Volume 12 - Issue 68
/ August 2023
93
http:// www.amazoniainvestiga.info ISSN 2322- 6307
DOI: https://doi.org/10.34069/AI/2023.68.08.9
How to Cite:
Danilevska, N., Asieieva, Y., Chusova, O., Tolmachov, O., & Berezovska, Y. (2023). Diagnostic markers and scale of differential
diagnosis of socially-disadaptative post-combat syndrome. Amazonia Investiga, 12(68), 93-102.
https://doi.org/10.34069/AI/2023.68.08.9
Diagnostic markers and scale of differential diagnosis of socially-disadaptative
post-combat syndrome
ДІАГНОСТИЧНІ МАРКЕРИ ТА ШКАЛА ДИФЕРЕНЦІЙНОЇ ДІАГНОСТИКИ
СОЦІАЛЬНО-ДЕЗАДАПТИВНОГО ПІСЛЯБОЙОВОГО СИНДРОМУ
Received: June 28, 2023 Accepted: August 24, 2023
Written by:
Danilevska Natalia1
https://orcid.org/0000-0002-7854-9007
Asieieva Yuliia2
https://orcid.org/0000-0003-3086-3993
Chusova Olha3
https://orcid.org/0000-0003-1943-109X
Tolmachov Oleksii4
https://orcid.org/0009-0008-1199-6567
Berezovska Yuliia5
https://orcid.org/0009-0005-5719-009X
Abstract
Mental disorders resulting from combat actions can
affect up a considerable percentage of servicemen.
Specific disorders have been observed in
combatants and veterans of different wars,
highlighting the influence of combat conditions on
mental health. Social maladjustment among it can
be highly prevalent, impacting combat readiness
and post-war adaptation.
The above emphasizes the significance of
differential diagnosis in identifying specific mental
conditions like Socially-Disadaptive Post-Combat
Syndrome and distinguishing them from other
disorders. Socially-Disadaptive Post-Combat
Syndrome is a condition that develops after the
return of a combatant from a combat zone and is
characterized by a maladaptive, conflictual
response to a wide range of insignificant social
situations.
The study aims to develop a diagnostic tool for
identifying Socially-Disadaptive Post-Combat
syndrome.
1
PhD (Medical Sciences), Assistant of the Department of Psychiatry, Psychotherapy, General and Medical Psychology, Narcology
and Sexology, Zaporzhzhia State Medical University, Zaporizhzhia, Ukraine. WoS Researcher ID: ACC-2295-2019
2
Doctor of Psychological Sciences (MD), Head of the language and psychological-pedagogical training department of Odessa
National University of Economics, Odessa, Ukraine. WoS Researcher ID: AAH-2650-2021
3
PhD (Psychological Sciences), senior teacher of the Department of language and psychological-pedagogical training of Odessa
National University of Economics, Odessa, Ukraine. WoS Researcher ID: ААЕ-5303-2021
4
PhD (Medical Sciences), Head of the psychiatric clinic of the Military Medical Clinical Center of the Southern Region, psychiatrist
of the highest category, narcologist of the highest category, forensic psychiatric expert of the highest category, sexopathologist of the
highest category, medical psychologist specialist, Odessa, Ukraine. WoS Researcher ID: JAC-0299-2023
5
Graduate student of the Department of Theory and Methods of Practical Psychology of the State institution «South Ukrainian
National Pedagogical University named after K.D. Ushynsky», Odessa, Ukraine. WoS Researcher ID: JBJ-0489-2023
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This study focuses on combat-related mental
disorders among Ukrainian combatants and
veterans who participated in the Anti-Terrorist
Operation / Joint Forces Operation (ATO/JFO)
from 2014 to 2021. The research involves 395
participants, with 39 combatants exhibiting
symptoms of Socially-Disadaptive Post-Combat
Syndrome forming the main research group, and 21
individuals with PTSD forming the comparison
group.
As a result of the study, we systematized diagnostic
markers and develop a Diagnostic Scale of
Socially-Disadaptive Post-Combat syndrome. Our
devised diagnostic scale consists of two sections: a
list of criteria related to specific circumstances
(comprising 4 criteria - 2 obligatory criteria and 2
optional criteria) and a list of symptoms
(comprising 16 symptoms).
We also believe that conducting research on
combatants and veterans of other wars is expedient.
Keywords: combat mental trauma, mental
disorders, combatants, veterans, differential
diagnosis, psychometry.
Introduction
Differential diagnosis of mental disorders has
always been a priority in neuroscience (Kent,
Nelson, & Northoff, 2023). This is particularly
relevant to disorders related to combat-related
mental trauma. The percentage of mental
disorders resulting from combat actions can
reach up to 16%. Moreover, mental disorders can
manifest in military personnel even after the war.
