In addition to direct threat that every war poses, it also has terrible echoes. It is difficult to go to war, but it is more difficult to leave it. Particularly for those who have gone through the hell of combat, shelling and the death of friends. Instead of heroic memories, many of these soldiers will develop social and psychological disorders – from physical injuries to initially imperceptible, but extremely dangerous pathologies, which only become apparent after some time, in civilian life. All of these factors are widely known as posttraumatic stress disorder (PTSD), which was first researched after the Vietnam War in America. Until recently, Ukraine’s own analogy had been the Afghan syndrome – a complex of injuries and shock experienced by those who fought in the War in Afghanistan. Today, when the Donbas and hundreds of thousands of Ukrainians are going through their own war, which we will likely end up the “Donetsk syndrome”.
Social psychiatry has various examples of “veteran syndromes” from the wars in Vietnam, Afghanistan, Chechnya, the Gulf Wars and so on. Any war is a great shock for people, since they find themselves in conditions that are not normal for the psyche. The American campaign in Vietnam became the breaking point, from which attention was finally paid to such things. In the first decade after this war, in peacetime, the USA lost nearly 20,000 people. It was calculated that the number of those who die in the first ten years after the end of military action exceeds the number of those who die during military action. Research has shown that the delayed consequences of war are far more significant than purely physical injuries, impacting more than just the mental health of servicemen. Psychological equanimity and the worldview of combatants, as well as their entire destiny are also heavily affected.
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Professor Vsevolod Stebliuk participated in the Anti-Terrorist Operation (ATO) as a volunteer-anaesthesiologist, saved about 80 people near Ilovaysk and is now actively involved in psychological rehabilitation of servicemen. Ukraine is on the verge of its own “veteran syndrome” which stems from the Maidan, he says. “Ukraine has been in a state of permanent social stress for almost a year,” he states. “The Maidan, particularly its hottest phases accompanied by violence, were the first to cause PTSD in a huge group of people. When the confrontation between protesters and the government reached its culmination in the centre Kyiv, we had three main groups of patients: Maidan activists, police officers, and families and close friends on both sides of the conflict. They all shared common clinical symptoms, including post-traumatic stress disorder (PTSD) and severe reaction to stress, as well as adaptation disorders.”
“We will most likely end up with the Donetsk Syndrome,” Serhiy Hryliuk, Director of the Social-Psychological Centre of the Ukrainian Armed Forces. “I mean experience in the hybrid war. Another problem is that we had to re-build the consciousness of most servicemen. Many ATO servicemen found themselves in a state of psychological breakdown when they realised the reality of war against Russia.”
Like in any war, Ukraine will have two categories of victims: the military and civilians. The military involved in the fighting include professional army personnel whose actual job is war. They are better prepared to cope with stress than average people. “In spite of the chaos in the Ukrainian army in previous years, this category of soldiers was probably ready for possible complications psychologically,” Dr. Stebliuk describes them. “However, contract servicemen include many who went into service for stability and a salary. They did not expect that they would actually have to fight.”
The next group includes mobilised reservists who have largely been forced to put on a uniform and take up arms. Of all Ukrainian servicemen in the Donbas, they are the most vulnerable to stress. “People do not become patriots and soldiers by force,” Dr. Stebliuk notes. “So, this group of soldiers was already distressed before they got involved in military action. Complications on the front have led to their failure to adapt.”
Another vulnerable group includes the police, particularly special units who experienced stress during the Maidan, such as Berkut and Sokil, as well as interior troops. For them, participation in the ATO is a compensation of sorts, the continuation of a stressful situation, which becomes “chronic” as they adapt to the war. Some of them fight in the ATO to get career growth, return to service after they were dismissed for violations or abuse, avoid responsibility for violations on the Maidan, or avoid lustration. These are definitely mature troops with strong adaptation skills.
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Surprisingly, patriots from voluntary battalions regardless of their subordination have the highest resilience against PTSD. Participation in the ATO fits in their life-long position allowing them to actually counteract crime and defend their country. For the most part, they are Maidan protesters, civil activists and the like. They are “people of war”, who feel comfortable under stressful tension.
Civilians vulnerable to stress include IDPs and families of ATO fighters. The first group is stressed out by a change in their usual way of life, uncertainty of the future, financial hardships and by what they perceive as hostile environment. For the second group, stress factors include concern for the fate, and the death or constant danger of the loss of their loved ones. Dr. Stebliuk emphasises that the Donetsk Syndrome will probably show itself the most in the coming six months.
THE SYMPTOMS OF DISTRESS
Vitaliy Andronatiy, Chief of the Defense Ministry Medical Department, confirms that approximately 80% of the servicemen who returned from the ATO are being diagnosed with psychological disorders. At the moment, these are caused by physical injuries.
“We are seeing severe traumatic conditions, the threat to life or their physical state,” says psychiatrist Andriy Karachevskiy, a lecturer at the Psychiatry and Narcology Department of the Bogomolets National Medical University, who is currently providing psychiatric help to ATO soldiers on a voluntary basis. “This causes insomnia, irritability and depression, and makes the survivors feel guilty for being alive. They have nightmares of cases where they faced mortal danger. The US psychiatrists qualify this as severe stress disorder for the symptoms that occur within the first month after the incident, and as PTSD when they continue after one month.”
