The Combat Related PTSD among the Sri Lankan Army Soldiers who Participated in the Eelam War in Sri Lanka

 Panduwawala, S,   Jayatunge, R.M

 Abstract: This study investigates the prevalence and severity of posttraumatic stress symptoms in a sample of soldiers of the Sri Lanka Army. The study was conducted from August 2002 to March 2006.  Eight hundred and twenty four (824) Sri Lankan Army servicemen of the infantry and services units who were referred to the Psychiatric ward Military Hospital Colombo were screened for combat related PTSD. The DSM- 4 was used to diagnose and determine the probable prevalence rate of posttraumatic stress symptoms. According to the results 56 combatants were found with full symptoms of PTSD and 6 combatants with partial PTSD.

Key Words: PTSD, Sri Lankan Combatants, Eelam War, Combat Trauma

Objectives:  To examine the combat related PTSD symptoms of the soldiers who fought in the armed conflict in Sri Lanka.  

Introduction: Sri Lanka, a country that was seen at the time of independence from Britain in 1948 as a first potential case of development success in the third world, surprisingly transformed subsequently into a state of political conflict and consequent armed struggles (Abeyratne, 2002). The armed conflict in Sri Lanka had many root causes. It was a conflict between the state security forces and Liberation Tigers of Tamil Ealam (LTTE).

The Sri Lanka Army engaged in prolonged military conflict against the armed separatists of the Northern Sri Lanka. The conflict started in 1981 with the killing of two members of the Sri Lanka Army by the rebels. In the early stages the conflict emerged as guerrilla attacks and later evolved into a proxy war. The armed conflict which continued until 2009 came to be known as the Eelam War. Following the armed conflict nearly 26, 0000 soldiers died and a large numbers became physically and psychologically disabled.

When the militants intensified their attacks on military and civil targets, the Sri Lanka Army deployed its entire bayonet strength for more than 25 years. During the critical period of the Eelam War the Sri Lankan military launched nearly 20 major military operations against the rebels starting from 1987 to 2009. Over 100, 000 members of the Sri Lanka Army had been directly or indirectly exposed to combat events during the Eelam War.  They were exposed to hostile battle conditions and many soldiers underwent traumatic combat events outside the range of usual human experience.

In 2009 May the Sri Lankan government declared that the country had won the war against the armed militants. Although the armed forces were able to gain a decisive victory it came with a huge social cost. The Eelam war affected the psychosocial health of the combatants and civilians. Significant numbers are still impacted by combat trauma.

Methodology: This study was conducted by the Visiting Psychiatrist of the Sri Lanka Army with the permission of the Medical Advisor of the Sri Lanka Army Medical Corps. From August 2002 to March 2006, eight hundred and twenty four (824) Sri Lankan Army servicemen of the infantry and services units who were referred to the Psychiatric ward Military Hospital Colombo were screened for combat related PTSD. This study was done while the soldiers were still on active duty.

The study sample consisted of servicemen referred to the Psychiatric Unit Military Hospital Colombo. Mainly the referrals were done by the medical officers of the OPD, Consultants in the Medical and Surgical units, Palaly Military Hospital, Victory Army Hospital Anuradhapura and other military treatment centers. The affected combatants had behavioral problems, psychosomatic ailments, depression and anxiety related symptoms, self-harm, attempted suicides, alcohol and substance abuse, and misconduct stress behaviors. The sample consisted of 824 (male = 806, female = 18) combatants of the Sri Lanka Army.

Client safety guidelines were observed during the study and informed consent was obtained and the methods used ensured participants’ anonymity. These soldiers were administered the PTSD Check List based on the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) with a structured face to face interview. This schedule was designed from similar trauma questionnaires used elsewhere in the world to detect PTSD.   

Results

Study results among the Sri Lanka Army soldiers and officers were as follows:

 PTSD rate was 6.7% following analysis of questionnaire from 824 combatants.

PTSD	No
Full criteria	56
Partial	6

Exposure to combat was significantly greater among those who were deployed in the North and East of Sri Lanka. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after serving in the above mentioned areas.

Among the 824 Sri Lankan combatants 135 (16.38%) were diagnosed with Adjustment Disorder,   129 (15.65%) were diagnosed with Depressive Disorder, 78 (9.46%) were diagnosed with Psychiatric illnesses such as Schizophrenia, Bipolar Affective Disorder and Acute Transient Psychotic Disorder, 65 (7.88%) were with Somatoform Disorder, 89 (10.8%) with Dissociative Disorder, 27 (3.27%) with Traumatic Brain Injury and 29 (3.51%) with Alcohol Abuse and Dependence and Substance Abuse Disorder. 

