RU2328977C2 - Method of posttraumatic stress-induced injury (ptsi) diagnostics - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used for diagnostics of posttraumatic stress-induced injury (PTSI). Stress situation, psychic trauma experiences are detected in patient anamnesis. In addition point number is evaluated according to questionnaire Mississippi scale. If PTSI is diagnosed, course is detected by duration experiences caused by severe, very severe, or catastrophic stress situation of acute and/or chronic character, or their combination associated with these experiences. Differentiated approach to diagnostics of clinical stages and PTSI severity level enables to realise differentiated approaches to treatment and rehabilitation of victims since each clinical stage and each severity level are necessary to be corresponded to PTSI pharmacotherapy and psychotherapy principles.

EFFECT: way provides more accurate clinical diagnostics of injuries caused by stress situations.

4 cl, 2 dwg, 4 tbl, 3 ex

Description

The invention relates to medicine, namely to psychiatry, and can be used in the diagnosis of post-traumatic stress disorder (PTSD).

The closest analogue of the proposed method is a model in accordance with the diagnostic criteria of ICD-10 (Mental and behavioral disorders (F00-F99. Class V ICD-10, adapted for use in the Russian Federation. - Moscow, 1998. - 282 p.).

In accordance with the diagnostic criteria of ICD-10, PTSD refers to rubric F 43 “Response to severe stress and impaired adaptation”, subheading F 43.1 “Post-traumatic stress disorder”. According to the ICD-10 criteria, the diagnosis of PTSD is based on the presence of a delayed and / or prolonged reaction to a stressful event or situation (short or long) of an exclusively threatening or catastrophic nature, which in principle can cause general distress in almost any person.

Clinical signs of PTSD include episodes of re-experiencing trauma in the form of intrusive memories (reminiscences), dreams or nightmares arising from a chronic feeling of “numbness” and emotional dullness, estrangement from other people, a lack of reaction to the environment, anhedonia, and evasion from activities and situations reminiscent of an injury. Typically, an individual is afraid and avoids what he is reminded of the initial trauma. There are occasionally outbreaks of fear, panic or aggression provoked by stimuli that trigger an unexpected memory of the injury or the initial reaction to it.

In PTSD, according to the diagnostic criteria for PTSD, there is a state of increased autonomic excitability with an increase in the level of wakefulness, an increase in the reaction of fright and insomnia.

Anxiety and depression are usually combined with the above symptoms, suicidal ideation is often noted, excessive consumption of alcohol and drugs can be a complicating factor.

The onset of this disorder occurs after an injury after a latent period, which can vary from several weeks to months (but rarely more than 6 months). The course is undulating, but in most cases there can be a recovery. A chronic course can be noted over the years and lead to persistent personality changes after experiencing a disaster.

According to the diagnostic criteria, DSM-IV (American Classification) PTSD is classified as an anxiety disorder. In accordance with the criteria of this classification, several necessary conditions are distinguished:

A. Impact on an individual or he has witnessed a traumatic event that includes the threat of death, or serious damage, or a threat to physical integrity. An individual's response should include intense fear, helplessness, or horror.

C. A traumatic event is persistently repeated in experiences, dreams, and memories.

C. Constant avoidance of stimuli associated with trauma, blocking of emotional reactions, numbness.

D. Persistent symptoms of increasing arousal (which were not observed before the injury): sleep disturbance, irritability, outbursts of anger, increased alertness, expectation of a threat.

E. The duration of the disorder (symptoms of criteria B, C, D) is more than 1 month.

F. The disorder causes a clinically significant severe emotional state or disorder in the social, professional, or other important areas of life. (Kaplan G.I., Sadok B.J. Clinical Psychiatry. In 2 vol. T.1 Translated from English. - M .: Medicine, 1994, 672 pp .; Popov Yu.V., View V.D. Modern Clinical Psychiatry. - M.: Expert Bureau - M, 1997. - 496 p .; N. Tarabrina Workshop on the Psychology of Post-Traumatic Stress. - St. Petersburg: Peter, 2001. - 272 p.).

The classification of ICD-10 vaguely presents the clinical signs of chronic PTSD. The syndromological signs necessary for making a psychiatric diagnosis are practically not presented. There is no systematization of clinical signs. The description of the clinical picture is blurry, there are no clinical differences from other neurotic disorders. This makes it difficult for clinicians to diagnose PTSD, they “do not see it,” which in turn affects the results and treatment tactics. In addition, psychologists are engaged in PTSD, but at the same time there are no clear criteria when psychologists should deal with this pathology, and when doctors should. Almost the only criterion used in the diagnosis of PTSD is the etiological factor, i.e. the nature of mental or psychological trauma, namely, catastrophic and emergency events, especially of a mass nature. Clinicians tend to focus on participating in hostilities, staying in a war zone, being held hostage, torture, other physical abuse, sexual abuse. At the same time, doctors and psychologists practically do not take into account when diagnosing PTSD the chronic nature of psycho-injuries, such as difficult financial situation, mentally exhausting people, systematic family quarrels and fights, which can be regarded as psychological and physical violence, as well as sexual violence in families, including incest. Psychiatrists are discussing the possibility of diagnosing PTSD in case of mental trauma caused by the loss of individuals of extraordinary significance (parents, relatives, friends, children, etc.).

The presence of severe mental trauma, which is the cause of mental suffering, is a prerequisite for the diagnosis of PTSD. However, this alone is not enough. At the same time, not all people show signs of PTSD after time, just like in the acute period, after mental trauma, and underestimation of the condition leads to diagnostic inaccuracy and often there is no adequate treatment, which leads to a chronic course of the disorder.

As for the criteria for the diagnosis of PTSD according to the American classification DSM-IV, although the criteria are more clearly defined, the clinical manifestations are also not fully described, they do not systematize the variety of clinical manifestations and syndromological manifestations, moreover, they are described in combination with psychological ones without distinction. This, in turn, leads to multiple descriptions by various authors of psychological signs characteristic of PTSD with multiple mental injuries. And this, in turn, further erodes the clinical picture of the disorder and makes diagnosis difficult.

Both classifications do not distinguish the stages of PTSD and the severity of clinical manifestations; they do not separate the stage of psychological manifestations from clinical ones.

Domestic scientists are also conducting PTSD studies to identify the clinical picture of PTSD and distinguish types of chronic PTSD according to the syndrome prevailing in the clinical picture:

- An alarming type of chronic PTSD;

- dysphoric;

- asthenic;

- somatoform (Voloshin V.M. Post-traumatic stress disorder (clinic, dynamics, course and modern approaches to psychopharmacotherapy): abstract of diss. ... doctor of medical sciences, M., 2004. - 49 p.).

This typology describes the predominance of a particular clinical syndrome in the clinical picture, however, their severity in the overall picture of the disorder is not reflected, does not indicate the dynamics of the development of PTSD, i.e. stages of development, does not illuminate the completeness of the clinical picture, which leads to inaccurate treatment tactics.

