In Conflict-Scarred Iraq, PTSD Symptoms Track Closely With Physical Complaints in Medical Clinics

Patients who walk into routine medical clinics in the Kurdistan Region of Iraq often arrive with headaches, stomach trouble, fatigue, and pain. A new cross-sectional study suggests that many of them may also be carrying something less visible: symptoms of posttraumatic stress disorder. Researchers from Bielefeld University, Koya University, and University of Kurdistan Hewlêr found that the severity of PTSD symptoms among adult medical outpatients was strongly and consistently linked to their burden of physical symptoms, even after accounting for age, gender, chronic disease, and the sheer number of traumatic events they had experienced. The work, published in Discover Psychology, offers one of the first glimpses into how psychological trauma and bodily distress intertwine in ordinary outpatient care in a region shaped by decades of conflict.

The study recruited 100 Kurdish-speaking adults attending nine outpatient clinics in the cities of Erbil, Sulaymaniyah, and Koya, covering internal medicine, gastroenterology, and neurology. Between October 2023 and March 2024, a single trained clinical psychologist conducted face-to-face interviews in private clinic rooms, using interviewer-administered questionnaires that took roughly fifteen to twenty minutes. Eligible patients had to be attending a routine appointment, able to give informed consent, and sufficiently fluent in Kurdish Sorani. Attending physicians confirmed eligibility and excluded eight individuals with severe cognitive impairment before consent, but played no role in the decision to participate, which rested entirely with the patients themselves.

The researchers used three well-established instruments adapted for the setting. Cumulative trauma exposure was measured with the War and Adversity Exposure Checklist, a 26-item inventory of general adversity and war-related event types developed for conflict-affected populations in the region. PTSD symptom severity was assessed with the Kurdish Sorani version of the PTSD Checklist for DSM-5, a 20-item scale scored from 0 to 80 that captures the four DSM-5 symptom clusters: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Somatic symptom burden was measured with the Patient Health Questionnaire-15, translated into Sorani through independent forward and back translation and piloted with 20 patients before the main study began.

The headline result is striking in its magnitude. Total PCL-5 severity correlated with PHQ-15 somatic symptom burden at r = 0.66, a strong association by psychological research standards. In a hierarchical regression model that first entered age group, gender, and self-reported chronic-disease status, then cumulative trauma exposure, and finally PTSD symptom severity, the addition of the PCL-5 score accounted for an additional 40 percent of the variance in somatic burden. The final model explained 48 percent of the variance overall, with an adjusted R-squared of 0.448. Each point increase on the PTSD scale was associated with an increase of roughly 0.38 points on the somatic symptom scale, with a bias-corrected bootstrap confidence interval running from 0.29 to 0.47.

Just as revealing was what did not predict physical symptoms. Cumulative trauma exposure, measured as the number of endorsed event types on the WAEC, showed no statistically significant correlation with somatic burden (r = 0.12, p = 0.24), even though it was associated with total PTSD severity (r = 0.26, p = 0.009). In other words, it was not the raw count of traumatic experiences that tracked with bodily complaints, but the intensity of current posttraumatic stress symptoms. The authors caution that the checklist did not capture the timing, duration, severity, or subjective meaning of events, and its observed range of 4 to 16 endorsed event types may have limited sensitivity, so the null finding should not be read as evidence that trauma exposure is unimportant.

An exploratory secondary analysis broke the PCL-5 into its four DSM-5 clusters and entered them simultaneously. All four correlated with somatic burden at the bivariate level, but when their mutual overlap was taken into account, only one cluster emerged with a bootstrap confidence interval excluding zero: negative alterations in cognition and mood, which includes persistent negative beliefs, distorted blame, shame, fear, and diminished interest. The authors interpret this cautiously. The cluster contains affective and cognitive content that overlaps with broader internalising distress, and because depression, anxiety, and general distress were not measured in this study, the coefficient should be treated as hypothesis-generating rather than as a stable, PTSD-specific effect.

