Tuesday, July 11, 2017

මනෝ විද්‍යා මහාචාර්‍ය දයා සෝමසුන්දරම් මහතා සමග :The Psychosocial Impact of PTSD in Sri Lanka


මනෝ විද්‍යා මහාචාර්‍ය දයා සෝමසුන්දරම් මහතා සමග මම පරියේෂණ ලිපි කිහිපයක්  ලියා තිබේ. ඒ අතර Essentials of Global Mental Health (Published by Cambridge University Press  Section 4 ( 23) Child soldiers by Professor Daya Somasundaram and Dr Ruwan M. Jayatunge ලිපිය නම් කල හැකිය​. මෙම පත්‍රිකාව අප ලියන්නේ පශ්චාත් ව්‍යසන ක්ලමථ අක්‍රමතාව (PTSD) ගැනය​.

(Daya Somasundaram is a senior Professor of Psychiatry at the Faculty of Medicine, University of Jaffna, and a consultant psychiatrist working in northern Sri Lanka for over two decades. He has also worked in Cambodia for two years in a community mental health programme with the Transcultural Psychosocial Organisation. Apart from teaching and training a variety of health staff and community-level workers, his research and publications have mainly concentrated on the psychological effects of disasters, both man-made wars and natural tsunami, and the treatment of such effects. He is a clinical associate professor at the University of Adelaide.)


The Psychosocial Impact of PTSD in Sri Lanka
Prof Daya Somasundaram, Dr Ruwan M Jayatunge

Posttraumatic stress disorder (PTSD) is a stress-related psychiatric disorder that is thought to emerge from complex interactions among traumatic events, multiple genetic factors (Zannas, Provençal & Binder, 2015) personality, past history and social support.   It is a major public health concern in both civilian and military populations, across race, age, gender, and socio-economic status (Soltis et al., 2014). PTSD develops after exposure to trauma such as physical or sexual assault, injury, combat-related trauma, natural or manmade disaster or death (Boccia et al., 2015). In addition Post-traumatic stress disorder can be acquired vicariously from witnessing traumatic events (Patki et al., 2015).

Posttraumatic stress disorder can affect quality of life, causing distress, impairing psychosocial and occupational functioning and overall well-being (Schnurr et al., 2009). PTSD can manifest itself in different clinical forms. The repetition syndrome can appear a long time after the traumatic event, following a paucisymptomatic latency period, which can last several years or even decades (Auxéméry, 2012). It has lifetime prevalence that is close to 10%. (Jorge, 2015).


PTSD and Sri Lankan Experience 

In the past few decades Sri Lankan society experienced man made and natural disasters that generated a large number of victims with PTSD. In the early days PTSD was a new diagnostic entity and some of the clinicians refused to believe that PTSD is emerging in Sri Lanka. Most of the victims were undiagnosed and untreated. In time there developed a collective trauma affecting society in mega proportions. These traumaticevents might have adverse intergenerational consequences.


1971 Uprising and Psychotrauma

The 1971 uprising that was led by the JVP or the People’s Liberation Front made an unsuccessful attempt to overthrow the Government by launching an island wide attack of the Police stations. The revolt was brutally crushed and over 12,000 youths were killed. (Figures estimated by Fred Halliday). Over 18, 000 were arrested and kept in various prisons and detention centers. The suspects were often tortured and some were kept in terrible conditions under the Jaffna Hammond Hill prison. A large number of suspects as well as civilians underwent traumatic conditions as a result of the 71 Insurrection. A considerable number of the ex rebels still experience intrusions, distrust, avoidance and emotional numbing even after 38 years of the 71 insurrection (Jayatunge, 2011).


1983 Communal Riots

In July 1983, anti Tamil riots broke out following   the ambush and killing of 13 Sri Lankan Army soldiers. Soon after this incident, the mob attacked the Tamil civilians killing and looting their property. The riots in 1983 created a massive collective trauma and many victims suffered posttraumatic stress. After the 1983 riots, a large number of traumatized youth joined various Tamil militant groups and fought against the Government Forces. Tens of thousands fled to Western Countries and to India. Thousands are still living with the posttraumatic memories of the 83 racial riots.


