Direct and Indirect Associations Between War‐Related Nightmares, Anxiety‐Depression Symptoms, and Somatization in a Sample of Displaced Lebanese Adults During the 2024–2025 Lebanese War: A Cross‐Sectional Study

ABSTRACT Background and Aims Somatization, the physical manifestation of emotional and psychological distress, is a prevalent issue in populations exposed to war and trauma. War‐related nightmares are common among displaced individuals and are linked to depression, anxiety, and somatization. Yet, the indirect role of depression‐anxiety in the association between war‐related nightmares and somatization remains underexplored, particularly in the Lebanese context during the 2024–2025 war. This study aimed to examine whether war‐related nightmares were associated with somatization both directly and indirectly through anxiety and depression considered simultaneously as parallel mediators among a sample of displaced Lebanese adults.

Methods: This cross‐sectional study enrolled 294 displaced Lebanese adults (mean age 25.4 years; 72.1% female) through a convenience and snowball sampling technique (October 2024–March 2025) that made this study prone to selection bias. A parallel indirect‐effect analysis was conducted using SPSS version 27 and PROCESS macro version 5.0, Model 4, with anxiety and depression entered simultaneously as parallel mediators. The model was adjusted for gender, occupation, and number of bombing exposures, and indirect effects were estimated using 5000 percentile‐bootstrap samples.

Results: A significant total indirect association between war‐related nightmares and somatization through anxiety and depression was observed (indirect effect: B = 0.14; Bootstrapped Standard Error = 0.04; Bootstrapped 95% Confidence Interval [0.07, 0.21]). The specific indirect association through depression was significant ( B = 0.07; BootSE = 0.04; 95% Bootstrapped Confidence Interval [0.01; 0.15]), whereas the specific indirect association through anxiety was not significant ( B = 0.06; BootSE = 0.04; 95% Bootstrapped Confidence Interval [−0.01; 0.14]). More frequent war‐related nightmares were significantly associated with higher anxiety ( B = 0.13; SE = 0.01, p < 0.001; 95% Confidence Interval [0.10, 0.16]) and higher depression ( B = 0.12; SE = 0.01, p < 0.001; 95% Confidence Interval [0.09, 0.15]). When both mediators were entered simultaneously, depression was significantly associated with higher somatization ( B = 0.58; SE = 0.28, p = 0.040; 95% Confidence Interval [0.03, 1.14]), whereas anxiety was not independently associated with somatization ( B = 0.50; SE = 0.29, p = 0.088; 95% Confidence Interval [−0.07, 1.06]). War‐related nightmares remained directly associated with somatization after accounting for both mediators ( B = 0.42; SE = 0.06, p < 0.001; 95% Confidence Interval [0.30, 0.55]). The total association between war‐related nightmares and somatization was B = 0.56 (SE = 0.06 p < 0.001; 95% Confidence Interval 0.45, 0.67).

Conclusion: War‐related nightmares were associated with somatization both directly and indirectly through anxiety and depression collectively among a sample of displaced Lebanese adults. The specific indirect association through depression was significant, whereas the specific indirect association through anxiety was not. Although findings should be interpreted within the context of interrelated trauma symptoms and the cross‐sectional design, which precludes temporal or causal conclusions, these results suggest a need for integrated mental health interventions addressing war‐related nightmares, anxiety, depression, and somatic symptoms in war‐affected populations.