The purpose of the invention is to develop a method for diagnosing PTSD, stages of development and highlight diagnostic criteria for the severity and stages of development of chronic PTSD.

The goal is solved due to the fact that, when diagnosing chronic PTSD, generally accepted methodological approaches are used: symptom, syndrome, disease. When constructing a clinical diagnosis, the initial (easily identifiable and unambiguous interpretation by different authors) signs are “symptoms” (K. Jaspers, Collected Works on Psychopathology. 2 vol. T. 1. - St. Petersburg: Academy, 1996. - 350 p. ) Taking into account the patterns of combination of individual symptoms allows us to clearly define the following concept - “syndrome” (Conrad K. Die symptomatischen Psychoses // Psychiatrie der Gegenwart. - Heideberg. 1956. Bd. 2. - S.88-97.), Determination of the patterns of the dynamics of syndromes allows you to unambiguously determine the following category - “disease” (Snezhnevsky A.V. On the nosological specificity of pathological syndromes // Journal of neuropath and psychiatrist named after S.S. Korsakov. - 1960. No. 1. - P.91-108. )

To achieve this goal, a clinical and psychopathological study is conducted by testing the subjects.

1. Identification of the subject’s history of the presence of stressful events, while the stress factor should be considered severe in severity, overly severe or catastrophic; acute or chronic in nature (Kaplan G.I., Sadok B.J. Clinical Psychiatry in 2 vols. T. 1. Per. from English. - M .: Medicine, 1994, 672 p.).

2. If a person has a history of life of one or more severe, or excessively severe, or catastrophic stressful events, or a combination of such stressful events throughout life, acute and / or chronic in nature; the presence of moderate, strong or very strong experiences of acute or chronic mental (s) trauma (s) within a few months or years after or during exposure to mental trauma; the presence of moderate, strong or very strong experiences of acute or chronic mental (s) trauma (s) at the time of examination; and a total score of the Mississippi Scale questionnaire of 70 or more is diagnosed as having PTSD.

3. The duration of stress experience determines the period of PTSD: within 1.5 months, diagnose acute post-traumatic stress disorder; from 1.5 months to 6 months - subacute post-traumatic stress disorder; for 6 months or more - chronic post-traumatic stress disorder.

4. The determination of the level of distress (GSI index according to the “Questionnaire for the severity of psychopathological symptoms (SCL-90-R.)”) Is a criterion for the severity of chronic PTSD: a mild severity of chronic PTSD is diagnosed with a GSI index value of up to 0.63 points; moderate severity of chronic PTSD is diagnosed with a GSI index of 0.64-2.00 points; a severe degree of chronic PTSD is diagnosed with a GSI index value of 2.01 or more points.

6. Moreover, in the presence of chronic PTSD, the clinical stage of PTSD is determined using the “Symptom Check List-90-Revised - SCL-90-R” (Symptom Check List-90-Revised - SCL-90-R) (Tarabrina N.V., 2001) identifying primary - obsessive-compulsive, anxious and psychotism, and secondary - depressive, somatization, phobic, paranoia, clinical syndromes and psychological syndromes - hostility and interpersonal sensitivity, as well as the “Dissociative Experience Scales for identifying dissociative syndrome ; they determine the number of symptoms that make up these syndromes, the frequency and intensity of the manifestations of these symptoms, and also determine the ratio of the manifestations of psychological, primary, secondary and dissociative syndromes, and the stage of initial clinical manifestations - mainly psychological disorders, is diagnosed with a predominance of manifestations of psychological syndromes: hostility and interpersonal sensitivity over clinical, with a constant presence of 1-2 strongly or very strongly expressed nnyh hostility and interpersonal symptoms of sensitive and / or 2-3 of symptoms constituting syndromes hostility and interpersonal senzitivnost which appear sometimes have a weak or moderate severity; upon detection of 1-2 symptoms from each clinical primary syndrome - obsessive-compulsive and anxious, as well as secondary - depressive, somatization and phobic anxiety, mild or severe, often or sometimes, and / or two or three symptoms that make up these the syndromes that appear sometimes, and have a mild or moderate severity; when revealing 1-2 symptoms of psychotism and paranoia, mild or moderate, sometimes appearing, when revealing 1-3 symptoms of dissociative manifestations, which sometimes appear - up to 30% on the “Scale of dissociative manifestations”; neurotic stage - the stage of severe disorders of a nonpsychotic level, diagnosed: with the detection of 3-4 symptoms from each primary clinical - obsessive-compulsive and anxiety syndromes, as well as secondary syndromes - depressive, phobic anxiety and somatization, moderate, severe or very severe, manifested often or constantly, and 2-3 symptoms, from the same syndromes, moderate or severe, which sometimes appear; when 2-3 symptoms are identified - psychotism, paranoia, sometimes or often, the intensity of the manifestations, which are expressed weakly or moderately; upon detection of 3-4 symptoms of dissociative manifestations, which appear sometimes or often - up to 60% on the "scale of dissociative manifestations"; when 3-6 symptoms of psychological syndromes are revealed - hostility and interpersonal sensitivity, moderate or severe, which often appear or are constantly present; the stage of psychotism - the stage of pronounced manifestations of the psychotic level, diagnosed: if more than 4 symptoms of the psychotic level are revealed in the clinical picture: psychotism and paranoia, present constantly or often, moderately, strongly or very strongly expressed; when identifying 7 or more symptoms from each primary syndrome: obsessive-compulsive, anxiety, and from secondary syndromes: somatization, depressive and phobic anxiety, which often appear or are present constantly, moderately, strongly or very strongly expressed; when identifying 5 or more symptoms of dissociative syndrome that appear frequently or constantly - from 30 to 100% on the "Scale of dissociative manifestations"; when identifying 7 or more symptoms from psychological syndromes of hostility and interpersonal sensitivity, which manifest themselves often or constantly, and have a severity from moderate to very strong.

A total of 382 people of both sexes aged 18 to 50 years were voluntarily examined.

Subjects are represented by persons with a history of acute or chronic psycho-traumatic situations of a severe, very severe or catastrophic nature (combat trauma, physical, psychological or sexual violence, including in family conditions, including incest, as well as loss of loved ones, difficult financial situation ) After acute injuries, at least 6 months have passed. Chronic traumatic situations were present in more than half of the subjects.

To achieve the goal of the study and the phased solution of the tasks, the study group selected individuals who had a history of mental stress, which, in accordance with the severity scale, refers to severe, excessively severe and catastrophic (Kaplan G.I., Sadok B.J., Clinical Psychiatry. In 2 vols. T.1 Per. From English. - M .: Medicine, 1994. - 672 p.).

