, 23% - 70% in
Palestine, and 10% - 30% in Iraq. These results suggest that
Palestinian adolescents may be enduring the most severe con-
tinuous traumatic stress and distress compared to Israeli, Leba-
nese, or Iraqi adolescents. Using a DBTF framework to exam-
ine the seemingly disproportionate physical and mental health
damage in Palestinian adolescents may offer a much needed
perspective. Using the DBTF framework may help explore the
effects of such protracted exposure to prolonged political con-
flict and other social and/or interpersonal traumas on physical
and mental health in Palestinian adolescents, and also examine
the utility and validity of the DBTF chronic traumatic stress
model.
A salient concern that may be precipitated by such chronic
traumatic stress exposure is existential annihilation anxiety,
which involves apprehension about life and death, as well as
personal and collective identity. Most studies have tended to
focus on two types of existential concern, i.e., fear of death (or
mortality salience) (e.g., Solomon, Greenberg, & Pyszczynski,
1991), and annihilation anxiety related to individual or collec-
tive identity (identity salience) (Hurvich, 2003; Kira, 2012a).
One of the purposes of this study is to explore whether fear of
death and annihilation anxiety mediates the relationship be-
tween type III traumas and mental health (e.g., PTSD, Complex
PTSD, depression and anxiety) as well as physical health. We
expected that fear of death in this community that is caught in
continuous intergroup conflict, is more directly related to iden-

I. A. KIRA ET AL.
tity salience and related annihilation anxiety and not vice versa.
We expected annihilation anxiety to be directly related to type
III trauma and related identity concerns more than to fear of
death.
The Goals of the Current Study
The goal of this study was to empirically explore the contri-
bution of type III chronic traumas, as compared to the other
trauma types, to the negative mental health and physical health
of Palestinian adolescents who were exposed to intergroup
structural violence among other trauma types. We hypothesized
that collective identity threats inherent in type III traumas
would predict identity salience, annihilation anxiety, and fear of
death (mortality salience), and that these construct would medi-
ate the relationship between trauma and mental and physical
health. The effects of continuous non-traumatic stress (e.g.,
hassles), and the effects of contextual conditions that forced
some young children and adolescents to commit atrocities ter-
rorizing others and traumatizing themselves in the same time,
were also of interest in the current research, as they may inten-
sify the effects of such continuous traumatic stress.
Methods
Participants were 438 Palestinian adolescents from the West
Bank, age ranged from 12 to 19 with a mean of 15.66 and SD
of 1.43%, 54.6% males (N = 239) and 45.4% females (N = 199),
39.9% were attending middle school (N = 175) and 60.1% were
attending high school (N = 263). For place of residence, 52.3%
resided in cities (N = 229), 44.4% resided in villages (N = 195),
while 3.2% resided in refugee camps (N = 14). Ninety nine
percent were Muslim Sunni, while 1% were Christians. The
mean family size in this sample was 7.99 with SD of 2.69. It
also worth mentioning that 20.4% (N = 89) evaluated their
school achievement as excellent, 34.9% (N = 153) as very good,
22.5% (N = 99) as good, 15.2% (N = 67) as fair (just pass), and
7% (N = 30) as poor.
Measures
The measures used in this study as identified in the following
section, have previously been shown to have adequate reliabil-
ity and validity on Iraqi and Arab populations and in Arabic
and English languages (e.g., Kira, Clifford, Wiencek, & Al-
haidar, 2001; Kira et al., 2006, 2008a). These measures were
originally constructed in English and subsequently translated
into Arabic by three bilingual mental health professionals who
each individually translated the measures and then met together
to establish a consensus on the final version. A fourth mental
health professional did the reverse translation. These measures
were pilot tested in focus groups.
Independen t V ar iables Measures (Cum ulative
Trauma Scale)
Cumulative trauma scale long version (CTS-L) includes 61
items and is based on the DBTF (Kira, 2001; Kira et al., 2008a,
2008b). Each item describes an extremely stressful event that
belongs to one of 6 different types of traumas: attachment, per-
sonal identity, collective identity, and secondary, survival, and
achievement traumas. Examples are: I was led to sexual contact
by one of my caregiver/parents, my mother has abandoned or
left/or separated from me when I was a child. On each item, the
participant is asked to report if he/she has had this experience
or not, how many times the event was experienced on a 5-point
likert scale (0 = never, 4 = many times), the age of first event,
and how much the event affected him or her positively or nega-
tively on a scale from 1 (extremely positive) to 7 (extremely
negative). In the analysis, the appraisal scale was divided into
two sub-scales: Positive appraisal (1 - 4) and negative apprais-
als (5 - 7). The measure includes two single item measures: one
for continuous not-traumatic stress (hassles): “I experienced a
nervous breakdown or felt like I was about to have one (e.g.,
about to lose control) due to seemingly small but recurrent or
continuous chronic stresses or hassles”. The other single item
measured being forced to commit a harmful act to others (I had
to harm some body). CTS-L provides us with general scales for
two of the cumulative trauma doses: Occurrence and frequency
of happenings, two appraisal sub-scales: negative and positive
appraisal. It includes, at this level, four sub-scales for each tra-
uma types. The measure has been used previously with differ-
ent clinical and community populations of adults and children,
and proved to have adequate reliability (Alpha of .80 - .90) and
good construct and predictive validity (Kira et al., 2008a, 2008b;
Kira et al., 2011a). The reliability of the CTS-L was found
adequate in the current study (alpha = .98). For the purpose of
the current study, we used the occurrence sub-scales and con-
structed additional measure that included 8 items that measured
assaultive and community non-terror related violence (8 item
scale) to compare its effects with the continuous conflict related
violence. The measure had an alpha of .69 in the current data.
The reliability of the CTS-L occurrence was found to be good
in the current study (alpha = .98). Reliabilities for collective
identity, personal identity, survival, family, and secondary,
attachment and achievement trauma occurrences were .90, .89,
.88, .92, .70, and .68 respectively in the current study.
Potential Me diating a nd/or Moderating Variabl e s
(Fear of Death, Identity Salience, and Annihilation
Anxiety)
Fear of death and dying measure (12-item measure): The
measure was previously developed and tested in Hebrew and
Arabic languages in Israel. Fear of death and dying was meas-
ured by 12 items, such as “I am afraid of death” and “The
thought of being unable to do things for myself at the end of
life troubles me very much” (Carmel & Mutran, 1997). Each
item was measured by a five-point scale ranging from 1 = com-
pletely disagree to 5 = completely agree. According to the re-
sults reported by Carmel and Mutran (1997) and Werner, P. &
Carmel, S. (2001), two indices, one for fear of dying and one
for fear of death, were found. Both factors had an adequate
internal validity: Cronbach’s alpha = .80 for the six items in the
fear of death factor and Cronbach’s alpha = .81 for the six items
of the fear of dying factor. The final score for each factor is the
average of the answers to the relevant items. The higher the
score, the greater the participant’s fear of death or/and dying. In
our study, we found evidence for the same two factors. Internal
consistency reliability (alpha) for the current study was .80. In
the current study, we utilized the fear of death sub-scale as
indicator of mortality salience.
