Flashback psychopathology in combatants with PTSD
Authors: Syropyatov O. G. , Dzeruzhynska N. О. , Marushchenko К. Yu. 
Published: March 2020

Background. Flashback is an artistic technique, primarily in cinema, with a temporary interruption of the narrative sequence in order to show some events in the past. In General psychopathology, flashback is an involuntary and unpredictable revival of traumatic experience through extraordinarily vivid memories lasting from a few seconds to several hours, during which veterans feel that a terrible reality from the past invades their real life. Subjectively, patients describe these conditions in the following phenomena: “war is in the eyes”, “I am here and not here”, scenes of death of a friend, scenes of violence. The boundaries between “that” and actual reality are blurred. Flashbacks are also observed when psychoactive substances are used – hallucinogens and stimulants, as well as alcohol. In narcology by flashback the occurrence of symptoms of intoxication after drug use cessation is meant. Flashbacks are also described in right-sided temporal lobe epilepsy, brain tumors, and other organic brain lesions. The literature suggests that flashbacks are a coping mechanism for coping with stress. At the same time, direct or symbolic reflection of the psychotrauma pattern in the content of recurrent memories is one of the main symptoms of diagnosis of psychogenic mental disorders. Wider psychopathological idea of the flashback evidence of nosological non-specificity of this phenomenon (Voloshin V. M., 2005; Alexander Yu. A., 2008; Zhmurov V. A., 2008; Krylov V. I., 2015). The diagnostic criteria for PTSD in ICD-10 do not distinguish flashback episodes from other mental disorders. In DSM-5, the flashback phenomenon is qualified as a dissociative episode and is considered along with reminiscences, illusions, hallucinations, meaningfully associated with recurrent experiences of psychotraumatic experiences, and is a diagnostic feature.
Objective. The aim of the study was to investigate clinical and psychopathological features of flashbacks in the structure of PTSD in combatant soldiers.
Materials and methods. Clinical follow-up examination of soldiers-combatants was conducted. With the system approach, we examined and selected according to the inclusion criteria 48combatants-servicemenof Armed Forces of Ukraine, males aged 31±0.7 years using the following study algorithm: 1) all respondents – combatants were tested using the Luscher test to screen for emotional disorders; 2) in the selected group of respondents with emotional disorders, a clinical and psychopathological study was further conducted with the additional use of the symptomatic questionnaire SCL-90-R (The Symptom Checklist-90-Revised) to clarify the main and additional symptoms of PTSD and comorbid psychopathological symptoms.
Results. A study using ICD-11 revealed signs of PTSD in examined combatants. It is a disorder that develops after exposure to an extreme threatening or terrifying event or series of events, and is characterized by three “pivotal” manifestations:

re-experiencing the traumatic event(s) at the present time in the form of vivid intrusive memories accompanied by fear or horror, flashbacks or nightmares;
avoidance of thoughts and memories of the event, or avoidance of activities or situations that reminiscent of the event;
a state of subjective sense of continuing threat in the form of hyper-alertness or increased reactions of fright.

The revealed profile of symptoms was accompanied by additional permanent and widespread and persistent derangements of regulation, self-assessment and interpersonal functioning. For all combatants surveyed, a new diagnostic category of ICD-11 “Complex PTSD” was used. As noted by V. I. Krylov (2015), the symptoms of re-experiencing (flashbacks) are characterized by two main rows – obsessive and overvalued experiences. We also highlighted the different phenomenology of flashbacks, which have the following differences. First, the obsessive nature of reminiscences is observed in those memories that the patient wants to forget, the leading value in this case is the content of memories. Second, for intrusive ideas the focus is on intense affective images and pictures of psychotraumatic events. Third, retrospective self-analysis of the correctness of their behavior in a psychotraumatic situation has a leading place in obsessive doubts. Fourth, overvalued memories and views from the beginning are arbitrarily and are supported by “brothers in arms”. Overvalued experiences are egosyntonic and identify with personality. The opposite view of the aims and meaning of war causes aggression. “Heroization” of their behavior in military conditions takes place. Fifth, nightmares with scenes of war that end in awakenings or sleep inertia states with disorientation in place and time can be accompanied by aggressive actions.
On the basis of phenomenological psychopathological analysis the main characteristics of the phenomenon of flashback were derived:
1) reflection of combat trauma in the content of re-experiencing;
2) spontaneous involuntary occurrence of re-experiencing without external provocation;
3) sensual richness of re-experiencing – visual images of flashback have a bright polychromatic character, auditory images are expressed, olfactory disorders are associated with combat experience (the smell of gunpowder, burning, blood); images of recurrent memories have a complete “military” plot;
4) re-experiencing are affectively saturated and repeat the feelings experienced by the combatant during the battle – it is fear, horror, expressed anxiety and bodily haptic sense of danger;
5) unlike epileptic phenomena, there is invariance of re-experiencing in psychogenic flashbacks.
Thus, the classic version of flashback in PTSD is characterized by the following clinical and psychopathological features: sensoralized representations and eidetic images; monomodal images; partial immersion in painful experiences with the preservation of contact with reality; preservation of all kinds of orientation, the absence of amnesia during flashback. In psychotic PTSD, accompanied by confusion, which in foreign literature are considered “dissociative disorders”, there are signs of atypical flashback, requiring a different strategy of patient management. These are the following features: transformation of eidetic images into illusions and hallucinations; polymodality of images; full immersion in painful experiences with the loss of contact with real reality; violation of orientation in place and time; partial amnesia of real events.
Conclusions. Phenomenological clinical and psychopathological analysis of flashbacks in PTSD allows not only to estimate the belonging of this disorder to combat mental pathology, but to carry out a differential diagnosis of this phenomenon for more effective assistance to military combatants.