Abstract
Objective. Factors of the environment, society, as well as internal personal psychological factors and personal experience, affect the formation of mental disorders. Society and stressors determine which behavioral scenarios of the individual will be relevant. Personality characteristics through behavioral responses determine which of the many potential stressors are significant and what impact they will have on the individual.
Modern understanding of the genesis of PTSD shows that the individual's overcoming of traumatic stressors of the combat situation depends on three groups of factors: the nature of traumatic events, individual psychological characteristics of veterans, and the conditions in which the demobilized falls after returning from war. The interaction of these factors with the process of cognitive processing of psycho-traumatic experience leads to an increase in mental stress or to the gradual assimilation of psycho-traumatic experience. As a result, it is possible to expect mental "restabilization" or the emergence of PTSD. The presence of additional bio-psycho-social stressors (e.g., substance abuse, family instability, concomitant medical comorbidity) significantly increases the likelihood of developing PTSD in veterans and the degree of social maladaptation in PTSD. The comorbidity of PTSD and TBI further increases the likelihood of social maladaptation in demobilized servicemen.
The relevance of studying the impact of life problems on social adaptation in veterans with PTSD and TBI is determined by the need to develop an adequate set of medical and psychological interventions and socio-psychological rehabilitation.Purpose: to investigate medical and anamnestic features and to conduct a modal analysis of life problems of veterans with PTSD and mTBI.
Methods and materials. 329 combatants (members of the Armed Forces, the National Guard, and "volunteer battalions") in eastern Ukraine who suffered from PTSD and mTBI were examined.The socio-demographic and medical-anamnestic examination was performed using the Unified map of patient research developed by us. Modal analysis of existing problems was carried out on the basis of ICD-10, their presence was assessed by diagnostic headings: Z55 - Z73.
Results. Antisocial traits and increased social conflict in veterans with PTSD and mTBI correlated with marital/sexual and parental problems, as well as insufficient family support, problematic alcohol/drug use, and inadequate social skills. and conflicting perceptions of their own social status.
Conclusions. The negative factors influencing the course of PTSD and mTBI identified by us became the material for the formation of targets of psychosocial therapy and optimization of pharmacological treatment.
Background
The relationship between social factors and the mental health of people is a relevant point of research today. The concept of social factors includes the real relationship of people to nature and to each other, i.e., economic, labor, production, class, national, family, household, and others [1-6].
The latest scientific research on the cause of mental disorders indicates that most mental disorders are polyetiological in nature, i.e., their formation is influenced by a combination of environmental factors, society, as well as internal psychological factors and personal experience. Factors related to the risk, occurrence, clinical presentation, and prognosis of PTSD are not sufficiently studied and systematized [4-9].
The study of environmental factors that affect the health of the population of the region indicates their spatial heterogeneity and uneven development [4,5]. Many scientists have studied the processes of bilateral interaction between the psychological state of the individual and the state of socio-economic tension in the country, and the relationship is that society and stressors determine which behavioral scenarios will be actualized, and personality characteristics through behavioral reactions determine which of the many potential stressors will have a significant effect and what forms of influence on the individual they will carry out.
The generalized modern understanding of the genesis of PTSD is that the individual's overcoming of traumatic stressors of the combat situation depends on three groups of factors: the nature of traumatic events, individual psychological characteristics of veterans, and the conditions in which the demobilized fall after returning from war. The interaction of these three factors with the process of cognitive processing of psycho-traumatic experience leads either to an increase in mental stress. Or to the gradual assimilation of psycho-traumatic experience. As a result, it is possible to expect mental "restabilization" or the emergence of PTSD [4,5,10].
The results of a study involving war veterans showed that the presence of additional psychological and social stressors (e.g., substance abuse, family instability, concomitant medical comorbidity) significantly increases the likelihood of developing PTSD [8,11-14]. It is established that the degree of social maladaptation in PTSD is determined by the severity of clinical manifestations of symptoms.
Also, scientific data indicate a high combination of PTSD in demobilized servicemen with medical somatic problems (neurological, respiratory, metabolic, autoimmune), which, according to various authors, are observed 1.5 - 3 times more often than in the contingent without PTSD [15-18].
