Long-Term Consequences of Combat Stress in Afghan War Veterans: Comorbidity of PTSD and Physical and Mental Health Conditions

Abstract

This research represents the first in the Republic of Kazakhstan focusing on Afghan war veterans identified as being at risk for Post-Traumatic Stress Disorder (PTSD). A comprehensive investigation was undertaken regarding the comorbidity of PTSD symptoms, somatic diseases (cardiovascular and others), and mental disorders. The study’s sample comprised 293 Afghan war veterans, while the control group consisted of 149 males without combat experience. The research methodology incorporated data extracted from medical records, a demographic questionnaire, the Mississippi PTSD Scale (military and civilian versions), the Spielberger–Khanin Anxiety Inventory, the Beck Depression Inventory (BDI), and the SCL-90-R questionnaire. Subclinical symptoms indicative of chronic PTSD were identified in 25.2% of veterans, as assessed by the Mississippi PTSD Scale. According to the Spielberger–Khanin questionnaire, veterans with subclinical PTSD exhibited a moderate level of situational (44.96 ± 6.39 points) and personal anxiety (44.14 ± 5.49 points), which were significantly higher than those observed in the control group (29.87 ± 6.50, p₂ < 0.001, 36.13 ± 6.82, p₂ = 0.003). Furthermore, based on the BDI, these veterans demonstrated an elevated level of depression (13.32 ± 1.36) in comparison to veterans without PTSD (8.61 ± 0.65, p < 0.001) and the control group (4.06 ± 0.75, p < 0.0001). The findings indicate that veterans exhibiting a high level of PTSD are characterized by a more pronounced manifestation of psychopathological indicators, as assessed by the SCL-90-R questionnaire. Compared to the control group, veterans exhibiting PTSD symptoms were found to have a comorbidity with somatic diseases: stage 3 hypertension in 45.2% vs. 21.3% (p₂ < 0.001), coronary heart disease in 45.5% vs. 13.4% (p₂ < 0.001), and type 2 diabetes mellitus in 20.3% vs. 6.1% (p₂ = 0.001). Consequently, Afghan war veterans should be regarded as a high-risk group for cardiovascular diseases (including hypertension and coronary heart disease), cerebrovascular diseases, and mental health disorders. Accordingly, a comprehensive approach is necessary to identify PTSD symptoms alongside concomitant anxiety–depressive disorders and somatic diseases in individuals who have experienced traumatic events.

1. Introduction

Recently, the increasing frequency of terrorist attacks, local wars, and armed conflicts has exerted a detrimental influence on the physical, mental health, and overall well-being of society [1]. Exposure to severe external threats and emotional stress during military operations results in the depletion of the body’s adaptive resources, the chronic suppression of the immune system, and, consequently, the emergence of various diseases. Even after 36–46 years post-war, it remains a critical period for the development of medical and social repercussions in war veterans [2].

The primary group of participants in the Afghan conflict comprises soldiers of draft age, now belonging to an older demographic; many originate from socially vulnerable segments of the population. According to the Ministry of Labor and Social Protection of the Population [3], as of 2025, approximately 16 veterans of the Afghan war reside in the Republic of Kazakhstan, with many having become disabled (exceeding 3000) due to sustaining severe injuries during military service. It is well established that military experience can exert long-term effects on mental health, even in later years [4,5]. Consequently, military service in active combat zones markedly increases the levels of neuropsychic stress and serves as a predisposing factor for the development of stress reactions and maladaptive outcomes, which may include a broad spectrum of psychopathological and somatic disorders.

The etiology of psychosomatic disorders is multifactorial. Various elements, including personality traits and genetic, environmental, and biological factors, significantly contribute to the pathogenesis of psychosomatic disorders [6]. Nonetheless, extensive data indicate that a substantial portion of psychosomatic symptom development is associated with experiences of psychotrauma. Specifically, stressors of diverse origins induce cognitive and affective shifts at the mental level and somatovegetative disturbances physiologically [7,8,9]. It is established that the overexertion of adaptive mechanisms under stress frequently results in the development of post-traumatic stress disorder (PTSD). In DSM-5 [10], PTSD was reclassified from the group of anxiety disorders to the new section “Trauma and Stressor-Related Disorders”, and in ICD-11, it is categorized under “Disorders specifically associated with stress” (L1-6B4) [11]. However, these classifications do not account for the long-term consequences of PTSD, additional factors that exacerbate its course, or the specific modifications of its clinical presentation. Frequently, PTSD coexists with anxiety–depressive disorders and somatic illnesses. Consequently, in most cases, comorbid PTSD takes a prolonged or chronic course, especially when individuals do not seek timely medical intervention. Contemporary research by Stellman S.D. et al. corroborates the lifelong impact of combat exposure on the mental health and physical well-being of United States veterans, even fifty years following participation in the Vietnam War [12]. Another investigation among the adult population of England identified a 78.5% comorbidity rate of concurrent illnesses in PTSD, with depression being predominant [13]. Additional studies reveal that between 14% and 16% of U.S. military personnel deployed to Afghanistan and Iraq also experience PTSD and/or depression [14]. It is noteworthy that depression and anxiety may both result from PTSD and serve as independent risk factors for its development following traumatic exposure.

It has been established that individuals with PTSD have an increased risk of developing and progressing cardiovascular diseases (CVDs) [15,16], and vice versa; there is evidence of a bidirectional relationship between these diseases [17,18]. Additionally, these symptoms can be exacerbated by anxiety, increased sensitivity, and excessive concern about one’s health. This issue predominantly affects cardiac patients due to the high prevalence of cardiovascular diseases and their pathophysiological association with damage to various organs [19,20,21]. Recent studies further corroborate the link between PTSD and the development of arterial hypertension [22,23,24].

Veterans of the Afghan conflict are classified within an age group characterized by a high prevalence of comorbid diseases, which escalates to 93% among individuals aged 45–64 years and reaches 98% in those over 65 years of age [25]. This issue of age-related illnesses, coexisting medical conditions, and elevated cardiovascular risk complicates the processes of diagnosis and pharmacological management, thereby increasing the probability of adverse outcomes such as re-hospitalizations, disability, and premature death. Furthermore, the overall health status may be adversely affected and deteriorate due to factors including retirement, unemployment, dissatisfaction with living conditions, and suboptimal family relationships [26,27,28]. These observations are corroborated by a recent study on the war experience in Ukraine, which identified low psychological resilience, loneliness, and inadequate social support as significant predictors of post-traumatic stress disorder (PTSD) symptoms, even within the civilian population [29].

