A Study on Combat-Related PTSD Among Sri Lankan Army Personnel

 

Dr. Neil J Fernando / Dr. Ruwan M Jayatunge

Abstract

From 1983 to 2009, the Sri Lankan Army engaged in an extended conflict known as the Eelam War, which saw a significant number of soldiers deployed in combat zones for prolonged periods. This relentless exposure to warfare led to a considerable incidence of combat stress among the troops. It was crucial to examine the effects of combat trauma on soldiers. Between March 2002 and December 2006, a clinical study was conducted involving 824 Army personnel who were referred to the psychiatric unit at the military hospital in Colombo due to various battle-related physical and psychological issues, as well as disciplinary infractions.  Each soldier underwent a structured face-to-face interview conducted by the Consultant Psychiatrist of the Sri Lanka Army, utilizing the PTSD Check List based on the DSM-IV criteria. The assessment focused on their combat experiences, personal circumstances, and current mental health status. Out of the 824 servicemen evaluated, 56 were diagnosed with full-blown Post-Traumatic Stress Disorder (PTSD), while an additional 6 exhibited partial PTSD symptoms. Those suffering from PTSD faced numerous psychosocial challenges that adversely impacted their military performance, family relationships, and social dynamics. The identified issues included low life satisfaction, a suboptimal state of physical well-being, diminished motivation, suicidal thoughts, substance abuse, social isolation and instances of domestic violence. To address these complex problems, affected combatants received a combination of pharmacological treatment and psychological therapies aimed at alleviating their symptoms and improving their overall well-being.

  

Key Words: Sri Lankan Army Servicemen, Eelam War, Post-Traumatic Stress Disorder

Introduction

The protracted armed conflict in Sri Lanka, lasting three decades, has given rise to a new cohort of veterans who are increasingly vulnerable to chronic mental health issues stemming from their extensive exposure to warfare. Over 100,000 personnel from the Sri Lanka Army experienced combat situations, either directly or indirectly, during this tumultuous period. Many of these soldiers faced traumatic events that are far beyond the realm of typical human experience, including enduring life in a war-torn environment, fear stemming from threats of enemy assaults, witnessing the deaths and injuries of fellow soldiers, handling human remains, and hearing the desperate cries of the wounded, all while feeling powerless to provide assistance. Such harrowing experiences have profoundly altered their psychological well-being.

As the conflict escalated, particularly during the Eelam War, the Sri Lankan military engaged in nearly 20 major military operations against insurgents from 1987 to 2009, deploying its full combat strength for over 25 years. The culmination of this conflict came in May 2009, when the Sri Lankan government announced a decisive victory over the LTTE, or the Liberation Tigers of Tamil Eelam. However, this military success was accompanied by substantial social repercussions, as both combatants and civilians continue to grapple with the psychological aftermath of the war. A considerable number of soldiers have been diagnosed with Post-Traumatic Stress Disorder (PTSD), highlighting the enduring impact of combat trauma on their lives.

 

The Sri Lankan Armed Conflict

The armed conflict in Sri Lanka was distinct from other global conflicts, characterized by its specific dynamics and underlying issues. This protracted struggle primarily involved the Sri Lankan government forces and the Liberation Tigers of Tamil Eelam (LTTE), a rebel group advocating for racial separation. Initially marked by small-scale guerrilla attacks, the conflict escalated into a full-scale war that predominantly affected the northern regions of the island. From 1976 until its end in 2009, the LTTE executed numerous assaults on both military and civilian targets, resulting in significant casualties and injuries. The group gained notoriety as one of the most formidable terrorist organizations worldwide, leading to its designation as a banned entity in several countries, including the United Kingdom, the United States, India, and Canada.

Employing modern weaponry and unconventional tactics, such as the use of child soldiers and suicide bombers, the LTTE posed a considerable challenge to the Sri Lankan military, which was compelled to mobilize its entire force for nearly three decades. The conflict, known as the Eelam War, became one of the longest-running conflicts in contemporary history. The war left behind a legacy of profound psychological trauma, manifesting as paralyzing anxiety, grief, and hopelessness among the affected populations. The Eelam War also resulted in a significant number of soldiers suffering from combat-related stress, yet the psychological impact on these combatants has received minimal attention. Tragically, the mental scars inflicted by the conflict have not been adequately addressed, and the lingering effects of combat trauma continue to haunt those who served.