Thus, the relevance of the study of this topic is determined by the current social situation. As well as the urgent need of combat veterans in comprehensive medical and social protection and socio-psychological rehabilitation.
Aim
To investigate medical and anamnestic features and conduct a modal analysis of life problems of veterans with PTSD and mild traumatic brain injury (MTBI).
Methods and materials
329 combatants (members of the Armed Forces, the National Guard and "volunteer battalions") in eastern Ukraine who suffered from PTSD and MTBI were examined. The study was conducted on the basis of the Municipal Non-Commercial Enterprise "Ternopil Regional Clinical Psychoneurological Hospital" of the Ternopil Regional Council, where this contingent underwent treatment and/or rehabilitation.
The survey was conducted using our Unified map of the patient's study, including the collection of information on certain socio-demographic and medical-social indicators, namely: age, gender, marital status, education, employment status, disability, living conditions, stay in the ATO area, duration of direct stay in the combat zone, duration of demobilization, military rank.
Modal analysis of existing problems was carried out on the basis of ICD-10; their presence was assessed under diagnostic headings Z55 - Z73, namely: Z55 - Problems related to learning and literacy, Z56 - Problems related to work and unemployment, Z59 - Problems related to housing and economic circumstances, Z56 - Problems related to work and unemployment, Z60 - Problems related to adaptation to lifestyle changes, Z61 - Problems related to negative life events in childhood, Z62 - Other problems related to parenting, Z63 - Problems related to the relationship of spouses or partners, Z64 - Problems related to certain psychosocial circumstances, Z72 - Problems related to lifestyle, Z73 - Problems related to difficult living conditions.
Results
In order to comprehensively analyze the factors that could affect the health of the study contingent, a number of factors included in section Z of ICD-10 were considered (Table 1, Table 2).
According to the results of calculating the coefficient of Fisher's φ * - angular transformation, it was found that in a statistically significant (φ * ≥1,975; p≤0,024) majority of respondents who made up all research groups had illiteracy or low literacy (Z55.0) - from 45, 54% to 46.3%, and they also had problems in the past related to the threat of losing a job or forced change (Z56.2 and Z56.1, respectively) - from 26.61% to 50.89%.
In addition, the vast majority of respondents (φ * ≥1.71; p≤0.044) had unsatisfactory living conditions (Z59.1) before the fighting - from 37.61% to 38.39%, and also had conflicts with neighbors and by the owners of the dwelling in which they lived (Z59.2) - from 35.71% to 37.04%.
The vast majority (φ * ≥1,936; р≤0,026) of the study groups, namely 41.37 ± 0.3%, lived alone (Z60.2). Among the potentially traumatic factors of past life should also be mentioned the loss in childhood of loved ones (Z61.0) - 56.22 ± 0.26%, forced to leave home in childhood (Z61.1) - 33.18 ± 0.15%, as well as excessive care and control from relatives (Z62.0, Z62.1) - 43.3 ± 2.24%. These factors were also characteristic of the majority (φ * ≥1,677; р≤0,047) of respondents in all research groups.