At present, the ongoing conflicts, including the war between Russia and Ukraine, the Palestinian–Israeli dispute, the conflict in Syria, and the civil war in Myanmar, are marked by substantial hostilities. These represent only a subset of numerous contemporary military conflicts occurring worldwide. Many of these conflicts are characterized by significant brutality, humanitarian crises, and extensive civilian involvement.

This study aims to explore the association between somatization and mental disorders that contribute to the long-term persistence of PTSD symptoms in Afghan war veterans with traumatic experience.

Consequently, it is imperative to promptly identify individuals with PTSD and associated comorbid conditions who necessitate intervention for psychophysiological, neurovegetative, and somatic symptoms, alongside social and psychological rehabilitation. Implementing preventive strategies may facilitate more effective correction of psychopathological manifestations, enable prediction of the progression of comorbid illnesses, and allow for the provision of specialized support to this population segment exhibiting signs of chronic stress.

2. Materials and Methods

2.1. Participants

This study comprises cross-sectional observational research conducted in 2024 among veterans of the Afghan war who are members of the Public Association “Union of Disabled People and Veterans of the War in Afghanistan” in Astana. The organization’s director informed the members about the study, after which voluntary participants completed questionnaires.

A total of 293 veterans who served in the 40th Combined Arms Army, as part of the LCSTA (limited contingent of Soviet troops in Afghanistan), from 1979 to 1989, participated in the study. Only veterans who are citizens of the Republic of Kazakhstan and directly engaged in military operations were included. Individuals with diagnosed psychiatric illnesses were excluded.

The control group consisted of 149 men employed at JFOOD Kazakhstan LLP. Astana, Kazakhstan («Tsesna-Astyk» concern) in Astana. This group was matched in various demographic characteristics with the experimental group but did not participate in military operations. Participants were recruited anonymously with the assistance of the organization’s leadership.

The mean age of the subjects in the primary cohort was 57.65 years (SD = 4.67 years), while in the control cohort, it was 58.54 years (SD = 5.87 years). No statistically significant differences in age were observed. The veterans have served in active military duty for an average of 39.7 ± 3.3 years. Each veteran’s active service duration was 1.8 ± 0.5 years (range 1–2.5 years).

All questionnaires were administered in two language versions: Kazakh and Russian, depending on the respondents’ choice. 5.1% of veterans chose the Kazakh language, and 4.1% of men from the control group opted for the Kazakh language when completing the questionnaires.

2.2. Ethics

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and the national standards of the Republic of Kazakhstan, specifically the State Standard of the Republic of Kazakhstan, Good Clinical Practice ST RK 1616-2006 [30]. The procedure received approval from the Decision of the Local Bioethics Committee of Astana Medical University No. 1, dated 30 January 2024. The data obtained from the questionnaires administered to study participants were collected with their informed consent for subsequent processing and publication. Confidentiality was maintained, and no questions that could reveal the participants’ identities were posed.

2.3. Methodological Basis

The initial questionnaire developed for the study collected demographic information, including age, ethnicity, educational background, marital status, employment status, place of conscription, place of military service, and duration of military service.

The research methodology encompassed the extraction of data from medical records, the utilization of psychodiagnostic techniques to identify psychopathological conditions, and the assessment of risk factors for somatic diseases. The study concentrated on current symptoms, specifically those that have manifested within the past month.

All psychometric instruments were employed in validated Russian language versions. Furthermore, questionnaires were translated into Kazakh for certain participants who preferred to utilize Kazakh when completing the study. The translation process was conducted collaboratively by the authors and a linguist, following a standard procedure involving direct translation and expert evaluation to ensure conceptual consistency. The internal consistency of the Kazakh versions was evaluated using Cronbach’s alpha, thereby confirming their psychometric reliability.

The study employed the following methodological approaches, considering their validity, reliability, and adherence to the diagnostic criteria outlined in the International Classification of Diseases 11th Revision (ICD-11) [31]:

2.3.1. The Mississippi PTSD Scale

The Mississippi PTSD scale (military version, civilian version) [32], as adapted by Tarabrina N.V. et al. [33], was employed to identify the characteristics of psychosocial functioning and the presence of probable PTSD. This scale facilitates an assessment of symptom severity, including typical manifestations of PTSD such as anxiety, depressive symptoms, and hyperexcitability. Depending on the version used (military or civilian), the threshold values for interpreting the final score vary. Considering standard threshold values, in our study, individuals scoring ≥ 78 points were categorized as having subclinical PTSD, indicating they did not meet the threshold for a probable clinical diagnosis of PTSD. The military version of the Mississippi scale demonstrates high internal consistency (α = 0.94), which is slightly lower than that of the civilian version (α = 0.86).

2.3.2. The Symptom Checklist-90-Revised (SCL-90-R)

To examine psychopathological and somatic symptoms, the screening instrument SCL-90-R [34], as adapted by Tarabrina N.V. [35], was employed. This symptomatic questionnaire comprises 90 items and evaluates the severity of psychological distress across nine clinical scales: somatization (SOM), obsessive–compulsive disorders (O-S), interpersonal sensitivity (INT), depression (DEP), anxiety (ANX), hostility (HOS), phobic anxiety (PHOB), paranoid symptoms (PAR), and psychoticism (PSY). The subscales of the SCL-90-R demonstrate commendable reliability (from α = 0.70 to α = 0.89).

2.3.3. The Spielberger–Khanin Questionnaire

The Spielberger–Khanin questionnaire [36], as modified by Khanin Y.L. [37], evaluates the respondent’s current emotional condition through 40 questions. Situational anxiety pertains to the immediate emotional state and the level of anxiety experienced at a given moment. Conversely, personal anxiety gauges a persistent propensity towards anxiety, regarded as a personality trait, independent of specific circumstances. The technique is distinguished by a high reliability coefficient (α = 0.90).

2.3.4. The Beck Depression Inventory (BDI)

The symptoms of depression were evaluated utilizing the Beck Depression Inventory (BDI) [38], adapted by Tarabrina N.V. in 2001 [35]. This particular inventory is designed to quantify the intensity of depressive symptoms, ranging from mild to severe depression. The instrument demonstrates high internal consistency (α = 0.86).

2.4. Statistical Analysis

The statistical analysis of the data obtained was conducted utilizing the GraphPad Prism Version 10.4.1 (532) software package. The parameters employed included mean value (M ± m), standard deviation (SD), and median (Me). The normality of the distribution of quantitative variables was assessed via the Shapiro–Wilk test. As the majority of variables did not conform to a normal distribution, nonparametric tests were applied for group comparisons. The Mann–Whitney U test, supplemented with Bonferroni correction, was utilized to evaluate the statistical significance of differences in indicators across the compared groups, thereby controlling for false-positive results in multiple comparisons. The association between variables was measured using the Spearman correlation coefficient (r). To compare the incidence rates of diseases between groups, the Pearson chi-square test (χ²) was employed. Internal consistency of the questionnaires was evaluated through Cronbach’s alpha (α). Differences were considered statistically significant when p < 0.05.