 

Methodology

This research was carried out by the Visiting Psychiatrist of the Sri Lanka Army, with the approval of the Medical Advisor of the Sri Lanka Army Medical Corps. Spanning from March 2002 to December 2006, the study involved a thorough screening of 824 Sri Lankan Army personnel from infantry and service units who were referred to the Psychiatric Ward at the Military Hospital following various stress-related symptoms and disciplinary infractions. Notably, this investigation took place while the soldiers remained on active duty. The participants were primarily referred by medical officers from the outpatient department, as well as consultants from both medical and surgical units at Palaly Military Hospital, Victory Army Hospital in Anuradhapura, Colombo, Panagoda and various other military healthcare facilities.

The servicemen exhibited a range of psychological issues, including behavioural disturbances, psychosomatic disorders, symptoms of depression and anxiety, self-harm tendencies, suicide attempts, substance abuse, and stress-related misconduct. The sample comprised 824 individuals, predominantly male (806), with a small female representation (18). Throughout the study, strict client safety protocols were adhered to, ensuring that informed consent was obtained and that the anonymity of participants was maintained. Each soldier underwent a structured face-to-face interview utilizing the PCL-4 (PTSD Checklist for DSM-4) is based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), which was published in 1994.  (American Psychiatric Association, 2000). This assessment tool was adapted from similar trauma questionnaires employed globally to effectively identify cases of PTSD.

  

Results

Study results among the Sri Lankan Army soldiers and officers were as follows:
The PTSD rate was 6.7% following analysis of the questionnaire from 824 combatants.

PTSD Full criteria 56   / Partial PTSD 6

The level of exposure to combat was notably higher for individuals deployed in the northern and eastern regions of Sri Lanka. Consequently, a significant proportion of participants in the study exhibited responses that met the criteria for major depression, generalized anxiety disorder, or post-traumatic stress disorder (PTSD) after their service in these areas.

Among the 824 Sri Lankan combatants assessed, 135 individuals, representing 16.38%, were diagnosed with Adjustment Disorder. Additionally, 129 combatants, or 15.65%, were found to have Depressive Disorder. The study also identified 78 individuals, accounting for 9.46%, with various psychiatric conditions, including Schizophrenia, Bipolar Affective Disorder, and Acute Transient Psychotic Disorder. Furthermore, 65 combatants, or 7.88%, were diagnosed with Somatoform Disorder, while 89 individuals, representing 10.8%, were identified with Dissociative Disorder. The assessment revealed that 27 combatants, or 3.27%, suffered from Traumatic Brain Injury, and 29 individuals, accounting for 3.51%, were diagnosed with Alcohol Abuse and Dependence, as well as Substance Abuse Disorder.  

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

Those who have served in the operational areas (for more than 3 years)	45
Sustained grievous injuries –	15
Sustained non-grievous injuries –	22
Witnessed Killing-	49
Past attempted suicides-	17
Experienced childhood trauma	30

Research indicates that the experience of active combat can significantly contribute to the development of stress-related disorders, including post-traumatic stress disorder (PTSD), among those who have participated in such intense and often life-threatening situations. The psychological impact of engaging in combat is profound, as individuals are frequently exposed to traumatic events that can overwhelm their coping mechanisms. This exposure not only affects their mental health during and immediately after their service but can also lead to long-term psychological challenges. The symptoms associated with PTSD, such as flashbacks, severe anxiety, and emotional numbness, can severely disrupt the lives of combatants, making it essential to understand the relationship between combat exposure.

Discussion

The recognition of posttraumatic stress disorder (PTSD) as a distinct diagnostic category emerged with the publication of the Diagnostic and Statistical Manual (DSM-III), largely influenced by the clinical observations of Vietnamese war veterans (Dadic-Hero et al., 2009). In contrast, despite the onset of the Sri Lankan armed conflict in the early 1980s, PTSD remained largely unacknowledged as a significant mental health issue affecting soldiers for an extended period (Jayatunge, 2014).

This study represents the first investigation into combat-related PTSD within the Sri Lankan context, offering a foundational understanding of the psychosocial challenges faced by combatants involved in the Eelam War. Notably, the research was conducted while many of these individuals were still actively serving in the military, underscoring its relevance and timeliness. Structured interviews were carried out in the Sinhalese language, allowing for a comprehensive assessment of each combatant's military deployment history. In certain instances, the study also involved discussions with commanding officers and family members, ensuring that cultural dimensions of trauma were adequately addressed.