Persons with clinical or psychological signs of PTSD were assigned to the main study group. This group consisted of 258 adults of both sexes, which accounted for 67.7% of the total number of subjects, the average age of 28.47 ± 0.58 years.

Subjects in whom there were no clinical or psychological signs of PTSD were assigned to the control group. This group consisted of 124 people (32.3% of the total number selected in the research group), the average age was 27.36 ± 0.66 years.

Thus, the formation of the main and control groups on the basis of the leading sign - the presence or absence of clinical or psychological signs of PTSD made it possible in the future to build a study on a logical route.

In order to study the structural correspondence of the main and control groups of subjects, their comparison was preliminarily carried out on key grounds: gender, age, and characteristics of social status (marital status).

In the main group, the number of men was 165 people (64.1 ± 3.3%), women - 93, respectively (35.9 ± 3.3%). In the control group of men - 91 people (73.6 ± 3.3%) and 33 women (26.4 ± 3.9%). There were no statistically significant differences in the distribution of the examined main and control groups by gender.

The average age of the subjects in the main group was 28.8 ± 0.6 years, in the control group - 27.6 ± 0.7. No statistically significant differences were found.

A study of the structure of the main and control groups of subjects by marital status showed that persons in marital relations in the main group account for 34.5%, in the control group 42.0%, unmarried: 65.6% of people from the main group and 58.0% - from the control. There were no statistically significant differences between the groups. The predominance in both groups of unmarried persons is due to the characteristics of the sample.

Thus, a comparison of the subjects of the main and control groups according to formal characteristics (gender, age, education) revealed their structural identity, which indicates the representativeness and comparability of the sample populations, as well as the opportunity to obtain reliable results.

In addition to a clinical study, all subjects underwent an experimental psychological examination in order to obtain quantitative indicators of clinical and psychological characteristics. The main search criteria for an experimental psychological study was to identify the presence of PTSD according to the Mississippi scale (MS) and the level of distress, its quantitative assessment, as well as the quantitative indicators of a number of clinical syndromes according to the “Questionnaire for the severity of psychopathological symptoms” (OVPS) (Tarabrina N.V. Workshop on psychology of post-traumatic stress. - SPb .: Peter, 2001. - 272 p.) to identify patterns of clinical manifestations in chronic PTSD.

In accordance with the test results obtained, the subjects at the first stage were grouped into two subgroups - “sick with PTSD” and “healthy”, based on the quantitative indicator of the Mississippi scale - “total points”, allowing us to conclude “healthy” / “PTSD” (up to 70 points - “healthy”, 70 and more - “PTSD”).

The obtained data of a quantitative indicator and conclusions about the presence or absence of PTSD according to the "Missippian scale" were compared with the results of a clinical examination of the subjects. As expected, patients with clinical or psychological signs of PTSD and assigned to the main research group had a conclusion on the "Mississippi scale" "sick with PTSD", their rates were 70 or more points. The subjects of the control group had indicators less than 70 points and naturally had a conclusion on the "Mississippi scale" - "healthy."

In order to identify the possibility of reasonably comparing data on various questionnaires and scales, a statistical study was conducted aimed at identifying the relationship between the test results of the subjects according to the “Psychopathological Symptoms Severity Questionnaire” (SIA), “The scale for assessing the severity of a traumatic event” (SHOVTS) and “ Mississippi Scale ”(MS). For this, we used the methodology for determining the correlative relationships of indicators. Pearson's correlation coefficients were calculated for the total score of the Mississippi scale with the scales of the OVPS and ShOVTS questionnaires for all subjects in the aggregate, as well as separately for individuals of the main and control groups.

An analysis of the data showed that the greatest strength of the correlative relationship was found in the group of subjects of the main group. They have an indicator of the total score on the Mississippi scale that has a direct correlation with the indicators of all scales of clinical syndromes and the GSI index (level of distress) for AFPS, as well as the SHOV indices (IN - symptoms of intrusion, AV - symptoms of avoidance, AR - symptoms of physiological arousal) . SHOVTS indicators meet the diagnostic criteria for DSM-IV. Thus, it was revealed that the data on PVPP and SHOVTS are dependent, which means that they can be compared.

A similar picture is revealed when considering the described relationships among all subjects, however, lower numerical values of the Pearson correlation coefficient are observed, which are provided mainly by the subjects of the main group, since in individuals of the control group the numerical values of the coefficients are several times smaller, which indicates the absence relationship.

Thus, we can conclude that the analyzed relationship in the main group of subjects exists. This allowed for further research.

The basis for an objective study of the patterns of diagnosis of the clinical picture of PTSD depending on the symptomatic manifestations accepted in psychiatry, the identification of patterns of development of the clinical picture and the development of a clinical model of chronic PTSD was the “Questionnaire for the severity of psychopathological symptoms” (OVPS). The initial analysis involved indices of seven scales of the questionnaire, which determine the severity in the quantitative assessment of the corresponding clinical syndromes: SOM (somatization), OS (obsessive-compulsive), DEP (depressive), ANX (anxious), RNOV (phobic anxiety), PAR (paranoid) , PSY (psychotism).

To identify the presence of a clinical picture in subjects who showed clinical or psychological signs of PTSD, a comparison was made of the significance of differences in the values of each scale in the main and control groups in terms of the “sick” / “healthy” conclusions and in comparison with the average values calculated for the indices ( table 1).

Table 1 The average values of the indices of the scales of clinical syndromes in the subjects of the main and control groups Study groups Som OS DEP Anx RNOV PAR Psy Control group 0.45 0.50 0.46 0.41 0.21 0.39 0.20 Main group 1,03 1.06 1.05 1.05 0.58 0.81 0.68 P _main-counter (SOM; OS; DEP; ANX; RHOV; PAR; PSY) <0.05

Student's test was used as a method for comparing the significance of differences. The comparison results revealed a significant difference between the quantitative indicators in the main and control groups, both the average indices of the syndrome indices and the ratios of the “sick” / “healthy” conclusions on each scale with a 95% probability of an error-free forecast. This allows us to make a reasonable conclusion about the presence of a certain syndromological clinical picture in chronic PTSD, which significantly differs from the clinical status of subjects without PTSD. The revealed differences between the main and control groups of subjects are manifested on each investigated clinical syndromological scale. The quantitative indices when comparing the clinical AFRP scales in the main group are more than 2 times higher than the similar values in the control group. In addition, the indicators of all clinical scales in the main group are above the average normal level, while in the control group they are within the normal range.

Thus, the predominance of the severity of clinical syndromes in subjects suffering from chronic PTSD, compared with persons in the control group, allows us to conclude that there is a certain pattern of symptoms, which makes it worthwhile to conduct further research aimed at finding these patterns in the clinical picture of PTSD.

To determine the leading (primary) clinical syndromes, at the first stage, an attempt was made to study the dynamics of indicators of various syndromological scales (OVPS) and the presence of interdependence between the syndromes.

