Monday, 15 August 2016

2016 - Posttraumatic Stress Disorder Outcomes In Conscripts serving as Combatants





Posttraumatic Stress Disorder Outcomes In Conscripts serving as Combatants
A. Marchenko, B. Driga, A. Goncharenko, 
A. Lobachyov, V. Tikhenko

This article was authorized to be uploaded to my blog by
             Colonel (Res)Andrew A. Marchenko, MD, DrMedScie 
   Professor of Psychiatry department of the Russian Military Medical Academy S.M-Kirov.
and by
Adjt. Maj   Ivan Hostens
Secretary of the Editorial Board
       Published at the International Review of the Armed Forces Medical Services,  
       Vol 89/2, Junio 2016.
    
       Presented at the 41º ICMM World Congress on Military Medicine,
       Bali, Indonesia, 17-22 May 2015. 



Summary



Methodology. 160 combatants served by conscript (108 with PTSD diagnosis) were examined during their hospitalization in psychiatry department. Psychopathological method, the PTSD Profile Scale, global assessment of functioning scale and the social adjustment rating scale were used.

Results. Mental disorders structure among examined combatants was determined by the prevalence of neurotic and stress-related disorders (73.3%) where posttraumatic stress disorder constitutes 67.1%. Differences in symptomatology profile allowed distinguishing three main clinical variants of combat PTSD: anxious-explosive (51.9%), dissociative (32.4%) and apathetic (15.7%). The first one is prognostically favorable (recovery in 37.5%), while in others positive outcome consisted only 17.2% and 17.7%. Most important factors in PTSD prognosis were: clinical variant of the disorder (CC = -0.22), the severity of distressing recollections (CC = -0.30) and a history of traumatic brain injury (CC = -0.24).


Conclusion. The results can be useful in the fitness for duty examination of the combatants served by subscript.

Keywords: PTSD, prognosis, combatants, military service by sub cript.Mots-clés: SSPT, le prognostic, les combattants, militaire service de appel.

It is generally accepted that post-traumatic stress disorder (PTSD) is still considered as one of the most controversial categories in psychiatry. The most capacious notion about conceptual complexity of PTSD is formulated, in our opinion, in Rosen, Spitzer and McHugh1, who identified three main aspects: the blurred understanding of the etiology, controversy of syndromological independence of PTSD and ambiguity of diagnostic criteria. Although years have passed since this work was published, in theoretical terms, little has changed. The focus of current researches is on finding of PTSD risk factors, as well as prognostic markers, such as, for example, in U. Schmidt et al.2, although the criteria for differentiating of these disorders from similar ones, e.g., from the loss reaction, are not defined yet as well as satisfactory approaches to the classification of certain forms of this disease are not established.

As a consequence, when analyzing the studies on the epidemiology of the disorder striking differences in the estimates of its prevalence, even in similar samples, are revealed. For example, according to the National Vietnam Veterans Readjustment Study full compliance with the PTSD criteria was found in 30.9%, partial compliance – in 22.5%, in total - 53.4%. At the same time, the experience of recent wars (OEF, OIF, etc.) shows significantly lower figures: among US veterans it varied in the range from 4 to 17%, and among British servicemen – from 3 to 6%3.

On the other hand, the incidence of PTSD among people who were in the combat zone (15.7%) is only slightly different from that among noncombatants (10.9%)4. Moreover, according to Frueh et al.5 convincing evidence of the trauma impact could not be detected in 59% of PTSD cases. Probably for the same reason estimates of PTSD prevalence in relation to gender and age are diametrically opposed6.

Perhaps that is why the constant work in order to improve the diagnostic criteria for PTSD and its systematization is conducted. For example, in the DSM-Y PTSD form with dissociative symptoms is separately specified. But is this step final in differentiating of PTSD subtypes that seems to be extremely important from the point of view of individual forecasts optimization, and, consequently, the choice of individual treatment strategy?

In this context, the aim of our work was to determine, first of all, the clinical features of combat posttraumatic stress disorder in soldiers served by conscript (usually young men with not finished process of personality development), to determine the prognosis of the disease. This purpose was considered to be important also from the standpoint of determining their fitness for duty, because many of them after the end of military service often try to realize accumulated combat potential by joining to military agencies, including the Ministry of Defense, under the contract, and moreover they consists mobilization reserve for deployment in case of full-scaled war.