Identity salience scale (Kira et al., 2011b) is 10 items scale
that had been developed in two studies with 880 Palestinian
adolescents. Identity salience or dormancy refers to the status of
400

I. A. KIRA ET AL.
one group identity in their nested hierarchy, whether it is cen-
tral, or peripheral. It includes questions like: I feel personally
threatened by hate crimes committed against me or the mem-
bers of my race, religion, culture or ethnic group or against
another group of my belonging; Sometimes I wish to die or kill
somebody or myself before my ethnic, or religion or nation or
any other group of my belonging gets harmed, eliminated or
subjugated. The response indicates how much he/she disagrees
or agrees on a scale from 1 to 7 (1 indicates absolutely disagree
and 7 absolutely agree). Higher scores indicate high identity
salience. There are follow up questions about the relative im-
portance of each group. Exploratory and confirmatory factor
analysis found support for two sub-scales: identity commitment
and identity militancy. Internal consistency reliability (alpha)
for the measure was .80 for adolescents (and .81 in another
adult Palestinian sample, N = 132), with alphas of .74 for com-
mitment and .75 for the militancy sub-scale. Test-retest reli-
ability after three weeks was .76. The measure was found to
have good predictive validity. Increased personal and collective
identity traumas predicted increases in identity salience. In-
creased identity salience predicted increase in AA and mortality
salience.
Annihilation anxiety scale (AA) (Kira et al., 2012a) is based
on the assumption that there are at least three main sources of
the emergence of annihilation threats: threats to personal iden-
tity, threats to collective identity, and threats from severe so-
cietal structural inequalities. Three items that represent the
three components were used in the study. For example, because
of what has happened to me personally or is happening to me
personally, I sometimes worry that I just lose my sense of self
(I worry that I will cease to exist as an individual person). The
answer was structured on 5 point-likert-type (5 indicating
strongly agree 4 and 1 indicating strongly disagree). The 3-
item scale has been used before in a study of Iraqi refugees in
the United States and studies including three samples of Pales-
tinian adults and adolescents and has showed good reliability
(alpha. ranged between .90 - .95) as well as evidence for con-
vergent, discriminant, and predictive validity. Results of a fac-
tor analysis of AA and general anxiety suggested that AA is
independent factor from general anxiety (Kira et al., 2012a).
The internal consistency reliability (alpha) for the measure in
this study was .93.
Dependent Variable Measures (PTSD, Depression,
Anxiety, Cumulativ e Trauma Disorders (CTD), and
Physical Health)
Clinician-administered PTSD scale (CAPS-2) (Blacke et al.,
1990) is widely used to assess PTSD. It is a structured clinical
interview that assesses 17 symptoms rated on frequency and se-
verity, each on a 5-point scale. CAPS demonstrated high reli-
ability with a range from .92 - .99 and showed good convergent
and discriminant validity. The measure has four subscales: re-
experiencing, avoidance, arousal and emotional numbness, de-
tachment or dissociation (Palmieri, Weathers, Difede, & King,
2007). In this study, we used the frequency sub-scale of CAPS-
2 that is widely used in the psychiatric literature. Alphas of the
four sub-scales in our sample were adequate (.96, .92, .89 and .85
respectively). Internal consistency reliability for the entire mea-
sure in this study was .97.
Center for epidemiologic studies depression measure (CES-D)
(Radloff, 1977): is a 20 item scale that has been widely used
with adults and adolescents. Each item is assessed on a 4-point
scale and reflects the frequency that each symptom is experi-
enced (0 = none of the time, 3 = all of the time). A cutoff score
of ≥16 is commonly used for the CES-D to indicate a need for
further assessment of the presence of major depressive disorder
(Radloff, 1977). High internal consistency (ranging from .85
to .92) and good convergent and discriminant validity, sensitiv-
ity and specificity had been reported (e.g., Mulrow et al., 1995).
Alpha for the measure in this study was .91.
Depression anxiety stress scales-anxiety (DASS-A): Anxiety
sub-scale (14 items): DASS was developed by Lovibond &
Lovibond (1995) and includes three sub-scales that measure
depression, anxiety, and stress. For the purpose of this study,
we used only the 14-item DASS-A sub-scale designed to mea-
sure anxiety. The DASS is increasingly used in different clini-
cal and research settings. A variety of studies (e.g., Lovibond &
Lovibond, 1995) have offered support for the convergent and
predictive validity and reported internal consistency reliabilities
(alphas) of .84 in non-clinical samples and .91 in clinical sam-
ples. Alpha for the measure in the present study was .95.
Cumulative trauma related disorders measure (CTD) (Kira
et al., 2012b). This 15 item measure was developed with five
community and clinic samples of African American and Arab
adolescents and adults. The CTD is an index measure for co-
morbid clustered syndromes that assesses 13 different symp-
toms: depression, anxiety, somatization, dissociation, auditory
and visual hallucinations, avoidance of being with people, pa-
ranoid ideations, concentration and memory deficits, loss of self
control, feeling suicidal, and feeling like hurting self. The re-
sults of exploratory factor analysis found support for four fac-
tors: Executive function deficits/loss of control, suicidality, dis-
sociation/psychosis, and depression/anxiety/somatization comor-
bidity. Confirmatory factor analysis results offered additional
support for the factor structure. The measure appears to have
good reliability (ranging from .85 and .98). Test-retest reliabil-
ity in a 6 week-interval was .76. Alpha for the measure in the
current study was .91. A number of studies (e.g., Kira, Clifford,
& Al-Haider, 2003) offered support for the measure’s predic-
tive validity. Specifically, Kira et al. (2003) found that different
kinds of traumas, and cumulative trauma in general accounted
for significant variance as predictors of CTD symptoms.
Health problems measure: The measure is a checklist (yes/no)
of eight types of health problems (based on DSM IV Axis III
codes 024-031) including cardiovascular (e.g., blood pressure,
heart problems), neurological (e.g., epilepsy), respiratory, di-
gestive, musculoskeletal, endocrine, and metabolic diseases that
the participant experienced. Higher scores indicate the exis-
tence of more health problems of the individual. Internal con-
sistency for the measure in the current study was .94.
Procedures
The study was approved by Palestinian Authority and IRB of
the authors’ respective institutions. Participants were recruited
through a West Bank School system and included 7 schools.
The seven schools were randomly selected from the Jenin area
and included schools that included students primarily from
refugee camps. Participation was completely voluntary and
fully informed. Research participants were told that they may
withdraw from the study at any time. Parents were informed
that the purpose of the research was to understand the effect of
different traumas experienced by children and their physical

I. A. KIRA ET AL.
and mental health. Active informed parental consent and writ-
ten adolescents’ ascent were obtained or offered by participat-
ing schools and research team members. Some parents ap-
proved verbally but chose not to sign due the political situation
at the time or for other reasons. No identifying information was
recorded that could link the subjects to the data. The disclosure
of the data could not reasonably place the subjects at any risk or
any liability according to federal and local human subjects’
guidelines. Interviews were conducted face-to-face in Arabic by
trained Palestinian teachers and local research team members
and took between 50 - 90 minutes. The participation was 75%
from randomly chosen classes within the seven schools. The
field work was conducted from January to March 2005.
