Monday, August 14, 2017

Combat Related PTSD Among The Sri Lankan Army Servicemen


 Dr Neil Fernando and Dr Ruwan M Jayatunge

The study investigated combat related PTSD (Post Traumatic Stress Disorder) and psychosocial problems among Army servicemen who fought in the Eelam War in Sri Lanka. A total of 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 in the period August 2002 to March 2006. The soldiers were administered the PTSD Check List based on DSM 4 with a structured face to face interview  by the Consultant Psychiatrist of the Sri Lanka Army. Among the eight hundred and twenty four (824) Sri Lankan Army servicemen fifty six (56) were found with full blown symptoms of PTSD. The combatants with PTSD experienced psychosocial problems that affected their military, personal and family lives. Disciplinary infractions, low motivation, suicidal ideation, alcohol and substance abuse and family violence were identified among the victims. Effective interventions would be needed to treat combatants with combat related PTSD.

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

The 30 year armed conflict in Sri Lanka has produced a new generation of veterans at risk for the chronic mental health problems that resulted following prolonged exposure to the war. Over 100,000 members of the Sri Lanka Army had been directly or indirectly exposed to combat situations during these years.  A large number of combatants underwent traumatic battle events outside the range of usual human experience. These experiences include constantly living in a hostile  battle ravaged environment,  seeing fellow soldiers being killed or wounded and sight of unburied decomposing bodies, handling human remains,  hearing screams for help from the wounded, and of helplessly watching the wounded die without the possibility of being rescued etc. These war trauma experiences changed their psychological makeup drastically. Following the combat trauma in Sri Lanka, a significant number of combatants of the Sri Lanka Army were diagnosed with Post Traumatic Stress Disorder (PTSD).

 The Sri Lankan Armed Conflict
Sri Lanka’s armed conflict was unique than other global conflicts and it had its own specifications. It was a conflict between the Government Forces and a rebel group better known as the LTTE (The Liberation Tigers of Tamil Eelam) whose intensions were racial separation. The conflict started with small guerrilla attacks and later evolved in to a massive armed conflict. The conflict took place predominantly in the Northern part of Sri Lanka.

The LTTE launched attacks against the military and civil targets from 1976 to 2009 killing a large number of people and disabling thousands. The LTTE was regarded as the most lethal terrorist group in the world. In the subsequent years the LTTE was banned in UK, US, India and in Canada.

The LTTE attacked the Sri Lankan armed forces with modern weapons. The LTTE used numerous unconventional methods to fight the Sri Lankan Forces using child soldiers and suicide bombers.  Sri Lankan military forces had to deploy its entire bayonet strength for nearly 30 years. The Northern conflict became one of the longest conflicts in the recent history.

From 1987 to 2009, the Sri Lanka Army had conducted major military operations against the separatists in which a large number of soldiers participated. In 2009 May the Sri Lankan government declared that the country won the war against the LTTE. The victory came at a huge price. The war caused lasting symptoms of paralyzing anxiety, grief, and hopelessness among the victims. The Eelam War created a collective trauma.
The Eelam War in Sri Lanka had generated a considerable number of soldiers affected by combat related stress. Although psychological trauma experienced by the soldiers was colossal it has been the least discussed. Deplorably Psychological wounds of the Eelam war were not addressed appropriately and the deleterious effects of combat trauma still affect the combatants.

Combat Related PTSD and Sri Lankan Combatants
The prolonged war in Sri Lanka has triggered widespread psychological trauma among the soldiers. The victims experienced intrusive thoughts, flashbacks, nightmares, intense rage, apathy, cynicism, alienation, depression, and mistrust and reduced life interests. These psychological scars affect in their daily lives making them dysfunctional and vulnerable.

The studies have shown that PTSD could be a disabling condition that affects the war veterans. Norris et al. (2002) indicate that Posttraumatic Stress Disorder (PTSD) represents a common, if not the most prevalent, mental health problem in community studies in post-conflict areas.