| Group | PTSD | TBI | MTBI | ||||||
|---|---|---|---|---|---|---|---|---|---|
| indicator | abs. | % | φ* | abs. | % | φ* | abs. | % | φ* |
| Z55 Problems related to learning and literacy | |||||||||
| 0 | 50 | 45.87 | 1.997 | 51 | 45.54 | 1.975 | 50 | 46.3 | 2.012 |
| 1 | 25 | 22.94 | 0.663 | 26 | 23.21 | 0.657 | 25 | 23.15 | 0.667 |
| 2 | 16 | 14.68 | 0.217 | 17 | 15.18 | 0.285 | 16 | 14.81 | 0.218 |
| 3 | 13 | 11.93 | 0.559 | 13 | 11.61 | 0.551 | 13 | 12.04 | 0.583 |
| 4 | 4 | 3.67 | 0.173 | 4 | 3.57 | 0.171 | 3 | 2.77 | 0.123 |
| 5 | 1 | 0.91 | 1.283 | 1 | 0.89 | 1.279 | 1 | 0.92 | 1.291 |
| Z56 Problems related to work and unemployment | |||||||||
| 0 | 10 | 9.174 | 2.805 | 10 | 8.92 | 2.863 | 10 | 9.259 | 2.767 |
| 1 | 55 | 50.46 | 2.161 | 57 | 50.89 | 2.219 | 54 | 50 | 2.091 |
| 2 | 29 | 26.61 | 1.134 | 30 | 26.79 | 1.182 | 29 | 26.85 | 1.141 |
| 3 | 13 | 11.93 | 0.570 | 13 | 11.61 | 0.562 | 13 | 12.04 | 0.574 |
| 4 | 2 | 1.835 | 0.443 | 2 | 1.78 | 0.437 | 2 | 1.852 | 0.446 |
| Z59 Problems related to housing and economic circumstances | |||||||||
| 0 | 18 | 16.51 | 0.085 | 18 | 16.07 | 0.252 | 18 | 16.67 | 0.086 |
| 1 | 41 | 37.61 | 1.710 | 43 | 38.39 | 1.822 | 41 | 37.96 | 1.721 |
| 2 | 40 | 36.7 | 1.926 | 40 | 35.71 | 1.911 | 40 | 37.04 | 1.937 |
| 3 | 7 | 6.42 | 0.259 | 8 | 7.143 | 0.313 | 7 | 6.481 | 0.302 |
| 4 | 3 | 2.75 | 0.807 | 3 | 2.67 | 0.795 | 2 | 1.852 | 0.762 |
| Z60 Problems related to the social environment | |||||||||
| 0 | 2 | 1.83 | 1.339 | 2 | 1.78 | 1.317 | 2 | 1.852 | 1.347 |
| 1 | 37 | 33.94 | 0.683 | 37 | 33.04 | 0.754 | 37 | 34.26 | 0.689 |
| 2 | 45 | 41.28 | 2.003 | 46 | 41.07 | 1.936 | 45 | 41.67 | 2.016 |
| 3 | 18 | 16.51 | 0.771 | 20 | 17.86 | 0.871 | 18 | 16.67 | 0.806 |
| 4 | 6 | 5.51 | 0.261 | 6 | 5.35 | 0.257 | 5 | 4.63 | 0.22 |
| 5 | 1 | 0.91 | 0.065 | 1 | 0.89 | 0.064 | 1 | 0.926 | 0.066 |
| Z61 Problems related to negative life events in childhood | |||||||||
| 0 | 61 | 55.96 | 2.216 | 63 | 56.25 | 2.276 | 61 | 56.48 | 2.235 |
| 1 | 36 | 33.03 | 1.677 | 37 | 33.04 | 1.709 | 36 | 33.33 | 1.714 |
| 2 | 11 | 10.09 | 0.435 | 11 | 9.82 | 0.429 | 10 | 9.259 | 0.406 |
| 3 | 1 | 0.917 | 1.486 | 1 | 0.89 | 1.495 | 1 | 0.926 | 1.496 |
| Z62 Other problems related to parenting | |||||||||
| 0 | 49 | 44.95 | 0.359 | 51 | 45.54 | 0.443 | 49 | 45.37 | 0.362 |
| 1 | 45 | 41.28 | 2.231 | 46 | 41.07 | 2.248 | 45 | 41.67 | 2.245 |
| 2 | 10 | 9.174 | 0.388 | 10 | 8.92 | 0.383 | 10 | 9.259 | 0.431 |
| 3 | 4 | 3.67 | 0.173 | 4 | 3.57 | 0.171 | 3 | 2.778 | 0.123 |
| 4 | 1 | 0.917 | 1.265 | 1 | 0.89 | 1.279 | 1 | 0.926 | 1.272 |
As additional anamnesis, which is describing members of the contingent examined as extremely problematic and conflict at home cohabitants, is the fact that the vast majority (φ * ≥2,027; r≤0,022) of representatives of all research groups pointed to the problems associated with relationships with spouses or sexual partners (Z63.0) - 17.28 ± 0.32%, problems in relationships with their own parents or with the parents of the spouses (Z63.1) - 42.53 ± 0.33%, as well as insufficient family support for them (Z63.2) - 27.65 ± 0.13%.
