The development of PTSD among Ukrainians is result of the body's response to trauma, and the activation of the stress reaction, including neurochemical and neuroendocrine processes. Adrenaline and norepinephrine play an important role, mobilizing the body to fight or avoid. During traumatic events, high levels of stress hormones reduce the activity of the hypothalamus, which can subsequently cause stress disorder. PTSD inevitably leads to biochemical changes in the brain. Patients have low cortisol levels and high catecholamine production. Also, people suffering from the disorder have chronically low serotonin levels, which causes appropriate behaviour: anxiety, increased irritability, aggression, outbursts of anger and suicidal thoughts. The scenario of the clinical picture of PTSD among Ukrainians, according to J. Wilson, is similar to that during the Vietnam War [20, 21].
The famous American psychiatrist Abram Kardiner in 1941, while studying this problem, called the changes caused by stress during an armed conflict, chronic war neurosis [22, 23]. That is why the symptoms of the disease have a similar clinical picture in our time and include complaints of patients about: excitability and irritability; fixation on the traumatic circumstances of past events; predisposition to aggression and inability to control it; escape from reality; acute reaction to sudden irritants.
The prevalence of PTSD among the population depends on the frequency of traumatic events. Thus, we can talk about injuries typical for certain political regimes, geographic regions in which natural disasters occur especially often, etc. In the 90s, the incidence of PTSD increased significantly: if in the 80s they corresponded to 1–2%, then in recent studies published in the USA, 7.8%, and there are pronounced gender differences (10.4% for women, 5.0% for men) [24, 25, 26].
Examination of individuals from the risk group (for example, Vietnam veterans, and victims of volcanic eruptions or criminal violence) gave an obvious increase in the prevalence of the diagnosis from 3–58% [27, 28, 29]. The intensity of the psychotraumatic situation is a risk factor for the development of PTSD. Other risk factors are: low level of education, social status; psychiatric problems preceding the traumatic event; the presence of close relatives suffering from psychiatric disorders, chronic stress. It should be noted that quite often individuals with PTSD experience secondary traumatisation, which usually occurs as a result of negative reactions of other people, medical personnel and social workers to the problems faced by people who have experienced trauma. Negative reactions manifest themselves in denial of the very fact of trauma, the connection between trauma and the individual’s suffering, blaming and even vilifying victims, and refusal to provide assistance. In other cases, secondary traumatisation can occur as a result of overprotection of victims, around whom those around them create a “traumatic membrane” that isolates them from the outside world, removing them from the influence of the stressors of everyday life.
Millions of people exposed to war-related stressors experience mental health disorders, including post-traumatic stress disorder. Certainly, pre-migration traumatic experiences, such as those directly related to war and conflict, are important predictors of negative mental health outcomes. At the same time, a range of migration-specific stressors play a very important role for refugees and asylum seekers. Among them, socio-economic factors (i.e. unemployment or underemployment, financial constraints/poverty, lack of secure housing), social and interpersonal factors (i.e. family separation, lack of family and friend support, change in previous social role, social isolation, discrimination, loss of social identity, lack of social support, gender role change), factors related to the asylum process and immigration policies (i.e. mandatory detention, long processing times, lack of access to legal services) are of paramount importance. The consequences of post-traumatic stress disorder depend on the type they belong to. The study identified four types of PTSD: severe; asthenic; dysphoric, somatoformat.
The results of the study recorded that the severe form of PTSD was observed more often in men, and was accompanied by unreasonable anxiety, constant worries; patients have sleep disturbances, insomnia, nightmares at night, panic attacks..
The asthenic type was recorded more often in women and is accompanied by lethargy, bad mood, and indifference to everything that surrounds a person. The patient oppresses himself, because he believes that he cannot return to normal life. Apathy leads to the fact that a person begins to lose physical shape, it comes to the point that it is difficult for him to get out of bed. Patients prefer daytime sleep, quickly agree to treatment.
Dysphoric type is a complex form, manifested by aggression, touchiness, anxiety, distrust of others. Such people like to conflict, are difficult to treat, in rare cases they voluntarily agree to treatment. The study registered that this type was more often recorded in men.
The somatoform type, like the asthenic type, was recorded in female patients. And it was accompanied not only by a psychological disorder, but also by other symptoms, for example, patients complain of pain in the heart and abdomen, headaches. The difficulty of this type is that the symptoms do not appear immediately, they can make themselves known after six months from the incident. If desired, the patient can express a desire to see a doctor. These differences are probably due to biochemical and hormonal differences in patients of different sexes.