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Not everyone who was at war and received a psychological trauma will subsequently have PTSD. “Of those who survived mortal danger, 10% of men and 20% of women can be diagnosed with PTSD, while of combatants – more than 30%,” explains Andriy Karachevskiy. “Let’s suppose that there are about 100,000 people fighting in the Donbas right now. So about 30,000 will suffer from PTSD, of which 10,000 will be severe lasting for years. These people will be easily provoked to aggression, lack patience and could cause problems in society. They are also more prone to alcoholism and drug abuse, not to mention suicide.”
War veterans are indeed a vulnerable group. According to statistics, they suffer more fatalities in road accidents, get involved in criminal groups, abuse alcohol and drugs, etc. The research of veterans who fought in Afghanistan in 2001 conducted by American experts revealed that 25% of them had PTSD.
Psychotherapists and occupational therapists feel that several types of these disorders are already visible among different groups of Ukrainian servicemen. The first type is active adaptation or overcoming stress through counteraction. “This type of reaction is specific to most “ideological” soldiers,” notes Vsevolod Stebliuk. “It manifests itself in aggressive behaviour, uncompromising attitude towards enemies, diminished ability to communicate and an acute sense of justice. This category of victims uses virtually no alcohol or drugs to alleviate stress, since for them, nothing compares to the adrenalin rush of military action. The constant feeling of danger and the risk of death are a kind of psychological stimulator. It is difficult for these people to switch to civilian life; the meaning of their existence is battle.” Potentially, they are an effective weapon of revolutions, uprisings and military coups.
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Anxiety and depression disorder is the third type. It is the most difficult and, unfortunately, the most wide-spread one, manifesting itself through insomnia, anxiousness, the premonition of danger, fear and severe depression, the loss of social and personal activity, no faith in the future as well as intents and attempts to commit suicide. This is most often seen in soldiers who have been maimed or suffered severe injuries. Attempts to battle such disorders with drugs and alcohol only exacerbate the situation.The second type is protective inhibition. Experts feel that this is the best form of adaptation. This reaction develops in people with a strong, balanced nervous system. Protective inhibition reactions are the ones that allow them to fall asleep during shelling, take rests, pull themselves together in the most extreme situations and perceive reality as if it is a movie. Dr. Stebliuk feels that this is also caused by the nature of military action in the Donbas, when there is no direct contact with fire but artillery shelling hardly stops. Constant shelling from mortars and multiple launch rocket systems forces this group to passively wait under cover. In civilian life, protective inhibition manifests itself in partial memory loss of the most tragic moments of military action. These people block out the most horrific events to protect themselves from re-living these experiences.
Experts note that at present, the first, and to a certain extent, the third types of reaction are prevalent among those who have been in military action. Medics often face mixed symptoms, including anxiety and activation, sleeplessness and the necessity to act, depressive disorders and inhibition.
THEY MUST FEEL NEEDED
According to experts, the Donetsk Syndrome will differ little from the Vietnam or Afghan syndromes, although what makes the Ukrainian case different is that people are not fighting on foreign soil. To a certain extent, the righteous protection of native land mitigates the effect of PTSD. The servicemen in Eastern Ukraine are protecting their land and clearly understand why they are suffering. However, it is not as simple as that.
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On the one hand, mass media are popularising the heroism of ATO participants, regularly showing edgy reports filled with concern and alarm. On the other hand, the soldiers and volunteers see the completely peaceful existence of the rest of society, the ongoing attempts of politicians to gain political dividends on the war, and bureaucrats who are trying to make money on this. This fuels internal conflicts in those fighting in Eastern Ukraine: “How is it that we are fighting for our country, for our land. We are losing the best and closest people to us, while the government and other people are completely indifferent to everything.”
Psychotherapists and occupational therapists agree that psychological rehabilitation of ATO participants must already begin with preventive preparation of soldiers for battle fatigue in boot camp, before battle. However, the Ministry of Defence can hardly dress its soldiers, let alone be concerned with psychological aid. Moreover, the relevant department in the General Staff was only established recently and is not yet operational. But the main thing is for soldiers to feel that they are needed, and that everything they experienced on the front was not in vain.
“It is important to understand that people with PTSD will not go to an in-patient psychiatric hospital, and they do not necessarily need hospitalisation. First and foremost, they need psychotherapeutic help, and in big cases – medication,” says Andriy Karachevskiy. “At present, there is no interaction between all participants of the rehabilitation process, which should already begin at the stage of medical evacuation at a mobile hospital (this role is often played by volunteers) and must be continued on a more qualified level, at in-patient hospitals.”
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ATO participants must be under constant observation of doctors, and undergo regular psychological testing for early detection of disorders, depression and suicidal tendencies. “We are only at the beginning of our struggle with the consequences of battle fatigue, and in the absence of relevant conditions, we will have a large amount of people who are not adapted to civilian life in the short-term,” Dr. Stebliuk sums it up. “In addition, the danger of the escalation of these disorders and their consequences – bursts of violence and an increase in the number of suicides – will exist for a very long time. Based on my own experience and recommendations of a friend who survived Afghanistan, I can say that nothing cures failure to adapt like the sense of being needed, both as a citizen and as a family member to the ones you love.”