Material and Methods



 
The work was conducted in two phases. In the first one 161 combatants served by conscript who were admitted to psychiatric departments were examined. Their ages ranged from 21 to 29 years (mean age - 25.0 + 2.13 years). All subjects during their military service were participants in the North Caucasus military conflict. The direct participation in combat operations was obligatory criterion for inclusion into the study. During this phase the structure of mental disorders was analyzed.

In the second phase combat PTSD was studied in detail. For this purpose from the above persons a contingent of 108 former servicemen with a diagnosis of post-traumatic stress disorder was selected. Age of the patients in this subgroup ranged from 22 to 28 years (in average - 24.8 ± 1.5 years).

All diagnostic conclusions were verified by using of additional tools: Composite International Diagnostic Interview7 and Mini International Neuropsychiatric Interview8.

Clinical method was used to determine the outcome of inpatient treatment which was based on criteria proposed by Semke9: 3 points – significant improvement (recovery) – marked reduction of symptoms and restoration of social adjustment, 2 points – insignificant improvement (persistence of some symptoms with insignificant restitution of social adjustment), 1 point - without improvement (no appreciable dynamics in the mental state with the same level of social maladaptation).

Conclusion on the level (or severity) of mental disorders was formulated with the Generalized Assessment of the Functioning Scale (GAF, axis V of the DSM-IV)10.

Individual clinical PTSD features and their dynamics during the treatment were established by using of the PTSD Profile Scale11, which represents a clinician rated symptoms list, each of them is to be graded from 0 to 3 points according its severity in comparison with the other manifestations.

Social adjustment level was determined in accordance with specially developed criteria12 in the main life domains: education, work (study), family relations, interpersonal relations, leisure, and general attitude towards life, which were rated on the scale from 1 to 5 points.

Statistical analysis of the results was performed with the application package «Statistica 6.0 for Windows». Mean values, the dispersion, quartile values etc. ​of assessed parameters were calculated with «Basic Statistics» module. Parametric data are presented as mean and the standard deviation (M+SD). The significance of differences between the parametric values was estimated with Student’s t-test, for nonparametric – with Pearson’s chi-square, t-Kruskal-Wallis test (procedure «Two-Sample Analysis»), and Mann-Whitney U-criterion.

Differences were considered as significant at p<0.05. During construction of classification schemes factor analysis was conducted. Predictive models were developed using discriminant analysis.

Results


Neurotic disorders had marked predominance in the structure of mental disorders among examined contingent and consisted almost three-quarter of all disorders (Table 1). In turn, post-traumatic stress disorder occupied the dominant position in the spectrum of neurotic pathology (67.1%). Most often, PTSD was observed in combatants who were hospitalized in the period from one year to five after participating in hostilities.



Table 1: Mental disorders structure in association with duration of the period from combat area withdrawal to hospitalization
ICD-10 groups
Duration of the period from combat area withdrawal to hospitalization
Total
Less than 1 year
From 1 year to 5
More than 5 years
Organic, including symptomatic, mental disorders (F0)
1 (5.0%)
6 (7.8%)
9 (14.1%)
16 (9.9%)
Mental and behavioral disorders due to psychoactive substance use (F1)
-
6 (7.8%)
8 (12.5%)
14 (8.7%)
Schizophrenia, schizotypal and delusional disorders (F2)
4 (20.0%)
3 (3.9%)
1 (1.6%)
8 (4.9%)
Mood [affective] disorders (F3)
1 (5.0%)
1 (1.3%)
-
2 (1.2%)
Posttraumatic stress disorder (F43.1)
13 (65.0%)
54 (70.1%)
41 (64.1%)
108 (67.1%)
Neurotic, stress-related and somatoform disorders (without PTSD) (F4)
1 (5.0%)
4 (5.2%)
5 (7.9%)
10 (6.2%)
Disorders of adult personality and behavior (F6)
-
3 (3.9%)
-
3 (1.9%)




To determine the clinical features of PTSD in individuals who participated in the combat actions at a young age, internal connections between the major clinical manifestations of PTSD were analyzed. To solve this problem factor analysis was conducted, where the values on PTSD profile scale were the variables. During this statistical procedure 3 factors were revealed that totally explained 68.4% of the variance (Table 2).

