The POWs of the Eelam War

 

Dr Ruwan M Jayatunge   

Abstract: This article discusses the psychosocial problems experienced by the POWs of the Eelam War. The Eelam War in Sri Lanka continued for nearly three decades. The rebel group that is known as the Liberation Tigers of Tamil Eelam fought against the Sri Lankan armed forces. The LTTE captured a significant number of servicemen during the armed conflict and most of them were executed disregarding the Geneva Convention. The remaining POWs were handed over to the Sri Lankan Government by the International Committee of the Red Cross. Although the survived POWs are free men today a large numbers are experiencing numerous psychological and physical ailments as a result of the war captivity. The descriptions of clinical cases are provided. These POWs need culturally congruent psychological /psychiatric treatment including holistic psychosocial rehabilitation.

Key Words :  Eelam War , POWs , PTSD , DESNOS ,

The Eelam War in Sri Lanka has caused numerous physical and mental health ailments among the survivors. The POWs suffered extreme conditions. During the armed conflict the LTTE (the Liberation Tigers of Tamil Eelam) captured a considerable number of servicemen from the Sri Lanka Army, Sri Lanka Navy and the Sri Lanka Police Service. Most of the captees were executed by the LTTE. Nonetheless a very small number of POWs managed to escape from captivity. The remaining prisoners of war (POWs) were freed after the interventions by the International Committee of the Red Cross (ICRC) and returned them to the Sri Lankan Government. Although the POWs found their freedom most of them live with psychological scars. They have rigorous impairments in emotional social and physical functioning.

To become a POW in a war is a horrendous experience.  Prisoner of war (POW) captivity can involve the most extreme trauma perpetrated by humans ( Neria  et al., 1998; Hourani &  Hilton, 2002).Throughout human history, those captured in war have presented their captors with the basic choice between immediate execution, immediate release, or continuing custody – holding them in custody pending their release or other disposition (Hickman, 2008). Starvation and the diseases and stresses of imprisonment could impact the POWs immensely. Debilitating events could leave either more frail or more robust survivors, depending on the extent of scarring and mortality selection. The majority of empirical analyses find more frail survivors (Costa, 2012).

The article 4 of the Third Geneva Convention protects captured military personnel from cruel treatment. One of the main provisions of the convention makes it illegal to torture prisoners and states that a prisoner can only be required to give their name date of birth, rank and service number (Third Geneva Convention of 1949). However the POWs of the Eelam War experienced mental and physical torture under their captivity. The harsh treatment of former prisoners of the Eelam War resulted in severe mental and physical health problems.

Though medical consequences of war attract attention, the health consequences of the prisoner-of-war (POW) experience are poorly researched and appreciated (Robson et al., 2009). In this context psychosocial health of the former prisoners of the Eelam War widely misunderstood and under researched.  The long-term psychological and psychiatric sequelae of the POWs of the Eelam War are unknown. Having suffered catastrophic war trauma these victims experience a wide range of psychosocial problems. Psychopathology and psychiatric diagnoses have found among them. Although they need long term care, symptoms of suspiciousness, isolation and detachment prevent them seeking mental health support services.

According to Ursano and colleagues (1981) POWs experience a profound degree of stress during their captivity. The POWs are at risk for developing PTSD (Friedman et al., 1994). After repatriation POWs can develop physical and psychological disorders due to sickness, nutritional deficit, past physical and mental trauma and readjustment problems. The severity of captivity and the presence or absence of social supports during and after the POW experience play major roles in the recovery or illness that may occur after repatriation (Ursano & Rundell, 1990). 

 The POWs Under the LTTE Custody

The LTTE had a number of prison camps in Devipuram,  Thunnukai Mullaivaikkal , Vallipunam Udyarkattu (Victor Base 1) in Northern Sri Lanka. These prisons were heavily-fortified prison complexes. According to the University Teachers for Human Rights Jaffna (UTHR) in early 1990s between 3000 to 4000 Tamil prisoners were held in Thunnukai detention camp by the LTTE (UTHR Chapter 3 :The Tortured community).

The LTTE did not provide accurate information about the captured servicemen and often they were killed after brief interrogations and these victims later fell into the MIA (missing in action) category. In 1990 the LTTE killed nearly 600 police officers in the Vinayagapuram and Trincomalee jungles after their surrender to the rebels.

The LTTE held a number of POWs for many years in secret locations without giving any information to the International Committee of the Red Cross or to the Sri Lankan authorities. During the 2002 Ceasefire Agreement the LTTE Northern leader Theepan (Velayuthapillai Bhagheerathakumar ) informed the Sri Lankan authorities that they had no more prisoners of war. However some of the ex-POWs affirmed that the LTTE held prisoners of war in secret locations in 2002 and after.

