Post-combat personality changes of combat veterans

Lytkin Vladimir Mikhailovich PhD in Medicine Associate Professor of the Department of Psychiatry at Military Medical Academy 194044, Russia, Saint Petersburg oblast', g. Saint Petersburg, ul. Akademika Lebedeva, 6 yan20220@mail.ru Other publications by this author     Zun Sergei Andreevich PhD in Medicine Associate Professor of the Department of Psychiatry at Military Medical Academy 194044, Russia, Saint Petersburg oblast', g. Saint Petersburg, ul. Akademika Lebedeva, 6 yan20220@mail.ru Other publications by this author     Kolodin Sergei Nikolaevich Lecturer, Department of Psychiatry, Military Medical Academy 194044, Russia, St. Petersburg, Akademika Lebedeva str., 6 yan20220@mail.ru

Yatmanov Aleksei Nikolaevich PhD in Medicine Postgraduate student, Military Medical Academy 194044, Russia, Saint Petersburg, Saint Petersburg, Akademika Lebedeva str., 6 yan20220@mail.ru Other publications by this author

The problem of post-combat personality changes among combat veterans in recent decades has become particularly important both in socio-psychological and clinical and organizational aspects ^[1].

The purpose of the work: to study the features of post-combat personality changes in combat veterans.

Materials and methods: the literature of the RSCI citation database is analyzed (elibrary.ru ) by keyword queries: "combat veteran", "combatant", "personality changes". The analysis includes 23 papers, 87% of which were published later than 2004.

Results. The term "traumatic personality" was first used in relation to Vietnam War veterans, although individual clinical observations of post-combat personality changes appeared much earlier ^[2]. Thus, after the Russian-Japanese War (1904-1905), states of depression, detachment, obsessive nightmares, transient dissociative disorders without clear boundaries with frequent transitions were described, after the First and Second World Wars - persistent obsessive states with trace effects, anxiety and amnestic disorders, the so-called. "persistent stress reactions" decades after the end of wars ^{[2, 3]}.

After the Vietnam, Afghan, and several other recent wars, studies of post-traumatic personality development in combatants are conducted mainly based on the positions of combat mental pathology, combat mental trauma, and combat PTSD ^[2-4]. It is noteworthy that in military medicine, a number of definitions carry different semantic meanings: "combat mental trauma" - clinical and organizational; "combat stress" - clinical and physiological; "combat stress disorders" - purely clinical ^[5]. Post-combat personality changes in combatants are usually considered in the context of the complex interaction of combat trauma and the personality transformed by it with a contradictory social environment ^{[2, 6, 7]}.

In studies of the problem of post-combat personality changes in combat veterans, two main approaches can be conditionally distinguished: clinically descriptive and conceptual.

In the framework of the first approach, it was shown that society (meaning "post-Vietnamese" and "post-Afghan"), in a broad sense, is unable to separate the war from the soldier who participated in it. Many socio-psychological and ideological factors that played an important role in past world wars are changing their importance in modern local wars. A common and most severe combat stress injury among Vietnamese veterans was the disbelief that the rest (mostly non–combatants) people are able to feel sympathy for them ^[2].

The combatant (despite the ambiguity of this term) ^[8], who has a constant feeling of being an "outcast of society", lives as if in two realities – "there" and "here" ^[4]. In his experiences, there is a thin membrane separating the present from the past, and at the same time, he is "neither there" nor "here." Having experienced a combat situation where the main law was "kill or survive" and, to some extent, having become accustomed to it, the veteran, upon returning home, sometimes finds himself unable to react naturally to everyday situations in civilian life. The adaptation of combatants occurs fragmentarily, according to the principle of a mosaic, the basis of which should be the formation of a belief in the need to continue living in the new post-war reality with the gradual consolidation of such personal qualities as trust, responsiveness, mercy, etc.^[4].

In terms of behavioral reactions, combat veterans were characterized by social isolation, distancing, and alienation from others ^[9]. Among Vietnamese veterans, groups of "successfully overcoming" (who adequately undergo internal transformation of trauma), "impulsive", "sociopaths" (disciplinarily maladjusted veterans), and "emotionally unstable" (maladjusted, mainly in emotional and volitional terms) were identified. In addition, such comparative variants of personality deviations among the "surviving" Vietnamese combatants as "animals", "slugs", "rags", "bores" and "double blindfolds" (with confusion and inability to determine their place in society) were described ^{[4, 10]}.