The Insurgency in 1988/89

The JVP launched its 2nd Insurgency during the time 1988/89 which cost the lives of over 60,000 people. The 88/89 terror period marked by killings of civilians as well as destruction of national assets. Unspeakable atrocities were committed against humanity during this terror period and the nation went through its darkest phase.  The Insurgency in 1988/89 created a bulky numbers of PTSD in the country. Some psychological studies indicate that a vast amount of victims as well as perpetrators of the 88/89 insurgency suffer from malignant PTSD.


Tsunami Disaster 2004

2004 December 26th Tsunami disaster was the immense natural disaster faced by Sri Lankans in its recent history. Over 30,000 people lost their lives and nearly 545,715 people became displaced. Tsunami 2004 created a deep psychological impact on the affected population.

PTSD is common after a major disaster (Kun et al., 2009).  As reported by Hollifield and team (2008) a   large minority of adults in one area of Sri Lanka reported significant psychiatric and somatic symptoms and impairment 20-21 months after the tsunami.

At 3 to 4 weeks after the December 2004 tsunami disaster Neuner and colleagues  (2006) assessed symptoms of posttraumatic stress disorder (PTSD) in 264 children who lived in severely affected coastal communities in Manadkadu (northern coast), Kosgoda (western coast), and Galle (southern coast) in Sri Lanka. The prevalence rate of tsunami-related posttraumatic stress disorder (PTSD) (ignoring the time criterion) ranged between 14% and 39%.


The Armed Conflict in Sri Lanka

Exposure to war zone stressors is common, yet only a minority of soldiers experience clinically meaningful disturbance in psychological function (Telch et al., 2015). Vasterling and colleagues   (2010) pointed out that Combat severity was more strongly associated with symptom increases among active duty soldiers with higher baseline PTSD symptoms.A considerable proportion of the more than 200,000 service members who participated in 30 long armed conflict in Sri Lanka were exposed to traumatic combat related events. Veterans who participated in the Eelam War have been found to be at increased risk for PTSD.

PTSD has been identified as one of the most commonly occurring mental illnesses in combatants (Abeyasinghe et al., 2012). A study done by Hanwella and team (2012) found a prevalence of PTSD in Sri Lanka in the Special Forces of 1.9% and among the regular forces of 2.9%. Fernanado and Jayatunge (2014) found 6.7% PTSD rate among the members of the Sri Lanka Army who were referred to the Psychiatric unit Military Hospital Colombo during 2002 to 2006.


Civilians Affected by the War

Unlike many earlier wars, which consisted mainly of soldiers meeting and dying in battlefields, civilians were also heavily affected by warfare (Kesternich et al, 2014) resulting in greater physical and mental tolls (Searing et al., 2013). Exposure to conflict, war and disaster situations impact on fundamental family and community dynamics resulting in changes at a collective level (Somasundaram, 2007).

Following the 30 year armed conflict in Sri Lanka civilians from the North and South suffered heavy loses. A large numbers experienced war related psycho traumatic reactions. An epidemiological survey done by Somasundaram and colleagues (2002) found 27% PTSD among the civilian population in Nothern Sri Lanka.  Southern part of Sri Lanka was mainly affected by the LTTE suicide bombings aiming civilian targets. These attacks created mass fear and uncertainty affecting the psychological health and well-being of the civilians.


War related Internal Displacements

Displacement, whether due to conflict, natural disasters or development, not only directly and negatively affects those who are displaced, but also can have far-reaching effects on the culture and society as a whole ( Jayathilaka & Amirthalingam, 2015).  The armed conflict in Sri Lanka uprooted a large number of families. An estimated 200,000 people fled overseas, while the large majority remained internally displaced on the island (Profiles on Internal Displacement.: Sri Lanka, 2005). According to Hussain and team (2011) among residents of Jaffna District in Sri Lanka, prevalence of symptoms of war-related mental health conditions was substantial and significantly associated with displacement status and underlying trauma exposure.