3. Results

3.1. Socio-Demographic Characteristics

The socio-demographic characteristics of the studied war veterans are presented in

Table 1. Socio-demographic characteristics of Afghan war veterans.

Characteristics	n = 293, 100%
	n	%
Nationality
Kazakhs	234	79.7
Russians	25	8.5
Ukrainians	18	6.2
Other nationalities	16	5.6
Age range
50–54	91	30.9%
55–59	99	33.7%
60–64	82	28.1%
65–69	16	5.6%
70 and older	5	1.7%
Education
Secondary	109	37.2%
Secondary Special	90	41.7%
Higher	29	21.1%
Marital Status
Married	174	59.5%
Divorced	90	30.8%
Single	29	9.7%
Employment Status
Employed:	159	54.3%
(a) engaged in physical labor	89	30.4%
(b) engaged in security activities	62	21.1%
(c) other areas of employment	8	2.8%
Non-employed:	134	45.7%
(a) pensioners	59	20.1%
(b) war invalids	12	4.1%
(c) invalids due to other groups of diseases	63	21.5%

.

The ethnic composition of war veterans demonstrated variation, with the predominant group being of Kazakh nationality (n = 234, 79.7%). The majority of the studied veterans were within the working age range (79.9%), comprising manual workers, security personnel, and other professions such as self-employed individuals and employees of educational institutions. Among the 134 unemployed veterans (45.7%), twelve individuals (2.8% or 4.1% of the total sample) were identified as disabled war veterans. Participants reported experiencing injuries including wounds, closed craniocerebral injuries, and concussions, often as a result of explosions in the combat zone in Afghanistan, which necessitated hospitalization. An additional sixty-three veterans (21.5% of the total) were assessed as having disabilities of I–III degree for various disease categories. The largest demographic segment (n = 99; 33.7%) was within the age group of 55–59 years, whereas the smallest segment (n = 5; 1.7%) was aged 70 years and above. A significant proportion of veterans (n = 231; 78.9%) possessed secondary or specialized secondary education, with the majority being married (n = 174; 59.5%).

A notable observation from the interview with veterans of the Afghan war was the high prevalence of traumatic events experienced during combat activities. The veterans reported a persistent sensation of stress and danger, attributable to injuries, wounds, adverse weather conditions, and an aggressive external environment. The subjects noted infectious diseases (such as malaria, hepatitis, dysentery, among others) and non-infectious conditions (including chronic lower back and back pain, gastric ulcers). Consequently, the lack of adequate medical intervention during service contributed to the development and progression of chronic symptoms and diseases over an extended period following the conflict. According to the interview data, fewer than 30% of veterans regard themselves as being in good health. They are registered with dispensaries or monitored at their residences by specialists such as neurologists (54.1%), endocrinologists, and general practitioners (54.1%), who provide outpatient and inpatient care on an annual basis.

3.2. Results of Psychodiagnostic Methods

A significant psychological consequence of exposure to combat conditions is post-traumatic stress of various severities, along with associated psychopathological symptoms. To determine the presence or absence of PTSD symptoms, the Mississippi PTSD Scale (military version) was administered to war veterans, while the civilian version was employed in the control group. Based on the responses to the Mississippi Scale (military version) and the established threshold value (≥ 78 points), war veterans were categorized into two groups: Group I (n = 74, 25.2%), consisting of veterans with subclinical PTSD, and Group II (n = 219, 74.8%), comprising veterans without PTSD (

Table 2. Comparative analysis of the Mississippi Scale indicators for the diagnosis of PTSD in war veterans and the control group (M ± SD).

Indicator	Veterans with Subclinical PTSD, n = 74	Veterans Without PTSD, n = 219	Control Group, n = 149	p-Value
Mississippi PTSD Scale	92.85 ± 14.69	68.06 ± 5.15	63.40 ± 7.93	p1 < 0.001
				p2 < 0.001
				p3 = 0.005

Note. p₁—veterans with subclinical PTSD and veterans without PTSD, p₂—veterans with subclinical PTSD and control group, p₃—veterans without PTSD and control group.

).

The aforementioned threshold value was selected based on prior research findings demonstrating its effectiveness in detecting clinically significant or subclinical PTSD symptoms within military populations [39].

The results presented in Table 2 demonstrate significant differences in the Mississippi PTSD scores between the study groups. Veterans with an average score of 92.85 ± 14.69 points on the scale were classified as veterans with subclinical PTSD. A statistically significant difference was found compared to the control group (63.40 ± 7.93, p₂ < 0.001). Thus, subclinical PTSD is considered an intermediate condition characterized by pronounced, but insufficient for diagnosis, manifestations of traumatic stress and demonstrating partial post-traumatic symptoms (1–3 clusters of symptoms). Such emotional and behavioral disorders can significantly affect the quality of life in the long term in individuals who took part in military operations. Another group of veterans was classified as veterans without PTSD and had lower average values relative to the control group (68.06 ± 5.15, p₃ = 0.005). This group had less pronounced symptoms of stress reactions, which indicates better adaptation to civilian life and less susceptibility to post-traumatic manifestations.

The SCL-90-R symptomatic questionnaire facilitated a more detailed and comprehensive evaluation of the emotional state of the subjects, as well as the identification of psychological symptoms that may suggest the presence of specific somatic diseases such as arterial hypertension (AH), ischemic heart disease (IHD), and gastric ulcer (

Table 3. Comparison of psychopathological symptoms based on the SCL-90-R questionnaire among subgroups of veterans with subclinical PTSD, without PTSD, and the control group.