There were no comprehensive studies to address the combat trauma reactions that surfaced among the Sri Lanka Army soldiers. It became a timely requirement to study the impact of combat stress reactions among the servicemen who faced one of the deadliest conflicts of the 21st Century.

This study was conducted by the Visiting Psychiatrist of the Sri Lanka Army with the permission of the Medical Advisor -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 conducted while the soldiers were still on active duty.

The study sample consisted of servicemen referred to the Psychiatric Unit Military Hospital Colombo during August 2002 to March 2006. 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 designed from similar trauma questionnaires used elsewhere in the world to detect PTSD.

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

PTSD Numbers
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.  The soldiers affected by war trauma had behavioral problems and their productivity was plummeting. Frequently the soldiers who had positive features of combat related stress without any physical disabilities were compelled to serve in the operational areas and engage in active combat. Some were charged with malingering when they tried to seek medical attention. A large number of Sri Lankan soldiers have become deserters over the past few decades. The numbers are exceeding over 50, 000 (AFP, 2011).

Sri Lankan Combatants with Complex PTSD
Some of the Sri Lankan combatants with full blown PTSD showed a wider range of clinical symptomatology with sever psychosocial impairments and these veterans would fit in to the diagnostic category of DESNOS (Disorders of extreme stress not otherwise specified) or Complex Post Traumatic Stress Disorder (C-PTSD). According to Herman (1992) Complex
Post-traumatic stress disorder (C-PTSD) is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma in the context of either captivity or entrapment those results in the lack or loss of control, helplessness, and deformations of identity and sense of self. Luxenberg, Spinazzola, & van der Kolk (2001) elucidate that characteristic of DESNOS is trauma which involves interpersonal victimization, multiple traumatic events, or, events of prolonged duration with disturbances in six areas of functioning  such as   regulation, of affect and impulses,  attention or consciousness, self-perception ,relations with others, somatization  and systems of meaning. During the Eelam War in Sri Lanka a large number of combatants experienced traumatic events that shook their foundations of beliefs about safety. They were exposed to combat for long periods and some had spent over decades in the operational areas constantly facing hostile enemy attacks. War was a cumulative traumatic experience for most of them.

Psychosocial Problems Associated with Combat Trauma
Combatants with war trauma experience problems in their living, working, learning, and social environments. Combat trauma has created potent barriers that obstruct recovery and personal growth. Post war researches of the Vietnam, Iraq and Afghanistan wars have shown that the combat exposure could negatively affect the mental health of the combatants. Hoge et al.(2004) indicate that exposure to combat results in considerable risk of mental health problems, including PTSD, major depression, substance abuse, impairment in social functioning, an inability to work, and the increased use of health care services. These psychosocial problems have domino effects that can last for many years. The Sri Lankan Army Servicemen diagnosed with PTSD need effective psychosocial rehabilitation to acquire functionality, recovery and reintegration.

Alcohol and Substance Abuse
Jacobsen et al. (2001) point out that 22-43% of people living with PTSD have a lifetime, prevalence rate of substance use disorders and the rate for, veterans is as high as 75%. The studies based on Vietnam and Afghan veterans in the US reveal that alcohol and substance abusers could be potential health hazards that go hand in hand with combat trauma. Analysis of data collected in a 1977 U.S. national epidemiologic study of substance abuse revealed that Vietnam veterans had substantially higher levels of alcohol consumption and binge drinking, than comparable groups of Vietnam “era” veterans with no Vietnam service other veterans and non-veterans (Boscarino, 1981).

Alcohol, tobacco and cannabis abuse are most prevalent problems among the Sri Lankan combatants experiencing war trauma and these practices lead to a significant health risk. The soldiers with PTSD often use alcohol and other substances to reduce the impact of intrusive memories, nightmares and break the social isolation. Alcohol and substance abuse have caused intense health, economical and family problems and the veterans need effective coping strategies to overcome the negative influence.

