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DOI 10.26724/2079-8334-2020-1-71-154-158 UDC 616-059+616-05+159.972 +351.862 (477)
A.O. Yanchuk, O.V. Guliak1, M.V. Tverezovsky1, I.I. Pavelko1, P.V. Bernaz2, S.O. Kuznichenko2 Ministry of Health of Ukraine, Kyiv, "Military Academy, Ministry of Defense of Ukraine, Odesa
Ode sa St ate I ni\iisi|\ of Iiileiiial \ll«iiis» Odi sa
MEDICAL, PSYCHOLOGICAL AND LEGAL ASPECTS TO SUBSTANTIATE THE CONCEPT OF REHABILITATION FOR MILITARY PERSONNEL -PARTICIPANTS OF THE ANTI-TERRORIST OPERATION
e-mail: kuznichenko@ukr.net
The purpose of the work was to substantiate the concept of medical and psychological rehabilitation and legal protection of the military personnel participating in ATO / OOS. The psycho-diagnostic study involved 93 military personnel participating in the ATO / OOS with the mean stay of 12-14 months in the war zone in eastern Ukraine, ranging in age from 20 to 30 years. The results of the study indicate that 53.78% of military participants in the ATO / OOS have certain symptoms of post-stress conditions; partial PTSD was diagnosed in 13.97% of the military; the presence of clinically pronounced disorders of post-stress states is subjectively noted by 19.35% of respondents. Depressive symptoms were recorded in 62.39% of respondents, of which 13.99% were at levels above moderate and high. More than half of the respondents noted the symptoms inherent in post-stress disorders -"invasion" - 59.23% for PTSD and 55.90% for ASD; "Avoidance" - 59.63% with PTSD and 66.27% with ASD; the indicator "Hyperactivation" - 58.21 points for PTSD, and 56.04 for ASD, dissociative symptoms and states of distress and maladaptation -65.66 points for PTSD and 65.56 for ASD. Given the above, it is necessary to work out at the legislative level the medical-psychological concept of rehabilitation of the military personnel participating in ATO / OOS. Into the program of combat training of military personnel, including commanders of all levels, to introduce a course of the basics of psychological assistance in order to adjust the emotional state by providing self and mutual assistance.
Key words: medical and psychological rehabilitation, participants in ATO / OOS, post-traumatic stress syndrome, acute stress disorder, screening.
The work is initiative.
Medical and psychological rehabilitation and social and psychological adaptation of the military men, who have undergone psycho-traumatic effects caused by a combat situation, are considered to be an extremely pressing problem today. The servicemen who perform combat missions in the ATO / JFO area are constantly confronted with combat stressful situations, which reprogram the organism's resources for survival in life-threatening conditions and are accompanied by the strain of adaptation mechanisms and the obvious signs of psychophysiological changes, which, being very intensive and extended, become the predictors of combat psychotrauma [2, 8, 9]. Post-traumatic stress disorder arises as a deferred or durable response (after a latent period, but not exceeding 6 months) to a stress event (short or long) of threatening or catastrophic character that can cause a deep stress in almost every person. Majority of the military actions participants are able to adapt to new living conditions, but the war effects affect everyone [2, 6].
It is known that over 70% of adults all over the world experience trauma at certain periods of their lives, and 31% have four or more traumatic events. Post-traumatic stress disorder is the most common psychopathological consequence of traumatic events. Duration of post-traumatic stress disorder (PTSD) prevalence varies depending on the social background of an individual and the country of residence, ranging from 1.3 to 12.2%, and the annual prevalence rate ranges from 0.2 to 3.8%. The main features of PTSD are the persistence of stress reactions and fear, avoiding recalls about an alarming event, mood changes, common feeling of imminent threat, sleep disturbance, and hyper-militancy [4, 9, 11].
The most important research achievements in the biological understanding of PTSD are nowadays considered to be the efforts aimed at drawing different conclusions in functionally integrated mechanistic models. Practical biological PTSD correlates today (Pitmanetal) include genes, epigenetic regulations, neuroendocrine factors, inflammatory markers, vegetative risks [11-14]. There is another side connected with the effects of post-stress events. Thus, according to American criminologists, one-third of prisoners serving criminal sentences for committing serious crimes against humans' life and health were veterans of the Vietnam War, many of them had been held captive. According to the experts, 93% of the crimes committed by combatants other than war were connected with their aggression and characterized by unpredictability, impulsiveness, inadequacy with the release of "automated" combat skills. The scholars are concerned that such type of post-traumatic stress has a longer, cumulative nature. In minds of individuals in such a state, devaluation of their own lives as well as the lives of others occurs; fear of death and personal responsibility for social consequences of the committed actions remit [2, 6].