According to Silva (2000) in the latter stages of the Eelam War as many as 1,400 men were detained in the LTTE-controlled Vanni area of northern Sri Lanka. In 2009 The Sri Lanka Army 59 Division troops were able to rescue 7 servicemen held captive by the LTTE at Vellamullaivaikkal detention center. By the end of the War in 2009 the LTTE killed a large number of Tamil prisoners including the POWs who were held at the Devipuram prison.

In 2010 the Sri Lanka Police recovered bodies of 26 Sri Lankan soldiers executed by the LTTE in Kilinochchi District. They were taken as prisoners of war by the vanquished rebel group and kept for years before they were executed.  These soldiers had been imprisoned at the Victor Base Prison at Vallipuram in Mullaitivu for more than three years (Ministry of Defence Sri Lanka). The LTTE kept some POWs to bargain with the Sri Lankan Government and their information had been sent to the International Committee of the Red Cross. Nonetheless the POWs were not treated according to the third Geneva Convention and they were kept in deplorable conditions.

The POWs of the Eelam War experienced severe form of stresses under the captivity and they suffered physical torture, humiliation, confinement, boredom and mock executions. Most of the surviving POWs show positive symptomatology of depression and anxiety related disorders. Their psychosocial wellbeing is relentlessly compromised by the effects of past traumas and guilt. In addition these victims are affected by the DDD Syndrome (that consists of debility, dependency and dread) that had been described by Faber, Harlow and West in 1957.

 Commander Ajith Kumara Boyagoda

The senior-most officer in LTTE custody was Commander Ajith Kumara Boyagoda. Commander Boyagoda joined the Navy on September 1974. He was commissioned as a Captain on March 8, 1997. He was the commanding officer of the SLNS "Sagarawardena"-330-tonne large gun boat of the Sri Lanka Navy. The ship had a crew of 42 officers and men. On the 20th September 1994 the ship was attacked by a large group of LTTE boats with suicide crafts in the high seas of Thalpadu in Mannar. Following the attack the ship began to sink. Only 18 people survived including its captain Commander Boyagoda. He became a POW on the 20th September 1994 and was detained for eight years. According to Commander Boyagoda he was well treated by the LTTE except at the beginning when he was kept in solitary confinement. In 2000 he launched a hunger strike demanding family members to visit him. Commander Boyagoda was released in 2002. He is now serving as a Managing Director in a private company.

Private U.S.R.Jayakumara

U.S.R.Jayakumara was a soldier attached to the 3rd Gajaba Regiment of the Sri Lanka Army. He became a POW when the LTTE attacked the Sri Lankan Army and naval base at Pooneryn in 1993. He was held in several locations in the jungle along with other prisoners of war. They were all chained together using a welding machine. It was a painful procedure and all prisoners sustained burn injuries. The wounds were not treated and it became infected. The anguish was unbearable. The captors shifted the POWs around from place to place in the North. They were kept in areas such as Nallur, Kodikamam, Mirisuvil, Periyamadu   Manthikai and Puthukudiyiruppu with no facilities. The POWs were transported in a cruel manner. They were packed tightly kept chained and handcuffed during the journey. Sometimes they were forced to march in the jungle. According to Jayakumara it was a tormenting period and they suffered from mental anguish and bad quality of food. Most of the time they were given pittu and brinjal curry to eat and finally they went on a hunger strike demanding favourable prison conditions. Private Jayakumara had to spend nearly nine years in the LTTE prisons and it became a prolonged interpersonal trauma for him. Finally he was released in 2002 after the interventions by the ICRC.

  

Private S.H. Gunawardena  

Soldier Gunawardena served in the third Battalion, Gajaba Regiment of the Sri Lanka Army. He was captured in 1993 in the Pooneryn attack. He was first pronounced MIA (missing in action) and then reported KIA (killed in action). His family was informed about his death and they held a funeral ceremony. Eventually the family came to know that Gunawardena was alive and detained by the LTTE. The family made frantic efforts to see him. Each time the requests were declined by the LTTE leaders. Private Gunawardene spent more than eight agonizing years as a POW in conditions of extreme privation.   

Private D. K. Hemapala

Private D. K. Hemapala of the third Battalion Gajaba Regiment of the Sri Lanka Army became a POW in 1993 during the Pooneryn attack. His physical health deteriorated rapidly due to maltreatment and callous prison conditions. He died during the captivity in 1998. Private Hemapala was 45 years old.

Lance Corporal P

Lance Corporal P was captured by the LTTE in 1993 and endured the next five and half years in prisoner of war camps. He was deeply traumatized and his psychological wounds were a direct result of his being in the LTTE prison camp. He is a casualty of war, strained by the emotions that had haunted since 1993. When he came home guilt and anger and helplessness built up. He struggled with depression and malignant anxiety.