Domestic Violence
Sri Lankan women generally enjoy a higher degree of gender equality than, many women in other countries in the region (UN- Human, Development Report 2001). However in the recent past there have been upsurge in acts of domestic violence and violence against women in Sri Lanka. The impact of the armed conflict on women in Sri Lanka has been felt in different ways by women of different ethnicities and social classes and by, women living in different areas of the country (OMCT 2002). According to the Police Women and Child Protection Bureau of Sri Lanka anywhere from 8,000 to 10,000 cases of domestic violence are reported to police annually. Domestic violence has become a pervasive societal problem in Sri Lanka with the Eelam War.

Combat trauma is a collective ordeal and both soldiers and their families face the psychosocial repercussions of war. Recent research has provided compelling evidence of mental health problems in military spouses and children, including post-traumatic stress disorder (PTSD), related to the war-zone deployments, combat exposures, and post-deployment mental health symptoms experienced by military service members in the family (Nash & Litz ,2013).

Often the families experience frustration, anxiety, marital problems, and behavioral problems. When the stress is overwhelming spouses emotionally distancing themselves from their husbands creating a deep void in the family communication. Combat trauma has created significant unhappiness, stress and conflict in marriages and families. Many spouses and children have become the secondary victims of the war.

The studies have shown that combat trauma linked to domestic violence. A number of studies have found that veterans’ PTSD symptoms can negatively impact family relationships and that family relationships may exacerbate or ameliorate a veteran’s PTSD and comorbid conditions (Price & Stevens, 2010). Jordan et al. (1992) indicate that Male veterans with PTSD are more likely to report marital or relationship problems, higher levels of parenting problems, and generally poorer family adjustment than veterans without PTSD.

Family violence is a widespread problem that occurs among the combatants with PTSD in Sri Lanka. Of the 56 Sri Lankan soldiers with PTSD 13 of them reported that they frequently physically abuse their spouses. They often used force to inflict injury, either emotional or physical, upon their spouses.

Suicide and Deliberate Self-Harm
Suicide is regarded as one of the major public health problems in Sri Lanka and has received considerable attention in recent years.  According to the World Health Organization Sri Lanka has one of the highest rates of suicide in the world (WHO, 1999).   Fernando et al. (2010) argue that deaths from suicide reached a peak in Sri Lanka in 1995. This phenomenon occurred exactly twelve years after the Eelam War.

Numerous researches indicate that there is a correlation between combat trauma and suicidal behaviors (Knox, 2008). Studies suggest that suicide risk is higher in persons with PTSD (Ferrada, Asberg, ., Ormstad, & Lundin 1998). Many researchers believe that    disturbing symptoms of PTSD increase the suicide risk and others of the view that comorbid psychiatric symptoms that are associated with PTSD drive the victims to commit suicide.  Studies estimated that patients suffering from PTSD have up to a seven-fold increased incidence of suicide, and four-fold increased risk of death from all external sources (Bullman &Kang, 1994).

There are many psychosocial and economic factors that contribute to suicides in Sri Lanka. Some Sociologists had viewed that the prolonged armed conflict in the North had drastic effects on the suicide rates in Sri Lanka.  During the past 15 years in war-torn Sri Lanka, it is estimated that nearly 50000 persons have been killed. Deaths due to suicide, in the same period, are estimated to be 106000 – twice the number due to war (WHO, 2001).  A significant number of soldiers have committed suicide in the battlefield during the Eelam War. In addition, a considerable amount of uncompleted suicides and self harm had been reported. ). Based on the said study of the 56 Sri Lankan soldiers diagnosed with PTSD 17 of them had suicidal attempts in the past.  According to the Military Spokesperson of the Sri Lanka Army from 2009 to 2012 postwar period nearly 400 soldiers had committed suicide (Sriyananda, 2012).

Psychosocial Rehabilitation of the Combatants
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 (WHO, 1996).