The study of Vietnam, Afghanistan and Iraq war veterans shows that they experience specific types of aggression: fear of attack from behind; feelings of guilt for remaining alive; identifying themselves with the people who were killed [2, 8].
© A.O. Yanchuk, O.V. Guliak, 2020
The research findings have shown that the veterans also had the instability of psyche, due to which even the smallest losses, difficulties pushed a person to a suicide [1, 11]. In Ukraine, such studies are only carried out at an early stage, but they are of great importance.
According to the Order of the Ministry of Defense of Ukraine No. 333 dated May 26, 2014 "On Approval of the Instruction on Organizing the Personnel Accounting in the Armed Forces of Ukraine", the list of non-battle irretrievable losses was provided. It said: «the personnel, who irrevocably quitted the ranks of the Armed Forces of Ukraine due to their perish (death), captivity, missed in action or for other reasons, represent irretrievable personnel losses [5]. According to the experts, two-thirds of suicides are committed not in the war zone, but in the permanent disposition points to which the military personnel are sent for recovery. Even more cases of suicide are recorded among those persons who have already completed service in the war zone. In spring 2019, the Head of the Committee on Affairs of Veterans, Combatants, ATO Participants and Disabled People, Verkhovna Rada of Ukraine, O. Tretyakov reported that more than a thousand veterans, with the mean age of about 35 years old, had committed suicide [6]. Thus, despite the measures taken to prevent non-battle losses, the statistics of such events do not decrease. The situation is getting more complicated because of the significant changes in the quality of the military personnel: nowadays the person who serves under the contract often has low cognitive abilities, the lower level of neuro-mental stability and adaptive capacity, that create prerequisites for increasing number of behavioral abnormalities [10]. Currently, a number of foreign scholars propose to supplement the diagnosis of post-stress disorders with one more category - post-traumatic personal disorders (or PTPD), which seems to be quite a logical step, taking into account the fact that the presence of chronic PTSD symptoms is common throughout the whole life of a person who survived a massive psycho-trauma. Undoubtedly, such a trauma can leave an indelible imprint in the soul of a person and lead to a pathological transformation of the personality [15]. Therefore, according to the Military Medical Doctrine of Ukraine, and taking into account the above-mentioned information, we consider it necessary to work out a common position on prevention, diagnosis, medical and psychological assistance, evacuation, treatment, medical and psychological rehabilitation of the wounded (injured, sick). It is very important to understand the reasons for the reduction (loss) of servicemen's combat capability and the ways to increase (or to preserve) it, that requires prevention of combat stress (preventive rehabilitation) [7].
The purpose of this research was to substantiate the concept of medical and psychological rehabilitation and legal protection of the military personnel participating in the anti-terrorist operation (joint forces operation).
Materials and methods. The study involved 93 servicemen, aged 20-30, with a mean duration of staying in the combat zone in the eastern part of Ukraine for 12-14 months. In particular, during the study on the presence of post-traumatic stress disorder and acute stress disorder in the combatants, the survey was carried out to the ATO / JFO military personnel who held full-time positions of the privates, sergeants and sergeant-level positions to determine the combat capability of the military units [12]. In the psychological study, the following scientific methods were applied: observation, testing, systematization, generalization of theoretical and empirical results of the study. The Traumatic Stress Questionnaire for the Diagnosis of Psychological Consequences developed by I. Kotenov was also used to detect PTSD symptom complex (trauma event, "avoidance" symptoms, "invasion" symptoms, hyperactivation, distress and maladaptation); acute stress disorder (ASD) symptom complex (trauma event, dissociative symptoms, "avoidance" symptoms, "invasion" symptoms, hyperactivation, distress and maladaptation, depression). The survey procedure with this questionnaire usage included filling in the questionnaire form and preliminary instructions how to work with it.
Results of the study and their discussion. The questionnaire included the participation of ATO / JFO military personnel with a mean duration of staying in the combat zone for 12-14 months who are at the military service at the present moment. Among this category of respondents, 9 servicemen (9.68%) were injured, 22 servicemen (22.66%) suffered a contusion. In the course of the study, we have obtained the results similar to the guidelines and systematic reviews, which have shown that 53.78% of the military personnel suffered from slight symptoms of post-stress states, 13.97% of the military personnel -combatants suffered from partial PTSD, 19.35% of the respondents had clinically obvious post-stress disorders. Depressive symptoms were recorded in 62.39% of the respondents, 13.99% of whom having depressive symptoms at above moderate and high levels (table 1).