Depending on the holistic behavioral strategy, various types of mental maladjustment were identified in Afghan veterans.: active-defensive (mainly adapted), passive-defensive (maladaptation with an intrapsychic orientation) and destructive (maladaptation with an interpsychic orientation). The following groups of people are described in this contingent: aggressively active (using violence and aggression to achieve their goals), aggressively passive (neurotics who suppress aggression in themselves), passively zero (who decide to forget the Afghan events) and active adaptants (seeking social growth at the expense of Afghan privileges). Among the personal changes among Afghan veterans that are important for the social structure, an "unstable type" of personality change was identified, in which it was extremely difficult for a combatant to control his actions, correctly assess and motivate them, and a "hysterical-explosive type" characterized by aggressiveness and a challenge to society. In a combat situation, combatants with destructive post-stress personality changes were described as "fractured," "broken," "goofy," and "frenzied" ^{[10, 11]}.

A number of studies focus on the differences between the mental state of people who participated in hostilities and others, namely: a pronounced desire to be understood (i.e., additional reinforcement of such a mechanism of psychological protection as rationalization); the tendency to be recognized in the fact that his personal efforts, activity, and practical actions did not go unnoticed (not only signs of heroism, but also simply overcoming oneself: self-respect for not being cowardly, not deserting, was no worse than others); the desire to be accepted into the system of social relations of peaceful life with a new, higher status than the previous one; a feeling of hostility of the social environment caused by a kind of "stupefaction" upon return (they risked their lives, but nothing has changed in the country, not everyone shares their views on the goals, nature and methods of warfare); a decrease in the threshold of sensitivity to social influences (veterans feel lies, injustice, resentment more acutely) and the possible formation of a guilt complex among some veterans, the desire to justify their participation in the war by any means. combat operations. It is noted that a commonality of manifestations has been established, characteristic of both Vietnamese and Afghan veterans in the process of their adaptation to civilian life: "carnival phrase (I am a hero)" - "phrase of disappointment" - "final phrase", which can be transformed either into a "phrase of recovery", accompanied by relative psychological normalization, or in the "phase of long-term consequences" with the development of psychosomatic pathology ^[9].

War qualitatively changes people's mentality and forms a specific worldview when the lines between good and evil, between heroism and crime are blurred. The so-called "Zombie syndrome" is described as the ultimate expression of the pathological personality development of combatants (as a psychopathological alternative to the militant "phenomenon of alertness"), in which combatants, even in peacetime, continue to live as in a war, willingly creating an environment of combat conflict (the so-called "dogs of war"), "Rambo syndrome", The key characteristic of which is the consciousness of a "special mission" with the voluntary assumption of difficult but noble altruistic duties ^[12].

Attention is also drawn to the fact that the search for self-actualization among some of the combatants can often end in various antisocial and informal organizations, as well as in criminal groups, among alcoholics and drug addicts ^[8]. At the same time, it emphasizes the fallacy of discretion in the military transformation of the personality of the inevitable potential of "criminality" ^[2].

In general, in conditions of combat, empathic emotions are suppressed, the value of human life decreases, since the psychological barrier to murder is removed; at the same time, personal responsibility and possible social consequences are not taken into account. The feelings of hostility, suspicion, and unconscious reactions of fear and anxiety formed during participation in hostilities and remaining in conditions of peaceful life, which are of the deepest nature and represent a signal of danger, are an incentive to activity that is often combined with aggression, which is facilitated by a high level of personal aggressiveness in general, with actualization and ease of release threat response stereotypes and automated combat skills ^{[3, 13]}.

Psychological changes in stress survivors are combined into the so-called "post-stress pathopsychological symptom complex", characterized by the appearance or increase of suspicion, the originality and rigidity of behavioral and emotional reactions, dissociation of the value-semantic sphere, stereotyping and inadequacy of psychological defense mechanisms and coping strategies, limited microsocial connections and the formation of avoidant behavior. In some cases, such a symptom complex is complemented by feelings of hatred, revenge, and even aggression against people responsible for traumatic events ^[10].