Children Affected by the Armed Conflict

Children worldwide have recently been exposed, more than ever, to the escalating brutality of war, political violence, ethnic strife, and large-scale terrorism (Klingman, 2007). War-related loss during middle childhood and adolescence presents significant risk for adverse mental health and dysfunction in young adulthood in addition to exposure to other war-related traumatic events (Morina, von Lersner & Prigerson 2011). Children and adolescents exposed to traumatic experience in a disaster can suffer from high levels of post-traumatic stress (Yule et al., 2000).

Over the past three decades a large number of Sri Lankan children exposed to cumulative traumatic events associated with war. War related violence, displacement negatively contributed to children’s psychological health.

Militant use of children in Sri Lanka became an acute problem with the Eelam War. The LTTE (Liberation Tigers of Tamil Eelam) have long used the practice of child soldiers against the well-equipped and financially robust Sri Lankan Army (Cohn &Goodwin-Gill, 1994). A significant number of child solders got killed in the war. Those who survived suffer deep physical and psychological traumas. These traumas affect their social and cognitive development.   Despite re-education, rehabilitation and social integration processes, a large number of Sri Lankan child solders continue to suffer from the adverse effects of war.


War Widows

The women who were left widows as a result of the Sri Lankan conflict are facing radically altered circumstances. There are estimated tens of thousands of War widows in Sri Lanka. With the death of their husbands; these women have become a psychologically and socially vulnerable group. Most of the women who underwent severe emotional pain still have not completely recovered. Many have become the victims of pathological grief. They are unable to work through their grief despite the passage of time. With the widowhood, they experience identity change, role adjustment and change in social status.

Widowhood is a stressful event for women, often coinciding with health, financial, and relationship losses (Miller   Smerglia &, Bouchet, 2004). War-related widowhood combined with lone motherhood constitutes a significant factor for elevated psychopathology (Morina & Emmelkamp 2012). In 2005, 86 Sri Lankan war widows were clinically interviewed based on Beck’s depression scale and depression was diagnosed in 23. Ten war widows said that they had contemplated suicide after they lost their husbands (Jayatunge, 2014).


Culture and PTSD

The relationship between trauma and culture is an important one because traumatic experiences are part of the life cycle, universal in manifestation and occurrence, and typically demand a response from culture in terms of healing, treatment, interventions, counseling, and medical care (Wilson, 2007). There are cultural differences in reaction to trauma.  Cultures influence the shape of PTSD over time (Jones et al., 2013).

The culture and history of Sri Lanka reveal that PTSD types of illnesses were common in the ancient days, and the recognition of this malady was not unique to the West.  Ancient and modern narratives tell of the posttraumatic symptomatology of the trauma victims (Jayatunge, 2012). Sri Lankan culture is enriched by the values of Buddhism, Hinduism, Islam and Christianity. Strong cultural ideals work as bufferes against psychotrauma. De Zoysa and Wickrama (2011) reported that unique religious and cultural coping strategies helped a group of Sri Lankan wounded veterans to improve their perceived mental health.


PTSD and Post War Sri Lanka

Post-war societies are marked by the effects of massive, large group traumatization (Delić et al., 2014). Direct experience of violence and poverty increase the risk of PTSD (Muldoon & Downes,    2007).

According to the World Health Organization (WHO) at least 10% of individuals who experience traumatic events will suffer from mental health conditions (Siriwardhana et al., 2013). The combination of the tsunami and civil war has taken a tremendous toll on the economic status of the country and has damaged the psychological health of the citizens (Sritharan & Sritharan, 2014).  In Sri Lanka PTSD prevalence estimates varying from 2.8 to 40% (Hollifield et al, 2008; Siriwardhana et al., 2013).

Exposure to prolonged violence, natural disasters and displacements have created robust post traumatic reactions among the victims. These Post-traumatic responses impact the psycho social well-being of the population. As reported by Knipe and colleagues (2014) the epidemiology of suicide in Sri Lanka has changed noticeably in the last 30 years and it had one of the highest rates in the world. The survivors experience numerous mental health problems. Therefore, major psychosocial interventions are required to restore the damages caused by the war and natural disasters.