It turned out that there is a direct high correlation dependence between the studied clinical scales (table 2).

table 2 The values of the Pearson correlation coefficient between clinical scales (OVPS) Syndromes Som OS DEP Anx RNOV PAR Psy SOM (somatization) one 0.781 (**) 0.771 (**) 0.842 (**) 0.678 (**) 0.642 (**) 0.713 (**) OS (obsessive-compulsive) 0.781 (**) one 0.875 (**) 0.905 (**) 0.797 (**) 0.771 (**) 0.813 (**) DEP (depressive) 0.771 (**) 0.875 (**) one 0.890 (**) 0.796 (**) 0.749 (**) 0.831 (**) ANX (disturbing) 0.842 (**) 0.905 (**) 0.890 (**) one 0.810 (**) 0.725 (**) 0.827 (**) RNOV (phobic anxiety) 0.678 (**) 0.797 (**) 0.796 (**) 0.810 (**) one 0.662 (**) 0.745 (**) PAR (paranoid) 0.642 (**) 0.771 (**) 0.749 (**) 0.725 (**) 0.662 (**) one 0.785 (**) PSY (Psychotism) 0.713 (**) 0.813 (**) 0.831 (**) 0.827 (**) 0.745 (**) 0.785 (**) one ** - p <0.01

Such a high degree of correlation indicates the synchronous dynamics of clinical scales. With an increase in the numerical values of any of the clinical scales, the numerical values of all the others increase simultaneously. Thus, chronic PTSD is a polysyndromic disease with a mosaic clinical picture. The same fact is graphically illustrated in figure 1.

As can be seen from figure 1, the values of the indices of the scales of clinical syndromes increase almost simultaneously with small fluctuations in the greater or lesser side, while the paranoia syndrome (PAR) and psychotism (PSY) are subject to the greatest fluctuation.

This fact causes in practice certain difficulties in isolating clinical syndromes that are of some leading importance, and, consequently, isolating clinical variants of PTSD. Therefore, in this situation, it has become advisable to use such non-trivial statistical approaches and methods as neural network modeling. The indisputable advantage of artificial neural networks is their ability to detect in the system and successfully model such forms of interconnections that are not available with a simple analytical study or using familiar, common statistical methods.

The goal of constructing a neural network model was to identify clinical syndromes that are leading, primary in the clinical picture of chronic PTSD. Since the analysis of quantitative indicators of the scales of clinical syndromes in the subjects was carried out using the OVPS questionnaire, the resulting GSI index (level of distress) can be used as a general expression of the clinical picture. In this sense, the task is to isolate such clinical syndromes (according to the numerical value of the scales) that would uniquely determine the formation of distress (determined by the value of the GSI index), i.e. primary in the formation of the clinical picture of PTSD is the removal of those syndromes that would secondarily determine the clinical picture of the disorder (they do not determine changes in the index scale of the clinical syndrome). Thus, the input parameters for the artificial neural network were the values of the indices of the scales of clinical syndromes, and the output parameter predicted in the model under construction was the GSI index (level of distress).

The results of the analysis of the neural network showed that according to the model, the clinical picture of chronic PTSD is determined by the three leading syndromes PSY (psychotism), OS (obsessive-compulsive), ANX (anxious).

Thus, according to the constructed neural network model for the development and dynamics of PTSD, the following syndromes are of key importance (listed in decreasing order of importance): psychotism (PSY), obsessive-compulsive (OS), anxious (ANX). Therefore, in the clinical picture of chronic PTSD, there is reason to single out the following leading primary syndromes that determine the development of the clinical picture and prognosis: psychotism syndrome, obsessive-compulsive and anxious. The remaining syndromes are secondary and have no decisive significance in the clinical diagnosis of PTSD. They have an effect on the level of distress.

At the next stage, various degrees of severity of PTSD were distinguished based on the varying severity of clinical syndromes. For this, the main group of subjects in the amount of 219 observation units was separately studied. All patients assigned to this group had clinical and psychological signs of PTSD and, according to the results of testing according to the Mississippian scale questionnaire, had the conclusion “PTSD is sick”.

Based on the level of distress (GSI index) according to the “Questionnaire for the severity of psychopathological symptoms”, three subgroups were identified, the average indices of which were significantly different. In subgroup 1, the indicator of the level of distress corresponded to numbers up to 0.63 points. The severity of PTSD in these individuals was defined as mild. In individuals with indicators of the level of distress in the range from 0.64 to 2.00, PTSD of moderate severity was diagnosed. Persons with indicators of distress levels in the range of 2.01 were diagnosed with severe PTSD.

The visual image shows that with various degrees of severity of chronic PTSD, the intensity of the manifestation of clinical syndromes is different, having a tendency to increase with increasing severity of chronic PTSD (figure 2).

The statistical method of analysis of variance revealed the presence of significant differences in the average values of the indices of all scales of clinical syndromes when comparing mild and moderate, moderate and severe, mild and severe severity of chronic PTSD (p <0.01), which indicates the validity of the separation of subjects suffering from chronic PTSD, into subgroups with varying degrees of severity of the disorder based on varying degrees of severity of the level of distress and the severity of the manifestation of clinical syndromes.

The next step in the study of the clinical manifestations of PTSD was the determination of the mutual relationship of the syndromes from the position of classification, the determination of the stages of development of chronic PTSD. For this purpose, quantitative indicators of the scales of clinical syndromes of each subgroup were subjected to cluster analysis by the method of tree clustering. At the same time, clustering was not carried out under observation units, but significant signs (scales of clinical syndromes). That is, the closeness of the values of the clinical scales in multidimensional space was established. As a result of the study, in each subgroup of chronic PTSD, their own clustering of syndromes was found. For the clinical diagnosis of chronic PTSD, the presence of three leading (primary) syndromes of obsessive-compulsive, anxiety and psychotism is necessary, while the presence of signs of psychotism syndrome is the main in importance, then obsessive-compulsive and then anxiety syndromes; and secondary syndromes (depressive, somatization, phobic, paranoid). Diagnosis of the stages of development of chronic PTSD is determined by a certain manifestation of the leading primary syndromes and their combination with secondary syndromes, as well as their intensity.

Thus, patterns of manifestation of clinical symptoms were identified, determined by a combination of primary and secondary syndromes, as well as the intensity of their manifestations.

In addition, an analysis of dissociative symptoms was performed. For this purpose, the “Scale” of “dissociation” was used. The test results of the subjects are presented in the form of a final quantitative indicator and its assessment in the form of a conclusion: “healthy,” to dissociations (Tables 3, 4).

Comparison of the degree of severity of dissociation between the subjects of the main and control groups showed more than 3 times higher level of the indicator in the subjects of the main group (suffering from PTSD).