Analysis
To understand the relationships between the variables identi-
fied in the study, we initially analyzed the prevalence of trauma
types and cumulative trauma load to explore the trauma profile
of the sample. We calculated the prevalence of different mental
health conditions in the sample to explore the levels of comor-
bidity and severity of symptoms. To identify the effects of po-
tentially confounding variables, we conducted partial correla-
tion between all the variables selected in the study controlling
for demographics, family size and residence (city, village, re-
fugee camps). Further, we tested a plausible path model, that
match the discussed theoretical framework, for direct, indirect
effects of type III traumas (continuous traumatic stress) medi-
ated by AA, identity salience, and fear of death sub-scale (mor-
tality salience), using structural equation model SEM (AMOS 7
software), (Arbuckle, 2006). Model fit indices were selected in
accordance with several recommendations and included the
normed 2 test statistic (2/df), the root mean square error of ap-
proximation (RMSEA), and the comparative fit index (CFI). As
you will recall, in considering these indices, 2/df values <5.0
are considered acceptable; RMSEA values <.05 indicate close
fit, values .05 to .08 indicate reasonable fit, and values >.10
indicate poor fit. CFI values >.95 indicate good fit (e.g., Kline,
2005; Hu & Bentler, 1999). We used bootstrapping procedures
with bias-corrected confidence intervals to test the significance
of the direct and indirect effects of each variable in the model.
Bootstrapping is considered a more robust procedure used to
compute p values, test hypotheses, and generate confidence in-
tervals for direct and indirect effects (e.g., Erceg-Hurn & Mi-
rosevich, 2008). Additionally, we tested several alternative mo-
dels, by changing the order of the predictors, mediators, and
outcome variables, to find which one of those alternative mod-
els had the best fit with data, regardless of our hypotheses.
Results
Trauma and Mental Heal t h Pr o fi l e s
Trauma profile: Participants in the study appeared to be
highly traumatized and their appraisal of the effects of traumas
was largely negative. Collective identity trauma type III con-
tinuous (chronic) traumatic stress (e.g., oppression, occupation
and group conflict related violence) had the highest prevalence
in their trauma profiles, followed by secondary traumas that are
more related to indirect exposure to such events. Survival trau-
mas that include terror and non-terror group conflict related
violence were equally high. Family related and personal iden-
tity traumas, as well assaultive and community (non-terror) vio-
lence, attachment, achievement traumas were less prominent in
the particiants’ trauma profile. When we analyzed specifics in
their trauma profile, witnessing killing due to terrorism, par-
ents and children participation in wars related to such conflict,
extreme poverty, oppression and genocide threat had the high-
est prevalence in the sample. Tables 2-4 describe the details of
the group’s trauma profile.
Table 2.
Prevalence of major and selected single trauma types with CTS-L sub-
scale scores.
Trauma Type M SD Prevalence (%)
Major Trauma Types
Collective Identity 2.40 2.27 84.9
Secondary 3.16 4.93 61.9
Survival 3.79 6.12 60.5
Family .88 1.66 40.0
Assaultive & Community
Non-Terror Violence .56 1.13 27.3
Personal Identity .82 2.45 22.4
Attachment .33 1.30 11.6
Achievement .02 .14 1.8
Selected Single Trauma Types
Witnessed Killing Due to Terrorism .45 .50 45.0
Parents Participated in a War .23 .42 23.0
Extreme Poverty 2.23 1.27 19.8
Natural Disaster .21 .45 19.4
Participated in a War or Combat .19 .40 18.5
Oppression and Genocide Threats 2.04 1.48 18.0
Sudden Death of Parents
or Close Relatives .16 .37 16.4
Physical Abuse .13 .34 13.0
Torture of a Parent .11 .32 10.3
Had to Harm Someone .09 .29 9.1
Life Threatening Accident .09 .29 8.9
Cumulative Stress Trauma* .11 .63 6.4
Community Violence .06 .24 6.0
Discriminated Against .05 .21 4.8
Tortured in Jail .03 .19 4.7
Abandonment by mother .03 .18 3.2
Incest .03 .16 2.5
Domestic Violence .02 .16 1.6
Life Threatening Illness .02 .13 1.6
Sexual Abuse (e.g., Rape) .01 .11 1.1
Note: *Had/would have a nervous breakdown due to frequent seemingly insig-
nificant hassles.
402

I. A. KIRA ET AL.
Table 3.
Frequency of multiple traumas.
Number of Trauma
Types Reported Prevalence (%)
No Trauma 15.1
Single Trauma 9.6
2 - 5 Traumas 26.5
6 or More Traumas 48.8
Total Mean = 7.88 SD = 11.89 100.0
Table 4.
Positive and negative appraisals.
Appraisal Mean SD Prevalence (%)
Positive .46 1.57 16.2
Negative 2.64 5.88 36.1
Mental health profile: In the measurement of depression, the
means core on the CESD was 20.29 (SD = 12.92) and 55.6% of
the participants scored 16 or higher on the CES-D scale (note
that 16 is the cut-off point for clinical depression recommended
for this scale). For DASS-A (anxiety) (Mean = 8.32, SD = 7.25)
33% of the sample scored 10 or higher (10 is the recommended
cut-off score for moderate to severe anxiety on this scale). For
PTSD (Mean = 27.94, SD = 20.49) 50.4% of the participants
scored in the elevated level of the scale (26 and above). For
annihilation anxiety (Mean = 7.21, SD = 3.11), 33.3% of par-
ticipants scored in the high side of scale (9 and above). For
CTD (Mean = 40.66, SD = 12.34), 53.1% reported that they
were depressed. 59.7% reported anxiety, 32.1% reported that
they feel sick most of the time, 26.5% reported that they feel
that they are almost two different people (different levels of dis-
sociation), 29.8% reported that they sometime hear voices or
see things others do not hear or see, 35.4% reported that they
try to avoid people and stay by themselves, 32.3% reported that
they believe that they have enemies that follow them wherever
they go, 42.7% believe that they have decreased memory and
concentration, 41.5% feel they do not have enough control of
their reactions, 32.7% felt or thought like killing themselves,
18.4% felt like hurting or injuring themselves, 11.5% reported
feeling like taking or took drugs, 37.9% reported that they are
not functioning in one or more areas in their life, and 39.6%
feltl apathetic with no emotions.
Partial correlations: Results of the partial correlation analy-
ses indicated that poverty and secondary traumas had the high-
est associations with PTSD along with the specific stressors of
being forced to be the aggressor and harm another. Poverty and
Secondary traumas had the highest associations with CTD. Col-
lective identity trauma (e.g. oppression and genocide threat),
secondary traumas, and poverty, followed by survival and cu-
mulative stress traumas, had the highest associations with AA.
Secondary traumas, assaultive and community violence, being
forced to be the aggressor and harm others, and cumulative
stress had the highest associations with depression. Chronic
(non-traumatic) stress and poverty had the highest associations
with poor health. It is worth noting that significant correlations
were mostly moderate with a few strong robust strength rela-
tionships (e.g., the relationship between collective identity tra-
uma, extreme poverty and annihilation anxiety). Table 5 inclu-
des the associations for all of the variables.