The depression symptoms are very diverse, but the most common ones occur in the form of emotional (sadness, anxiety, irritability, self-depreciation, decreased interest to the outside world), physiological (sleep disorders, change in appetite, decreased energy, pain and a variety of unpleasant sensations in the body), behavioral (passivity, difficulty of person's involvement into the purposeful
activity, contact avoidance, entertainment refusal, alcohol and psychoactive substance abuse) and mental manifestations (problems in concentrating, difficulty in decision-making, pessimistic vision of the future, thoughts about suicide, slowness in thinking) [1].
Table 1
Survey results of the military personnel participating in the ATO according to the traumatic events impact
assessment scale (%)
No Assessing the impact of a traumatic event < 50 points (no symptoms) 50-60 points (certain symptoms) 65-70 points (partial PTSD or ASD) > 70 points (probability of clinically obvious disorders)
1 Post-traumatic Stress Disorder (PTSD) 12.90 53.78 13.97 19.35
2 Acute Stress Disorder (ASD) 50.53 22.58 9.67 17.22
3 Depression 32.25 53.76 8.62 5.37
The danger of these mental disorders lies in such consequences as: deviant, delinquent and additive behavior. An extreme degree of depression can become a suicide [1].
Qualitative analysis of the statistical data obtained in the study shows that 12.90% of the respondents had a trauma event preceding the development of post-traumatic stress disorder symptoms; in acute stress disorder, the presence of a traumatic event was observed in 50.53% of the respondents. This means that a serviceman encountered or witnessed events related to death, threat of death or a serious injury - a threat to his/her or other people's physical integrity; this event was accompanied by intense emotional experiences (fear, helplessness, horror) (table 2).
Table 2
Results of PTSD and ASD screening in ATO / JFO military personnel (%)
PTSD Quantitative indices ASD Quantitative indicators
Trauma event 12.90 Trauma event 50.53
Invasion 59.23 Dissociative symptoms 60.31
Avoidance 59.63 Invasion 55.90
Hyperactivation 58.21 Avoidance 66.27
Distress and Maladaptation 65.66 Hyperactivation 56.04
- - Distress and Maladaptation 65.56
The index of "invasion" according to the events impact scale was 59.23% for PTSD and 55.90% for ASD. This means that the traumatic event is persistently experienced again by unpleasant memories, recurrent dreams or "flashbacks" that are repeated and cause obvious psychological discomfort.
The "avoidance" index according to the events impact scale was 59.63% for PTSD and 66.27% for ASD. It may be manifested in the avoidance of trauma-associated stimuli, attempts to avoid thoughts. feelings or conversations about traumatic events, attempts to avoid activity, places or people who provoke these memories, reduction of interest and active prticipation in meaningful activities.
The "hyperactivation" index was 58.21% for PTSD and 56.04% for ASD. It can be manifested in increased irritability, outbreaks of anger, unmotivated vigilance and exaggerated readiness for "escape reaction", lack of physical fatigue, need for rest. In addition to the "hyperactivation" index, a qualitative analysis of the "over vigilance" index was performed. It had 4.96 points and the scale of "exaggerated response" - 4.85 points (with the highest possible score - 5.0). These data confirm the high pronouncement of psycho-emotional state.
The index of "dissociative symptoms" was 60.31%. It may indicate that in the period of trauma or after trauma an individual may have: a subjective feeling of emotional dependence; "emotional dullness" or lack of emotional response; narrowed awareness of the outside world; derealization; depersonalization; dissociative amnesia (inability to recall some important aspect of a traumatic event). Dissociation can occur in the form of absorption (it is characterized by strain, sense of activity and enthusiasm for activity) and in the form of depersonalization (it is characterized by the loss of individuality, a subjective feeling implying the loss of reality, loss of emotions. feeling of ennui). Dissociation can also lead to the identity changes. In this state, visible violations in the experience of the Self-integrity are marked.
The main concern is connected with the obtained data about distress and maladaptation. According to our study, "distress and maladaptation" with PTSD occurred in 65.66% of the servicemen and in 65.56% with ASD. This index is connected with the violation of psychological adaptation, decreased professional ability to work and worsening the quality of life activity.