Scale	Veterans with Subclinical PTSD/Veterans Without PTSD			Veterans with Subclinical PTSD/ Control Group			Veterans Without PTSD/ Control Group
	U1	Me1	p1	U2	Me2	p2	U3	Me3	p3
Somatization (SOM)	1025	0.04	0.354	116	0.37	0.016 *	404	0.33	0.030 *
Obsessive–Compulsive Disorders (O-S)	804	0.25	0.014 *	60.5	0.65	<0.001	293.5	0.4	0.001 ***
Interpersonal Sensitivity (INT)	967	0.34	0.185	88.5	0.56	0.001 **	344.5	0.22	0.005 **
Depression (DEP)	998.5	0.04	0.268	79	0.43	0.001 ***	288	0.39	0.001 ***
Anxiety (ANX)	1049	0.2	0.442	121.5	0.5	0.023 *	382	0.3	0.016 *
Hostiles (HOS)	1020	0.17	0.333	64.5	0.45	<0.001	261	0.28	0.0002 ***
Phobic Anxiety (PHOB)	784.5	0.21	0.009 **	52.5	0.64	<0.001	245	0.43	<0.001
Paranoid Symptoms (PAR)	108	0.30	0.008 **	108	0.3	0.007 **	424.5	0.13	0.048 *
Psychoticism (PSY)	1010	0.25	0.276	17.5	0.21	0.351	610	0.04	0.898
Global Symptom Severity Index (GSI)	771.5	0.25	0.008 **	11	0.58	<0.001	138.5	0.33	<0.001

Note. U—Mann–Whitney test, Me—Median, * p < 0.05, ** p < 0.01, *** p < 0.001.

).

The analysis of pairwise comparisons regarding the severity of psychopathological symptoms, as measured by the SCL-90-R questionnaire (Table 3), reveals distinctions in the studied parameters among veterans with PTSD symptoms, veterans without PTSD, and the control group. These differences may be attributed to the specific clinical features of PTSD, which is not solely a stress response but also a complex disorder impacting emotional, cognitive, and somatic components. On the “Somatization” scale, the differences between veterans with PTSD symptoms and those without PTSD were not statistically significant (p₁ = 0.354); however, both groups showed significant differences from the control group (p₂ = 0.016, p₃ = 0.030), indicating elevated levels of somatic complaints. Regarding the Obsessive–Compulsive Disorders scale, veterans with subclinical PTSD scored higher than veterans without PTSD (p₁ = 0.014) and the control group (p₂ < 0.001). Additionally, significant differences were observed between veterans without PTSD and the control group on this scale (p₃ = 0.001). The increase in obsessive symptoms observed in both subgroups of veterans may be associated with attempts to cope with uncontrollable memories of traumatic events through repetitive behaviors or obsessive thoughts. Veterans frequently experience social isolation, feelings of misunderstanding from others, and increased vulnerability in interpersonal relationships. This is substantiated by the values on the Interpersonal Sensitivity scale, where scores are significantly higher in both groups of war veterans compared to the control group (p₂ = 0.001, p₃ = 0.005), although no significant differences were observed between the veteran groups (p₁ = 0.185). There were no significant differences between veterans on the Depression scale (p₁ = 0.268); however, both groups demonstrated statistically significantly higher values than the control group (p₂, p₃ = 0.001). The Anxiety indicator was elevated and significantly different in veterans with subclinical PTSD and in veterans without PTSD symptoms when compared to the control group (p₂ = 0.023, p₃ = 0.016). The Hostility scale revealed significant differences between the two veteran groups and the control group (p₂ < 0.001, p₃ = 0.0002, respectively). Furthermore, the fear of recurrence of a traumatic event can lead to the development of specific phobias and avoidance behaviors, which is reflected in an increase in the Phobic Anxiety scale. Consequently, the values observed were significantly higher among veterans exhibiting PTSD symptoms compared to the other veteran cohort (p₁ = 0.009) and surpassed those in the control group (p₂ < 0.001). Veterans without PTSD also demonstrated higher scores than the control participants (p < 0.001). Regarding the Paranoid Symptoms scale, higher scores were recorded in veterans with subclinical PTSD when compared to veterans without PTSD (p₁ = 0.008) and the control group (p₂ = 0.007). Additionally, veterans without PTSD significantly differed from the control group (p₃ = 0.048). The Psychoticism scale did not show statistically significant differences among the groups (p₁, p₂, p₃ > 0.05), which may suggest relative stability of this indicator across the examined participants. The “Global Symptom Severity Index” was notably higher in veterans with PTSD symptoms relative to both veterans without PTSD (p₁ = 0.008) and the control group (p₂ < 0.001). Veterans without PTSD also exhibited an elevated index compared to the control group (p₃ < 0.001), indicating the presence of an overarching psychopathological burden even in the absence of clinical PTSD symptoms.

According to

Table 4. Correlation analysis using Spearman’s coefficient (r) between PTSD symptoms, as measured by the Mississippi Scale (MS), and the scores of the SCL-90-R questionnaire in war veterans exhibiting subclinical PTSD.

MS
Indicators	r	p-Value
Somatization (SOM)	0.624 *	0.015
Obsessive–Compulsive Disorders (O-S)	0.253	0.359
Interpersonal Sensitivity (INT)	0.686 **	0.006
Depression (DEP)	0.723 **	0.003
Anxiety (ANX)	0.569 *	0.029
Hostiles (HOS)	0.462	0.084
Phobic Anxiety (PHOB)	0.551 *	0.036
Paranoid Symptoms (PAR)	0.019	0.945
Psychoticism (PSY)	0.302	0.269
Global Symptom Severity Index (GSI)	0.581 *	0.025

Note. * p < 0.05, ** p < 0.01.

, veterans with subclinical PTSD exhibited significant positive correlations between PTSD symptoms and several indices of the SCL-90-R questionnaire, namely: somatization, depression, anxiety, phobic anxiety, interpersonal sensitivity, and the overall symptom severity index. A moderate to high positive correlation was observed between PTSD symptoms and the Somatization index (r = 0.624 *, p = 0.015), thereby corroborating the role of somatic symptoms as integral components of the post-traumatic response. Furthermore, a highly significant positive correlation was identified with the Interpersonal Sensitivity index (r = 0.686 *, p = 0.006). Consequently, greater severity of PTSD is associated with increased discomfort in interpersonal interactions among veterans, manifesting as vulnerability and heightened sensitivity to criticism. This relationship suggests that PTSD contributes to social withdrawal, suspicion, relationship difficulties, and serves as a pivotal factor in social maladjustment. Additionally, a robust positive correlation was established between PTSD symptoms and the Depression indicator (r = 0.723 **, p = 0.003), indicating that veterans experience symptoms such as loss of interest, apathy, and diminished motivation. The Anxiety indicator also demonstrated a positive correlation (r = 0.569 *, p = 0.029) with PTSD symptoms, accompanied by a pronounced anxious background characterized by persistent anticipation of danger, nervousness, and tension. A highly significant positive association was found with the Phobic Anxiety index (r = 0.551 *, p = 0.036), which may manifest through avoidance behaviors and panic reactions. Regarding the “General Symptom Severity Index,” a moderately high positive correlation was observed (r = 0.581 *, p = 0.025), affirming that increased PTSD severity corresponds with heightened overall psychological symptomatology, thereby evidencing a profound link between PTSD and general mental maladjustment—including disorders related to self-control, self-esteem, and social interaction. This may also indicate a high likelihood of developing comorbid disorders. The correlation analysis underscores a broad spectrum of psychosomatic and affective disorders, even in the absence of a formal PTSD diagnosis, highlighting the importance of early detection and intervention. To evaluate anxiety levels among the studied groups, the standardized Spielberger–Khanin questionnaire was employed. The analysis of psychodiagnostic data obtained from this instrument revealed statistically significant differences in levels of personal and situational anxiety between the two veteran groups and the control group (

Table 5. Results of self-assessment of anxiety levels using the Spielberger–Khanin questionnaire (M ± m).