Conceptual approaches consider the problem of post-combat personality changes in combatants within the framework of various models of combat stress and combat PTSD.

In the process of analyzing the psychological and psychiatric consequences of wars from the conceptual standpoint of the doctrine of combat stress, two main points of view on the nature of combat post-stress reactions were formed: the concept of "predisposition" and the concept of "causality". These two points of view gradually converged. It has been established that an extraordinary mental trauma, especially one that acts for a long time, can change the characterological structure of a personality and the type of its response to varying degrees ^{[2, 3]}. Various concepts of the effects of combat stress and attitudes towards veterans have been described: "the concept of disappearing stress", "the concept of residual (delayed) stress", "post-Vietnam syndrome" as "a group of symptoms, large and small, specific and undefined, with affective, interpersonal and adaptive components" ^[14].

The constant threat to life, as a characteristic feature of the combat situation, causes situations in which the demands of reality imposed on the individual sometimes clearly exceed the resources of the latter. This discrepancy creates combat stress. It is also necessary to take into account the fact that the psychological aspect of combat stress, namely, the lifting of the ban on murder and violence, the mass sanctioned extermination of some people by others makes combat stress incomparable with any extraordinary event occurring in peaceful conditions ^[3].

Currently, it has been established that combat stress is a systemic multilevel reaction of the human body to the effects of a complex of factors of armed struggle against the enemy and the accompanying social and living conditions, with a real awareness of the high risk of death or serious loss of health, which manifests itself at personal, psychophysiological, emotional-vegetative and somatic levels with significant, and possibly the leading role of changes in the subconscious sphere, consisting in the gross deformation of the basic Ego structures ^[15].

Combat stress, which leads to the formation of PTSD, has a number of differences compared to stress factors leading to PTSD of a different etiology.: its polymorphism and duration, the cumulative nature of numerous stress factors, the presence of certain preliminary special training of military personnel to increase stress resistance, etc. The real clinical picture of combat PTSD is much richer and more complex than that described in the relevant section of the ICD-10 ^{[6, 13, 16]}.

Modern war, as, in many ways, an "epidemic of mental trauma," breaks all moral norms and determines the destructive path of combat stress. At the same time, however, two "barriers" to the effects of stress are formed: a prebiological "barrier" addressed primarily to the deep structures of the brain, consciousness and spirit (we are talking about a professionally trained army with a military worldview, a high level of moral training, having a sense of military duty, etc.) and a personal one. The "barrier" as an individual attitude to the defense of the fatherland, awareness of his personal role in this patriotic impulse ^{[7, 17]}.

Studies of the socio-psychological content of modern combat stress have shown that the responses to it are threefold: 1) physiological - the body's response to the demanded compensatory regulation of unbalanced functional systems; 2) psychological - the reaction of resisting mental exhaustion through "restrained" volitional acts and professionally important qualities; 3) social - the most significant for the individual the answer to the threat of the destruction of the identification of the potential of the individual and the image of his "I" in the system of moral patterns: duty, honor and military duty. It is the latter component that occupies a leading place in the genesis of post-combat personality changes. The priority of knowledge about the inner world of a warrior, the personal connection of his identification image "I" with the content and psychological assimilation of the concept of "military security" is emphasized ^{[7, 17]}.

In the conceptual approach, combat PTSD is considered as a phenomenologically unified entity, differing only in varying degrees of severity, frequency and severity of symptoms depending on the stages of the disease. At the same time, PTSD is assessed not as a prolonged acute reaction to stress, but as a qualitatively different condition resulting from an acute reaction, but based on a variety of other factors: genetic predisposition, presence of altered soil, previous traumatic experience, characteristics of personal premorbidity, etc.

For the clinical picture of combat PTSD, specific features are the presence of inversion symptoms that move between the poles of the neurotic and psychotic registers from the minimum to the maximum degree of severity; certain features of positive symptoms of PTSD, when repeated experiences of memories of psychotrauma often transform into obsessive-phobic states with obsessive fears for the safety of their loved ones ^{[2, 13]}.