For instance, Post-traumatic stress disorder
(PTSD) – a condition with a delayed onset, can
affect veterans at a rate exceeding 8% (Inoue et
al., 2023; Negrusa, Negrusa, 2014; Kozhyna et
al., 2021). This irreversibly impacts the combat
readiness of the army during wartime and
subsequently affects the social adaptation of
veterans.
All this raises the issue of adequate, effective and
valid psychodiagnostic tools. Our work is
devoted to the analysis of existing studies of the
specific disorders of combatants in various world
wars. Our attention is focused on the urgent need
for Ukraine – to identify diagnostic markers of
Socially-Disadaptive Post-Combat Syndrome
and to prove the results regarding the validity,
reliability and standardization of the developed
scale of differential diagnosis of Socially-
Disadaptive Post-Combat Syndrome among
Ukrainian participants in hostilities and veterans
who took part in ATO/OOS with 2014 to 2021.
The aim of the research is to identify and
systematize the diagnostic markers of Socially-
Disadaptative Post-Combat syndrome and
develop, based on these markers, the Diagnostic
Scale of Socially-Disadaptive Post-Combat
syndrome in comparison to PTSD.
The object of the research is the diagnostic
markers of Socially-Disadaptative Post-Combat
syndrome and PTSD.
Methodology and material
In the research we used following methods:
theoretical-methodological analysis on the
research topic, psychodiagnostical, and
mathematical-statistical methods.
This clinical retrospective and prospective study
were conducted at the Zaporizhzhia Military
Hospital and Zaporizhzhia State Medical
University, Zaporizhzhia, Ukraine. We
examined 395 combatants and veterans who
Danilevska, N., Asieieva, Y., Chusova, O., Tolmachov, O., Berezovska, Y. / Volume 12 - Issue 68: 93-102 / August, 2023
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participated in the Anti-Terrorist Operation/Joint
Forces Operation (ATO/JFO) from 2014 to 2021.
The research was conducted in accordance with
the principles of deontology and bioethics. The
Bioethics Commission of Zaporizhzhia State
Medical University (review document, No. 5
dated June 6, 2014) approved this study. All
participants provided informed consent for their
voluntary participation in the study.
Sample of the exploration. Out of 395
combatants, we identified individuals who
exhibited symptoms of Socially-Disadaptive
Post-Combat Syndrome in their clinical
presentation. A total of 39 combatants were
included in the main research group (MG).
Additionally, we selected combatants who
presented with mental disorders similar to
Socially-Disadaptive Post-Combat Syndrome in
terms of clinical manifestations, debut features,
dynamics, and triggering factors, namely PTSD.
This comparison group (CG) comprised 21
combatants. All participants in the study were
male. There were no statistically significant
differences in age and military service-related
features and conditions among the patients.
Using the A. Wald procedure, we compared all
research groups and identified symptoms of
Socially-Disadaptive Post-Combat Syndrome in
the MG that significantly differed from the
symptoms in the CG. Based on these distinctive
symptoms, we developed the Scale of
Differential Features between Socially-
Disadaptive Post-Combat Syndrome and PTSD.
Analysis of recent research and publications
It is well-known that manifestations of social
maladjustment among veterans can be significant
in terms of prevalence. These include loneliness,
which may affect 50% or more, divorce rates
reaching up to 20%, involvement in criminal
activities accounting for 8% of all committed
offenses, unemployment rate of 20%, and suicide
rates exceeding 17%. However, the actual figures
might be even higher (Inoue et al., 2023; Gates et
al., 2012; Negrusa, & Negrusa, 2014; Xia et al.
2020; Finlay et al., 2019; Lwi et al., 2022;
Holliday et al., 2022; Reijnen, & Duel, 2019;
Burdett et al., 2019).
Moreover, cases of delayed detection of mental
disorders related to combat-related mental
trauma are not uncommon, leading to negative
consequences (Randles, & Finnegan, 2022).
Timely identification and correction of such
pathology are essential to minimize these adverse
effects.
Combatants and veterans from various wars have
been described to experience specific disorders
such as Combat Stress Reaction, "Soldier's
Heart" (Effort Syndrome or Da Costa's
Syndrome), and others. PTSD gained widespread
recognition after the Vietnam War (Jones, 2001;
Adler, & Gutierrez, 2022; Borges et al., 2020).