Type of Anxiety	Veterans with Subclinical PTSD, n = 74	Veterans Without PTSD, n = 219	Control Group, n = 149	p-Value
Situational anxiety (points)	44.96 ± 6.39	41.43 ± 6.03	29.87 ± 6.5	p1 = 0.379 p2 < 0.001 p3 < 0.001
Personal anxiety (points)	44.14 ± 5.49	42.55 ± 6.24	36.13 ± 6.82	p1 = 0.753 p2 = 0.003 p3 = 0.002

Note: p₁—veterans with subclinical PTSD and veterans without PTSD, p₂—veterans with subclinical PTSD and control group, p₃—veterans without PTSD and control group.

).

Veterans exhibiting subclinical PTSD demonstrated a moderate level of situational anxiety, averaging 44.96 ± 6.39 points. The data are significantly elevated in comparison to the control group, which recorded an average of 29.87 ± 6.5 **, p₂ < 0.001. This suggests a marked reactivity to stressful situations. Nonetheless, no statistically significant differences were observed between the two veteran groups, with p₁ = 0.379. Veterans presenting PTSD symptoms were characterized by increased irritability, emotional instability, a tendency towards mood swings, and feelings of fear and panic in environments reminiscent of combat conditions. Additional features included signs of excessive suspiciousness, suspicion of others, hyperreactivity to potential threats, and unwarranted health anxiety. Consequently, in this cohort, elevated anxiety levels manifest through prominent vegetative symptoms (such as shortness of breath, feelings of air deprivation, hand trembling, and muscle tension) and behavioral symptoms (including avoidance of anxiety-provoking situations and difficulties with concentration). These factors contribute to a vicious cycle, as illustrated in Figure 1.

This diagram in Figure 1 illustrates the mechanism of development and consolidation of psychosomatic disorders, comprising three components: 1. Chronic anxiety is characterized as a persistent state of internal tension and worry, which may endure for an extended period; 2. Somatic symptoms refer to physical manifestations (e.g., rapid heartbeat, dizziness, chest pain, etc.), that do not invariably have an organic cause but can be associated with psychological states [40,41,42,43,44]; 3. Anxiety encompasses acute anxiety attacks that can be intensified by somatic symptoms and further exacerbate the anxious state, thereby forming a vicious cycle. A similar pattern was observed concerning personal anxiety, with the highest values noted in the group of veterans with subclinical PTSD (44.14 ± 5.49 points), which also statistically surpasses the control group’s indicators (36.13 ± 6.82 **, p₂ < 0.003). Consequently, personal anxiety is a consistent indicator predominantly determined by individual personality traits, including temperament, genetics, and socio-environmental influences. Among veterans exhibiting symptoms of PTSD, this predisposition is amplified by the experience of severe traumatic events, rendering them more susceptible to everyday stressors and predisposing factors for the onset of anxiety disorders and exacerbation of PTSD symptoms. The distinctions between veterans without PTSD and the control group were statistically significant (p₃ = 0.002). Although veterans without PTSD do not exhibit pronounced anxiety, an underlying tension related to their experienced events persists. In stressful circumstances, a transient deterioration of condition may occur, which can contribute to psychoemotional exhaustion and a decline in quality of life. Notably, no significant differences were observed between the two veteran groups (p₁ = 0.753). The data suggest a higher level of personal and situational anxiety among veterans with subclinical PTSD, as well as an overall increase in anxiety in veterans compared to the control group. An analysis of depression severity, using the Beck Depression Inventory (BDI), indicated a significant difference between the subgroups (Figure 2).

According to Figure 2, veterans exhibiting subclinical PTSD demonstrate a higher level of depression (13.32 ± 1.36) in comparison to both veterans without PTSD (8.61 ± 0.65, p < 0.001) and the control group (4.06 ± 0.75, p < 0.0001). In this cohort, elevated depression levels are characterized by specific symptoms, including a pessimistic outlook on the future, intrusive memories, recurrent re-experiencing of the injury event, the loss of a comrade, and captivity. The depression level in veterans without PTSD is significantly greater than that in the control group (p < 0.001). Regarding the control group, individuals without combat experience exhibit an average score within the normal range on the BDI. These findings corroborate the pronounced comorbidity between depressive symptoms and PTSD, despite an average of 39.7 ± 3.3 years having elapsed since active military service [45,46], and suggest an increased risk of developing depression even among veterans lacking a clinical PTSD diagnosis. Beyond severe mental health disorders, war veterans frequently suffer from various somatic illnesses. Data extracted from outpatient records indicate that war veterans were admitted for inpatient treatment with diagnoses including the consequences of other and unspecified cerebrovascular diseases (I69.8) in 44.8% of cases, and less frequently, unspecified encephalopathy (G93.4) in 9.3%. The diagnoses also encompass cerebrovascular insufficiency (CVI) graded 2–3 (with mixed etiology, including atherosclerotic, hypertensive, vascular, traumatic, and other causes), as well as multiple comorbidities, ranging from one to ten concurrent conditions (

Table 6. Comorbidity of PTSD symptoms and multiple disorders in two groups of war veterans and a control group.