Among the problems associated with certain psychosocial circumstances, a statistically significant majority (φ * ≥1.643; p≤0.05) of respondents noted problems related to having many children (Z64.1) - 55.3 ± 0.26%, and search and use of harmful and dangerous chemicals (Z64.2) - 32.3 ± 0.15%.
Among the problems related to other psychosocial circumstances, a statistically significant majority (φ * ≥2,272; p≤0,012) of respondents noted problems related to release from prison (Z65.2) - 43.32 ± 0.2 %, and with other legal circumstances (Z65.3) - 45.92 ± 0.38%, which once again indicates the extremely ambiguous position of respondents in the structure of social strata of Ukrainian society.
The antisocial nature of the personal anamnesis of the representatives of all studied groups is confirmed, in conclusion, by the fact that the largest number of respondents mentioned among the problems related to the social environment (φ * ≥1,734; p≤0,042) and problems related to difficult living conditions (φ * ≥1.66; p≤0.048), problems related to alcohol use (Z72.1) - 23.64 ± 0.43%, with drug use (Z72.2) - 36.2 ± 0,42%, with the inadequacy of social skills (Z73.4) - 24.89 ± 0.12%, with stress (Z73.3) - 27.29 ± 0.5%, and conflict related to their social status (Z73.5) - 19.91 ± 0.64%.
| Group | PTSD | TBI | CTBI | ||||||
|---|---|---|---|---|---|---|---|---|---|
| indicator | abs. | % | φ* | abs. | % | φ* | abs. | % | φ* |
| Z63 Other problems are related to loved ones, including family circumstances | |||||||||
| 0 | 19 | 17.43 | 2.027 | 19 | 16.96 | 2.134 | 19 | 17.59 | 2.04 |
| 1 | 46 | 42.2 | 2.319 | 48 | 42.86 | 2.386 | 46 | 42.59 | 2.329 |
| 2 | 30 | 27.52 | 2.372 | 31 | 27.68 | 2.408 | 30 | 27.78 | 2.405 |
| 3 | 9 | 8.25 | 0.271 | 9 | 8.03 | 0.267 | 8 | 7.407 | 0.206 |
| 4 | 5 | 4.58 | 0.854 | 5 | 4.46 | 0.842 | 5 | 4.63 | 0.859 |
| Z64 Problems related to certain psychosocial circumstances | |||||||||
| 1 | 60 | 55.05 | 2.195 | 62 | 55.36 | 2.255 | 60 | 55.56 | 2.214 |
| 2 | 35 | 32.11 | 1.643 | 36 | 32.14 | 1.674 | 35 | 32.41 | 1.653 |
| 3 | 10 | 9.17 | 0.388 | 10 | 8.92 | 0.383 | 10 | 9.259 | 0.431 |
| 4 | 4 | 3.67 | 2.491 | 4 | 3.57 | 2.515 | 3 | 2.778 | 2.277 |
| Z65 Problems related to other psychosocial circumstances | |||||||||
| 2 | 47 | 43.12 | 2.272 | 49 | 43.75 | 2.179 | 47 | 43.52 | 2.275 |
| 3 | 50 | 45.87 | 2.519 | 51 | 45.54 | 2.528 | 50 | 46.3 | 2.516 |
| 4 | 10 | 9.17 | 0.443 | 10 | 8.92 | 0.437 | 9 | 8.333 | 0.4 |
| 5 | 2 | 1.83 | 1.608 | 2 | 1.78 | 1.632 | 2 | 1.852 | 1.617 |
| Z72 Problems related to lifestyle | |||||||||
| 0 | 2 | 1.83 | 1.020 | 2 | 1.78 | 1.004 | 2 | 1.852 | 1.026 |
| 1 | 26 | 23.85 | 1.734 | 26 | 23.21 | 1.973 | 26 | 24.07 | 1.941 |
| 2 | 39 | 35.78 | 2.314 | 41 | 36.61 | 2.378 | 39 | 36.11 | 2.323 |
| 3 | 22 | 20.18 | 0.966 | 23 | 20.54 | 0.708 | 22 | 20.37 | 0.972 |
| 4 | 7 | 6.42 | 0.069 | 7 | 6.25 | 0.068 | 7 | 6.481 | 0.07 |
| 5 | 6 | 5.51 | - | 6 | 5.35 | - | 6 | 5.556 | 0.07 |
| 6 | 6 | 5.51 | 0.261 | 6 | 5.35 | 0.257 | 5 | 4.63 | 0.22 |
| 7 | 1 | 0.91 | 0.065 | 1 | 0.89 | 0.064 | 1 | 0.926 | 0.066 |