Table 3 The average level of dissociation in individuals of selected subgroups Subgroups Dissociation rate n M m Healthy 24 2.6 0.6 Risk subgroup 52 3,5 0.5 Mild PTSD 71 5.5 1,1 PTSD of moderate severity 85 14,4 1,5 Severe PTSD 21 26.3 4.1 p (PTSD, I st. - PTSD. II st.) <0.05; p (PTSD. II s.p. - PTSD. III s.t.) <0.05 where M is the average, m is the average error

Table 4 The distribution of subjects according to the presence of signs of dissociation into subgroups Subgroups The presence of dissociation Is healthy Dissociation Healthy n 24 0 % one hundred 0 m 0 0 Risk subgroup n 52 0 % one hundred 0 m 0 0 Mild PTSD n 69 2 % 97.2 2,8 m 2.0 2.0 PTSD of moderate severity n 72 13 % 84.7 15.3 m 3.9 3.9 Severe PTSD n fourteen 7 % 66.7 33.3 m 7.9 7.9

Differences in the level of dissociation in the tested subgroups: healthy, risk group and mild PTSD have no significant difference. When comparing the level of dissociation in individuals suffering from PTSD with varying degrees of severity, a statistically significant increase in dissociation rates with increasing severity of the disease was found.

In the control group: a subgroup of healthy and risk subjects with dissociative symptoms were not detected. In the subgroup of individuals suffering from mild PTSD, the smallest percentage of subjects with dissociative disorders is detected - only 2.8%. With an increase in the severity of chronic PTSD, the number of persons with dissociation increases: with PTSD of moderate severity 15.3%, with severe - 33.3%, respectively. Thus, the level of dissociative symptoms is significantly higher in the subgroups of patients suffering from PTSD, and tends to increase with increasing severity of the disorder and is one of the clinical signs of chronic PTSD.

In general, an analysis of the dynamics of the indicators according to the “Questionnaire for the severity of psychopathological symptoms” and the “Scale for assessing the impact of traumatic events (which corresponds to the diagnosis of PTSD according to the DSM-IV criteria — identifying syndromes of intrusion, avoidance, and physiological arousal) of the subjects of various subgroups showed the following picture of clinical and dynamic patterns of development chronic PTSD.

1. The ratio of clinical and psychological syndromes is different depending on the clinical stage of the disorder.

3. Symptoms of the primary syndromes of obsessive-compulsive and anxious are detected in all clinical stages, but their severity increases with neurotic and psychotic. Signs of psychotism at the stage of initial manifestations are practically absent or weakly expressed.

4. The multiplicity of the increase in numerical values in the psychotic stage is dominated by indicators of the primary syndrome of psychotism and secondary paranoia and phobic anxiety, as well as psychological - hostility.

5. At the stage of initial manifestations of chronic PTSD, physiological arousal syndrome predominates.

6. At the neurotic stage of chronic PTSD, indicators of the syndromes of invasion, avoidance and physiological arousal are almost equal.

7. At the psychotic stage of chronic PTSD, indicators of invasion and avoidance syndromes prevail over the indicator of physiological arousal.

In addition, an analysis of dissociative manifestations in subgroups was carried out.

To measure quantitative indicators and analysis of dissociative symptoms, the "Scale of dissociative manifestations" was used. The test results of the examined on this questionnaire are presented in the form of one final quantitative indicator and its assessment in the form of a conclusion: “healthy”, “dissociation”.

A distinctive criterion for the symptoms of dissociative manifestations during the psychological stage of PTSD is that these signs appear sometimes. Among the signs of dissociation, dissociative amnesia is more common, for example, recognition of victims by other people, while they themselves do not recognize these people and consider them unfamiliar, do not greet them (false recognition). They learn about this from friends themselves, relatives, acquaintances. In addition, among the predominant symptoms, derealization is detected - they will not recognize a previously familiar place. It is perceived as first seen. These people are immersed in the experiences of television films so deeply that they do not notice what is happening around them, detaching themselves from the surrounding reality. At the same time, they perceive their dreams and fantasies as reality; they can sit staring into space, not thinking about anything, and losing control of time. These individuals may experience a sharp change in activity, expressed in the fact that suddenly they easily do what was previously possible with great effort. Sometimes psychogenic amnestic manifestations are revealed when they do not remember how they performed this or that act. They behave differently in the same situations, unpredictable, inconsistent, as if they were two different people. Experiences of events from the past are revealed, including traumatic ones, as if this is happening now (flashback), which are observed in almost half of the subjects of this subgroup, but this rarely happens (most people estimate the flashback frequency at 10% of one hundred%). The perception of a dream as a reality and the realization that the individual, being in his experiences, did not hear what he is told from the outside, is also one of the most intensely experienced symptoms in these individuals. Such manifestations in them are associated, as a rule, with the experience of past emotionally significant traumatic events, or current events in which there is any resemblance to an earlier event. This may be the name of the offender, intonation, punishment, etc., most often, the analogy is “turned on” through the emotional memory of past events. Subjects sometimes indicate that their body does not belong to them.

In chronic PTSD of the neurotic stage, the symptoms described above are almost the same, but their severity and frequency of manifestations are much higher and more frequent. In addition to the symptoms of derealization, when immersed in experiences that become more obvious (they experience a sense of unreality of surrounding people and objects), they have more pronounced symptoms of depersonalization (sometimes they do not recognize themselves in the mirror, as if they are observing themselves from the outside), as well as psychogenic amnesia , they more often forget some important events from their life. Flashbacks are marked by a greater number of faces and more pronounced (some up to 100% intensity, i.e. almost always when recalling past events). Many individuals in this subgroup indicate that they do not notice physical pain.

In the subgroup of people suffering from chronic PTSD of the psychotic stage, practically all of these or those manifestations of dissociation are detected. Most often these are flashbacks, as well as signs of derealization, depersonalization, psychogenic amnesia. The severity and frequency of manifestations is high. They have longer and more often (on average from 30-60 to 100%) dissociative symptoms. It is noteworthy that the "inclusion" in the experience they have is not only and not so much emotional as the state that they perceive as "normal." According to them, they are constantly in memories, practically cannot forget the fact of traumatic events, and only episodes of memories from various events are replaced. Therefore, dissociative symptomatology manifests itself more often, longer and more persistent. Symptoms are manifested situationally, either when monotonous labor is performed, or when riding in public transport or under other similar circumstances that contribute to immersion in a trance state, a state of altered consciousness (narrowing), immersion in oneself.

Thus, as a result of clinical observations and the obtained data, the stages of development of chronic PTSD were identified.