Factor 1 was labeled as anxious-explosive clinical variant of PTSD. It included irritability, hypervigilance, exaggerated startle response, concentrating difficulties, physiological reactivity to traumatic event cues. Factor 2 was characterized by dissociative episodes, psychological distress at exposure to traumatic event cues, dissociative amnesia, sleep difficulty. Reduced interests, avoidant behavior, feelings of detachment, sense of a foreshortened future have formed factor 3. 
Table 2: Factor structure of PTSD symptoms in studied sample
PTSD symptoms
Factor 1
Factor 2
Factor 3
Recurrent distressing recollections
0.199
-0.766
-0.016
Recurrent distressing dreams
-0.801
-0.057
0.023
Dissociative flashback episodes
-0.295
-0.160
0.368
Efforts to avoid thoughts and feelings associated with trauma
-0.531
-0.299
0.173
Efforts to avoid activities associated with trauma
-0.549
0.492
-0.312
Avoidant behavior
-0.303
0.594
-0.476
Dissociative amnesia
-0.239
0.366
0.623
Reduced interests
-0.560
0.290
-0.112
Feelings of detachment
-0.727
-0.159
-0.307
Restricted range of affects
-0.199
-0.154
0.157
Sense of a foreshortened future
-0.476
-0.193
-0.334
Sleep difficulty
-0.709
0.118
0.254
Irritability
0.082
-0.218
-0.765
Difficulty concentrating
0.475
-0.324
0.459
Hypervigilance
-0.223
-0.699
-0.271
Exaggerated startle response
0.052
-0.448
-0.437
Physiological reactivity to traumatic event cues
0.183
-0.365
-0.001


Derived factors formed the clinical variants of PTSD which were determined according to the predominant symptoms. The distribution of patients according to this variance has shown the predominance of anxious-explosive one (51.9%), and dissociative (32.4%) and apathetic (15.7%) met significantly less.

Patients with dissociative PTSD variant were met substantially more frequently during the first year after leaving the combat area (61.5%), while apathetic PTSD variant was not observed at all (Table 3). At the same time among persons, hospitalized in the period from 1 year to five, patients with anxious-explosive variant were definitely prevailed (53.7%).  


 
Table 3: Distribution of patients by in clinical PTSD variant depending on the length of the period after leaving the combat area before first hospitalization
First admission time
PTSD variants
Anxious-explosive
Dissociative
Apathetic
Less than 1 year (n=13)
5 (38.5%)
8 (61.5%)
0 (0%)
1 year to 5 (n=54)
29 (53.7%)
14 (25.9%)
11 (20.4%)
More than 5 years (n=41)
22 (53.7%)
13 (31.7%)
6 (14.6%)


Analysis of comorbid mental disorders (Table 4) has showed that anxious-explosive PTSD variant was combined more frequently with personality (26.8%) and substance related (25.0%) disorders, while dissociative and apathetic ones – with other anxiety disorders (25.7% and 52.9%, respectively).

Table 4: The structure of comorbid mental disorders in different PTSD variants*
PTSD clinical variant
F0
F1
F3
F41
F45
F6
Anxious-explosive
10 (17,9%)
14 (25%)
1 (1,8%)
8 (14,3%)
0 (0%)
15 (26,8%)
Dissociative
7 (20%)
6 (17,1%)
2 (5,7%)
9 (25,7%)
1 (2,9%)
4 (11,4%)
Apathetic
2 (11,8%)
3 (17,7%)
0 (0%)
9 (52,9%)
1 (5,9%)
1 (5,9%)
Total
21 (19,4%)
25 (23,5%)
3 (3,1%)
31 (28,6%)
6 (5,1%)
22 (20,4%)
* F0 – Organic, including symptomatic, mental disorders, F1 – Mental and behavioral disorders due to psychoactive substance use, F3 – Mood [affective] disorders, F41 – other anxiety disorders, F45 – somatoform disorders, F6 – Disorders of adult personality and behavior

Analysis of treatment outcomes in combatants showed that in patients with anxious-explosive variant recovery was observed more frequently than in the other two types (Table 5). 

Table 5: Treatment outcomes in different PTSD clinical variants
Outcome type
Anxious-explosive
n=56
Apathetic
n=17
Dissociative
n=35
Total
n=108
Without improvement
15 (26.8%)
4 (23.5%)
16 (45.7%)
35 (32.4%)
Insignificant improvement
20 (35.7%)
10 (58.8%)
13 (37.1%)
43 (39.8%)
Significant improvement / recovery
21 (37.5%)
3 (17.7%)
6 (17.2%)
30 (27.8%)


These data were also verified by comparison of the outcome means in groups, which was significantly more favorable in anxious-explosive variant (2.09+0.79 points) than in dissociative (1.71+0.75 points), while in apathetic variant it consisted 1.94+0.66 points.