The prevalence of PTSD within military populations is well-documented, attributed to the high frequency and nature of traumatic experiences encountered in combat zones (Romanoff, 2006). Research by Clancy et al. (2006) indicates that factors such as age, extensive combat exposure, and both pre- and post-military traumas contribute to heightened PTSD symptoms.

Sri Lankan combatants experienced prolonged exposure to combat, surpassing the durations faced by veterans of World War II, Vietnam, Korea, and the Gulf War. As a result, a significant number of these soldiers have developed PTSD and other trauma-related mental health disorders, with many cases remaining undiagnosed.

Combat exposure significantly alters the psychological landscape of military personnel. Those who have faced the traumas of war are particularly vulnerable to developing post-traumatic stress disorder (PTSD), as highlighted by Friedman et al. (1994). Research by Collie and colleagues (2006) suggests that nearly 30% of individuals who have served in combat zones may experience PTSD. Furthermore, combatants often grapple with a range of mental health issues, including depression, traumatic brain injury, and substance abuse, as noted by Kane et al. (2013). Gaylord (2006) emphasizes that combat veterans are susceptible to the adverse effects associated with deployment. The current study reveals that a striking 80.35% of combatants diagnosed with PTSD had spent over three years in combat zones, indicating that the length of exposure to combat is a significant risk factor for developing this debilitating condition. 

In addition to the challenges faced by combat veterans, the prevalence of PTSD is also notably high among adult survivors of childhood trauma, including sexual and physical abuse. Research conducted by Ehring and colleagues (2014) underscores that early adversities, such as emotional neglect, parental loss, and abuse, are critical risk factors for the emergence of various psychiatric disorders in adulthood, including PTSD, as supported by findings from Anda et al. (2006) and Burri et al. (2013). The current study further reveals that 53.57% of soldiers diagnosed with PTSD reported having endured adverse childhood experiences, such as physical and sexual abuse, neglect, and the loss of parental figures, highlighting the profound impact of early trauma on mental health outcomes in later life.

The National Vietnam Veterans Readjustment Study, which took place between 1986 and 1988, revealed that the lifetime prevalence of post-traumatic stress disorder (PTSD) among Vietnam veterans was 31% for men and 27% for women, with current prevalence rates at 15% and 9%, respectively, according to the Department of Veterans Affairs (2007). In contrast, the estimated rates of PTSD among veterans of the Iraq and Afghanistan conflicts are approximately 11% and 18%, respectively, although these figures are believed to be underreported (Hoge et al., 2004; Nacasch et al., 2010).

A recent investigation into Sri Lankan combatants shows a significantly lower rate of PTSD, recorded at 6.7%, compared to veterans from Vietnam, Iraq, and Afghanistan. This difference may be due to various cultural and religious influences that serve as protective factors against developing PTSD. These elements not only provide solace but also help in finding meaning in traumatic experiences and encourage quicker post-traumatic growth and recovery after trauma. However, it is important to note that the sample in this study was not randomly selected; rather, it consisted of individuals who were referred for treatment and psychological evaluations. Consequently, the findings may not accurately represent the broader reality of combat trauma within the Sri Lanka Army, suggesting that the actual prevalence of PTSD could be significantly higher, with rough estimates indicating rates between 12% and 16% among soldiers.

In this research, six soldiers were identified as having partial PTSD. The term "partial PTSD" is used in the literature to describe individuals who do not fully meet the diagnostic criteria for PTSD but still exhibit significant symptoms (Kulka, Schlenger, & Fairbank, 1990; Gudmundsdottir & Beck, 2004). Stein and colleagues (1997) note that those with partial PTSD may be missing one or two of the three necessary avoidance or numbing symptoms, as well as one of the two required hyperarousal symptoms. Breslau, Lucia, and Davis (2004) emphasize that PTSD is typically associated with the most severely affected trauma victims, who can be clearly differentiated from those with subthreshold PTSD. However, Dickstein et al. (2013) point out that individuals exhibiting subthreshold PTSD symptoms are at an elevated risk for psychological and functional impairments, including a higher likelihood of suicidal thoughts.