Path Analysis
Results of the path analysis indicated that the model that best
represented the theoretical framework of the effects of con-
tinuous traumatic stress (type III traumas) had acceptable fit
(Chi square = 52.555, df = 22, CFI = .964, RMSEA = .056). In
this model, mental health was a latent variable with all four
mental health variables (PTSD, CTD, Depression and anxiety)
observed predicting variables. All observed mental health vari-
ables significantly predicted the latent variables. In this model,
type III traumas (collective identity related continuous trau-
matic stress) had significant direct effects on annihilation anxi-
ety (AA), identity salience, and poor physical health. Type III
traumas also had significant indirect effects on mental health
(and all its variables in the model: PTSD, CTD, depression and
general anxiety) as well as on mortality salience (fear of death
sub-scale). AA and identity salience mediated most of these
indirect effects. AA had a significant direct effect on mental
health, as well as identity salience and mortality salience (fear
of death sub-scale). AA also had significant indirect effects on
all of the mental health variables. Identity salience had a sig-
nificant direct effect on mortality salience (fear of death) and
mental health, and significant indirect effects on all mental
health variables. Mortality salience (fear of death) had a sig-
nificant direct effect on mental health (latent) and an indirect
effect on all observed mental health variables. Physical health
had significant direct effect on mental health (latent) and a sig-
nificant indirect effect on all observed mental health variables.
Table 6 describes the direct, indirect and total effects and their
confidence intervals for each independent variable in the model.
Figure 1 maps the path model that illustrates the direct rela-
tionships of the independent variables.
Alternative Models (AM)
To test different alternative models, we replaced predictors in
each model. In the first alternative model we put fear of death
as predictor, the fit was relatively poor. In the second alterna-
tive model, we changed the predictor to identity salience. While
the fit for this model improved, RMSEA was relatively high. In
the third model, we put physical health as the predictor. The
resulting model fit was poor. In the fourth model, we put anni-
hilation anxiety as the predictor; the model had an acceptable fit.
In the fifth model (the chosen model that fit the discussed theo-
retical framework), we put collective identity type III trauma as
predictor, the model had relatively the best fit. Table 7 presents
each model predictor variable, mediating and outcome variables
and their fit indices.
Discussion and Conclusion
Consistent with the hypotheses of this study, the results of
analyses indicated that continuous traumatic stressors (type III
traumas) related to collective identity was the strongest con-
tributing factor predicting the severity of physical and mental
health symptoms in this sample of Palestinians adolescents.
These specific types of continuous trauma may be understood
as priming collective identity salience and collective annihila-
tion/subjugation anxieties (AA). In this study, annihilation

I. A. KIRA ET AL.
404
.02
Poor Health
.14
Annihilation Anxiety)
e5
.29
MH
.51
PTSD
e7
.47
CTD
e8
.51
Depression
e9
.52
Anxiety
e11
e2
e13
N
= 438
Chi Square = 52.555, df = 22, p=.000
CFI = .964
RMSEA=.056
Collective
Identity
(Type III)
Traumas
.06
Identity Salience
e6
.18
Fear of death
e3
.37
.14
.19
.16
11
.37
.17
.72
.69 .71
.71
.15
.37
.14
Figure 1.
Path model for the direct effects of type III trauma on physical and mental health. Note: MH = Mental Health, PTSD = Post-Traumatic Stress Disor-
der, CTD = Cumulative Trauma Related Disorders. All paths are significant beyond .05.
Table 5.
Partial correlation between trauma and mental health variablesa.
Major Trauma Types PTSD CTD Annihilation AnxietyGeneral Anxiety Depression Poor Health
Cumulative .20** .24*** .22*** .20** .25*** .13*
Collective Identity .08 .17** .43† .08 .03 .16*
Secondary .27*** .30*** .32*** .23** .29*** .08
Survival .10 .21*** .28*** .10 .18** .10
Family .10 .16* .20** .08 .14* .05
Assaultive & Community Non-Terror Violence .19** .22*** .19** .17* .25*** .07
Personal Identity .18** .17* .16* .16* .19** .06
Attachment .17* .16* .22*** .21** .17* .11
Achievement .11* .04 −.06 .11* .08 .06
Extreme Poverty .28*** .29*** .33† .18** .20** .23***
Selected Single Trauma Types
Witnessed Killing Due to Terrorism .10 .18** .21*** .10 .15* .07
Lots of Crime/Violence in Neighborhood .15* .20** .03 .13* .17* .10
Oppression and Genocide Threats .05 .15* .40† .03 .01 .18**
Physical Abuse .17* .22*** .17* .17* .22*** .12
Sexual Abuse (e.g., Rape) .13* .18* .14* .08 .20** .13*
Life Threatening Accident .16* .20** .11 .20** .17* .02
Had to Harm Someone .26*** .21*** .21*** .19** .31*** .14*
Cumulative Stress Trauma .20** .28*** .27*** .23*** .31*** .39†
N
ote: *p < .05, one-tailed. **p < .01, one-tailed. ***p < .001, one-tailed. †p < .0001, two-tailed; aAfter controlling for age, gender, family size, residence and education.

I. A. KIRA ET AL.
Table 6.
Direct, indirect, and total effects of type III trauma on physical and mental health with confidence intervals (CI)a.
Effects AA IS FD PH MH PTSD Anxiety D CTD
Type III Chronic Traumas
Direct CI .37†[.30/.44] .17† [.09/.26] .000 .15** [.06/.23]_____ _____ _____ _____ _____
Indirect CI _____ .04* [.01/.08] .13† [.09/.17]_____ .22† [.17/.27].16† [.12/.20].16† [.12/.20] .16† [.12/.19] .15† [.12/.19]
Total CI .37† [.30/.44] .21† [.14/.29] .13† [.09/.17].15** [.06/.23].22† [.17/.27].16† [.12/.20].16† [.12/.20] .16† [.12/.19] .15† [.12/.19]
Annihilation Anxiety
Direct CI _____ .11* [.02/.19] .14** [.06/.22]_____ .37† [.28/.45]_____ _____ _____ _____
Indirect CI _____ _____ 04* [.01/.07]_____ 04* [.02/.08].29† [.23/.36].30† [.23/.36] .29† [.23/.36] .28† [.22/.35]
Total CI _____ .11* [.02/.19] .18† [.09/.26]_____ .41† [.32/.49].29† [.23/.36].30† [.23/.36] .29† [.23/.36] .28† [.22/.35]
Identity Salience
Direct CI _____ _____ .37† [.30/.45]_____ .16** [.07/.24]_____ _____ _____ _____
Indirect CI _____ _____ .000 _____ .05* [.03/.09].15† [.09/.21].15† [.09/.21] .15† [.09/.21] .15† [.09/.20]
Total CI _____ _____ .37† [.30/.45]_____ .21† [.13/.29].15† [.09/.21].15† [.09/.21] .15† [.09/.21] .15† [.09/.20]
Fear of Death
Direct CI _____ _____ _____ _____ .14** [.05/.23].000 .000 .000 .000
Indirect CI _____ _____ _____ _____ .000 .10** [.03/.17]10** [.04/.17] .10** [.03/.17] .10** [.03/.16]
Total CI _____ _____ _____ _____ .14** [.05/.23].10** [.03/.17]10** [.04/.17] .10** [.03/.17] .10** [.03/.16]
Physical Health
Direct CI _____ _____ _____ _____ .19** [.08/.31]_____ _____ _____ _____
Indirect CI _____ _____ _____ _____ .000 .14** [.05/.22].14** [.06/.22] .14** [.06/.22] .13** [.05/.21]
Total CI _____ _____ _____ _____ .19** [.08/.31].14** [.05/.22].14** [.06/.22] .14** [.06/.22] .13** [.05/.21]
Mental Health
Direct CI _____ _____ _____ _____ _____ .71† [.65/.77].71† [.66/.78] .71† [.65/.77] .69† [.61/.75]
Indirect CI _____ _____ _____ _____ _____ _____ _____ _____ _____
Total CI _____ _____ _____ _____ _____ .71† [.65/.77].71† [.66/.78] .71† [.65/.77] .69† [.61/.75]
R2 .139 .056 .177 .021 .288 .507 .525 .507 .474
Note: AA = Annihilation Anxiety, IS = Identity Salience, FD = Fear of Death, PH = Physical Health, MH = Mental Health, PTSD = Post-Traumatic Stress Disorder, D =
Depression, CTD = Cumulative Trauma Related Disorders. Note: *p < .05, one-tailed. **p < .01, one-tailed. †p < .001, two-tailed. aAll confidence intervals are 95%.