In wartime conditions, general principles of PTSD therapy should include: the principle of normalization – the therapist explains to the patient that his symptoms are a reaction of the normal psyche to an abnormal situation; the principle of partnership and enhancing the dignity of the individual, which is especially important for victims of violence; the principle of individuality– taking into account the fact that the post-traumatic process is very complex, and there are no general principles of therapy suitable for all patients; an interdisciplinary approach with the use, if necessary, of medications, physical exercise and a healthy diet, reading inspiring literature, providing social assistance, etc.
The therapeutic approach depends on the severity of PTSD:
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Uncomplicated PTSD. This type of PTSD responds well to pharmacotherapy targeting the symptoms of PTSD and many types of short-term trauma-focused psychotherapy.
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PTSD accompanied by comorbid disorders of a transient nature (addictions, anxiety disorder, depression), which is more common than the previous option. In some cases, comorbid disorders become a more important problem for the patient than PTSD. PTSD therapy should simultaneously address the comorbid disorder.
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“Post-traumatic personality disorder” (e.g., borderline personality disorder, somatophoric disorder, and dissociative disorder), which often results from prolonged psychological trauma in childhood (e.g., sexual abuse). This type of PTSD is often accompanied by behavioural problems (impulsivity, anger reaching rage, aggression and self-aggression, problems with sexual behaviour, eating disorders), emotional instability, emotional impoverishment, depression, panic disorders, cognitive problems (for example, amnesia or fragmentation of memories). Dissociation is often observed. This type of PTSD requires long-term therapy, including the development of emotion regulation skills and communication skills (especially in the area of family relationships), treatment of addictions, and the development of skills necessary for employment. During therapy, it is necessary to create a sense of security in the patient before the therapist can move on to working on the trauma.
The methods with the most evidence base for assessing the effectiveness of PTSD are recognized as trauma-focused cognitive behavioural therapy (TF-CBT), including its individual variants, such as cognitive psychotherapy, cognitive-process psychotherapy, cognitive psychotherapy, prolonged exposure CBT, narrative exposure psychotherapy, as well as eye movement desensitization and reprocessing of mental trauma (EMDR) [30].
TF-CBT consists of three main stages: stabilization, reprocessing (cognitive processing and narrative), integration and consolidation, with a total of 20 sessions of 15–18, evenly divided between 3 blocks. Among the targets of TF-CBT are affective/emotional, cognitive, behavioural, and biological. Cognitive psychotherapy is highly effective, lasting 15–20 sessions, which are held weekly individually and/or in a group to modify pessimistic and catastrophic assessments and memories associated with psychological trauma in order to overcome behavioural and cognitive patterns that support avoidance and interfere with normal daily functioning. The main goal of therapy is to modify pessimistic and catastrophic assessments and memories associated with psychological trauma in order to overcome behavioural and cognitive patterns that support avoidance and interfere with normal daily functioning. Under the guidance of a psychotherapist, the patient learns to identify internal and external stimuli, as well as specific triggers that support PTSD symptoms. In order to reduce the severity of intrusions, a thorough assessment of memories and integration of traumatic experience is carried out. Socratic dialogue is recommended for working with dysfunctional thoughts related to trauma appraisal and core beliefs that support feelings of constant threat. An additional target is dysfunctional cognitive and behavioural patterns that block adaptive coping strategies and recovery of consistent memories of the traumatic event, such as rumination, safety seeking, and thought suppression [31, 32].
In the treatment of PTSD, the use of cognitive-process psychotherapy (12 sessions) has proven its effectiveness in overcoming avoidance associated with traumatic experience, its new conceptualization and teaching skills of problem-solving behaviour [33]. The method has proven its effectiveness in reducing PTSD symptoms in working with different types of traumatic impacts, including natural disasters, child abuse, participation in military operations, rape; the standard protocol includes 12 sessions. The main goal is to overcome avoidance associated with traumatic experience, its new conceptualization and teaching skills of problem-solving behaviour. For this purpose, psychoeducation is used, keeping a diary of automatic thoughts, identifying maladaptive thoughts that support PTSD symptoms, Socratic 21 dialogue, aimed at changing the attitude to the traumatic experience, for example, overcoming self-blame [34, 35]. The final stage involves improving skills for assessing and correcting beliefs related to the traumatic event, and reinforcing adaptive cognitive strategies in relation to issues of safety, trust, power, control, respect and closeness, those areas that may have been affected by the traumatic experience, with the main goal being to improve the patient’s daily functioning and quality of life.