Among the six Sri Lankan soldiers diagnosed with partial PTSD, significant functional impairments were evident, manifesting as difficulties in marital relationships, parenting, and overall quality of life.  Sri Lankan soldiers returning from war encounter a range of psychosocial challenges. Pearrow and Cosgrove (2009) highlight that veterans often experience heightened stress levels due to combat and the associated traumatic events, which can severely disrupt their functioning both during active duty and upon reintegration into civilian life. This pattern was similarly observed in Sri Lankan soldiers suffering from PTSD, who displayed various work-related and psychosocial dysfunctions. Issues such as domestic violence, substance abuse, suicide attempts, and self-harm were prevalent among these individuals. The symptoms stemming from combat trauma significantly affected their marital relationships, vocational stability, and social interactions, underscoring the profound impact of their experiences on their daily lives.

Individuals diagnosed with post-traumatic stress disorder (PTSD) often experience a range of comorbid psychiatric conditions, including depression, various anxiety disorders, and issues related to alcohol or substance abuse and dependence, as noted by Friedman et al. (1994). The presence of these comorbid disorders can significantly hinder both the prognosis and treatment outcomes for those suffering from PTSD, as highlighted by Abram et al. (2013). Epidemiological studies reveal that a considerable majority of individuals with PTSD also fulfill the criteria for at least one additional psychiatric disorder, with a notable portion having three or more such diagnoses (Brady, 2000). In Sri Lanka, combatants with PTSD have been observed to frequently present with other psychiatric issues, including depression, substance use disorders, and, in some cases, psychosis. 

The primary approaches to treating PTSD encompass both psychotherapy and pharmacological interventions. Current guidelines advocate for psychotherapy to be the first-line treatment for PTSD (National Collaborating Centre for Mental Health, 2005). Among the medications commonly prescribed, antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), have been widely utilized (Davidson, 2000; Davidson & Connor, 1999; Cukor et al., 2009). Notable therapeutic interventions identified by Spinazzola, Blaustein, and van der Kolk (2005) include prolonged exposure therapy, cognitive processing therapy, cognitive restructuring, and eye movement desensitization and reprocessing (EMDR), all of which have shown efficacy in treating PTSD. 

In Sri Lanka, combatants suffering from PTSD receive a combination of pharmacological treatments, such as antidepressants, mood stabilizers, antipsychotics, and pain relievers, alongside various psychotherapeutic approaches, including Cognitive-behavioural therapy (CBT), EMDR, and Rogerian therapy. The pharmacological treatments aim to alleviate acute PTSD symptoms and improve sleep quality. Rogerian Person-Centred Therapy provides a supportive environment for combatants to express and process their repressed negative emotions, while Cognitive Behavioral Therapy has been effective in enhancing their social functioning. A study conducted in 2005 involving eighteen Sri Lankan combatants treated with EMDR revealed that twelve participants experienced significant clinical improvement after just five to six sessions of this therapy.

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 considerable number of former combatants have reintegrated into civilian life without undergoing any prior screening, leading to various readjustment challenges. The psychosocial rehabilitation of these war veterans has been acknowledged as an essential aspect of recovery in the country. To effectively meet the diverse needs of combatants affected by the war, a comprehensive array of interventions is necessary, encompassing social, educational, occupational, behavioural, and cognitive strategies.

  

Conclusion

This study marks the first investigation into combat-related posttraumatic stress disorder (PTSD) in Sri Lanka, focusing specifically on soldiers from the Sri Lankan Army who served during the Eelam War. A total of 824 soldiers were subjected to clinical interviews utilizing the PTSD Checklist for DSM-4, which identified 56 individuals exhibiting full-blown PTSD symptoms. The findings underscore the emergence of combat-related PTSD as a pressing mental health concern for these veterans. Those grappling with the aftermath of war-related trauma encounter significant difficulties across various facets of their lives, including personal relationships, job performance, and social engagements. The long-term effects of such trauma have profoundly impacted their mental health and overall functionality. To effectively address and alleviate the consequences of combat trauma in Sri Lanka, it is imperative to implement targeted interventions. Additionally, further research is crucial to thoroughly assess the extent of combat-related trauma among these veterans, ensuring they receive the essential psychosocial support and treatment necessary for their recovery.

  

Acknowledgments

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

2)     Gen (Dr) Sanjeewa Munasinghe – Colonel Commandant of the Sri Lanka Army Medical Corps

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