Thus, according to the data obtained from the assessment of the traumatic event impact among the interviewed military personnel participating in the ATO / JFO. The majority of respondents had the
symptoms characteristic of post-stress disorders - "invasion", "avoidance", "hyperactivation", dissociative symptoms, distress and maladaptation state.
Consequently, if these symptoms do not receive discharge, i.e. the energy arising from overexitement is immobilized and continues to be accumulated, then a mental disorder gradually develops and transforms into psycho-trauma.
The acquired psycho-trauma becomes a self-acting factor within a person. In this state, a psycho-traumatized person may experience unmotivated and uncontrollable outbreaks of aggression, as well as coldness and indifference towards relatives [3, 8].
That is why, according to the current statistics, 80% of divorces recorded in Ukraine during 20152016 occurred in the families of demobilized servicemen, most of them having taken place in the first six months after returning from war. According to other researches, within a year after demobilization, from 35% to 60% of the ATO / JFO participants' families are about to break up. The following example shows that according to the data of Lutsk City Council, in Lutsk every second demobilized soldier has divorced [4].
The main manifestations of post-stress psychological maladaptation in the military personnel -participants of the ATO / JFO are now considered to be the feeling of alienation, "abandonment" and "unnecessariness"; cognitive dissonance due to the indifference of a "peaceful" community to war; the strong belief that civilians can not understand what a military man has endured; social maladaptation. unemployment; an attempt to apply new acquired behavioral strategies in a peaceful life, that is negatively assessed by the relatives; failure to settle family conflicts peacefully, cases of physical, sexual and psychological abuse; over-actualization of the "combat brotherhood" feeling and its opposition to the "peaceful" community; experience of getting rid of psycho-emotional stress with the use of psychoactive substances [4].
One of the main problems in implementing psychological rehabilitation measures for ATO / JFO participants is nonrecognition of the need to undergo psychological examination and rehabilitation by the military personnel themselves that is caused by their unwillingness to be connected with people suffering from psychological (mental) disorders.
Therefore, in order to detect ASD or PTSD in the military personnel, including the servicemen who got injured or had contusions while performing their combat missions, and to provide them with timely medical and psychological assistance, it is necessary to introduce the obligatory psychological examination at the legislative level.
Considering the above-mentioned information, as well as the fact that the health of the population is one of the main factors for achieving national security and welfare of the state as a whole, it is necessary to introduce new approaches to solve public health problems, taking into account the Medium-Term Government Priority Action Plan up to 2020, approved by the Cabinet of Ministers of Ukraine, Decree No. 275-r dated April 3, 2017 [3, 10].
1. According to the performed study, the Traumatic Stress Questionnaire for the Diagnosis of Psychological Consequences developed by I. Kotenov is an efficient screening tool for assessing the presence of post-traumatic stress disorder in the military personnel participating in the ATO / JFO.
2. The results of the study have shown that 53.78% of the military personnel -participants of the ATO / JFO have certain symptoms of post-stress states; 13.97% of the military personnel have partial PTSD; 19.35% of the respondents subjectively assert that they experience clinically obvious disorders of the post-stress states. Depressive symptoms have been recorded in 62.39% of the respondents; 13.99% of them have experienced symptoms at above a moderate and at a high level.
3. According to the obtained data on the assessment of the traumatic event impact, more than half of the respondents experience the symptoms which are characteristic of the post-stress disorders, such as: "invasion" - 59.23% with PTSD and 55.90% with ASD; "avoidance" - 59.63% with PTSD and 66.27% with ASD; "hyperactivity" - 58.21% with PTSD and 56.04% with ASD. Dissociative symptoms and states of distress and maladaptation - 65.66% with PTSD and 65.56% with ASD.
4. It is necessary to enshrine in law medical and psychological support for the military personnel participating in the ATO / JFO starting from the time of screening process and appointment to the position, during the period of military service, as well as during their staying in the reserve (retirement).