Table 7.
Alternative models (AM) for the effects on collective identity type III traumas (CIT), mental (MH) and physical health (PH).
Model Fit Indices
AM Predictor Variables Mediating Variables Outcome Variables
χ2 df p CFI RMSEA
AM1 Fear of Death (FD) CIT AA IS MH PH 67.278 22 .000 .946 .069
AM2 Identity Salience (IS) CIT FD AA MH PH 60.347 22 .000 .952 .068
AM3 Physical Health (PH) CIT FD AA MH 63.045 22 .000 .948 .073
AM4 Annihilation Anxiety (AA) FD IS CIT MH PH 47.775 19 .000 .964 .059
AM5 Collective Identity Type
III Traumas (CIT) CIT FD AA MH PH 52.555 22 .000 .964 .056
anxiety partially mediated the positive effects of type III trau-
mas on (decreased) physical and mental health as well as the
positive effects on (increased) fear of death (mortality salience).
Mortality salience triggered by AA contributed further to these
negative effects. Additionally continuous non-traumatic stres-
sors (hassles) were significantly associated with AA, symptoms

I. A. KIRA ET AL.
of depression, general anxiety, PTSD, CTD and poor physical
health.
Another important finding of this study was that being forced,
contextually, to be an aggressor (e.g., committing terror act)
and harming others was significantly associated with AA, sym-
ptoms of PTSD, CTD, depression, and general anxiety for the
potential aggressor. The contextual conditions that forced some
to commit atrocities terrorizing others and traumatizing them-
selves, in the same time, appeared to have serious negative
effects, not only to the victims, but also to those who commit-
ted such acts. These results highlight the importance of an ex-
tension of stress generation theory to include perpetration as a
dependent stressor in the stress generation causal chain.
Continuous collective identity and secondary traumas, re-
lated to the Israeli Palestinian conflict, seem to be more of a
contributing factor to negative physical and mental health con-
ditions compared to other trauma types (e.g., personal identity
and attachment traumas). The experience of these traumas are
were most strongly related to the highest PTSD and other syn-
dromes found in this population, compared to other severely
traumatized populations (e.g., Israelis & Iraqis; Dimitry, 2012).
The fact that Palestinians are a minority group who have suf-
fered occupation and subjugation for an extended period of
time may be an important factor for their health and well-being.
Gelkopf, Solomon, Berger, and Bleich (2008) found that after
19 months of terrorist attacks Arab Israelis and Jewish Israelis
reacted similarly to the situation. However after 44 months,
PTSD in the Arab population increased three-fold, and resil-
iency almost disappeared. They concluded that specific condi-
tions inherent in political conflict may put minorities at risk and
only be observable as terrorism-related stressors become chro-
nic. Further, a recent study on Palestinian adults found that
such collective identity traumas are associated with negative
post-traumatic growth (Kira et al., 2013).
The results of this study highlight the importance of resolu-
tion of the ongoing continuous conflict and achieving peace.
Alleviating the annihilation and subjugation anxieties normally
associated with the occupation and collective identity threats
resulted from specific policies (e.g. collective punishment and
loss of national identity), is important to help Palestinian chil-
dren.
The results of this study support the centrality of collective
identity salience related anxieties that may be activated by po-
litical conflict and the related ongoing traumatic stress. This
noted centrality suggests it is at the core of the etiology of re-
lated pathology as well as a key for resolution (cf., Kelman,
2001; Kira, 2002; Kira, 2006; Kira et al., 2011b). The results of
this study highlight the primacy of identity salience over mor-
tality salience in such dynamics as, in this study, mortality sa-
lience was triggered by collective identity salience and related
annihilation anxieties and not vice versa.
Addressing collective identity concerns in resolution efforts
of this conflict and working on positive identity development
with Palestinian adolescents might help alleviate such concerns.
Kelman, 2001, argues that long-term resolution of this deep-
rooted conflict requires changes in the groups’ national identi-
ties, such that affirmation of one groups’ identity is no longer
predicated on negation of the other’s identity. However, con-
flict resolution by peacemaking with mutual accommodations
and cultural changes on both sides while acknowledging simi-
larities and differences in their basic identity structures, and
assumptive stereotypes does seem possible.
Further, the results of this study highlighted the severe nega-
tive effects of poverty as a continuous social structural danger
to physical and mental health. Fuller-Rowell, Evans, & Ong
(2012), in a longitudinal study, found that 13% of the effect of
poverty on allostatic load is explained by perceived discrimina-
tion due to poverty. They suggest that social-class discrimina-
tion is one important mechanism behind the influence of pov-
erty on physical health. The importance of alleviating poverty
through economic and social development may be one of the
important keys to improving the overall health and mental
health of Palestinian children.
Recent research by Dickstein et al. (2012) on coping strate-
gies with continuous traumatic stress (e.g., terrorism) of Israelis
found that substance use coping, denial/disengagement and so-
cial support seeking strategies were all associated with psy-
chiatric symptoms, and the only coping strategy found to be
protective strategy was acceptance and positive reframing (see
also Nuttman-Shwartz & Dekel, 2009). Positive reappraisal,
being optimistic, and possessing a futuristic orientation have
been significantly negatively correlated with AA and depres-
sion (e.g., Kira et al., 2011a). Chronic stress and continuous
traumatic stress is a serious complex trauma. Newer advance-
ments in complex trauma treatment (e.g. Courtois, Ford, Her-
man, & van der Kolk, 2009; Courtois & Ford, 2013), and mul-
ti-systemic, multi-modal, multi-component ecological approa-
ches could be utilized for those who exhibit severe post-com-
plex trauma symptoms (Kira, 2010).
Additionally, while DBTF integrative trauma framework is
theoretically plausible and may have greater heuristic and ex-
planatory power than other trauma frameworks, the results
provide further evidence of its utility and empirical validity.
The goal of the paper was to advance the theory of chronic tra-
umatic stress and test one of its basic assumptions that type III
traumas are the most severe type for those who are subjected to
it. The inclusion of continuous traumatic stress, as the most se-
vere type of trauma, is an important contribution.
Future research is needed to replicate such results on victims
of different types of continuous traumatic stress that may in-
volve different or similar dynamics.
Limitation of th e S tudy
The current paper investigates empirically the relationship
between several variables using a cross-sectional, correlational
approach. The research points to only relationships and predic-
tions. Cross-sectional studies can draw only probabilistic con-
clusions from the results. Unobserved confounding variables
can distort statistical inference. Further, using snowballing sam-
pling in the study limits the generalizability of the results. Fu-
ture studies that use longitudinal or controlled approaches and
larger representative samples are needed. Nevertheless, the
findings provide evidence of the association between continu-
ous traumatic stress and the severity of physical and mental
health symptoms in Palestinians adolescents.