Contrary to expectations comorbid mental disorders have exerted only a limited influence on the treatment outcomes (Table 6), mostly in patients with organic pathology, where in 57.9% improvement was not achieved, while in other cases the frequency of this outcome was appreciably lower and varied from 20% to 35%. 



Table 6: Treatment outcomes in PTSD patients with different comorbid disorders
F0
F1
F3
F41
F45
F6
Total
Without comorbid pathology
Without improvement
11 (57,9%)
5 (21,7%)
1 (33,3%)
8 (28,6%)
1 (20,0%)
7 (35,0%)
33 (33,7%)
2
(20,0%)
Insignificant improvement
5 (26,3%)
12 (52,2%)
2 (66,7%)
7 (25,0%)
4 (80,0%)
9 (45,0%)
39 (39,8%)
5 (50,0%)
Significant improvement / recovery
3 (15,8%)
6 (26,1%)
-
13 (46,4%)
-
4 (20,0%)
26 (26,5%)
3 (30,0%)




To improve accuracy of prognosis the impact of disorders severity was studied next. The distribution of patients by type of outcomes depending on the level of functioning by the GAF Scale at admission (Table 7) showed that the less was functioning impairment the larger portion of favorable outcomes was observed. 


Table 7: Treatment outcomes in patients with different levels of functioning in admission
Symptoms severity in admission according to GAF Scale
Significant improvement / recovery
Insignificant improvement
Without improvement
< 50
1 (4.5%)*
11 (50.0%)
10 (45.5%)
50-64
16 (28.1%)
22 (38.6%)
19 (33.3%)
> 64
12 (41.4%)
11 (37.9%)
6 (20.7%)
* - In comparison with the low level of PTSD severity χ2 < 0,05.



The overall level of social adjustment had an importance only in cases of anxious-explosive variant where at low rates of social adjustment the maximum number of unsatisfactory treatment results was noted. In other variants the differences were insignificant (Table 8).


 
Table 8: Treatment outcomes in different level of social adjustment
PTSD clinical variant
Social adjustment level
Significant improvement / recovery
Insignificant improvement
Without improvement
Anxious-explosive
> 3.5
2 (50.0%)
0 (0%)
2 (50.0%)
2.5 – 3.4
9 (33.3%)
15 (55.6%)
3 (11.1%)
< 2.5
9 (36.0%)
6 (24.0%)
10 (40.0%)*
Dissociative
> 3.5
1 (25.0%)
1 (25.0%)
2 (50.0%)
2.5 – 3.4
4 (22.2%)
7 (38.9%)
7 (38.9%)
< 2.5
1 (7.7%)
5 (38.5%)
7 (53.8%)
Apathetic
> 3.5
1 (100.0%)
0 (0%)
0 (0%)
2.5 – 3.4
0 (0%)
7 (77.8%)
2 (22.2%)
< 2.5
2 (28.6%)
3 (42.9%)
2 (28.6%)
* - In comparison with the middle level of social adjustment χ2 < 0,05. 


At the final stage of the work we have attempted to develop a model for prediction of treatment outcome in military personnel with PTSD. To solve this problem, patients with lack of improvements and minor improvements were combined into one group of nonresponders, which in accordance with the regulatory acts should have a limited fitness for military service. Persons with recovery, which, respectively, can continue to service, made the comparison group of responders. These characteristics have made dependent variable while the rest of the studied parameters were considered as independent. Step by step discriminant analysis was performed. As a result the following equation was derived: 


y = 0,91 - 0,64X1 + 0,47X2 - 0,54X3 - 0,46X4 - 0,29X5 - 0,51X6 - 0,40X7 + 0,39X8 + 0,61X9  - 0,75X10 + 0,67X11 + 0,42X12 - 0,41X13 + 0,32X14 - 0,3X15, 


where X1 - intrusive distressing recollections severity, X2 – hypervigilance severity, X3 - dissociative episodes severity, X4 - traumatic brain injury history, X5 - heart rate at admission, X6 - match to anxious-explosive variant of PTSD, X7 - the severity of the psychological distress at exposure to traumatic event cues, X8 – exaggerated startle-reflex severity, X9 - age at hospitalization, X10 - level of education, X11 - level of professional adjustment; X12 – hyperthymic character accentuation, X13 – global social adjustment level, X14 - avoidance of traumatic thoughts and feelings severity, X15 - the duration of being in combat zone.