Combatants with war trauma 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.  Psychosocial Rehabilitation practices help war veteran’s re-establish normal roles in the community, independence and their reintegration into community life. These interventions should help to manage behaviors, perceptions and reactions to the physical / psychological injury or condition which may hold back the process of recovery or maintenance of the veteran’s well-being.

A combat veteran’s transition to civilian society from combat is fraught with complications in familial and interpersonal relations, vocational endeavors, and at times, adherence to societal and legal boundaries (Fairweather & Garcia, 2007).  A range of social, educational, occupational, behavioral and cognitive interventions would be needed to address the needs of the combatants who were affected by war trauma. The Sri Lanka Army combat veterans with PTSD will need an effective psychosocial rehabilitation process to reintegrate in to civilian society after their military service.

Case Discussion

1)                  Private UG met with a blast injury in 1997 near Thaladi camp in the Northern Sri Lanka. He was wounded and psychologically shattered by the blast. After several months of the incident he complained of severe headache, insomnia and unexplainable fear feelings. Private UG experienced nightmares related to the blast injury and always wanted to avoid the places and conversations related to the blast injury. Despite the overwhelming stress he was compelled to serve in the war zone. He became irritated and could not control his anger. Several times he was punished for disciplinary infractions by his platoon leaders. His private life was falling apart as well.  Often he experienced sexual dysfunctions and became abusive towards his spouse.  As a result of family turmoil, his wife left him. Following family problems and work related stress Private UG tried to commit suicide. In 2002 He was referred for psychological therapy and diagnosed with PTSD. He was treated with medication, CBT and EMDR which helped to minimize his anxiety related symptoms.  He was treated as an inpatient at the Military Hospital Colombo and then referred for family counselling.  The follow up revealed that his wife had returned home and Private UG is leading a productive life now.

2)                   Lt BXX26 witnessed the death of seven soldiers in Paranthan (in Northern Sri Lanka) following mortar attacks. Although he was physically unharmed he witnessed how the incoming mortar killed seven of his men immediately. Their bodies were blown in to pieces and this horrible event caused an acute stress reaction in him. Later he was evacuated to Colombo. After the Paranthan incident Lt BXX26 experienced intrusions, flashbacks, nightmares and avoidance. He was diagnosed as having PTSD.  Lt BXX26 felt that he was personally responsible for the deaths of seven soldiers in Paranthan and had severe survival guilt. Following overwhelmed negative feelings several times he tried to commit suicide. His treatment took years and finally the doctors were able to diminish the survival guilt and suicidal ideation.

3)                  L/ Cpl WXX43 became a psychological casualty of the war after handling human remains at Mulative- Comma Point.   He could not forget the decomposed and swollen bodies that he buried. Some of the victims were known to him and some were his platoon members who fought with him against the enemy. The bodies were half swollen and putrefied. Some of the dead bodies were eaten by the Monitor Lizards (Varanus exanthematicus). It was a dreaded picture that he could not forget. Following these events he felt despair. Gradually his nights became disturbed; he was depressed and had no aim in life. He stopped associating with people and became more withdrawn. His mind was full of past combat events and sometimes he had a sense of re-experiencing the traumatic battle events especially the events that occurred at Comma Point. While experiencing PTSD symptoms Corporal W became extremely hostile. Once he physically punished his teenage daughter and she was hospitalized for several days.  He became disgusted with life and numerous times he planned to commit suicide.  He was consuming large amounts of alcohol to evade startling reactions and nightmares. In 2003 he decided to take his own life and took Organophosphate pesticide. His life was saved by immediate hospitalization. After the medical treatment he was referred for a psychological evaluation and found with full blown symptoms of PTSD.