The clinical dynamics of combat PTSD has 4 stages of development.

Stage 1 – OCP (acute stress reaction), corresponding to the ICD-10 acute stress response;

Stage 2 is HP (neurotic reactions), corresponding according to ICD–10 to an adaptation disorder with a predominance of emotion disorders;

Stage 3 – PCP (pathoharacterological manifestations), corresponding to combatant accentuation;

Stage 4 is actually PTSD.

In line with the presented concept ^[13], the nosospecific basis of combat PTSD consists of chronic post-reactive personality changes and signs of comorbid organic pathology, which transform and mask the classic signs of PTSD. The severity of combat PTSD in combatants depends on premorbid personal vulnerability and the severity of stress, the dynamics is associated with indicators of social functioning. At the same time, changes in the personality of the combatants affect not only the emotional and cognitive, but also the motivational and value spheres. After leaving the combat zone, ordinary life for combatants sometimes becomes stressful.

The transformation of the combatant personality structure that began in combat conditions affects not only the deep emotional and affective "layers" of the psyche, but also the ontogenetically later and, consequently, more vulnerable cognitive and ideational levels (motivation system, worldviews, etc.). With the relative preservation of higher emotions in combatants, first of all, reactive behavior is distorted. While in proactive behavior, moral attitudes towards altruism, justice, and the formation of "militant corporatism" persist and sometimes even strengthen.

Special attention is paid to post-combat personal changes among combat veterans in the Russian concept of "combat mental trauma" ^[3]. The term itself, while not universally recognized, is usually used in an operational sense – as a pathological condition of the central nervous system caused by the effects of weapons and combat stress factors, the phenomenology and pathogenesis of which are determined by the specificity of external etiological causes, taking into account the effects of internal conditions. Combat personality deviations can be attributed to combat PTSD, considered as prolonged or delayed conditionally adaptive mental changes and mental disorders resulting from the effects of factors of the combat situation. It is noted that some of these changes in combat conditions may be adaptive in nature, and in civilian life they lead to various forms of social maladaptation.

Premorbid factors such as distorted family upbringing, the presence of epileptoid, hyperthymic, unstable and conformal traits, affective rigidity, inadequacy in relation to frustration, feelings of guilt, etc. predispose to the development of chronic consequences of BPT.

The radicals (traits) of anxiety and aggressiveness acquired in a combat situation persist even after the cessation of stressful effects, are firmly absorbed by the personality, while forming a stable emotional-behavioral stereotype in the form of combined affective-explosive and anxiety-obsessive symptom complexes. The presence of character accentuations significantly more often caused a tendency to a prolonged course of psychogenic reactions and adaptation disorders in the long term due to fixation of experiences of traumatic experience. It was revealed that the duration of stay in a combat situation had a significant impact on the further dynamics of the mental state, which caused a deepening of personal deformation and intensified the disadapting process. The combatants who suffered psychogenic (neurotic) disorders in a combat situation adapted better to the conditions of peaceful life than those who did not react to mental trauma. The probability of persistent socio-psychological maladjustment subsequently increases with increasing severity of the stress and the significance of mental trauma, which is determined by individual personality traits.

Within the framework of the concept of BPT, the defensive-epileptoid type of personality changes in combatants was identified, which is considered as the basis of all psychopathological manifestations of BPT. The components of these characterological deformations acquired in a combat situation are a peculiar worldview, suspicion, vulnerability, impaired social communication, an increased risk of aggressive outbursts, super-valuable and delusional formations.

It was noted that war veterans, even for a layman, are noticeably different from all other patients with stressful conditions. Among the painful experiences and behavioral features of combatants already during the period of participation in the war and, even more noticeably, in the post–combat period, a whole set of symptoms appears that can only occur in people who have experienced combat stress. Mental changes formed under the influence of chronic combat stress, after returning to civilian life, become the basis for the development of combat PTSD and post-war personality changes, taking into account the great importance of additional social factors ^[3].