The use of individual cognitive-behavioural psychotherapy with prolonged exposure has proven itself – 15–20 sessions to increase the tolerance of unpleasant stimuli associated with traumatic experience, teaching patients to gradually come into contact with feelings, memories and situations associated with trauma [36]. The main goal of this method is to increase the tolerance of unpleasant stimuli associated with traumatic experience, it is aimed at teaching patients to gradually come into contact with feelings, memories and situations associated with trauma. The main task is to teach that triggers and memories are safe and tolerable and should not be avoided. The duration of therapy is about 3 months with weekly sessions from 60 to 120 minutes, a total of 8 to 15 sessions are held, in some cases 15 to 20 are recommended. At the beginning of therapy, the psychotherapist describes the treatment plan and validates the patient's traumatic experience, then training in anxiety coping skills and breathing exercises is carried out. After this, the actual exposure is carried out; for its successful implementation, a therapeutic alliance and a safe atmosphere must be formed, where, under conditions of emotional support, a collision with very frightening stimuli is possible. The exposure can be carried out in the imagination, or as homework in vivo; at present, virtual reality (VR) programs are actively used for conducting the exposure. When conducting VR exposure, the duration of the session is 45–60 minutes, each scene is repeated until the level of distress is reduced by half compared to the first presentation. The next scene is used after the patient confirms his readiness; the goal of therapy is to make the discomfort bearable. The pace of psychotherapy is determined by the condition and individual characteristics of the patient.
Individual narrative exposure therapy lasting from 4 to 10 sessions is also used to work through traumatic experiences [37, 38]. The method is actively used to help refugees; the main task is to create a consistent life narrative, into the context of which the traumatic experience fits. Important in the behaviour of the psychotherapist are sympathetic understanding, active listening, unconditional positive acceptance and maintenance of the therapeutic alliance. Under the guidance of the psychotherapist, the patient creates his life narrative in chronological order, focusing mainly on the traumatic experience, but also including positive events. It is believed that this unites the context of cognitive, affective and sensory memories of the trauma. By creating a narrative, the patient forms a consistent, coherent biographical history from fragmentary memories. An important task of psychotherapy is to combine in the narrative the past with episodes of traumatisation, the present with traumatic memories of past events and the future, where the traumatic experience is defined as one of the life episodes. Patients with PTSD may be shown the use of biofeedback techniques – 10 sessions to reduce anxiety and tension, teach self-regulation skills and reduce the level of tension.
In cases of prolonged or multiple traumatisations, individual dialectical behavioural therapy (DBT) is used to form an alternative assessment of the traumatic experience [39, 40]. The name itself defines the main goal of the therapy - the formation of an alternative assessment of the traumatic experience, which is often clearly perceived by patients as unbearable and hopeless, the behavioural module is aimed at developing optimal behaviour patterns in the process of comparing various, sometimes contradictory options. The task of the psychotherapist in each individual case is to find the optimal balance between acceptance and change, for which the appropriate techniques are used, to solve individual problems; individual techniques of TF-CBT, compassion-focused psychotherapy, acceptance and responsibility psychotherapy can be additionally used.
In the process of dialectical behavioural therapy of PTSD, mindfulness, training in distress tolerance and emotional regulation skills, increasing interpersonal effectiveness, exposure and response prevention, counter-behaviour, validation, and self-acceptance are used. Eye movement desensitization and reprocessing (EMDR) is a method of confronting traumatic experiences using targeted bilateral stimulation (through rhythmic 23 eye movements) with simultaneous imagery of the traumatic event. Eye movements and other forms of stimulation of dual focus of attention, in addition to eye movements, it is possible to use sound stimulation or tapping on various parts of the body, provides simultaneous desensitization and cognitive restructuring, as well as integration of traumatic memories and a decrease in the severity of PTSD symptoms. This is a method of individual psychotherapy lasting 6–12 sessions, which can be held sequentially every day. F. Shapiro – the author of the method is based on the fact that emotional trauma can disrupt the work of the information processing system, therefore it will be preserved in the form caused by the traumatic experience, and contributes to the formation of intrusive symptoms of post-traumatic syndrome. Eye movements (there may be other alternative stimuli) used in EMDR activate the information processing system and restore its balance. Psychotherapy consists of 8 consecutive phases: anamnesis; preparation; assessment; desensitization; installation; body scanning; completion; re-assessment.
Treatment and rehabilitation of patients with PTSD should be comprehensive and carried out by a team of specialists: psychiatrist/psychotherapist, family doctor, internal medicine specialist, with the active participation of patient and his family.