Indeed, specific conditions of combat operations
in each country and various factors affecting the
psyche can result in differences in the clinical
presentation, even leading to the identification of
new conditions. For instance, after episodes of
gas warfare during World War I, the term "Gas
Neurosis Syndrome" emerged to describe a
specific mental condition observed in combatants
of that war (Hulbert, 1920). The Norwegian
sailors in the merchant navy who survived World
War II were diagnosed with a specific mental
disorder known as "War Sailor Syndrome"
(Askevold, 1976). For a prolonged period,
medical practitioners encountered specific
manifestations in Gulf War veterans before the
concept of the Gulf War Syndrome was
formulated (Auxéméry, 2013). Additionally, in
the literature, there is an amalgamation of various
pathological mental manifestations under the
term Hybrid war syndrome (Danyk, &
Zborovska, 2008).
With the onset of the unprovoked and
unmotivated invasion of Ukraine by the Russian
Federation starting in 2014, Ukrainian
combatants have also been documented to
experience war-associated mental disorders
(Loganovsky et al., 2018). The following
pathological conditions have been described:
specific alcohol depression, Post-combat delayed
response syndrome, Socially-Disadaptative Post-
Combat syndrome, and the Ukrainian syndrome
(Napryeyenko et al., 2018; Danilevska, 2018a;
Danilevska, 2018b; Matyash, & Hudenko, 2014).
The diversity of these disorders burdens and
impairs the quality of timely diagnosis, leading
to treatment delays, and consequently, disability.
It is known that 7.2% of Ukrainian combatants
were declared disabled due to mental and
behavioral disorders from 2014 to 2021
(Kyrychenko et al., 2022). However, as of 2018,
compared to 2014, there was a slight decrease in
the incidence of affective disorders by 14% and
neurotic disorders by 3.2% (Havlovskyi, 2019).
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However, starting from 2022, when the war
escalated to a full-scale conflict, negative
indicators may increase, further emphasizing the
need for high-quality tools in timely
psychometry.
In this study, our scientific inquiry was directed
towards identifying specific criteria for Socially-
Disadaptative Post-Combat syndrome and
applying them as a differential diagnostic tool to
distinguish this condition.
Results
Despite the absence of core symptoms of PTSD
such as "flashbacks," nightmares, and
reminiscences in the clinical presentation of
combatants in the MG, we find it appropriate to
conduct a differential diagnosis between Socially-
Disadaptive Post-Combat Syndrome and PTSD
because all combatants experienced life-threatening
situations during their participation in the ATO /
JFO. Additionally, they exhibited other secondary
symptoms such as an enhanced startle reaction, a
state of autonomic hyperarousal, hypervigilance,
anxiety, depression, and anhedonia in their clinical
profile.
We conducted a comparative analysis of markers in
combatants from the MG and identified those that
showed significant differences from the CG at a
level of <0.05. This was done to determine the
markers of Socially-Disadaptive Post-Combat
Syndrome that are diagnostically significant.
We utilized TIBCO STATISTICA® 13.0 (TIBCO
Software Inc. №JPZ8041382130ARCN10-J) and
MICROSOFT EXEL 2013 (license code 00331-
10000-00001-АА404) for data analysis, applying
descriptive and mathematical statistical methods for
statistical analysis. For calculating mutual
information (MI) and Jeffreys divergence (J-
divergence, J) based on Kullback's method, we
employed the method of sequential analysis
developed by A. Wald, relying on T. Bayes'
theorem, with adaptations by A.A. Genkin and E.V.
Gubler.
Upon ranking these diagnostically significant
markers of Socially-Disadaptive Post-Combat
Syndrome based on their diagnostic significance
level, we obtained the following results (Table 1).
Table 1.
Diagnostic informativeness criteria of Socially-Disadaptative Post-Combat syndrome
Criteria MG vs CG
Diagnostic informativeness criteria
)
2
χp(
J
MI
maladaptive verbal and behavioral patterns of social interaction
<0,001
6,23
2,37
feelings of subjective distress or disharmony
<0,001
1,18
0,14
increased sense of justice
<0,001
2,43
0,52
increased tendency to defend their rights including to the level of querulant or
conflicting behavior
<0,001
3,91
0,95
non-acceptance of civil, political, moral and ideological norms and patterns of
interaction of other people
<0,001
2,43
0,52
dysphoricity or anger in response to a wide range of social situations
0,015
3,33
0,55
intolerance of other people's thoughts or actions
<0,001
2,99
0,71
increased tendency to be offended, touchiness or hurt
<0,001
13,11
6,07
egocentrism
0,006
2,36
0,41
nonconformity
0,010
1,61
0,22
conflictedness
<0,001
4,15
0,95
tendency to impulsive actions and deeds
0,015
3,33
0,55
automatic comparison of individual components of social and interpersonal
interaction in the civilian environment with those available in the combat
zone, giving preference to the latter
<0,001
3,22
0,84
yearning memories of certain components of social and interpersonal
interaction in the combat zone
<0,001
3,22
0,84
irritability
<0,001
3,72
0,96
mood swings
0,033
2,43
0,35
a wide range of low-significant substressful social factors exacerbate
symptoms
<0,001
13,22
6,30
a latency period from a few days to one month after leaving the combat zone
<0,001
8,45
3,62
stay in the combat zone for 3 months or more
0,005
0,92
0,09
the duration of symptoms is 3 months or more
0,050
0,43
0,02
● The symptoms that had positive J scores were attributed to the diagnostic symptoms of Socially-
Disadaptive Post-Combat Syndrome, while the symptoms that had negative J scores were associated with
the diagnostic symptoms of PTSD.