REFERENCES
Al-Krenawi, A., Graham, J., & Kanat-Maymon, Y. (2009). Analysis of
trauma exposure, symptomatology and functioning in Jewish Israeli
and Palestinian adolescents. British Journal of Psychiatry, 195, 427-
432. doi:10.1192/bjp.bp.108.050393
Arbuckle, J. L. (2006). A mos 7.0 User’s Guide. Chicago: SPSS.
Berg, A. O., Melle, I., Rossberg, J., Romm, K., Larsson, S., Lagerberg,
406

I. A. KIRA ET AL.
T. V., Andreassen, O., & Hauff, E. (2011). Perceived discrimination is
associated with severity of positive and depression/anxiety symptoms
in immigrants with psychosis: A cross-sectional study. BMC Psy-
chiatry, 11, 77. doi:10.1186/1471-244X-11-77
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Klaumin-
zer, G., Charney, D. S., & Keane, T. M. (1990). A clinician rating
scale for assessing current and lifetime PTSD: The CAPS-1. The Be-
havior Therapist, 13, 187-188.
Bowlby, J. (1988). A secure base: Parent child attachment and healthy
human development. New Work: Basic Books.
Brody, G., Chen, Y., Kogan, S., Murry, V., Logan, P., & Luo, Z. (2008).
Linking perceived discrimination to longitudinal changes in African
American mothers’ parenting practices. Journal of Marriage and Fa-
mily, 70, 319-331. doi:10.1111/j.1741-3737.2008.00484.x
Bryant-Davis, T., & Ocampo, C. (2005). Racist incident-based trauma.
Counseling Psychologist, 33, 479-500.
doi:10.1177/0011000005276465
Burke, B. L., Martens, A., & Faucher, E. H. (2010). Two decades of ter-
ror management theory: A meta-analysis of mortality salience re-
search. Personality & Social Psychology Review, 14, 55-195.
doi:10.1177/1088868309352321
Canetti, D., Galea, S., Hall, B. J., Johnson, R. J., Palmieri, P. A., & Hob-
foll, S. E. (2010). Exposure to prolonged socio-political conflict and
the risk of PTSD and depression among Palestinians. Psychiatry, 73,
219-232. doi:10.1521/psyc.2010.73.3.219
Carmel, S., & Mutran, E. (1997). Wishes regarding the use of life sus-
taining treatments among elderly persons in Israel: An explanatory
model. Social Science and Medicine, 45, 1715-1727.
doi:10.1016/S0277-9536(97)00104-4
Cassidy, J., & Shaver, P. (1999). Handbook of attachment: Theory,
research, and clinical a pp l ic at i ons. New York: Guilford Press.
Cassiman, S. A. (2005). Toward more inclusive poverty knowledge: Trau-
matological contributions to the poverty discourse. The Social Policy
Journal and Cutting Edge of Social Policy Research, 4, 93-106.
doi:10.1300/J185v04n03_06
Cohen, S., Janicki-Deverts, D., Doyle, W. J., Miller, G. E., Frank, E.,
Rabin, B. S., & Turner, R. B. (2012). Chronic stress, glucocorticoid
receptor resistance, inflammation, and disease risk. Proceedings of
the National Academy of Scie nc es , 1 09 , 5995-5999.
doi:10.1073/pnas.1118355109
Courtois, C. A., Ford, J. D., Herman, J. L., & van der Kolk, B. A. (2009).
Treating complex traumatic stress disorders: An evidence-based
guide. New York: Guilford Press.
Courtois, C. A., & Ford, J. D. (2013). Treatment of complex trauma: A
sequenced, relationship-based approach. New York: Guilford Press.
DeLongis, A., Folkman, S., & Lazarus, R. S. (1988). The impact of dai-
ly stress on health and mood: Psychological and social resources as
mediators. Journal of Personality and Social Psychology, 54, 486-
495. doi:10.1037/0022-3514.54.3.486
Dickstein, B. D., Schorr, Y., Stein, N., Krantz, L. H., Solomon, Z., &
Litz, B. T. (2012). Coping and mental health outcomes among Is-
raelis living with the chronic threat of terrorism. Psychological Trau-
ma: Theory, Research, Practice, and Policy, 4, 392-399.
doi:10.1037/a0024927
Dimitry, L. (2012). A systematic review on the mental health of chil-
dren and adolescents in areas of armed conflict in the Middle East.
Child: Care, Health and Development, 38, 153-161.
doi:10.1111/j.1365-2214.2011.01246.x
DuBois, D. L., Burk-Braxton, C., Swenson, L. P., Tevendale, H. D., &
Hardesty, J. L. (2002). Race and gender influences on adjustment in
early adolescence: Investigation of an integrative model. Child De-
velopment, 73, 1573-1592. doi:10.1111/1467-8624.00491
Erceg-Hurn, D., & Mirosevich, V. (2008). Modern robust statistical
methods: An easy way to maximize the accuracy and power of your
research. American P sy ch ol og is t, 63, 591-601.
doi:10.1037/0003-066X.63.7.591
Erikson, E. H. (1968). Identity, youth and crisis. New York: Norton.
Everly, G. E., & Lating, J. M. (2002). A clinical guide to the treatment
of the human stress response (2nd ed.). New York: Kluwer Acade-
mic/Plenum Publishers.
Figley, C. (1995). Compassion fatigue: Coping with secondary trauma-
tic stress disorder in those who treat the traumatized. Philadelphia,
PA: Brunner/Mazel.
Flores, E., Tschann, J. M., Dimas, J. M., Pasch, L. A., & de Groat, C. L.
(2010). Perceived racial/ethnic discrimination, posttraumatic stress
symptoms, and health risk behaviors among Mexican American ado-
lescents. Journal o f Counseling Psychology, 57, 264-273.
doi:10.1037/a0020026
Ford, J. D. (1999). Disorders of extreme stress following war-zone mi-
litary trauma: Associated features of posttraumatic stress disorder or
comorbid but distinct syndromes? Journal of Consulting and Clinical
Psychology, 67, 3-12. doi:10.1037/0022-006X.67.1.3
Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood
abuse. Cambridge, MA: Harvard University Press.
Freyd, J. J., DePrince, A. P., & Gleaves, D. (2007). The State of Betra-
yal trauma theory: Reply to mcnally—Conceptual issues and future
directions. Memory, 15, 295-311. doi:10.1080/09658210701256514
Fuller-Rowell, T. E., Evans, G. W., & Ong, A. D. (2012). Poverty and
health: The mediating role of perceived discrimination. Psychologi-
cal Science, 23, 734-739. doi:10.1177/0956797612439720
Galtung, J. (1969). Violence, peace, and peace research. Journal of
Peace Research, 6, 167-191. doi:10.1177/002234336900600301
Gee, G., & Walsemann, K. (2009). Does health predict the reporting of
racial discrimination or do reports of discrimination predict health?