The stage of initial clinical manifestations - mainly psychological disorders, is diagnosed: when the severity of manifestations of psychological syndromes: hostility and interpersonal sensitivity over clinical prevails, while the constant presence of 1-2 very or very strong symptoms of hostility and interpersonal sensitivity and / or 2-3 symptoms is detected constituting hostility and interpersonal sensitivity syndromes, which sometimes manifest and have mild or moderate severity; upon detection of 1-2 symptoms from each clinical primary syndrome - obsessive-compulsive and anxious, as well as secondary - depressive, somatization and phobic anxiety, mild or severe, often or sometimes, and / or two or three symptoms that make up these the syndromes that appear sometimes, and have a mild or moderate severity; with the detection of 1-2 symptoms of psychotism and paranoia, mild or moderate, sometimes appearing, with the detection of 1-3 symptoms of dissociative manifestations, which sometimes appear - up to 30% on the “Scale of dissociative manifestations”.

Neurotic stage - the stage of severe disorders of a nonpsychotic level, diagnosed: with the detection of 3-4 symptoms from each primary clinical - obsessive-compulsive and anxiety syndromes, as well as secondary syndromes - depressive, phobic anxiety and somatization, moderate, severe or very severe, manifested often or constantly, and 2-3 symptoms, from the same syndromes, moderate or severe, which sometimes appear; when 2-3 symptoms are identified - psychotism, paranoia, sometimes or often, the intensity of the manifestations, which are expressed weakly or moderately; upon detection of 3-4 symptoms of dissociative manifestations, which appear sometimes or often - up to 60% on the "scale of dissociative manifestations"; with the detection of 3-6 symptoms of psychological syndromes - hostility and interpersonal sensitivity, moderate or severe, which often appear or are constantly present.

The stage of psychotism is the stage of pronounced manifestations of the psychotic level, it is diagnosed: when more than 4 symptoms of the psychotic level are revealed in the clinical picture: psychotism and paranoia, present constantly or often, moderately, strongly or very strongly expressed; when identifying 7 or more symptoms from each primary syndrome: obsessive-compulsive, anxiety, and from secondary syndromes: somatization, depressive and phobic anxiety, which often appear or are constantly, moderately, strongly or very strongly expressed; when identifying 5 or more symptoms of dissociative syndrome that appear frequently or constantly - from 30 to 100% on the "Scale of dissociative manifestations"; when identifying 7 or more symptoms from psychological syndromes of hostility and interpersonal sensitivity, which manifest themselves often or constantly, and have a severity from moderate to very strong.

Clinical examples.

Clinical example 1.

Patient 23 years old, student. She complained of easily arising irritability, restless, anxious sleep, sometimes nightmares, chest pains, lumps in the throat, excessive anxiety for various reasons, short temper, vulnerability, restlessness, she felt worthless, sometimes felt guilty, often “scrolled” past traumatic events in the head. This condition has been noted since his youth, which is gradually increasing, especially after another quarrel.

She was born full-term, childbirth without complications, the first child in the family. A history of chronic psycho-traumatic situation from 7 years old, associated with family relationships, first in the parental family, and then in his own, was revealed. Parents divorced when she was 4 years old. Mother remarried. Relations with the stepfather were difficult. The family systematically clashed, including in its presence, experienced a state of psychological humiliation, helplessness, and fear. With 10 years, a feeling of loneliness. In adolescence, her stepfather repeatedly tried to persuade her to have sexual relations. I was afraid to say mother. The experiences were strong, still remain. He has been married for 3 years, but the relationship does not work out, constant quarrels, insults, psychological humiliation on the part of her husband. When quarreling screams, throws things. The financial situation is difficult. Combines study with work. He does not see the prospects of marriage; he is very worried about this, afraid that he will be left alone.

In somatic and neurological status without features. No somatic pathology was detected. In the mental status: the consciousness is clear, the position is active, tidy, he comes into contact willingly, deceptions of perception are not revealed. She notes that sometimes there is a feeling that other people sometimes penetrate her thoughts, do not understand her, do not sympathize with her, underestimate her. Incredulity to some people. Consistent thinking, hasty speech, verbose. The emotional background is reduced, restless, sometimes loses the thread of conversation. Emotionally unstable, easily affected. She notes that periodically there are memories of the quarrels that have occurred, she does not feel the joy of life, does not experience sexual satisfaction, does not see future prospects in family relationships, and has difficulty making decisions. The memory is saved, attention is sometimes scattered. Self-esteem is low. Criticism saved.

The total score on the "Mississippi scale" is 80. The indicator of the level of distress on the "Questionnaire for the severity of psychopathological symptoms" was 0.49 points. Dissociative manifestations on the “Dissociation Scale” averaged 25%.

Case analysis. The patient has been diagnosed for several decades (since childhood) with a chronic traumatic situation that can be attributed to psychological violence, which can be attributed to severe chronic mental trauma. And also experienced several attempts at rape. This acute stress is recurring, which can also be attributed to chronic, very severe. He has been experiencing strong feelings over the years for past and ongoing events. Experiences last more than 6 months.

The clinical picture is polymorphic, 1-2 symptoms of primary syndromes are revealed - obsessive-compulsive, anxious, psychotism syndrome. 1-2 symptoms of secondary syndromes are also determined - depressive, somatization, paranoia, and also dissociation. Signs of hostility and interpersonal sensitivity were revealed, as well as 2 symptoms of dissociation (severity - 25%).

The Mississippi scale research findings are consistent with the post-traumatic stress disorder conclusion. An indicator of the level of distress indicates PTSD of mild severity. The clinical picture corresponds to the initial stage of chronic PTSD.

Conclusion: chronic PTSD of mild severity, stage of initial clinical manifestations.

Clinical example 2.

A sick man, 28 years old, complained of severe outbreaks of anger, irritability, constant nervousness, difficulty falling asleep, restless anxious sleep. This condition over the years. It cannot cope on its own. From the anamnesis it is known that, being in military service in the army, he was sent to the Chechen Republic to participate in the anti-terrorist operation, where he stayed for 6 months, in addition, there were lengthy and repeated hospitalizations associated with a leg wound.

He got into battle on the second day of his stay in Chechnya. The column of troops was defeated by the militants, it was necessary to pick up the wounded, but the car was blown up, there were many wounded, burned alive. He experienced fear, accompanied by chills. Such feelings appear when recollecting events. Then there were many interrogations by the generals. It was also scary for its fate, "shaking." I had to see the death of many colleagues, experienced anger, which remains to this day. There are nightmares. I tried to take drugs, but as it did not get any easier, I refused. He began to take alcohol, but became more aggressive, so he did not abuse too. Upon returning from Chechnya, a state of depression appeared, then aggression, sleep was disturbed and still has not recovered. Nightmares began to constantly dream, at this time a little less. I wanted to return to Chechnya, to the war, because he didn’t understand those around him, he didn’t want to live, haunted by obsessive memories. In a company in a state of intoxication and aggression, he killed a man who attacked a friend with a knife and wounded him. I served 3 years. Relatives turned away, trying not to tell anyone about it. He is not proud of the fact that he served in Chechnya, since, in his opinion, people have a bad attitude towards those who were at war.