Centroid coordinates were as follows: for responders - (-1.56) and for nonresponders - (0.57). Analyzed case refers to the group, to which centroid is closer the value obtained in the course of solving the equation.

According to the factor structure of the canonical functions it was also possible to draw a conclusion about the importance of separate factors in the outcome prediction. The data in table 9 suggest that the most important role in this context were played by such factors as the severity of intrusive memories of traumatic events, the presence of traumatic brain injury history and the corresponding of symptoms profile to PTSD anxious-explosive variant. 


Table 9: Factor structure of the canonical discriminant function
Correlation coefficients
Intrusive distressing recollections severity
-0,30
Hypervigilance severity
0,05
Dissociative episodes severity
-0,18
Traumatic brain injury history
-0,24
Heart rate at admission
-0,11
Match to anxiety-explosive variant of PTSD
-0,22
Severity of the psychological distress at exposure to traumatic event cues
-0,12
Exaggerated startle-reflex severity
0,08
Age at hospitalization
0,19
Level of education
-0,13
Level of professional adjustment
0,08
Hyperthymic character accentuation
0,14
Global social adjustment level
0,03
Avoidance of traumatic thoughts and feelings severity
-0,06
Duration of stay in combat zone
0,03




Discussion

Our findings on the structure of mental disorders among the combatants, where PTSD was diagnosed as leading pathology in 67.1% of cases, have confirmed previous data of many researchers, according to which PTSD consists up to 80% of the medical consequences of combat exposure in Russian servicemen13. At the same time, conventional opinion about the clinical typology of this disorder has not been formed to date. So, presented above anxious-explosive, dissociative and apathetic PTSD variants are somewhat different from the DSM-Y, where the only subtype with dissociative symptoms is separated as well as from classification proposed by Voloshin14, who derived anxious, dysphoric, apathetic and somatoform PTSD types. The differences with the last systematization can be explained, firstly, by the younger combatant’s age in our sample, due to which relevance of somatoform symptomatology was quite low, as evidenced by the Akhmedova’s data15 that showed the relationship of these symptoms with the age of patients. Second, the background of another explanation may lie in the peculiarities of the combat actions, that did not assume the use of chemical or radiological weapons or other factors, apprehensions about which usually underlies to formation of such disorders as "orange syndrome"16 or radiation psychosomatic illness17, which are, as to our opinion, typical examples of post-stress somatoform disorders.


Our findings has shown also, that, contrary to expectations, comorbid disorders had no significant impact on the PTSD outcomes, despite a number of studies postulating the existence of such a link, at least for depressive and anxiety disorders18. Perhaps this fact can be explained by "reactive" nature of a significant portion of such comorbidities, in which concomitant symptomatology represents a psychological response to an axial PTSD symptoms, and therefore conforms the dynamics pattern of the basic disorder.


Summarizing the content of the work, the importance of anxiety and explosive manifestations should be again emphasized, due to their contribution in determination of PTSD phenomenology in former servicemen. Of particular importance, on our opinion, it is the fact that only in cases of dominance of these symptoms the association of the disease dynamics with the social adjustment characteristics, which facilitated the determination of psychotherapeutic interventions. At the same time the dissociative variant differs significantly from others by more frequent association with the signs of organic brain injury, and treatment outcomes were largely determined by the actual nosological parameters and therapeutic (especially pharmacological) tactics. Finally, apathetic variant was usually diagnosed at the late periods of the disease, and it probably can be regarded as a stage in the development of PTSD with a predominance of personal transformation that requires considerable effort in the psychotherapeutic and psychosocial rehabilitation and correction.
Conclusions
  1. Mental disorders structure among combatants served by conscript is determined by the prevalence of neurotic and stress-related disorders (73.3%) most of which constitutes posttraumatic stress disorder (67.1%).
  2. Differences in symptomatology profile of combat PTSD allow distinguishing three main clinical variants of PTSD: anxious-explosive (51.9%), dissociative (32.4%) and apathetic (15.7%). Anxious-explosive variant is more favorable from prognostic point of view (significant improvement/recovery in 37.5% of cases), dissociative variant is prognostically negative (no improvement in 45.7% of cases).
  3. Most important factors in predictive models of PTSD short-term outcome are: clinical variant of the disorder (CC = -0.22), the severity of distressing recollections (CC = -0.30) and a history of traumatic brain injury (CC = -0.24).
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