Promotion of human rights and justice are the key way to reinstate the social equilibrium. The victims of trauma need appropriate treatment psychosocial support and culturally sensitive rehabilitation. Apart from these measures infrastructure reconstruction and reconciliation should be focused in the post war Sri Lankan society.


Treatment Measures

In the modern day Sri Lanka, the psychological victims of   trauma are treated with Allopathic medicine, traditional Ayurvedic medicine, Psychotherapy and Spiritual therapies. Psychiatrists treat the war trauma victims with depression and PTSD and other anxiety related disorders with SSRIs (Selective serotonin re-uptake inhibitors) and sometimes combine antipsychotics when there are signs of severe disturbed behavior with psychotic manifestations. Ayurvedic specialists use various types of traditional remedies to ease the anxiety. Psychologists and Psychotherapists often use Person-centered (Rogerian) therapy, EMDR, and Cognitive behavior therapy.  According to Jayatunge (2014) EMDR has been successfully used to treat Tsunami victims and combatants who were affected by war trauma.


Psychosocial Rehabilitation

Rehabilitation is an ecological approach that aims at the long term recovery and maximum self-sufficiency. In 1996 the World Health Organization came out with a consensus statement on psychosocial rehabilitation. The WHO defined psychosocial rehabilitation as a process that facilitates for individuals who are impaired, disabled or handicapped by a mental disorder to reach an optimal level of independent functioning in the community. Many physically and psychologically traumatized individuals need psychosocial rehabilitation to recover. Warren (2002) of the view that addressing the broader emotional, social and economic needs of survivors is a critical aspect of the rehabilitation process. Support survivors in becoming reintegrated into all aspects of community life, including education, employment, recreation, and social and political activities.


Conclusion

Sri Lanka is challenged by the adverse effects of two youth uprisings, 30 year internal armed conflict and a great natural disaster in 2004. During the past four decades a large number of people were exposed to traumatic events. A generation of people suffered from psychological aftermath of man made and natural disasters. Significant number of individuals are living with emotional scars.

Various trauma related ailments such as PTSD, Adjustment Disorders, Depression, Somatization etc have found among the victims. Some of the psycho trauma reactions are still undiagnosed and victims do not receive adequate treatments. However these psycho traumas affect the psycho social well-being of the victims, their families and to the society. Effective treatment and psycho social rehabilitation measures should be implemented to help the individuals affected by psycho trauma and prevent future violence. These treatment measures should reflect the concepts of recovery with the ability to live a full and meaningful life.


References 

Abeyasinghe, N.L., de Zoysa, P, Bandara, K.M., Bartholameuz, N.A., Bandara, J.M.(2012).The prevalence of symptoms of Post-Traumatic Stress Disorder among soldiers with amputation of a limb or spinal injury: a report from a rehabilitation centre in Sri Lanka.  Psychol Health Med. 2012;17(3):376-81.

Auxéméry, Y. (2012).Posttraumatic stress disorder (PTSD) as a consequence of the interaction between an individual genetic susceptibility, a traumatogenic event and a social context.Encephale. ;38(5):373-80.

Boccia, M., D’Amico, S., Bianchini, F., Marano, A., Giannini, A.M., Piccardi, L.(2015). Different neural modifications underpin PTSD after different traumatic events: an fMRI meta-analytic study. Brain Imaging Behav.

Cohn, I., Goodwin-Gill, G.S.(1994).Child Soldiers: The Role of Children in Armed Conflict.Clarendon Press.

Debeer, B.B., Kimbrel, N.A., Meyer, E., Gulliver, S.B., Morissette, S.B.(2014).Combined PTSD and depressive symptoms interact with post-deployment social support to predict suicidal ideation in Operation Enduring Freedom and Operation Iraqi Freedom veterans.Psychiatry Res.  30;216(3):357-62.