He was born in the family as the eldest among three children. Mother is a livestock breeding leader. Father handyman on a state farm. Parents often quarreled and divorced. When the patient was 15 years old, the marriage broke up completely. He attended kindergarten as a child, went to school at the age of 7, graduated from 10 classes. In childhood, often played "in the war." He loved to watch films about our service of our guys in Afghanistan, dreamed of getting to war, wanted to be a military man. After leaving school I learned to be a driver. He moved to the city where he worked before the army.

He currently works as a driller at a metallurgical plant, married, has a son of 2.5 years.

In somatic and neurological status without features.

In mental status: clear consciousness, active, neat position. He comes into contact not quite willingly, tense, deception of perception is not detected. Consistent thinking. The emotional background is reduced, emotionally unstable, restless, restless, easily affected. The memory is retained, although sometimes it is difficult to remember anything. Criticism saved.

The patient notes very strong outbursts of anger, which he can not restrain, screaming, throwing things. A very strong feeling that others do not understand him and do not sympathize with him. At the same time, the feeling is that if he trusts other people, they will abuse his trust. The feeling that others are talking or watching him. A strong sense of awkwardness when they talk about him or look at him. Sometimes the feeling that he is watching himself from the side. Thoughts that not everything is in order with his body and with reason. Frequent feeling of nausea, bouts of chills. Severe nervousness if left alone. Difficulty falling asleep, restless, anxious sleep. Having difficulty making a decision. Frequently recurring obsessive thoughts. Experiencing severe difficulty in breathing, tingling in various parts of the body, lumps in the throat, heart palpitations. Difficulty concentrating, tension, over-alertness, increased emotional sensitivity, excessive anxiety. Guilt. Considers himself worse than others. Self-esteem is low.

A number of symptoms sometimes appear, in particular, a feeling of discontent with other people, thoughts of suicide, a feeling of being trapped, an unexpected, causeless fear, a depressed mood, a feeling of loneliness, even if surrounded by people. He notes that periodically there is no interest in anything. Sometimes there is a feeling that someone else’s thoughts are in the head. Sometimes he experiences impulses to harm someone, a sense of awkwardness when it is necessary to eat with people. Occasionally, thoughts come that he should be punished for sins.

The total score on the "Mississippi scale" is 80, which corresponds to the conclusion - sick with PTSD. The level of distress according to the “Questionnaire for the severity of psychopathological symptoms” is 1.61, which indicates a moderate severity. Identified 2 symptoms of dissociation are very pronounced and 2 symptoms are moderate.

Case analysis. The patient has a history of both acute and chronic psycho-traumatic situations: both severe (difficult family situation, divorce of parents), and very severe (loss of friends, fellow soldiers, trial, serving a sentence), and catastrophic (war, participation in hostilities ) The experiences are strong. More than 6 months have passed since the events, which corresponds to chronic PTSD.

In the clinical picture, polymorphic symptoms are detected. Many symptoms of a non-psychotic level: moderately severe obsessive-compulsive and anxiety syndromes, as well as depressive, somatization. Symptoms are very pronounced, often appear, some constantly. Symptoms of psychotism, paranoia, phobic syndromes appear sometimes, are not constant, but are present distinctly. Dissociative disorders are mild, but present. Pronounced aggressiveness, hostility, interpersonal sensitivity. This clinical picture corresponds to the chronic PTSD of the neurotic (nonpsychotic) stage.

Given that the level of distress corresponds to moderate severity, the final conclusion is: chronic PTSD of moderate severity of a nonpsychotic stage.

Clinical example 3.

Patient K., 27 years old, male. He works as a communications electrician at OJSC Electrosvyaz.

Complaints of headaches, anxiety, fear, digestive upset (frequent stools), irritability, anger.

He participated in the anti-terrorist campaign in Chechnya twice - 6 years ago during military service and 2 years ago as a volunteer. During the war he was repeatedly in the area of explosions, direct military operations. After demobilization, after 6 months, fears and feelings of anxiety appeared, mood decreased, sleep was disturbed, dreams of military content appeared.

He was born the third child in a large family (6 children). Father works as a communications electrician, mother is a milkmaid. There were no complications in childbirth. The financial situation was insufficient due to the low remuneration of parents. Father sometimes abused alcohol, which became the reason for quarrels between parents. They kept their household. I went to school from the age of 7. The teenage period passed without conflict. He graduated from 11 classes. I learned to be a driver. I could not get another profession due to material difficulties. 2 years ago father died. Alcohol is used sparingly, sometimes there are periods of abuse. Married, has a son of 6 years, and also raises his wife’s child.

In the somatic and neurological status, pathology was not detected. Mental status. The consciousness is clear, the position is active. Oriented correctly in the location, time, his personality. Reluctantly enters into conversation, No deception of perception is revealed, consistent thinking. The mood is suppressed, restless, restless, indicates a lack of interest in anything, perceives the future as hopeless, often thoughts of death, expectation, anxiety that something bad happens to him are frequent. Sometimes people think that they should be punished for their sins. He experiences a strong sense of fear, often there are bouts of panic, especially manifested in interpersonal relationships, to say something wrong, look ridiculous. Avoids places that cause fear, including communication. Overly shy in communication, tense. It notes a feeling of distraction. Considers himself worse than others, often there is a feeling of worthlessness. It is believed that people are unfriendly to him. He believes that people cannot be trusted, that people underestimate him. He experiences a feeling of loneliness, even if he is in society. Sometimes he does not feel close to anyone. At the same time, notes that, if left alone, nervousness intensifies. Hot-tempered, emotionally unstable, easily affected, there is a desire to destroy, break something. Notes sleep disturbance, nightmares. Often there is trembling in the body, bouts of heat or chills, weakness, often there is a feeling of loss of strength. Often there are thoughts that not everything is in order with the mind and body. Rarely in the head he hears voices that other people do not hear. Often feels guilty. Almost constantly recalls past events. The head is constantly obsessive thoughts. Re-checks several times, what he does is experiencing difficulties in making decisions, doubts. Sometimes there is a desire to repeat the same actions.

She doesn’t tell anyone about her memories and experiences. Often notes that in a conversation he does not listen, what they say to him and then does not remember, just as he sometimes does not remember where this or that thing came from. Sometimes she doesn’t recognize people who claim to know him. It happens that he forgets some important events from his life, date. Often there is a feeling of unreality of the world. Also often there is a feeling that the world around us perceives through fog, and objects and people seem distant. Often, memories of past events are experienced as if they were happening in the present. Often alone talks to himself. Often he cannot remember whether he really did something or just wanted to do. The total score on the Mississippi scale was 96 points, indicating the presence of PTSD. The level of distress (GSI index) was 2.47 points, which corresponds to a severe degree of PTSD. A lot of symptoms (over 7) of manifestations of dissociation were revealed according to the “Scale of dissociative manifestations” - some of them are very pronounced up to 80-90%, some moderately 40-50%, some weakly up to 10%. The depression rate in the Beck Depression Questionnaire is 31, which corresponds to “overt depression”.