Diseases	Veterans with Subclinical PTSD, n = 74	Veterans Without PTSD, n = 219	Control Group, n = 149	χ2	p-Value
	n (%)	n (%)	n (%)
Discirculatory encephalopathy (DEP) stage 2	29 (39.2%)	106 (48.4%)	15 (10.3%)	χ21 = 1.89 χ22 = 26.48 *** χ23 = 59.04 ***	p1 = 0.169 p2 < 0.001 p3 < 0.001
Discirculatory encephalopathy (DEP) stage 3	3 (3.9%)	20 (11.4%)	3 (2%)	χ21 = 1.97 χ22 = 0.79 χ23 = 7.67 **	p1 = 0.160 p2 = 0.375 p3 = 0.005
Arterial hypertension (AH) stage 1	12 (16.5%)	25 (7.2%)	5 (3.4%)	χ21 = 1.15 χ22 = 11.61 *** χ23 = 7.69 **	p1 = 0.282 p2 = 0.001 p3 = 0.005
Arterial hypertension (AH) stage 2	22 (30.1%)	40 (18.3%)	15 (10.1%)	χ21 = 4.35 * χ22 = 13.81 *** χ23 = 4.69 *	p1 = 0.36 p2 < 0.001 p3 = 0.030
Arterial hypertension (AH) stage 3	33 (45.2%)	65 (29.8%)	32 (21.3%)	χ21 = 5.53 * χ22 = 12.8 *** χ23 = 3.07	p1 = 0.019 p2 < 0.001 p3 = 0.079
Ischemic heart disease (IHD)	34 (45.5%)	68 (31.1%)	20 (13.4%)	χ21 = 5.41 * χ22 = 28.5 *** χ23 = 15.14 ***	p1 = 0.020 p2 < 0.001 p3 < 0.001
Diabetes mellitus (DM) type 2	15 (20.3%)	23 (10.4%)	9 (6.1%)	χ21 = 4.68 * χ22 = 10.42 ** χ23 = 2.22	p1 = 0.031 p2 = 0.001 p3 = 0.136
Sensory disorders	14 (18.9%)	44 (20.1%)	29 (19.7%)	χ21 = 0.04 χ22 = 0.01 χ23 = 0.02	p1 = 0.827 p2 = 0.923 p3 = 0.882
Chronic obstructive pulmonary disease (COPD)	6 (7.8%)	21 (9.4%)	7 (4.7%)	χ21 = 0.15 χ22 = 1.05 χ23 = 3.02	p1 = 0.703 p2 = 0.306 p3 = 0.082
Spinal diseases	15 (20.7%)	76 (34.6%)	21 (14.1%)	χ21 = 5.38 * χ22 = 1.39 χ23 = 19.4 ***	p1 = 0.020 p2 = 0.237 p3 < 0.001
Other concomitant diseases	8 (10.5%)	30 (13.7%)	18 (12.1%)	χ21 = 0.41 χ22 = 0.08 χ23 = 0.20	p1 = 0.523 p2 = 0.781 p3 = 0.651

Note. * p < 0.05, ** p < 0.01, *** p < 0.001. χ²₁—veterans with subclinical PTSD/veterans without PTSD, χ²₂—veterans with subclinical PTSD/control group, χ²₃—veterans without PTSD/control group.

).

According to Table 6, differences in the prevalence of several chronic diseases were observed between two groups: war veterans and the control group. The data demonstrate the comorbidity of PTSD with multiple somatic diseases. Veterans with subclinical PTSD, compared with the control group, were more frequently diagnosed with grade 2 DEP (39.2% vs. 10.3%, p₂ < 0.001), grade 2 hypertension (30.1% vs. 10.1%, p₂ < 0.001), grade 3 hypertension (45.2% vs. 21.3%, p₂ < 0.001), coronary heart disease (45.5% vs. 13.4%, p₂ < 0.001), and type 2 diabetes (20.3% vs. 6.1%, p₂ = 0.001). Conversely, chronic obstructive pulmonary disease (COPD), spinal diseases, and other comorbidities did not exhibit statistically significant differences from the control group. These findings support the hypothesis regarding the association of PTSD with cardiovascular diseases and metabolic disorders [47], consistent with established mechanisms of stress and its physiological impacts [48]. Regarding veterans without PTSD, compared to the control group, increased prevalence was observed for grade 2 DEP (48.4% vs. 10.3%, p₃ < 0.001), grade 2 hypertension (18.3% vs. 10.1%, p₃ = 0.030), coronary heart disease (31.1% vs. 13.4%, p₃ < 0.001), and type 2 diabetes (10.4% vs. 6.1%, p₃ = 0.136). No statistically significant differences were identified between the groups concerning other somatic diseases (p > 0.05 in all cases). Accordingly, war veterans without PTSD exhibit a higher degree of comorbidity with cardiovascular diseases and diabetes. This phenomenon may be attributed to the long-term effects of military service in high-risk zones on veterans’ somatic health, even in the absence of pronounced PTSD symptoms.

4. Discussion

Post-traumatic stress disorder (PTSD) is widely recognized as one of the most prevalent disabling conditions among military personnel and war veterans, often progressing to a chronic state. Accurate diagnosis can be challenging due to symptom overlap with depression, anxiety [49,50], and obsessive–compulsive disorder [51]. Moreover, there is a paucity of research concerning the etiology of PTSD, as well as its comorbid forms and related pathologies.

As part of our research, we analyzed the characteristics of the impact of chronic stress related to PTSD on the development of mental disorders and cardiometabolic diseases within the study and control groups.

The definition of subclinical PTSD varies across studies [52,53]. In our study, a threshold of ≥78 points was selected to indicate an increased severity of PTSD symptoms that remains below the established diagnostic cutoff for the Mississippi PTSD Scale.

The mean values on the Mississippi scale in veterans with subclinical PTSD (92.85 ± 14.69) demonstrated statistically significant differences compared to veterans without PTSD (68.06 ± 5.15, p₁ < 0.001) and the control group (63.40 ± 7.93, p₁ < 0.001). These findings may indicate the presence of pronounced post-traumatic experiences that do not meet the criteria for a clinical diagnosis but significantly influence emotional well-being and behavior. Elevated rates may reflect enduring emotional tension, which hampers social integration, promotes social isolation, and diminishes quality of life. These results align with prior scientific research, which has established the impact of PTSD on psychological health, sleep quality, and social adaptation [54,55]. In recent years, subclinical forms of PTSD, characterized by the presence of traumatic symptoms that do not meet all diagnostic criteria, have garnered increasing scholarly and clinical interest. Theoretical and empirical research demonstrates that subthreshold PTSD may be associated with significant disturbances in mental health and the functioning of cognitive, emotional, and physiological systems [56]. The chronic nature of subclinical symptoms aligns with models of cumulative stress and latent vulnerability. According to the cumulative stress hypothesis [57], exposure to repeated or prolonged stressors results in allostatic load, a state of physiological exhaustion arising from the body’s continual adaptation to stressors. Even in cases where PTSD symptoms do not reach the diagnostic threshold, their persistence can induce biochemical, neuroendocrine, and behavioral alterations, thereby contributing to the decline of mental and physical health. Concurrently, the latent vulnerability model [58] posits that certain individuals possess an inherent biological and psychological predisposition to develop post-traumatic stress disorder. Subclinical manifestations of the disorder may go unnoticed and be undervalued by both clinical professionals and the veterans themselves, thereby diminishing the propensity to seek professional assistance. Consequently, post-traumatic stress disorder (PTSD) can advance and exacerbate the overall health condition of military veterans. This underscores the importance of paying attention to, monitoring, and potentially implementing preventive measures for even the subclinical forms of PTSD.