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IV(|k-|>¡IIII
МЕДИКО-ПСИХОЛОГ1ЧН1 ТА ЮРИДИЧН1 АСПЕКТИ ОБГРУНТУВАННЯ КОНЦЕПЦП РЕАБКШТАЦП ВШСЬКОВОСЛУЖБОВЩВ-УЧАСНИК1В
АНТИТЕРОРИСТИЧНО1 ОПЕРАЦП Янчук А. О., Гуляк О. В., Тверезовський М.В., Павелко 1.1., Берназ П.В., Кузшченко С. О. Метою роботи було обгрунтування концепцй медико-психолопчно! реабштацй та правового захисту вшськовослужбовщв-учасниюв АТО/ООС. У психодiагностичному дослщженш взяли участь 93 вшськовослужбовця-учасника АТО/ООС iз середшм термшом перебування в зош бойових дш на сходi Укра'ши 12-14 мюящв у вщ вщ 20 до 30 роюв. Результати дослщження свщчать, що у 53,78 % вшськових-учасниюв АТО/ООС вщзначаються окремi симптоми постстресових сташв; частковий ПТСР дiагностовано у 13,97 % вшськових; наявшсть клшчно виражених розладiв постстресових сташв суб'ективно вщзначають 19,35 % респондента. Депресивна симптоматика зафксована у 62,39 % респондента, з яких 13,99 % на рiвнях вище середнього та високому. Бшьше половини респондентiв вщзначають симптоми, якi притаманнi постстресовим розладам - «вторгнення» - 59,23 % при ПТСР та 55,90 % при ГСР ; «уникнення» - 59,63 % при ПТСР та 66,27 % при ГСР; показник «пперактиващя» -58,21 бали при ПТСР, та 56,04 при ГСР, дисощативш симптоми та стани дистресу i дезадаптацй - 65,66 бали при ПТСР та 65,56 при ГСР. З огляду на вищесказане, необхщно опрацювати на законодавчому рiвнi медико-психолопчну концепцiю реабштацй вшськово-службовцiв-учасникiв АТО/ООС. В програму бойово! пiдготовки вiйськовослужбовцiв, у тому чи^ командирiв всiх рiвнiв, ввести курс з основ психолопчно! допомоги, з метою коригування емоцшного стану методом надання само- та взаемодопомоги.
Ключовi слова: медико-психологiчна реабiлiтацiя, учасники АТО/ООС, посттравматичний стресовий синдром, гострий стресовий розлад, скриншг.
Стаття надшшла 12.03.2019 р.
МЕДИКО-ПСИХОЛОГИЧЕСКИЕ И ЮРИДИЧЕСКИЕ АСПЕКТЫ ОБОСНОВАНИЯ КОНЦЕПЦИИ РЕАБИЛИТАЦИИ ВОЕННОСЛУЖАЩИХ-УЧАСТНИКОВ АНТИТЕРРОРИСТИЧЕСКОЙ ОПЕРАЦИИ Янчук А.А., Гуляк А.В., Тверезовская М.В., Павелко И.И., Берназ П.В., Кузниченко С.А.
Целью работы было обоснование концепции медико-психологической реабилитации и правовой защиты военнослужащих-участников АТО / ООС. В психодиагностическом исследовании приняли участие 93 военнослужащих-участника АТО / ООС со средним сроком пребывания в зоне боевых действий на востоке Украины 1214 месяцев в возрасте от 20 до 30 лет. Результаты исследования свидетельствуют, что у 53,78% военных-участников АТО / ООС отмечаются отдельные симптомы постстрессовых состояний; частичный ПТСР диагностирован у 13,97% военных; наличие клинически выраженных расстройств постстресових состояний субъективно отмечают 19,35% респондентов. Депрессивная симптоматика зафиксирована в 62,39% респондентов, из которых 13,99% на уровнях выше среднего и высоком. Более половины респондентов отмечают симптомы, присущие постстресових расстройствам - «вторжение» - 59,23% при ПТСР и 55,90% при ГСР; «Избегание» - 59,63% при ПТСР и 66,27% при ГСР; показатель «Гиперактивация» - 58,21 балла при ПТСР, и 56,04 при ГСР, диссоциативные симптомы и состояния дистресса и дезадаптации - 65,66 балла при ПТСР и 65,56 при ГСР. Учитывая вышесказанное, необходимо проработать на законодательном уровне медико-психологическую концепцию реабилитации военнослужащих-участников АТО / ООС. В программу боевой подготовки военнослужащих, в том числе командиров всех уровней, ввести курс основ психологической помощи, с целью корректировки эмоционального состояния методом предоставления само и взаимопомощи.
Ключевые слова: медико-психологическая реабилитация, участники АТО / ООС, посттравматический стрессовый синдром, острый стрессовое расстройство, скрининг.
Рецензент Голованова I.A.