Delić, A. , Hasanović, M. , Avdibegović, E., Dimitrijević, A. , Hancheva, C. , Scher, C , Stefanović-Stanojević, T. , Streeck-Fischer, A, Hamburger A.(2014).Academic model of trauma healing in post-war societies. Acta Med Acad.; 43(1):76-80.

de Silva, V.A., Jayasekera, N.E., Hanwella, R. (2012).Smoking among troops deployed in combat areas and its association with combat exposure among navy personnel in Sri Lanka. Subst Abuse Treat Prev Policy.  9;7:27.

De Zoysa, P., Wickrama, T. (2011). Cultural and religious coping and mental health of disabled veterans in Sri Lanka.Journal of Military and Veterans Health, 19(3), 4-12.

Hollifield, M., Hewage, C., Gunawardena, C.N., Kodituwakku, P., Bopagoda, K., Weerarathnege, K. (2008).Symptoms and coping in Sri Lanka 20-21 months after the 2004 tsunami. Br J Psychiatry 192: 39–44.

Hanwella R., De Silva V. (2012).Mental health of Special Forces personnel deployed in battle. Soc Psychiatry Psychiatr Epidemiol. 47: 1343–51.

Husain, F., Anderson, M., Lopes Cardozo, B., Becknell, K., Blanton, C., Araki D., Vithana, E.K. (2011).Prevalence of war-related mental health conditions and association with displacement status in postwar Jaffna District, Sri Lanka. JAMA. 3;306(5):522-31.

Jayathilaka, D., Amirthalingam, G. (2015). The Impact of Displacement on Dowries in Sri Lanka.Brookings LSE Project on Internal Displacement.

Jayatunge, R. M. (2012). Post-Traumatic Stress Disorder (PTSD) – A malady shared by east and west. US Army FSMO Office. Retrieved from


Jayatunge, R.M. (2014).Shell Shock to Palali Syndrome- PTSD Sri Lankan Experience. Sarasavi Publishers. Sri Lanka.

Jones, E., Vermaas, R.H., McCartney, H., Beech, C., Palmer, I., Hyams, K., et al. (2003).Flashbacks and post-traumatic stress disorder: the genesis of a 20th-century diagnosis Br J Psychiatry.; 182: 158–63.

Jorge, R.E.(2015).Posttraumatic stress disorder.Behavioral Neurology and Neuropsychiatry. doi: 10.1212/01.CON.0000466667.20403.b1.

Kesternich, I., B. Siáinger, J. P. Smith, and J. K. Winter (2014). “The E§ects of World War II on Economic and Health Outcomes across Europe”, Review of Economics and Statistics, Vol. 96, 103-118.

Klingman, A. (2007).Children and War Trauma. Child Psychology in Practice. 2. Research Advances and Implications for Clinical Applications.

Knipe, D.W. , Metcalfe, C., Fernando, R., Pearson, M., Konradsen, F., Eddleston, M., Gunnell, D. (2014). Suicide in Sri Lanka 1975-2012: age, period and cohort analysis of police and hospital data. BMC Public Health.  13; 14:839

Kun P., Han, S., Chen, X., Yao, L.(2009).Prevalence and risk factors for posttraumatic stress disorder: a cross-sectional study among survivors of the Wenchuan 2008 earthquake in China.Depress Anxiety.;26(12):1134-40.

Morina, N., von Lersner, U., Prigerson, H.G.(2011).War and bereavement: consequences for mental and physical distress. PLoS One.  ;6(7):e22140.

Morina, N., Emmelkamp, P.M.(2012).Mental health outcomes of widowed and married mothers after war.Br J Psychiatry. ;200(2):158-9.

Miller, N.B., Smerglia, V.L, Bouchet N.(2004).Women’s adjustment to widowhood: does social support matter?J Women Aging.;16(3-4):149-67.

Muldoon ,O.T., Downes, C. (2007). Social identification and post-traumatic stress symptoms in post-conflict Northern Ireland.Br J Psychiatry.  ;191:146-9.

Neuner, F.1., Schauer, E., Catani, C., Ruf, M., Elbert, T.(2006).Post-tsunami stress: a study of posttraumatic stress disorder in children living in three severely affected regions in Sri Lanka.J Trauma Stress. ;19(3):339-47.