4)                  Private SXXT31 served in the operational area for 9 years and firsthand experienced combat trauma. He witnessed how his unit members got killed following enemy fire, mortar blasts and artillery attacks etc. and became severally overwhelmed while handling human remains. After experiencing these events over a long period he suffered severe transient headaches and loss of memory. By 2002 he was diagnosed with full blown symptoms of PTSD. He was frequently troubled by nightmares and flashbacks. When he experienced flashbacks he used to re live the traumatic event and often became disconnected from reality. Once Private SXXT31 went in to a dissociative flashback and he had squeezed the neck of his five year old daughter. When the little girl was suffocating his wife accidentally noticed the horrible event and alerted the neighbors and saved the little girl from Private SXXT31’s strong grip. The girl was immediately hospitalized and later recovered. Private SXXT31 became extremely distressed and felt guilty after realizing that he tried to strangle his own daughter. He had no memory of the incident and did not realize how he grabbed the daughter’s neck.

5)                  Private MXX33 underwent traumatic battle events in the North and as a result of war trauma he suffered full blown symptoms of PTSD. His condition was undetected and untreated for a number of years. After he became a psychological casualty of the war his behavior changed drastically. He became hostile and several times he was charged with disciplinary infractions. He could not serve in the operational areas. He felt uncomfortable to travel in military vehicles which trigged after seeing a land mine explosion in Mannar and to carry fire arms. He could not get a help from his unit and finally decided to become AWOL. He found a job in a private company as a driver.  While he was employed in the company his PTSD symptoms troubled him once again. He had nightmares, intrusions and flashbacks. His memory was fading and he could not concentrate. His hostile behavior led his wife and children to leave him.  Following stress, isolation and depression he tried to commit suicide by hanging. His neighbors immediately intervened and hospitalized him. At the hospital he revealed that every night in his dreams he used to see the horrible events of the war. When he was experiencing flashbacks he could hear gun fire and the helicopter sounds.   He could not tolerate noises and his emotions had become numbed. After structured clinical interviews Private MXX33 was diagnosed with PTSD and sent for appropriate treatment.  He rejoined the Army and today serves as a productive member. He is now free of suicidal thoughts.

Treatment Methods
In Sri Lanka the psychological victims of war trauma are generally treated with Allopathic medicine, traditional Ayurvedic medicine, Psychotherapy and Spiritual therapies. For treatment procedures of combat related PTSD medication and psychotherapy are widely used.
Drug therapy is an essential component of PTSD treatment in Sri Lanka. Serotonin Reuptake Inhibiters like fluoxatine paroxatine are often used to combat depression and anxiety.  These drugs provide symptomatic relief. Sometimes Antipsychotics (typical and atypical) are prescribed to relieve severe anxiety, agitation, delusions, hallucinations and disordered thought.
Psychotherapy and counselling are important therapies in treating PTSD. According to Bisson et al. (2007) the first-line psychological treatment for PTSD should be Trauma-focused cognitive-behavioural therapy or EMDR (Eye Movement Desensitization and Reprocessing). Among the Psychotherapies CBT and EMDR are broadly used to treat Sri Lankan combatants.   EMDR is one of the evidence based effective approaches in the treatment of PTSD (Bisson et al, 2007). Sri Lankan combat veterans diagnosed with combat related PTSD showed significant improvements from pre- to post treatment following EMDR (Jayatunge , 2008).

Some combatants and their families prefer to use indigenous treatment methods as supportive therapy.  In addition spiritual therapy and meditation (Methha meditation -meditation of loving-kindness, Vipassanna meditation -mindfulness mediation) are widely used in rehabilitation centers.

These 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.

  Dr. Neil Fernando
Dr. Neil Fernando (MBBS, MD) is a Senior Consultant Psychiatrist and a Senior Lecturer at Kotalawala Defense University. He was the visiting Psychiatrist of the Sri Lanka Army.  Dr Neil graduated from the Faculty of Medicine, University of Peradenitya in 1979 and joined the state health service.   Dr Neil Fernando is one of the best known psychiatrists in Sri Lanka today. He is the pioneer in community mental health services in Sri Lanka.   

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