Findings from the national longitudinal study of youth. Social Sci-
ence & Medicine, 68, 1676-1684.
doi:10.1016/j.socscimed.2009.02.002
Gee, G., Spencer, M., Chen, J., & Takeuchi, D. T. (2007). A nationwide
study of discrimination and chronic health conditions among Asian
Americans. American Jou rnal of Public Health, 97, 1275-1282.
doi:10.2105/AJPH.2006.091827
Gelkopf, M., Solomon, Z., Berger, R., & Bleich, A. (2008). The mental
health impact of terrorism in Israel: A repeat cross-sectional study of
Arabs and Jews. Acta Psychiatr Scand, 117, 369-380.
doi:10.1111/j.1600-0447.2008.01164.x
Gilbert, S. (1989). L’Individuation psychique et collective. Paris: Au-
bier.
Gilman, S. E., Cochran, S. D., Mays, V. M., Hughes, M., Ostrow, D., &
Kessler, R. C. (2001). Risk of psychiatric disorders among individu-
als reporting same-sex sexual partners in the National Comorbidity
Survey. American Journal of Public Health, 91, 933-939.
doi:10.2105/AJPH.91.6.933
Green, B. L. (1995). Defining trauma: Terminology and generic stres-
sors dimensions. Journal of Applied Social Psychology, 20, 1632-1642.
doi:10.1111/j.1559-1816.1990.tb01498.x
Greene, M. L., Way, N., & Pahl, K. (2006). Trajectories of perceived
adult and peer discrimination among Black, Latino, and Asian Ame-
rican adolescents: Patterns and psychological correlates. Develop-
mental Psychology, 42, 218-238. doi:10.1037/0012-1649.42.2.218
Hammen, C. (2006). Stress generation in depression: Reflections on
origins, research, and future directions. Journal of Clinical Psychol-
ogy, 62, 1065-1082. doi:10.1002/jclp.20293
Helms, J., Nicolas, G., & Green, C. (2012). Racism and ethno-violence
as trauma: Enhancing professional and research training. Trauma-
tology, 18, 65-74. doi:10.1177/1534765610396728
Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of pro-
longed and repeated trauma. Journal of Traumatic Stress, 5, 377-391.
doi:10.1002/jts.2490050305
Hobfoll, S. E., Canetti-Nisim, D., & Johnson, R. J. (2006). Exposure to
terrorism, stress-related mental health symptoms, and defensive cop-
ing among Jews and Arabs in Israel. Journal of Consulting and
Clinical Psychology, 7 4, 207-218. doi:10.1037/0022-006X.74.2.207
Hobfoll, S. E., Palmieri, P. A., Johnson, R. J., Canetti-Nisim, D., Hall,
B. J., & Galea, S. (2009). Trajectories of resilience, resistance, and
distress during ongoing terrorism: The case of Jews and Arabs in Is-
rael. Journal of Consulting and Clinical Psychology, 77, 138-148.
doi:10.1037/a0014360
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in cova-
riance structure analysis: Conventional versus new alternatives. Stru-
ctural Equation Modeling, 6, 1-55. doi:10.1080/10705519909540118
Hurvich, M. (2003). The places of annihilation anxieties in psychoana-
lytic theory. Journal of the American Psychoanalytic Association, 51,

I. A. KIRA ET AL.
579-616. doi:10.1177/00030651030510020801
Kelman, H. C. (2001). The role of national identity in conflict resolu-
tion: Experiences from Israeli-Palestinian problem-solving work-
shops. In R. D. Ashmore, L. Jussim, & D. Wilder (Eds.), Social iden-
tity, intergroup conflict, and conflict reduction. Oxford and New
York: Oxford University Press.
Kira, I. (2001). Taxonomy of trauma and trauma assessment. Trauma-
tology, 2, 1-14.
Kira, I. (2002). Suicide terror and collective trauma: A collective terror
management paradigm. Chicago, IL: American Psychological Asso-
ciation Annual Convention.
Kira, I. (2004). Secondary trauma in treating refugee survivors of tor-
ture and their families. Torture, 14, 38-44.
Kira, I. (2006). Collective identity terror in the Israeli-Palestinian con-
flict and potential solutions. In J. Kuriansky (Ed.), Terror in the holy
land, inside the anguish of Israeli-Palestinian conflict (pp. 125-130).
New York: Praeger.
Kira, I. (2010). Etiology and treatments of post-cumulative traumatic
stress disorders in different cultures. Traumatology: An International
Journal, 16, 128-141. doi:10.1177/1534765610365914
Kira, I., Clifford, D., Wiencek, P., & Al-Haidar, A. (2001). Iraqi refu-
gees in Southeast Michigan: First report. Dearborn: ACCESS com-
munity Health and Research.
Kira, I., Clifford, D., & Al-haider (2003). Assessing and treating cu-
mulative trauma disorders (CTD) in Iraqi refugees. Toronto: Ameri-
can Psychological Association Annual Convention.
Kira, I., Templin, T., Lewandowski, L., Clifford, D. Wiencek, E., Ham-
mad, A., Al-Haidar, A., & Mohanesh, J. (2006). The effects of tor-
ture: Two community studies. Peace and Conflict: Journal of Peace
Psychology, 12, 205-228. doi:10.1207/s15327949pac1203_1
Kira, I., Lewandowsk, L., Templin, T., Ramaswamy, V., Ozkan, B., &
Mohanesh, J. (2008a). Measuring cumulative trauma dose, types and
profiles using a development-based taxonomy of trauma. Trauma-
tology, 14, 62-87. doi:10.1177/1534765608319324
Kira, I., Lewandowski, L., Templin, T., Ramaswamy, V., Chiodo, L.,
Ozkan, B., & Mohanesh, J. (2008b). Measuring Cumulative Trauma
dose, types and profiles using a development-based taxonomy of tra-
umas: The long version. Boston, MA: American Psychological Asso-
ciation 116th Annual Convention.
Kira, I., Lewandowsi, L., Templin, T., Ramaswamy, V., Ozkan, B., Mo-
hanesh, J. (2010a). The effects of perceived discrimination and
backlash on Iraqi refugees’ physical and mental health. Journal of
Muslim Mental Health, 5, 59-81. doi:10.1080/15564901003622110
Kira, I., Smith, I., Lewandowski, L., & Templin, T. (2010b). The ef-
fects of perceived gender discrimination on refugee torture survivors:
A cross-cultural Traumatology Perspective. Journal of the American
Psychiatric Nurses Association, 16, 299-306.
doi:10.1177/1078390310384401
Kira, I., Templin, T., Lewandowski, L., Ramaswamy, V., Bulent, O.,
Abu-Mediane, S., Mohanesh, J., & Alamia, H. (2011a). Cumulative
Tertiary appraisal of traumatic events across cultures: Two studies.
Journal of Loss and Trauma: International Perspectives on Stress &
Coping, 16, 43-66. doi:10.1080/15325024.2010.519288
Kira, I., Alawneh, A. N., Aboumediane, S., Mohanesh, J., Ozkan, B., &
Alamia, H. (2011b). Identity salience and its dynamics in Palestini-
ans adolescents. Psychology, 2, 781-791.
doi:10.4236/psych.2011.28120
Kira, I., Templin, T., Lewandowski, L., Ramaswamy, V., Bulent, O., Mo-
hanesh, J., & Abdulkhaleq, H. (2012a). Collective and personal anni-
hilation anxiety: Measuring annihilation anxiety AA. Psychology, 3,
90-99. doi:10.4236/psych.2012.31015
Kira, I., Templin, T., Lewandowski, L., Ashby, J. S., Oladele, A., & Ode-
nat, L. (2012b). Cumulative trauma disorder scale: Two studies. Psy-
chology, 3. doi:10.4236/psych.2012.39099
Kira, I., Lewandowski, L., Somers, C., Yoon, J., & Chiodo, L. (2012c).