The statistical work was thorough for a modest sample. The researchers checked multicollinearity with tolerance and variance inflation factors, examined residual diagnostics including the Durbin-Watson statistic, Mahalanobis distance, and Cook’s distance, and used 5,000 bootstrap resamples for confidence intervals. A sensitivity analysis removing the sex-specific menstrual item from the PHQ-15 left the primary estimate essentially unchanged. A power analysis based on the noncentral F distribution indicated the sample could detect incremental effects of roughly f-squared = 0.08 for the primary model, but smaller unique effects, particularly among the correlated PTSD clusters, may have gone undetected.

The findings fit a broader international literature. Studies of war veterans, refugees, community samples, and clinical populations have repeatedly documented co-occurrence between posttraumatic stress and physical symptom burden, including pain, fatigue, sleep disturbance, and gastrointestinal complaints. Meta-analytic evidence links trauma exposure with functional somatic syndromes, and network analyses have implicated disturbed sleep as a possible bridge between the two symptom domains. Yet cluster-level findings have varied across populations: some studies of traumatised refugees point to negative alterations in cognition and mood and arousal, while others using ICD-11 frameworks highlight sense of threat and avoidance. The new study adds a setting-specific data point from routine medical care in a region where specialist mental-health services remain scarce and stigma can constrain help-seeking for psychological problems.

The authors are careful about what the study cannot show. The cross-sectional design cannot establish temporal order or causation, and reciprocal frameworks, in which physical symptoms and posttraumatic stress maintain each other, remain plausible but untested. Recruitment relied on non-probability convenience sampling, with a single interviewer and no complete record of how many eligible patients declined or left before assessment, so selection bias of unknown direction is possible and the sample cannot be considered representative of medical outpatients across the Kurdistan Region. Medical characterisation was limited to a single yes-or-no question about chronic disease; specific diagnoses, illness severity, pain status, medication use, and medical explanations for individual symptoms were unavailable, leaving substantial residual confounding. Moreover, because both questionnaires were administered in the same interview and share some overlapping content, common-method effects cannot be excluded.

Even with those caveats, the clinical implications are hard to ignore. Patients with high somatic burden in conflict-affected settings may be presenting their distress through the language of the body, and routine medical visits may be the only point of contact with the health system where that distress could be recognised. The researchers stress that the results do not establish that elevated physical symptom scores identify PTSD, that physical symptoms are psychogenic, or that any particular screening pathway works. Instead, they argue for further evaluation of integrated, patient-centred assessment approaches, with research examining diagnostic accuracy, acceptability, medical differential assessment, referral feasibility, and clinical outcomes before implementation recommendations are made. Future studies, they suggest, should use larger, prospectively recruited samples with detailed medical and psychological measures, longitudinal designs to establish temporal ordering, and formal validation of the Sorani PHQ-15. For a region where generations have lived through repression, war, terrorism, and displacement, the study is a reminder that the line between psychological injury and physical illness may be far thinner than clinic walls suggest.

Subject of Research: The association between PTSD symptom severity and somatic symptom burden among adult medical outpatients in the Kurdistan Region of Iraq

Article Title: PTSD symptom severity and somatic symptom burden among adult medical outpatients in the Kurdistan Region of Iraq: a cross-sectional study

Article References: Mahmood, H. N., Ghafoor, Z. A., Ibrahim, H., & Neuner, F. (2026). PTSD symptom severity and somatic symptom burden among adult medical outpatients in the Kurdistan Region of Iraq: a cross-sectional study. Discover Psychology, 6(1), Article 278. https://doi.org/10.1007/s44202-026-00940-z

Image Credits: AI Generated

DOI: 10.1007/s44202-026-00940-z

Keywords: PTSD, somatic symptoms, medical outpatients, trauma exposure, Kurdistan Region of Iraq, PCL-5, PHQ-15, cross-sectional study, psychosomatic medicine, conflict-affected populations, mental health, hierarchical regression