Patki, G., Salvi, A., Liu, H., Salim, S. (2015).Witnessing traumatic events and post-traumatic stress disorder: Insights from an animal model.Neurosci Lett.  . pii: S0304-3940(15)00427-9.

Profiles on Internal Displacement. Sri Lanka. Compilation of the information available in the Global IDP Database of the Norwegian Refugee Council. (2005).

Schnurr, P.P., Lunney, C.A., Bovin, M.J., Marx, B.P.(2009).Posttraumatic stress disorder and quality of life: extension of findings to veterans of the wars in Iraq and Afghanistan. Clin Psychol Rev.  ; 29(8):727-35.

Searing, E.A,. Rios-Avila, F, Lecy, J.D.(2013).The impact of psychological trauma on wages in post-conflict Bosnia and Herzegovina.Soc Sci Med.  ;96:165-73.

Siriwardhana, C., Adikari, A., Bortel, T.V., McCrone, P., Sumathipala, A. (2013). An intervention to improve mental health care for conflict-affected forced migrants in low-resource primary care settings: a WHO MhGAP-based pilot study in Sri Lanka (COM-GAP study). Trials, 14:423.

Siriwardhana, C., Adikari ,A, Pannala G, Siribaddana S, Abas M, Sumathipala A, et al. (2013). Prolonged Internal displacement and common mental disorders in Sri Lanka: the COMRAID study. PLoS One.; 22: 8.

Sritharan, J., Sritharan, A. (2014). Post-Conflict Sri Lanka: The Lack of Mental Health Research and Resources among Affected Populations.International Journal of Humanities and Social Science Vol. 4 No. 3.

Soltis, K., Acierno, R., Gros, D.F., Yoder, M., Tuerk, P.W. (2014).Post-traumatic stress disorder: ethical and legal relevance to the criminal justice system.J Law Med Ethics. ; 42(2):147-54.

Somasundaram, D., Jamunanatha, C.S. (2002).Psychosocial consequences of war: northern Sri Lankan experience. In: De Jong JTVM, editor.  Trauma, war and violence: public mental health in socio-cultural context. New York: Plenum;   pp. 205–258.

Somasundaram, D. (2007). Collective trauma in northern Sri Lanka: a qualitative psychosocialecological study. International Journal of Mental Health Systems, 1(1), 5.

Telch ,M.J. , Beevers, C.G. , Rosenfield, D. , Lee, H.J. , Reijntjes, A. , Ferrell, R.E. , Hariri, A.R. (2015).5-HTTLPR genotype potentiates the effects of war zone stressors on the emergence of PTSD, depressive and anxiety symptoms in soldiers deployed to iraq. World Psychiatry.  14(2):198-206.

Vasterling, J.J, Proctor, S.P., Friedman, M.J., Hoge, C.W., Heeren, T., King, .LA., King, D.W. (2010). PTSD symptom increases in Iraq-deployed soldiers: comparison with nondeployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. J Trauma Stress.  ; 23(1):41-51.

Warren, S.C. (2002). Rehabilitation Redefined. The Journal of ERW and Mine Action 6.3

Wilson, J. P. (2007). The Lens of Culture: Theoretical and Conceptual Perspectives in the Assessment of Psychological Trauma and PTSD.Cross-Cultural Assessment of Psychological Trauma and PTSD International and Cultural Psychology Series. pp 3-30.

World Health Organization. (1996). psychosocial rehabilitation: a consensus statement. Geneva: World Health Organization.

Yule W., Bolton, D, Udwin, O., Boyle, S., O’Ryan, D., Nurrish, J.(2000).The long-term psychological effects of a disaster experienced in adolescence: I: The incidence and course of PTSD. J Child Psychol Psychiatry.;41(4):503-11.

Zannas, A.S., Provençal, N., Binder, E.B. (2015).Epigenetics of Posttraumatic Stress Disorder: Current Evidence, Challenges, and Future Directions. Biol Psychiatry. pii: S0006-3223(15)00281-4.

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