The clinical picture of combat PTSD is not limited to the signs of PTSD described in the well-known classifications. Many war veterans tend to have so-called "comorbid symptoms" that can significantly transform and even mask the classic signs of PTSD. At the same time, a synergistic type of comorbidity is distinguished, in which, unlike primary (autochthonously manifesting) disorders, pathocharacterological manifestations are synergistic with PTSD, an autonomous type that is characteristic of PTSD co-existing with somatopsychic disorders, and an absorbing type of comorbidity, in which the dynamics of PTSD acting in conjunction with depressive disorders is characterized by a gradual replacement of psychogenic manifestations with autochthonous affective ones. disorders ^[18]. It is noted that the stereotype of the dynamics of PTSD, including pathological symptom complexes related to the range of personality disorders of demonstrative, borderline, excitable, paranoid and schizoid types, is largely associated with the development of comorbid symptom complexes ^[18].

Considering the problem of post-traumatic personality dynamics among war veterans in the context of the complex interaction of a pathologically altered personality with an extremely contradictory socio-social attitude to the current life problems of veterans, it is noted that virtually every veteran goes through a certain life path filled with crises (mental traumas) that destroy pre-war ideas about themselves and the world; traumatic experience "breaks" the entire psychological system of personal protection. As a result, at the cognitive level, life is divided into two halves (not always equal) – life before and after the injury. Everything that happened before the trauma determines the individual level of the barrier of mental adaptation, in other words, it allows us to determine why in some cases PTSD develops, while in others a person finds the strength and opportunity to "build" constructive dynamics of adaptation to peaceful conditions ^[7]. A survivor of a combat injury gradually restricts his contacts to a circle of comrades, while at the same time reducing the social and professional level of his functioning. The personality structure begins to reveal features that are not typical of a person in the pre-war period. Among them are hostile or distrustful attitudes towards the outside world; unmotivated outbursts of aggression with destructive and autodestructive tendencies; restriction of social contacts up to social isolation.;

Currently, PTSD is considered as a continuous, permanent process, during which non-pathological and pathological, psychological and mental forms of reaction are observed, constituting a kind of "post-traumatic life." The polymorphism of PTSD manifestations has led to an expansion of the criteria for PTSD, which is reflected in the concept of the "PTSD complex". According to most researchers, personal transformations are based on changes in the semantic core of personality that develop after an extreme situation ^{[2, 7]}. Previously, identity disorder was considered as an axial symptom of the development of PTSD, in which the former personality is displaced into the subconscious (leaving in this case the possibility of psychotherapeutic correction of PTSD), and the new identity is regarded as a "post-traumatic stress personality disorder" ^[16].

When considering the problem of personality, on the one hand, as a pathogenetic factor in the genesis of PTSD, and on the other, as a clinical phenomenon, its deviations in the context of combat PTSD are analyzed at three levels: pre-traumatic personality traits or disorders (premorbid personality), intratraumatic personality traits (personality-driven reactions to traumatic stress), post-traumatic personality disorders (combatant accentuation, chronic personality changes, etc.) It is noted that combat stress, which has not found a constructive way out in peacetime, in some cases acquires the character of a "moral injury" that strikes at the moral values of the individual.

The essence of post-traumatic personality disorders in this approach is determined by the leading maladaptation, destructive reactions, social isolation, deviant and a (anti)social forms of behavior. Practice shows that numerous forms of personality changes in combat PTSD do not fit into the narrow scope of the diagnostic category of ICD-10, taking into account the fact that personality traits are not only predictors of the development of PTSD, but also its manifestations ^{[2, 7]}.

As a result of a number of observations, it was found that the clinical picture of PTSD is polymorphic, polysyndromic and includes manifestations of neuroticism, psychoticism, dissociative disorders, psychological disorders and personality disorders. With this approach, obligate primary and optional secondary syndromes are distinguished in the clinical structure of PTSD, and in dynamics, the stages of initial clinical manifestations, neurotic and psychotic, which include, in particular, post–traumatic personality changes. PTSD in the chronic course of the process can be characterized as "post-traumatic realism", as a way of pathologically adaptive functioning of a person in the post-traumatic period ^[16]. Based on the intensity of distress, mild, moderate, and severe degrees of the disorder were identified, and personality type was considered a risk factor for developing PTSD.