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The weight of symptom informativeness is
determined by the value of MI, therefore, we
ranked the criteria of Socially-Disadaptative
Post-Combat syndrome from more informative
to less informative in the context of their
significance for differential diagnosis (Fig. 1).
According to the method of sequential analysis
by A. Wald, the diagnostic conclusion (in this
case, the conclusion about the presence of
Socially-Disadaptive Post-Combat Syndrome in
the patient) is made based on the summation of J
values for each diagnostic criterion; the level of
significance of the conclusion is indicated by the
threshold value of the J sum (∑J): when ∑J ≥13,
the probability of the conclusion is p < 0.05;
when ∑J = ≥20, the probability of the conclusion
is p < 0.01; and when ∑J = ≥30, the probability
of the conclusion is p < 0.001.
Thus, the group of most significant criteria,
which, according to the MI ranking, reach a sum
of J ≥30, includes the first three criteria from Fig.
1.
Fig. 1. Ranking of criteria of Socially-Disadaptative Post-Combat syndrome in order of strength of their
diagnostic value (MI)
In the next stage, we differentiated the
diagnostically significant criteria of Socially-
Disadaptive Post-Combat Syndrome into two
groups: symptoms and circumstances. Criteria
such as a latency period from a few days to one
month after leaving the combat zone, a wide
range of low-significant substressful social
factors exacerbating symptoms, stay in the
combat zone for 3 months or more, and the
duration of symptoms being 3 months or more
were excluded from the general list of diagnostic
symptoms and placed in an additional list of
circumstances because they are not symptoms
per se but indicators of the circumstances
contributing to the symptomatology. The rest of
the criteria were included in the main list of
symptoms. The final ranking of criteria for
diagnosing Socially-Disadaptive Post-Combat
Syndrome is presented in Fig. 2.
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Fig. 2. Ranking of symptoms and circumstances of Socially-Disadaptive Post-Combat syndrome in order
of strength of their diagnostic value (MI)
Thus, the group of the most significant criteria,
which, according to the MI ranking, reach a sum
of J≥30, includes the first six symptoms from
Fig. 2. Therefore, based on the MI ranking
(Fig. 2), the most crucial and sufficient
symptoms, from a diagnostic perspective, for
reliably establishing the diagnosis of Socially-
Disadaptive Post-Combat Syndrome, are as
follows: increased tendency to be offended,
touchiness or hurt, maladaptive verbal and
behavioral patterns of social interaction,
irritability, increased tendency to defend their
rights, including to the level of querulant or
conflicting behavior, conflictedness, automatic
comparison of individual components of social
and interpersonal interaction in the civilian
environment with those available in the combat
zone, giving preference to the latter. These
symptoms are fundamental to the studied
syndrome and serve as criteria for differentiating
it from PTSD. However, the rest of the symptoms
are also important and can be considered
additional symptoms.
We classified circumstances such as "a latency
period from a few days to one month after
leaving the combat zone" and "a wide range of
low-significant substressful social factors
exacerbate symptoms" as obligatory criteria of
the circumstances, considering their high MI
scores. While the rest were categorized as
optional criteria of circumstances.
Based on the established list of criteria, we
developed an instrument for the diagnosis and
differential delineation of Socially-Disadaptive
Post-Combat Syndrome from PTSD (Fig. 3).
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«Diagnostic Scale of Socially-Disadaptive Post-Combat syndrome»
Patient name: ___________________________________________________________
Obligatory criteria of the circumstances*:
- a latency period from a few days to one month after leaving the combat zone
- a wide range of low-significant substressful social factors exacerbate symptoms
Optional criteria of circumstances:
- stay in the combat zone for 3 months or more
- the duration of symptoms is 3 months or more
No.