| Z73 Problems related to difficult living conditions | |||||||||
| 1 | 2 | 1.835 | 0.648 | 2 | 1.78 | 0.639 | 2 | 1.852 | 0.652 |
| 2 | 15 | 13.76 | 1.089 | 15 | 13.39 | 1.071 | 15 | 13.89 | 1.096 |
| 3 | 30 | 27.52 | 2.236 | 30 | 26.79 | 2.155 | 30 | 27.78 | 2.238 |
| 4 | 27 | 24.77 | 1.757 | 28 | 25 | 1.878 | 27 | 25 | 1.66 |
| 5 | 21 | 19.27 | 1.642 | 23 | 20.54 | 0.768 | 21 | 19.44 | 1.708 |
| 6 | 12 | 11.01 | 0.529 | 12 | 10.71 | 0.522 | 11 | 10.19 | 0.49 |
| 7 | 2 | 1.835 | - | 2 | 1.78 | 1.122 | 2 | 1.852 | - |
In order to verify the claim that there were no differences between the number of respondents in the study groups who indicated the presence of a factor influencing the state of health (Z), listed in Tables 1 and 2, a comparison was made between the study groups with the calculation the coefficient of Fisher's φ * - angular transformation (Table 3), which fully confirmed this statement (φ * ≤0,111058; p> 0,1).
| Group | PTSD-TBI | PTSD-CTBI | TBI-CTBI |
|---|---|---|---|
| Z55 Problems related to learning and literacy | |||
| 0 | 0.033286 | 0.043133 | 0.076632 |
| 1 | 0.022879 | 0.017631 | 0.005076 |
| 2 | 0.04028 | 0.010371 | 0.029754 |
| 3 | 0.025317 | 0.008635 | 0.033952 |
| 4 | 0.007571 | 0.066913 | 0.059903 |
| 5 | 0.001497 | 0.000743 | 0.00224 |
| 6 | - | 0.043133 | - |
| Z56 Problems related to work and unemployment | |||
| 0 | 0.0198 | 0.006571 | 0.026371 |
| 1 | 0.045504 | 0.048024 | 0.093738 |
| 2 | 0.015624 | 0.020651 | 0.005201 |
| 3 | 0.025317 | 0.008635 | 0.033952 |
| 4 | 0.004129 | 0.001264 | 0.005392 |
| Z59 Problems related to housing and economic circumstances | |||
| 0 | 0.035747 | 0.012904 | 0.04865 |
| 1 | 0.073621 | 0.032684 | 0.040549 |
| 2 | 0.092126 | 0.031517 | 0.123643 |
| 3 | 0.05558 | 0.004646 | 0.050782 |
| 4 | 0.006034 | 0.065922 | 0.060525 |
| Z60 Problems related to the social environment | |||
| 0 | 0.003756 | 0.001637 | 0.005392 |
| 1 | 0.082023 | 0.029035 | 0.111058 |
| 2 | 0.020351 | 0.037549 | 0.058105 |
| 3 | 0.110164 | 0.012904 | 0.096925 |
| 4 | 0.01223 | 0.066304 | 0.054643 |
| 5 | 0.001497 | 0.001186 | 0.002684 |
| Z61 Problems associated with negative life events in childhood | |||
| 0 | 0.032532 | 0.057886 | 0.025818 |
| 1 | 0.000908 | 0.027031 | 0.026308 |
| 2 | 0.02115 | 0.064352 | 0.043712 |
| 3 | 0.002018 | 0.000666 | 0.002684 |
| Z62 Other problems related to parenting | |||
| 0 | 0.059257 | 0.041774 | 0.017067 |
| 1 | 0.020351 | 0.037549 | 0.058105 |
| 2 | 0.0198 | 0.006571 | 0.026371 |
| 3 | 0.007571 | 0.066275 | 0.059265 |
| 4 | 0.002018 | 0.000666 | 0.002684 |
| Z63 Other problems related to loved ones, including family circumstances | |||
| 0 | 0.038392 | 0.012976 | 0.051368 |
| 1 | 0.064702 | 0.037848 | 0.026453 |
| 2 | 0.013976 | 0.022514 | 0.008722 |
| 3 | 0.017067 | 0.064607 | 0.04805 |
| 4 | 0.009133 | 0.003772 | 0.012905 |
| Z64 Problems related to certain psychosocial circumstances | |||
| 0 | 0.034423 | 0.056185 | 0.022221 |
| 1 | 0.002706 | 0.026846 | 0.024328 |
| 2 | 0.01949 | 0.006881 | 0.026371 |
| 3 | 0.007571 | 0.066275 | 0.059265 |
| Z65 Problems related to other psychosocial circumstances | |||