The results of the study of the intrapsychic personality structure of veterans in the context of transactional analysis revealed the presence of personality disharmony in the majority of people with PTSD. The indicators of ego states in this subgroup of individuals are lower than the average, and this difference increases as the severity of the disorder increases.

In PTSD, a decrease in the proportion of extroverted personality types is revealed to their complete absence in severe PTSD. The severity of the disorder and personality introversion are closely related, while the characteristics of personality types in the subgroups of PTSD correspond to its clinical picture. The more introverted a person is initially, the greater the risk of developing severe PTSD ^[16].

Studies of the long-term effects of combat stress from the perspective of a biopsychosocial approach have allowed us to hypothesize that non-psychotic mental disorders in war veterans, which include personal deviations, are characterized by affective stress dysregulation, since all these individuals were exposed to combat stress and other types of stressors. In this situation, the primary, determining role is played by violations of the basic emotions of anger and anxiety, secondary to them and having a protective and coping character are depression and guilt ^[6].

According to the presented concept, psychological features in the long-term period of combat stress are characterized by a wide range of disorders, including both changes in the functioning of the Ego and cognitive processes. Violations of the personal functioning of combatants represent a continuum from compensated changes at the pre-painful ("psychological") level, characterized by an imbalance of the central "I" function, to total personal disharmony associated with an increase in the severity of mental disorders. The dysfunction of the "I" of combatants with typical manifestations of PTSD is expressed in a constructive deficit, the dominance of deficient and an increase in destructive indicators. The dysfunctional cognitive patterns identified in combatants, which are part of psychological changes in the long-term post-combat period, not only increase the severity of obligate symptoms, but also increase the risk of antisocial, addictive behavior.

The different psychopathological structure of PTSD and the correlation of depression with other components of the symptom complex suggest a syndrome-forming role of the dominant depressive affect in PTSD, with several characteristic types of the syndrome correlating with premorbid personality traits. Thus, in the anxious type of PTSD, accentuated, anancastic, and hysterical premorbid personality traits predominate, in the dysphoric type, anancastic and emotionally unstable ones predominate, in the apathetic type, anancastic and hysterical ones predominate, and in the somatoform type, personalities with alexithymic traits predominate ^[19].

From the perspective of the development of the ideas of classical psychoanalysis, mainly within the framework of the concept of adaptive psychodynamics. According to K. Horney's philosophical and cultural-sociological theory of neuroses, various forms of neurotic evolution of the personality of emergency participants are considered as the "core" of the procedural dynamics of the psychopathological consequences of an emergency. The pathogenesis of these consequences is based on the phenomena of Ego stress, more specifically, the clinical picture of the syndrome of primary traumatic Ego stress (stress of realizing a new traumatic reality). Socially acceptable variants of the psychopathological evolution of the personality of emergency participants are distinguished, which include autistic personality transformation and psychosomatic evolution, and socially unacceptable variants: substance abuse evolution and individual mental degeneration ^[12]. From the standpoint of the system-dynamic approach, all identified mental disorders, including personal deviations that occur in the long-term post-stress period, are considered not as outlined variants of mental pathology, but as stages of the adaptation strategy of the body and personality, reflecting the individual reserve capabilities of a person. They determine the whole variety of forms of mental and physical health, including pre-painful conditions. In fact, these protective and adaptive forms of situational response (including "painful" ones) are ultimately aimed at achieving the necessary adequate adaptive result ^{[9, 20]}.

Some attention in the study of the problem of post-combat personality changes is paid to their preclinical forms (accentuations).

It was noted that the post-traumatic signs included in the structure of the "traumatic personality" did not always correspond to the diagnosis of PTSD, while playing a concomitant role, which could significantly affect the condition of the combatant, therefore they were designated as partial or subthreshold PTSD. There are complete and subsyndromic forms of PTSD. Most people with such forms of PTSD remain permanently untreated ^{[6, 16]}.

The works of K. Leonhardt and A.E. Lichko created the doctrine of "accentuated personalities", which were considered as disharmony in character development, as an exaggerated expression of its individual features, which led to increased vulnerability of the individual to certain kinds of influences and made it difficult for her to adapt in some specific situations. At the same time, there could be an increased individual ability to adapt socially in other situations that are not relevant to this one.