PTSD, Trauma types, cumulative trauma, and IQ: The Case of Afri-
can American and Iraqi refugee adolescents. Psychological Trauma:
Theory, Research, Pract i c e , and Policy, 4, 128-139.
doi:10.1037/a0022121
Kira, I., Ashby, J., Lewandowski, L., Smith, I., & Odenat, L. (2012d).
Gender inequality and its effects in females torture survivors. Psy-
chology, 3, 352-363. doi:10.4236/psych.2012.34050
Kira, I., Fawzi, M., & Fawzi, M. (2012e). The dynamics of Cumulative
Trauma and Trauma types in adults’ patients with psychiatric disor-
ders: Two cross-cultural studies. Traumatology.
Kira, I., Abou-Mediene, S., Ashby, J., Odenat, L., Mohanesh, J. & Ala-
mia, H. (2013). The dynamics of post-traumatic growth across diffe-
rent trauma types in a Palestinian sample. Journal of Loss and Trau-
ma: International Perspectives on S tr es s & Coping, 18, 120-139.
doi:10.1080/15325024.2012.679129
Kline, R. B. (2005). Principles and Practice of Structural Equation
Modeling (2nd ed.). New York: The Guilford Press.
Liu, R. T. (2013). Stress generation: Future directions and clinical impli-
cations. Clinical Psychology Review.
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative
emotional states: Comparison of the depression anxiety and stress
scales (DASS) with the beck depression and anxiety inventories.
Behavior Research and Therapy, 33, 335-342.
doi:10.1016/0005-7967(94)00075-U
Lazarus, R. S. (1999). Stress and emotion: A new synthesis. New York:
Springer.
Lazarus, R. S. (2000). Toward better research on stress and coping.
American Psychologist, 55, 665-673.
doi:10.1037/0003-066X.55.6.665
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New
York: Springer.
Madianos, M. G., Sarhan, A. L., Koukia, E. (2011). Posttraumatic stress
disorders comorbid with major depression in West Bank, Palestine:
A general population cross-sectorial study. The European Journal of
Psychiatry, 25, 19-31. doi:10.4321/S0213-61632011000100003
McEwen, B. S. (2000). The neurobiology of stress: From serendipity to
clinical relevance. Brain Research, 886, 172-189.
doi:10.1016/S0006-8993(00)02950-4
McNair, R. (2002). Perpetration-induced traumatic stress: The psycho-
logical consequences of killing. Westport, CT: Praeger.
Nuttman-Shwartz, O., & Dekel, R. (2009). Ways of coping and sense of
belonging to the college in the face of a persistent security threat.
Journal of Traumatic Str e s s, 22, 667-670.
Palmieri, P., Weathers, F., Difede, J., & King, D. (2007). Confirmatory
factor analysis of the PTSD Checklist and the Clinician-Adminis-
tered PTSD Scale in disaster workers exposed to the World Trade
Center Ground Zero. Journal of Abnormal Psychology, 116, 329-341.
doi:10.1037/0021-843X.116.2.329
Pascoe, E. A., & Richman, S. L. (2009). Perceived discrimination and
health: A meta-analytic review. Psychological Bulletin, 135, 531-554.
doi:10.1037/a0016059
Pearlin, L. I., Aneshensel, C. S., & Leblanc, A. J. (1997). The forms and
mechanisms of stress proliferation: The case of AIDS caregivers.
Journal of Health and Social Behavior, 38, 223-236.
doi:10.2307/2955368
Peretz, T., Baider, L., Ever-Hadani, P., & De-Nour, A. (1994). Psycho-
logical distress in female cancer patients with Holocaust experience.
General Hospital Psychiatry, 16, 413-418.
doi:10.1016/0163-8343(94)90117-1
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale
for research in the general population. Applied Psychological Meas-
urement, 1, 385-401. doi:10.1177/014662167700100306
Rothschild, B. (2000). The body remembers: The psychophysiology of
trauma and trauma treatment. New York: W. W. Norton & Com-
pany.
Seeman, T. E., McEwen, B. S., Rowe, J. W., & Singer, B. H. (2001).
Allostatic load as a marker of cumulative biological risk: MacArthur
studies of successful aging. PNAS: Proceedings of the National Aca-
demy of Sciences of the United States of America, 98, 4770-4775.
doi:10.1073/pnas.081072698
Selye, H. (1956). The stress of life. New York: McGraw-Hill.
Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience,
molecular biology, and the childhood roots of health disparities:
Building a new framework for health promotion and disease preven-
tion. Journal of the American Medical Association, 301, 2252-2259.
doi:10.1001/jama.2009.754
Solomon, S., Greenberg, J., & Pyszczynski, T. (1991). A terror man-
408

I. A. KIRA ET AL.
agement theory of social behavior: The psychological functions of
esteem and cultural worldviews. In M. P. Zanna (Ed.), Advances in
experimental social psychology (pp. 93-159). San Diego, CA: Aca-
demic Press.
Sterling, P., & Eyer, J. (1988). Allostasis: A new paradigm to explain
arousal pathology. In S. Fisher, & J. Reason (Eds.), Handbook of life
stress, cognition, and he al th (pp. 629-649). Oxford, England: Wiley.
Straker, G., & The Sanctuaries Counseling Team (1987). The continu-
ous traumatic stress syndrome: The single therapeutic interview. Psy-
chology in Society, 8, 46-79.
Sue, D. (2010). Microaggressions in everyday life: Race, gender, and
sexual orientation. Hoboken, NJ: Wiley.
Terr, L. C. (1991). Childhood traumas: An outline and overview. Ame-
rican Journal of Psychiatry, 148, 10-20.
Turner, R. J., Blair, W., & Donald, L. (1995). The epidemiology of so-
cial stress. American So ci o logical Review, 60, 104-124.
doi:10.2307/2096348
Uliaszek, A. A., Zinbarg, R. E., Mineka, S., Craske, M. G., Griffith, J.
W., Sutton, J. M., Epstein, A., et al. (2012). A longitudinal examina-
tion of stress generation in depressive and anxiety disorders. Journal
of Abnormal Psychology, 121, 4-15. doi:10.1037/a0025835
van der Kolk, B. A., Weisaeth, L., & van der Hart, O. (1996). History
of trauma in psychiatry. In B. A. van der Kolk, A. C. McFarlane, & L.
Weisaeth (Eds.), Traumatic stress. The effects of overwhelming ex-
perience on mind, body, and so c i et y . New York: Guilford Press.
Werner, P., & Carmel, S. (2001). Life-sustaining treatment decisions:
Health care social workers’ attitudes and their correlates. Journal of
Gerontological Social Work, 34, 83-97. doi:10.1300/J083v34n04_07
Williams, D., & Mohammed, S. (2009). Discrimination and racial dis-
parities in health: Evidence and needed research. Journal of Behav-
ioral Medicine, 32, 20-47. doi:10.1007/s10865-008-9185-0
Winter, D. D., & Leighton, D. C. (2001). Structural violence. In D. J.
Christie, R. V. Wagner, & D. D. Winter (Eds.), Peace, conflict, and
violence: Peace psychology in the 21st century (pp. 99-101). New
York: Prentice-Hall.