| 2 | 0.062253 | 0.039132 | 0.022715 |
| 3 | 0.033286 | 0.043133 | 0.076632 |
| 4 | 0.01949 | 0.064481 | 0.045511 |
| 5 | 0.003756 | 0.001637 | 0.005392 |
| Z72 Problems related to lifestyle | |||
| 0 | 0.003756 | 0.001637 | 0.005392 |
| 1 | 0.054401 | 0.018584 | 0.072984 |
| 2 | 0.077217 | 0.030369 | 0.04647 |
| 3 | 0.029979 | 0.015674 | 0.014132 |
| 4 | 0.013057 | 0.004646 | 0.017702 |
| 5 | 0.01223 | 0.003485 | 0.015715 |
| 6 | 0.01223 | 0.066304 | 0.054643 |
| 7 | 0.001497 | 0.001186 | 0.002684 |
| Z73 Problems related to difficult living conditions | |||
| 1 | 0.004129 | 0.001264 | 0.005392 |
| 2 | 0.029584 | 0.010315 | 0.039898 |
| 3 | 0.06357 | 0.022514 | 0.086084 |
| 4 | 0.019723 | 0.019546 | - |
| 5 | 0.105394 | 0.013943 | 0.091138 |
| 6 | 0.023619 | 0.063825 | 0.040726 |
| 7 | 0.004129 | 0.001264 | 0.005392 |
Discussion
The fact that the vast majority (φ * ≥2,027; р≤0,022) of the representatives of all research groups indicated problems related to the relationships with spouses or sexual partners (Z63.0) - 17.28 ± 0.32%, problems in relationships with own parents or with parents of spouses (Z63.1) - 42.53 ± 0.33%, as well as on insufficient family support for them (Z63.2) - 27.65 ± 0.13%. Indeed, problematic family relationships of veterans with PTSD, especially in combination with trauma, do not only complicate the patient's recovery process but also in part constitute a barrier to medical care and rehabilitation. Moreover, they can cause deterioration in the mental health of family members [1,7,19].
According to the modal analysis, the largest number of respondents noted the presence of life problems related to the social environment (φ * ≥1,734; р≤0,042) and problems related to difficult living conditions (φ * ≥1,66; р≤ 0.048), which indicated the difficulty of building interpersonal relationships [16,20] and subjectively unexpected unwillingness to return to peaceful life [19]. Thus, conflicts related to one's social status (Z73.5) - 19.91 ± 0.64%; with stress (Z73.3) - 27.29 ± 0.5%; with the inadequacy of social skills (Z73.4) - 24.89 ± 0.12% confirmed the antisocial nature of the personal history of all studied groups, which was important for further tactics of therapy and rehabilitation [4,19,20]. Additional factors were problems related to alcohol use (Z72.1) - 23.64 ± 0.43% and drug use (Z72.2) - 36.2 ± 0.42%, which required their inclusion as targets of psychotherapeutic intervention [16].
Conclusion
1. Representatives of the surveyed contingent were characterized by the presence of increased social conflict, which correlated with the indication of problems associated with the relationship with spouses or sexual partners, problems in relationships with their own parents or with the spouses' parents, as well as insufficient family support.
2. The antisocial features of the personal history of all study groups are confirmed by the presence of problems related to alcohol use, drug use, inadequate social skills, stress, and conflict related to their social status.
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