It should be noted that in military psychiatry, "psychopathies" and "accentuation" are assessed as various degrees of personal changes (from total, integral to particular, partial, affecting certain substructures of personality). At the same time, stable individual characteristics are presumably of endogenous origin, while changeable ones are exogenous. In each form of accentuation, it is legitimate to compare the disadaptive pattern of behavior characteristic of it, which can reach the nosological level ^[21].

Depending on the individual's attitude to various areas of personality (cognitive, volitional, affective, sensorimotor), hyposthenic (schizoid, psychasthenic, depressive, asthenic) and hypersthenic (paranoid, explosive, hyperthymic, hysteroid) forms are distinguished. Most accentuants are "mosaic" personalities with two or more disharmonious patterns, which implies a certain freedom to choose one type of maladaptation in similar stressful situations.

Considering the possibility of applying the theory of registers of mental activity from the zone of pathology to the zone of normality, as well as the modern theory of stress diathesis, both mental states and personality traits underlying these states were included in the continuum of registers. In the practice of military specialists, people with neuropsychiatric instability, referred to as "mental tension", "pre-illness", "subnormal", "maladjustment", are of the greatest interest.

The Register of Mental Health of military personnel, designated as neuropsychiatric instability ("pre-illness"), corresponds to such forms of psychoemotional stress in which stressful conditions are not completely overcome and tend to "hang up". The prevalence of personality traits in this register within the framework of personality accentuations, when personal radicals make adaptation difficult and require compensation, reaches 40%. These personal radicals, or more precisely, universals reflecting maladaptive shifts in the main functional systems of the brain, are components of pre–painful mental states and are divided into radicals with a predominance of inhibition and radicals with a predominance of arousal.

In general, "neuropsychiatric instability" includes short-term states – "pre-nosological analogues" of neuroses and relatively long–term abnormal personality reactions - "pre-nosological analogues" of psychopathic decompensations, in fact - accentuations ^[21].

Based on the study of the dynamics of personality accentuation among veterans of combat operations in Afghanistan and Chechnya (in the pre-war, military and post-war periods of life), taking into account the fact that different situations cause characteristic patterns of reactions, and each individual reaction is based solely on previous experience and genetic history, and taking into account the fact that a change in functioning After leaving an extreme situation, the personality can move in both negative and positive directions, previously it seemed advisable to introduce the concept of "combatant accentuation" into practice. Naturally, depending on individual constellations of biological, personal and environmental factors, the severity of acquired personality changes can vary from latent accentuation to pronounced psychopathization ^[10].

Dynamic situational "combatant accentuation" is understood as a set of personality and character traits acquired as a result of direct participation in hostilities and pre-existing personal characteristics, the dynamics of which is determined by the specifics of combat and peaceful conditions of existence, and the manifestation is different variants of the interaction of combatant proper and inherent character traits that determine various social adaptation. The very fact of their verification can be considered as a kind of "background" ("soil") for the possible development of polynosological neuropsychiatric disorders. The zone of greatest vulnerability (the "place of least resistance") in the structure of combatant accentuation turns out to be a deeply individual and personally processed complex of combat experiences, which plays a leading role in its formation and dynamics, and contrasts with the conditions of peaceful life.

It was noted that combatant accentuations are formed by superimposing new character traits on premorbid features of the pre-war period accentuations as a result of the specific effects of combat stress and intrapersonal conflict between a socio-moral position that arose in combat and society's rejection of it in peacetime.

The spectrum of combatant accentuation manifestations is much smaller than the signs of the pre-war period accentuation and is limited to only three types: anxious-asthenic, explosive-aggressive and hysterical-unstable. At the same time, the characterological structure of the personality changes, but the type of reaction remains the same (sthenic, asthenic, dyssthenic). New characterological personality traits acquired in combat conditions, as a rule, make it difficult for combatants to adapt to civilian life, however, depending on the conditions (combat, non-combat), combat accentuation can be constructive and contribute to adaptation, or it can be destructive and cause disadaptation. Both adaptation and disadaptation can be fragmented and selective.