Contemporary research indicates that the psychotraumatic repercussions of combat stress continue to substantially influence the psychosomatic health of veterans [2,59]. Furthermore, biological aging intensifies numerous health issues and diminishes cognitive functions [60], which may further exacerbate the symptoms of PTSD further. According to the conceptual framework of delayed PTSD [61,62], characteristic symptoms may manifest or worsen years or even decades following the initial trauma, particularly when individuals are subjected to new stressors or experience age-related physiological changes. This phenomenon largely accounts for the persistent or emerging symptoms of PTSD observed in Afghan war veterans 36 to 46 years post-service. Additionally, some data suggest premature aging among veterans, with biological age surpassing chronological age by an average of 15.6 years [63]. Consequently, a 50-year-old veteran may exhibit organ and system conditions akin to those of a 65-year-old individual, thereby increasing the risk of premature mortality before the age of 60, a rate significantly higher than that observed in the general population.

According to the SCL-90-R questionnaire (Table 3), combat veterans, in comparison to the control group, demonstrate a statistically significant increase in the level of psychopathological symptoms, even in the absence of clinically manifested PTSD. Elevated scores on the Somatization scale observed in both groups of veterans relative to the control group are consistent with existing literature, which indicates a tendency for individuals exposed to combat stress to exhibit mental stress manifesting as somatic symptoms [64]. Additionally, the severity of symptoms on the Obsessive–Compulsive Disorders scale among veterans, particularly those with subclinical PTSD, was higher than that in the control group (p₂ < 0.001). This may reflect an attempt at subjective regulation of anxious experiences and may also indicate a difficulty in adapting to a changing social environment, a phenomenon frequently noted in individuals with post-traumatic experiences. The primary manifestations of the disorder included unwanted thoughts, obsessive images, repeated actions, and a propensity to doubt. Additionally, noteworthy differences observed in the Interpersonal Sensitivity and Depression scales (p₂, p₃ = 0.001) further corroborate the existence of disturbances within the emotional-regulatory domain, as well as indications of diminished self-esteem and social isolation. Simultaneously, the degree of depression persisted at elevated levels irrespective of the severity of PTSD, suggesting a possible cumulative impact of combat experience. The scores for Anxiety, Phobic Anxiety, and Paranoid Symptoms were notably heightened among veterans exhibiting subclinical PTSD. This validates the hypothesis that subclinical manifestations of PTSD are associated with heightened autonomic activation and mistrust of others, thereby complicating the adaptation process. The General Symptom Severity Index was notably elevated in both veteran groups in comparison to the control group (p₂, p₃ < 0.001). This indicates that the existence of a sustained psychopathological burden, even in the absence of a clinical diagnosis of PTSD, is crucial for the early identification and prevention of mental disorders in individuals exposed to traumatic stress.

The results of the correlation analysis (Table 4) affirm the complex nature of symptoms in veterans with subclinical PTSD. Notably, a high positive correlation was observed between PTSD symptoms and the “Depression” indicator (r = 0.723 ***, p = 0.003), indicating a profound affective disorder associated with the post-traumatic condition. Similarly, a positive correlation was identified with “Interpersonal sensitivity” (r = 0.686 **, p = 0.006), suggesting difficulties in social adaptation and increased vulnerability to interpersonal stressors characteristic of this population. A positive correlation with the “Somatization” indicator (r = 0.624 *, p = 0.015) reflects the psychosomatic manifestation of emotional experiences. Additionally, the indicators of “Anxiety” (r = 0.569 *, p = 0.029) and “Phobic anxiety” (r = 0.551 *, p = 0.036) further confirm the presence of persistent anxious tension and avoidance behaviors associated with military trauma. Our study revealed moderately high rates of anxiety according to the Spielberger–Khanin questionnaire and its relationship with PTSD symptoms among former participants of the Afghan war (Table 4). This association was reported by researchers Goodson, J. et al., and Knowles K.A. et al. [65,66]. In our studied groups of veterans with subclinical PTSD, the level of personal anxiety, as an indicator of individual anxiety, was high compared to the control group (44.14 ± 5.49, p₂ = 0.003). These individuals tend to perceive a threat to their self-esteem and life in a wide range of situations and react with a very pronounced state of anxiety. Regarding situational anxiety as an indicator of the intensity of experiences that arise from typical events, a high level was also observed (44.96 ± 6.39, p₂ < 0.001). The predominant features included increased fatigue, a feeling of constant tension, self-doubt, impaired concentration, and a tendency towards negative forecasting. Concerning the group of veterans without PTSD, they exhibit a moderately high level of both personal (42.55 ± 6.24, p₃ < 0.002) and situational (41.43 ± 6.03, p₃ < 0.001) anxiety in comparison to the control group. Although veterans exhibiting PTSD symptoms scored higher on the scale compared to those without PTSD, the difference did not achieve statistical significance for situational (p₁ = 0.379) and personal (p₁ = 0.753) anxiety. In the control group, personal anxiety was measured at 36.13 ± 6.82 points and situational anxiety at 29.13 ± 6.82 points, both significantly lower than those observed in the veteran groups. This suggests a stable emotional background, a reduced predisposition to anxiety disorders, and the absence of chronic stress exposure, which are characteristic features of combat veterans.