The combatants with full-blown symptoms of PTSD were found with following associations:

Those who have served in the operational areas (for more than 3 years)	45
Sustained grievous injuries -	15
Sustained none grievous injuries –	22
Witnessed Killing-	49
Past attempted suicides-	17
Experienced childhood trauma	30

Results suggest that exposure to active combat may be responsible for stress reactions such as PTSD among the combatants.      

Discussion:

Posttraumatic stress syndrome (PTSD) was recognised as an unique diagnostic category in the Diagnostic and statistical manual (DSM-III) following the recognition of the clinical picture in Vietnamese war veterans (Dadic-Hero et al., 2009). Although the Sri Lankan armed conflict began in early 1980s for a long period PTSD was not recognized as a debilitating disorder that could affect soldiers (Jayatunge, 2014).

This is the first combat related PTSD study in Sri Lanka and it provides an initial overview of the existing psychosocial problems among the combatants who participated in the Eelam War. The significance of this study is that it was done when most of the combatants were still on active duty.

During the study structured interviews were conducted in Sinhalese language and every combatant’s military deployment history was assessed. In some cases their commanding officers were contacted and family members too interviewed. In addition cultural aspects of trauma were taken in to consideration.

PTSD is widely prevalent in the military community because of the frequency and type of trauma seen in the combat zone (Romanoff, 2006). Clancy et al (2006) found that age, greater combat exposure, and pre-military and post-military traumas are associated with increased PTSD symptomatology. The Sri Lankan combatants had prolonged combat exposure longer than the World War 2, Vietnam, Korean and Gulf War veterans. Following prolonged traumatic combat exposure a large number of soldiers sustained   PTSD and other trauma-related mental health ailments. Some of the PTSD conditions are still undiagnosed.

Combat exposure can change the psychological makeup of soldiers. Military personnel exposed to war-zone trauma are at risk for developing PTSD (Friedman et al., 1994). Collie and colleagues (2006) assume that approximately 30% of people who have been in war zones develop PTSD.  Combatants struggle with depression, PTSD, traumatic brain injury, and substance abuse (Kane et al., 2013).   As indicated by Gaylord (2006) combat veterans are at risk for experiencing the negative effects of deployment.  The findings of the current study specify that among the combatants with PTSD 80.35% had served in the combat zone for more than three years. The duration of combat exposure had been a risk factor.

Ehring and colleagues (2014) indicate that Posttraumatic stress disorder is highly prevalent in adult survivors of childhood sexual and/or physical abuse. Early childhood adversities such as physical and sexual abuse, emotional neglect, parental loss, etc., are major risk factors for the development of a range of psychiatric disorders in adulthood, including posttraumatic stress disorder (Anda et al., 2006; Burri et al., 2013). According to the current study 53.57 % of soldiers with PTSD had experienced adverse childhood traumas such as physical and sexual abuse, neglect and maternal and paternal deprivation.

The National Vietnam Veterans Readjustment Study, conducted 1986-88 found that lifetime prevalence of PTSD among Vietnam veterans was 31% for men and 27% for women. Current prevalence was 15% and 9% respectively. (Department of Veterans Affairs, 2007).The rates of PTSD among veterans of Iraq and Afghanistan are conservatively estimated to be 11% and 18%, respectively, and suspected to be underreported (Hoge et al., 2004 ; Nacasch et al., 2010).

The current PTSD study among the Sri Lankan combatants shows a low PTSD prevalence rate (6.7%) compared to Vietnam, Iraq and Afghanistan veterans. There could be several factors including cultural and religious factors which acted as buffers and protected the combatants from the development of PTSD. However this sample was not randomly selected and it was a presented sample that was refereed for treatment and psychological evaluations. Therefore this study may not reflect the actual picture of combat trauma in the Sri Lanka Army. The actual PTSD numbers may be high. According to rough assumptions PTSD rate among the soldiers of the Sri Lanka Army could be 12 % - 16 %.

In this study six soldiers were found with partial PTSD. Within the literature on PTSD, individuals who fail to satisfy diagnostic criteria yet report notable symptomatology have been termed as experiencing partial PTSD ( Kulka, Schlenger, & Fairbank, 1990; Gudmundsdottir &  Beck , 2004). According to Stein and colleagues (1997) patients with partial PTSD lack one or two of the three required avoidance or numbing symptoms, and/or one of two required hyperarousal symptoms. Breslau, Lucia and Davis (2004) state that PTSD identifies the most severe trauma victims, who are markedly distinguishable from victims with subthreshold PTSD. However Dickstein et al (2013) highlight that subthreshold posttraumatic stress disorder symptomatology is associated with increased risk for psychological and functional impairment, including increased risk for suicidal ideation. Six of the Sri Lankan soldiers with partial PTSD had significant functional impairments such as marital and parenting problems and impairments in quality of life and functioning.