Symptom
J
A sign of the
presence of a
symptom
1
Increased tendency to be offended, touchiness or hurt
13,11
2
Maladaptive verbal and behavioral patterns of social interaction
6,23
3
Irritability
3,72
4
Increased tendency to defend their rights including to the level of querulant or
conflicting behavior
3,91
5
Conflictedness
4,15
6
Automatic comparison of individual components of social and interpersonal
interaction in the civilian environment with those available in the combat zone,
giving preference to the latter
3,22
7
Yearning memories of certain components of social and interpersonal
interaction in the combat zone
3,22
8
Intolerance of other people's thoughts or actions
2,99
9
Dysphoricity or anger in response to a wide range of social situations
3,33
10
Tendency to impulsive actions and deeds
3,33
11
Increased sense of justice
2,43
12
Non-acceptance of civil, political, moral and ideological norms and patterns of
interaction of other people
2,43
13
Egocentrism
2,36
14
Mood swings
2,43
15
Nonconformity
1,61
16
Feelings of subjective distress or disharmony
1,18
Total (∑J): _______
* - All obligatory criteria of the circumstances must be present to establish a diagnosis.
Reference values:
∑J ≥13 - diagnosis of Socially-Disadaptive Post-Combat syndrome possible, the probability of diagnosis is 95%,
p < 0,05;
∑J = ≥20 - diagnosis of Socially-Disadaptive Post-Combat syndrome probable, the probability of diagnosis is 99%,
p < 0,01;
∑J = ≥30 - diagnosis of Socially-Disadaptive Post-Combat syndrome reliable, the probability of diagnosis is 99,9%,
p < 0,001.
Fig. 3. The form of Diagnostic Scale of Socially-Disadaptive Post-Combat syndrome
We, therefore, propose the developed instrument
"Diagnostic Scale of Socially-Disadaptive Post-
Combat Syndrome among PTSD" for screening
and diagnosing mental disorders in combatants.
We acknowledge that this scale will also be
beneficial to healthcare professionals for
identifying Socially-Disadaptive Post-Combat
Syndrome as a comorbid condition.
Discussion
War and post-war periods differ in terms of a
surge in mental pathology associated with
combat-related psychological trauma. The
question of the specificity of psychological
trauma in different wars remains debatable.
There are indications that the nature of the war
and its localization may impose certain
characteristics on the clinical presentation of
mental disorders in combatants and veterans,
leading to the identification of new, hitherto
undescribed psychiatric disorders (Adler, &
Gutierrez, 2022; Cypel, DePhilippis, & Davey,
2023; Kozhyna, Zelenska, Viun, Khaustov, &
Asieieva, 2021).
A relevant example is the Gulf War syndrome -
a condition characterized by a complex of
symptoms that puzzled healthcare professionals
for a considerable period and was only identified
in participants of the war in the Persian Gulf.
Additionally, one-third of the sailors in the
Norwegian merchant navy became disabled due
to War Sailor Syndrome (Askevold, 1976;
Boman, 1982; Malt, & Weisaeth, 1989;
Minshall, 2014).
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However, most of these conditions are not
specific to a particular military conflict or
national contingent and can be observed in
different wars. For example, PTSD is one such
condition. While extensively described among
American veterans of the Vietnam War, it is also
diagnosed in other cases (Magruder et al., 2015;
Thakur et al., 2022).
In this study, we report on the criteria for
Socially-Disadaptive Post-Combat Syndrome in
Ukrainian combatants who participated in the
ATO / JFO. The condition we described leads to
social maladjustment among military personnel
after returning from the combat zone and may be
observed as a comorbid disorder, further
complicating their well-being. We believe that it
requires further clarification of the symptom
continuum, and conducting research on
combatants and veterans of other wars would be
beneficial.
Conclusions
In this study, we identified symptoms of
Socially-Disadaptive Post-Combat Syndrome
that significantly differ from PTSD in
combatants. Based on their systematization, we
constructed a ranking of diagnostic
informativeness criteria in ascending order of
their diagnostic significance, categorizing these
criteria into symptoms and circumstances.
By considering the diagnostic significance of the
symptoms, we were able to distinguish the main
symptoms and additional symptoms of Socially-
Disadaptive Post-Combat Syndrome.
We developed the "Diagnostic Scale of Socially-
Disadaptive Post-Combat Syndrome among
PTSD" and propose its clinical utilization. The
proposed scale can be used for screening and
diagnosing mental disorders, including comorbid
conditions, among combatants and veterans.
The diagnostic scale developed by us consists of
two sections: a list of criteria of the
circumstances (comprising 4 criteria - 2
obligatory criteria and 2 optional criteria) and a
list of symptoms (comprising 16 symptoms).
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