In our study, we observed a relatively high prevalence of depression among war veterans and identified statistically significant differences between the groups. It was determined that veterans exhibiting PTSD symptoms demonstrated a markedly higher severity of depressive symptoms compared to both veterans without PTSD (8.61 ± 0.65, p < 0.001) and the control group (4.06 ± 0.75, p < 0.001). These findings align with those of other researchers; for instance, in an online survey involving 1250 US servicemen in Afghanistan, conducted twenty years after the conflict, depressive symptoms continued to intensify in 75% of participants, while 32% experienced increasing episodes of anger, and 64% suffered from mental health issues [67]. Similarly, Vietnam War veterans exhibited elevated levels of depression comorbid with PTSD even after four decades or more [68]. Another investigation focusing on Iraq and Afghanistan war veterans reported a high prevalence of comorbid conditions: PTSD was diagnosed in 29% of cases, and depression in 25% [69]. In summary, most research indicates that PTSD among veterans significantly contributes to the exacerbation of depressive symptoms, and up to 9% of outpatient visits within military medical facilities are attributed to depression [14]. The statistically significant differences identified between the groups substantiate the role of combat experience and PTSD in the development of a psychopathological background. Furthermore, they suggest the influence of additional factors on the level of depression within these groups. Consequently, in the cohort of veterans without PTSD, the high prevalence of mental disorders was linked not only to the life experience of traumatic events but also to disability, previous surgeries, unemployment, and housing issues, thereby corroborating the hypothesis of social causality in poor mental health [70,71,72]. Conversely, the control group exhibited scores within the normal range on the Beck Depression Inventory, which permits its consideration as a relatively psycho-emotionally stable sample. The data obtained underscore the significance of screening not solely for PTSD, but also for associated depressive conditions in veterans, irrespective of the primary diagnosis. Furthermore, they highlight the necessity for psychosocial support and ongoing monitoring of military veterans over the long term. Moreover, a correlation has been identified between the comorbidity of PTSD and the subsequent development of somatic illnesses, often emerging decades later in veterans of the Afghanistan conflict. This association is corroborated by other research, such as the study by Dursa E. et al., which demonstrated a substantial relationship between combat exposure and the prevalence of chronic diseases among diverse veteran cohorts (including those from Vietnam, Iraq, and Afghanistan) [73], encompassing complaints such as fatigue, headaches, muscle pain, and somatic symptoms [74,75]. Consequently, consultations with Afghan veterans reveal persistent symptoms including headaches (56%), dizziness (46.5%), fatigue (36%), joint pain (48.4%), and lower back pain (84.3%). In conjunction with subjective complaints, a comparison was conducted regarding the incidence rates of various diseases between the two veteran groups and the control group, based on medical records (see Table 6). The findings align with contemporary research on the association between PTSD and the development of cardiovascular diseases [17,76,77]. Consequently, in the cohort of veterans with subclinical PTSD, grades 2 and 3 hypertension are notably more prevalent compared to the group without PTSD (45.2% vs. 29.8%, p₁ = 0.019) and the control group (45.2% vs. 21.3%, p = 0.030). This may suggest a potential correlation between PTSD and more severe hypertension, as well as significant disturbances in vascular tone regulation, which corroborates the modern concept of “comprehensive strain” [78,79]. According to this model, the persistent activation of the physiological stress systems within the hypothalamic–pituitary–adrenal (HPA) axis results in cumulative “physiological wear and tear” on the body. This condition indicates a disruption in the regulatory equilibrium among the neuroendocrine, immune, cardiovascular, and metabolic systems, which over time elevates the risk of cardiovascular disease (CVD), diabetes, immune dysfunction, and accelerated biological aging. Recent research substantiates that veterans suffering from PTSD exhibit elevated comprehensive strain scores even decades following combat exposure [80,81].

Veterans exhibiting symptoms of PTSD demonstrated a significantly higher prevalence of coronary heart disease (45.5% vs. 31.1%, p₁ = 0.020) in comparison to veterans without PTSD, as well as when compared to the control group (45.5% vs. 13.4%, p = 0.001). This may be attributable to chronic stress, inflammatory changes, and metabolic disorders common among patients with PTSD. Additionally, the incidence of type 2 diabetes mellitus (DM) among veterans with PTSD was markedly higher (20.3% vs. 10.4%, p₁ = 0.031). This finding may reflect impaired glucose regulation associated with chronic stress and inflammation. A similar pattern was observed when compared to the control group (20.3% vs. 6.1%, p = 0.005), indicating the involvement of stress-induced metabolic disorders in disease pathogenesis. Although no statistically significant differences were identified in the prevalence of grade 2 cerebrovascular insufficiency (CVI) between the veteran groups (p > 0.05), grade 3 CVI was more prevalent among veterans without PTSD (11.4% vs. 3.9%). This may be attributable to variations in stress levels, mental state, and cognitive impairment, as well as the possibility of more rapid progression of other diseases that influence the development of CVI in veterans with PTSD symptoms. No significant association was detected between PTSD and respiratory, spinal, and sensory disorders (p > 0.05), suggesting their probable independence from the presence of PTSD or the impact of other risk factors unrelated to traumatic experiences. Consequently, the findings align with the study conducted by Dario Nakić et al., which reported a high incidence of chronic diseases among Croatian war veterans compared to the general population [82], thereby supporting the hypothesis and the existence of a close relationship between psycho-emotional disorders and somatic illnesses.

5. Conclusions

The study’s findings demonstrate that, irrespective of the severity or absence of PTSD symptoms, war veterans continue to suffer from mental disorders and somatic illnesses that tend to deteriorate over time. Furthermore, the presence of PTSD symptoms in veterans significantly amplifies psychopathological manifestations, thereby contributing to the progression towards a chronic trajectory of depressive, anxiety, and adaptation disorders. A consistent association has been identified between PTSD and various somatic conditions, including severe hypertension, coronary heart disease, and type 2 diabetes mellitus. The diagnosis of PTSD symptoms is frequently complicated by the concurrent course of comorbid conditions, an increase in the number of medications administered, a high incidence of traumatic events, and the age-related characteristics of the studied population. This emphasizes the necessity for comprehensive long-term mental health support systems that address not only the clinical diagnosis of PTSD but also subclinical and residual symptoms that may contribute to the development of chronic psychopathology. Considering that the study participants belong to the working-age population, their health status bears broader implications for the socio-economic development of the nation. It is essential to maintain the provision of effective healthcare for this group of veterans, which can contribute to the sustainability of the labor market and reduce long-term healthcare costs. These findings underscore the importance of early identification of psychosomatic disorders and can inform the development of tailored intervention strategies and health policies aimed at enhancing veterans’ quality of life and preventing long-term disability. Furthermore, the results contribute to a deeper understanding of the long-term dynamics of trauma-related disorders in post-conflict populations. In this context, effective treatment necessitates a comprehensive, interdisciplinary approach that includes a detailed anamnesis, assessment of PTSD symptoms, usage of standardized psychodiagnostic methods, and preventive measures focused on early intervention, targeted treatment, and improving the quality of life of individuals with chronic PTSD.

6. Limitation

A potential limitation pertains to the absence of comprehensive formal validation of the questionnaires employed in the Kazakh language. Nonetheless, the translation process was conducted collaboratively by the authors and a linguist, with subsequent verification for conceptual and semantic precision. Future research should undertake a thorough psychometric validation of these questionnaires. Although socio-demographic data were gathered, their analysis was not pursued, as the primary objective of the study was to examine the relationship between PTSD and psychosomatic indicators. Moving forward, it is essential to consider the impact of these factors. Given that the study employed a cross-sectional design, data were collected at a single point in time, which precludes the possibility of monitoring the progression of symptoms and conditions over a period.