Case analysis. The patient has a history of both acute and chronic psycho-traumatic situations: catastrophic (war, participation in hostilities), and very severe (loss of friends, fellow soldiers), and severe (chronically difficult financial situation, father’s death). The experiences are strong, mainly related to staying at war, the loss of people. More than 6 months have passed since the events, which corresponds to chronic PTSD.

In the clinical picture, polymorphic symptoms are detected. A large number of symptoms of primary syndromes: severe obsessive-compulsive and anxiety syndromes, as well as secondary: depressive, somatization. Symptoms are present constantly or frequently, some sometimes. The phobic syndrome, as well as the syndromes of psychotism and paranoia are clearly revealed. The intensity of the symptoms is severe and some very strong, are present constantly or often. Dissociative disorders are also pronounced. Hostility, interpersonal sensitivity is revealed.

The clinical picture clearly reveals signs of syndromes of psychotism and paranoia, as well as phobic. Their apparent presence indicates that the criteria correspond to the chronic PTSD of the psychotic stage of development. Signs of impaired adaptation in this patient are not detected. Given that the level of distress corresponds to a severe PTSD, the final conclusion is: chronic severe PTSD, a psychotic stage.

Thus, the identified patterns of diagnosis of PTSD contribute to a more accurate clinical diagnosis of the disorder in people who have experienced stressful events, and will also focus on people's suffering in chronic mental injuries. A differentiated approach to diagnosing the stages of development and severity of PTSD allows for differentiated approaches to the treatment and rehabilitation of victims. At each stage of development, as can be seen from the clinical picture, appropriate approaches to pharmacotherapy and psychotherapy of PTSD are necessary. This will help to improve the results of treatment and rehabilitation, as well as the prognosis.

Claims (4)

1. A method for diagnosing post-traumatic stress disorder (PTSD), which consists in identifying a life history of a stressful event, emotional trauma, characterized in that it additionally determines the number of points according to the Mississippian scale questionnaire and when an individual has one or more severe history of life, or an excessively severe or catastrophic stressful event, or a combination of such stressful events throughout life, acute and / or chronic in nature; the presence of moderate, strong or very strong experiences of acute or chronic mental (s) trauma (s) within a few months or years after or during exposure to mental trauma; the presence of moderate, strong or very strong experiences of acute or chronic mental (s) trauma (s) at the time of examination; and a total score of the Mississippi Scale questionnaire of 70 or more diagnoses the presence of PTSD. 2. The method according to claim 1, characterized in that in the presence of PTSD, determine the period of its course by determining the duration of the period of experiences associated with a severe, very severe, or catastrophic stressful event, acute and / or chronic, or their combination, during whom these experiences appear, and with the duration of the period of experiences: for 1.5 months, they diagnose acute post-traumatic stress disorder; from 1.5 to 6 months - subacute post-traumatic stress disorder; for 6 months or more - chronic post-traumatic stress disorder. 3. The method according to claim 2, characterized in that when detecting chronic PTSD, its severity is determined by detecting the level of distress by the numerical value of the GSI index calculated using the "Psychopathological Symptoms Severity Questionnaire (SCL-90-R)", wherein: the severity of chronic PTSD is diagnosed with a GSI index value of up to 0.63 points; moderate severity of chronic PTSD is diagnosed with a GSI index of 0.64-2.00 points; a severe degree of chronic PTSD is diagnosed with a GSI index value of 2.01 or more points. 4. The method according to claim 2, characterized in that in the presence of chronic PTSD, the clinical stage of PTSD is determined using the “Psychopathological Symptoms Severity Questionnaire - SCL-90-R” to identify primary - obsessive-compulsive, anxious and psychotism, and secondary - depressive somatization, phobic, paranoid clinical syndromes, and psychological syndromes - hostility and interpersonal sensitivity, as well as the “Dissociative Experience Scale” for identifying dissociative syndrome; determine the number of symptoms that make up these syndromes, the frequency and intensity of the manifestations of symptoms, and also determine the ratio of the manifestations of psychological, primary, secondary and dissociative syndromes, and the stage of initial clinical manifestations - mainly psychological disorders, is diagnosed with a predominance of manifestations of psychological syndromes: hostility and interpersonal sensitivities over clinical, with a constant presence of 1-2 strongly or very strongly expressed symptoms of hostility and interpersonal sensitivity and / or 2-3 symptoms of hostility and interpersonal sensitivity, which sometimes appear and have mild or moderate severity; upon detection of 1-2 symptoms from each clinical primary syndrome - obsessive-compulsive and anxious, as well as secondary - depressive, somatization and phobic anxiety, mild or severe, often or sometimes, and / or two or three symptoms that make up these the syndromes that appear sometimes, and have a mild or moderate severity; when revealing 1-2 symptoms of psychotism and paranoia, mild or moderate, sometimes appearing, when revealing 1-3 symptoms of dissociative manifestations, which sometimes appear - up to 30% on the “Scale of dissociative manifestations”; neurotic stage - the stage of severe disorders of a nonpsychotic level, diagnosed: with the detection of 3-4 symptoms from each primary clinical - obsessive-compulsive and anxiety syndromes, as well as secondary syndromes - depressive, phobic anxiety and somatization, moderate, very or very severe, manifested often or constantly, and 2-3 symptoms from the same syndromes, moderately or severely expressed, which sometimes appear; when 2-3 symptoms are identified - psychotism, paranoia, sometimes or often, the intensity of the manifestations, which are expressed weakly or moderately; upon detection of 3-4 symptoms of dissociative manifestations, which appear sometimes or often - up to 60% on the "scale of dissociative manifestations"; when 3-6 symptoms of psychological syndromes are revealed - hostility and interpersonal sensitivity, moderate or severe, which often appear or are constantly present; the stage of psychotism - the stage of pronounced manifestations of the psychotic level, diagnosed: if more than 4 symptoms of the psychotic level are revealed in the clinical picture: psychotism and paranoia, present constantly or often, moderately, strongly or very strongly expressed; when identifying 7 or more symptoms from each primary syndrome: obsessive-compulsive, anxiety, and from secondary syndromes: somatization, depressive and phobic anxiety, which often appear or are constantly, moderately, strongly or very strongly expressed; when identifying 5 or more symptoms of dissociative syndrome that appear frequently or constantly - from 30 to 100% on the "Scale of dissociative manifestations"; when identifying 7 or more symptoms from psychological syndromes of hostility and interpersonal sensitivity, which manifest themselves often or constantly, and have a severity from moderate to very strong.

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