It should also be noted the phenomenon of the so-called "post-traumatic personal growth", "eustress variant of adaptive personality transformation", in which, in case of successful coping with trauma, basic beliefs become qualitatively different from what they were before the trauma. A crisis caused by trauma, if successfully experienced, can bring a person to a new level of development.

It is characteristic that the combat transformation of personal changes occurs much faster in time than the formation of accents in peacetime, and causes partial disharmony of the combatant's personality, manifested mainly by behavioral deviations.

In general, combatant accentuation is a dynamically situational subclinical variant of post-traumatic stress disorder, against which, under unfavorable conditions, further personality psychopathization and the development of psychogenic disorders, as well as the formation of comorbid alcohol and drug addiction pathology, can occur.

It is advisable to predict the likelihood of developing mental disorders in combat accentuation based on a combination of factors such as the severity and duration of traumatic effects, individual characteristics of combat personality transformation, time elapsed after participating in hostilities and additional traumatic peacetime situations. Correction and medical and psychological rehabilitation of persons with combatant accentuation should be carried out in a differentiated manner, taking into account its type. It is especially necessary in the first months after the return of combatants to civilian life, when they have the highest risk of aggressive, violent and suicidal behavior.

Subsequently, it was shown that veterans of local wars are more likely to have so-called "stuck" personality accents (according to K. Leonhardt), which may lead to a transition from the concept of a "combatant personality" to the problem of an "organic combatant personality" ^[8], which is considered a threat to the stability of society.

Attention should also be paid to the situation in borderline psychiatry, when the problem of personality disorders reveals significant differences compared with established classical canons ^{[18, 22, 23]}, when diagnostic and classification judgments are reviewed, taking into account the fact that one pole of personality disorders adjoins endogenous psychoses, and the other – to psychogenies.

Earlier in military psychiatry, the question of the expediency of introducing, along with the Gannushkin–Kerbikov criteria, another dynamic criterion as an assessment of clinical manifestations during psychopathy under the influence of an external factor was considered.

In this regard, the criteria for diagnosing psychopathies in military personnel should be divided into two groups.: 1) static, which do not change their content (totality, stability) and 2) dynamic, which change their content depending on the external environment (severity of clinical manifestations, degree of social maladaptation). At the same time, dynamic criteria are given a leading role in the recognition of psychopathies, since without them it is impossible to establish the totality and persistence of disharmony ^[10].

With the possible identification of three main groups of personality pathology, namely: personality disorders occurring mainly in the sphere of its resources, in the sphere of character and personality disorders, and in the sphere of its content and life meanings ^[24], it can be assumed that post-combat personality deviations are most tropic to the last distinguished group. After participating in combat, a person may have new views, positions, and interests that seem to merge with the core of the personality (with its self) and become its existential essence.

Modern ideas about personality are changing in the direction of creating an integrative model, in which personality is considered as a kind of integrating apparatus – a kind of invisible coordinating organ of the psyche. At the same time, a number of fundamental conceptual shifts are outlined, which are reflected in the development of ICD-11 ^[22]. In this classification, five main behavioral patterns were identified, designated as the "Big Five", which, in a broad sense, are statistical clusters reflecting typical abnormal combinations of human behaviors in different cultures.

Based on the new views, personality is no longer considered only as a set of constitutional socially significant stereotypes of behavior and reactions. The structure of personality begins to be dominated by what used to be called its "semantic sphere" (self–awareness with its key element - identity, "I-concept" and related concepts such as self-esteem, self-esteem, etc.).

With this approach, three main criteria become leading in the diagnosis of personality disorders: self-awareness dysfunctions, interpersonal dysfunctions, and maladaptive behaviors.

In addition to the category "Personality disorder and related features", the ICD-11 project introduces for the first time another category – "Personality difficulties", which is essentially an analogue of personality accentuation ^[22].

Conclusion. Taking into account modern (sometimes very controversial) ideas about personality disorders and the socio-psychological characteristics of society in the conditions of the SVR, the problem of post-combat personality changes among combat veterans is, in our opinion, becoming increasingly relevant, which implies further comprehensive development of this problem.