The war affected Sri Lankan soldiers face a number of psychosocial problems. Pearrow and Cosgrove (2009) indicated that veterans’ exposure to heightened levels of stress resulting from combat and associated threatening and catastrophic events can markedly disrupt their functioning, not only while on the front lines but also upon their reentry into civilian life. With regard to Sri Lankan soldiers with PTSD the investigators found the same outcome. The Sri Lankan combatants with PTSD were found to be affected by numerous work related and other psycho social dysfunctions. Domestic violence, Alcohol and substance abuse, attempted suicides and self harms, disciplinary infractions were found among them.  Combat trauma symptoms impacted their marital, vocational, and social function.

The individuals with PTSD frequently suffer from other comorbid psychiatric disorders, such as depression, other anxiety disorders, and alcohol or substance abuse/dependence (Friedman et al., 1994). Comorbid disorders have an adverse impact on the prognosis and treatment of individuals with PTSD (Abram et al., 2013).  Data from epidemiologic surveys indicate that the vast majority of individuals with PTSD meet criteria for at least one other psychiatric disorder, and a substantial percentage have 3 or more other psychiatric diagnoses (Brady, 2000). Sri Lankan combatants with PTSD were found have other comorbid psychiatric disorders such as Depression, Substance Abuse Disorder and sometimes Psychosis.  

The main treatments for PTSD are psychotherapy and medication. Recent guidelines suggest that psychotherapy should be initiated as a first-line treatment for PTSD ((National Collaborating Centre for Mental Health, 2005). The most commonly used medications have been antidepressants, and specifically SSRIs (Davidson, 2000; Davidson & Connor, 1999; Cukor et al., 2009). Spinazzola, Blaustein and van der Kolk (2005) identify prolonged exposure (PE), cognitive processing therapy, cognitive restructuring, and eye-movement desensitization and reprocessing (EMDR) as some of the leading interventions for PTSD.

In Sri Lanka the combatants with PTSD are treated with drug therapy (anti depressants, mood stabilizers, anti psychotics, pain killers etc.) psychotherapy (CBT, EMDR, Rogerian therapy) and traditional healing methods. Drug therapy helps to minimize acute PTSD symptoms and normalize sleep. Rogerian Person Centred Therapy allows the combatants to release their bottled up negative emotions.  Cognitive Behavior Therapy has helped the combatants to improve their social functioning. In 2005 eighteen Sri Lankan combatants were treated with EMDR and twelve of them showed significant clinical improvement after 5-6 sessions of EMDR.

Among the traditional therapies Thovilaya has been identified as a conventional healing method. It is a form of psychodrama geared to heal the patient as well as his environment. Spiritual therapy also plays a vital role in treating soldiers with combat trauma. Spiritual therapy especially Buddhist psychotherapy helps the war victims to find meaning and achieve post traumatic growth.

In Sri Lanka a large number of ex combatants transited to civil society without any prier screening process. Many of them have readjustment problems. Psychosocial rehabilitation of the war veterans have been recognized as a crucial component in Sri Lanka. A range of social, educational, occupational, behavioral and cognitive interventions would be needed to address the needs of the combatants who were affected by the war.

Conclusion 

This study investigated the extent of posttraumatic stress disorder (PTSD) among the soldiers of the Sri Lanka Army who fought in the Eelam War. The findings indicate that combat related PTSD is becoming one of the critical mental health problems among soldiers in Sri Lanka. The affected combatants with war trauma experience problems in their living, working, learning, and social environments. War trauma has drastically impacted their mental health and long-term functioning. Effective measures have to be implemented to heal combat trauma in Sri Lanka. In addition further studies are needed to systematically assess the magnitude of combat trauma among the combatants and provide them appropriate psychosocial treatment.

Acknowledgments

1)      Dr. Neil Fernando -The former Consultant Psychiatrist of the Sri Lanka Army

2)      Gen (Dr) Dudley Perera - The former Medical Advisor -Sri Lanka Army Medical Corps

3)      Gen (Dr) Sanjeewa Munasinghe - Colonel Commandant of Sri Lanka Army Medical Corps

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