Lance Corporal P joined the Sri Lanka Army in 1991 as a signalman. After his basic training he was sent to the operational area. In 1993 he was posted to Welioya Senapura Camp. In the same year the LTTE attacked the camp and overran it killing a large number of soldiers. Lance Corporal P was captured alive by the enemy. During the attack he witnessed the killing of his   superior officer. The officer was killed with a mammoty.  After killing the officer his eyes were taken out. Lance Corporal P witnessed this shocking incident with fear and horror. He was then taken to one of the LTTE camps and stripped naked. A group of LTTE child soldiers severely assaulted him with cables and batons.  The beating went for nearly a half hour. He was in pain and bleeding from the ear. One of the leaders came and stopped the beating and gave him water. He was handcuffed and put in a cell. He slept on the damp floor.

The following day Lance Corporal P was taken for questioning. It went for several days. During the interrogations he was savagely beaten, electrocuted and constantly questioned to get classified radio signal codes used by the Sri Lanka Army Signal Corps (SLASC). The interrogators mistakenly identified Corporal P as an officer of the SLASC. When the interrogators could not obtain any vital information from Corporal P, he was subjected to solitary confinement.

For nearly seven months he was kept in solitary confinement with sensory deprivation. After spending a few weeks in the dark small prison cell Corporal P lost his sense of time and orientation. His biological clock became disrupted. After seven months he had disorientation, hallucinations and affective disturbances. After the solitary confinement he was subjected to systematic physical and mental torture.  Several times he was taken to slaughter grounds for mock executions. On one occasion a Tamil prisoner who belonged to a different rebel group (EPRLF) was shot in front of his eyes.

According to Lance Corporal P the guards were extremely brutal in their handling of prisoners of war. Interrogators as well as the prison guards administered beatings and torture frequently. He was handcuffed for interminable periods and kept in painful positions. He was not able to resist torture without cooperating with his captors. He was subjected to psychological manipulation and blackmail. Following the long term repressive conditions, the torture and degradation under which Corporal P suffered resulted PTSD.  Lance Corporal P had to spend nearly five agonizing years as a POW under the LTTE custody. 

He was released in 1998 with the intervention of the International Red Cross. When he came home he could not feel happiness. His emotions were numbed and he had immense fear that the LTTE would capture him again. He had deep suspicion, intrusions, flashbacks, nightmares and suicidal ideation.

In 2000 he was diagnosed as having full blown symptoms of PTSD. Over the years his anxiety disorder has been developed in to a malignant level.  He has numerous DESNOS (Disorders of Extreme Stress Not Otherwise Specified) related symptoms including affect dysregulation, suicidal preoccupation, amnesia, severe guilt and shame, inability to trust people, somatization, hopelessness and despair. In 2005 Lance Corporal P was medically discharged from the Sri Lanka Army following his psychological disability.

Private SXJ

Private SXJ served in the Sri Lanka Sinha Regiment and unexpectedly became a POW during the Operation Riviresa (Operation Sun-rays) in 1995. His captors kept him in a temporary camp along with other prisoners.  This transitory camp was controlled by a LTTE regional leader and it was used as a supply camp. From this camp food, ammunition and medical supplies were sent to the front line.   

According to Private SXJ there were nearly twenty POWs and they were used as conscript labourers to build bunkers. In this prison camp Private SXJ noticed that some POWs were subjected to forced blood draw by the LTTE. The blood was then transfused to the wounded LTTE cadres. After the blood was forcefully drawn the POWs were not given any nourishing supplements. The victims looked extremely weak and exhausted. They had no energy even to stand up. The victims were lying on the floor helplessly.

The POWs were constantly guarded by armed members of the LTTE. There were a number of female cadres and sometimes they did the guard duty. The day time the POWs laboured to build bunkers using heavy Palmyra logs. The prisoners were under fed and constantly beaten. They were tired and exhausted. At night the POWs were kept in a large bunker that was converted in to a prison cell.

The LTTE temporary camp persistently came under fire by the Sri Lankan forces. During an air attack the guards ran for cover. Hence Private SXJ had a chance to escape. He ran deep in to the thick jungle. Some guards fired at him but he escaped without any injury.

Several days he crawled in the jungle. He ate tree leaves and grass to survive. On the third day of his escape Private SXJ met several wood cutters in the jungle and they helped him to come to a remote village. The home guards who defended the village from the LTTE attacks took him to the nearest Army camp.  There he was given food and water then he was hospitalised. Although Private SXJ spent a few weeks under the LTTE captivity he was intensely terrified and suffered an acute stress reaction.

Constable HXC

Constable HXC was one of the captees of the Sri Lanka Police who had spent excruciating period as a POW. He was kept in an awful prison condition along with other POWs. They were subjected to physical and mental torture. Their food rations were irregular and sometimes they were intentionally given rotten food. Many prison inmates suffered from dysentery and skin infections.

According to Constable HXC one of the LTTE prison guards who spoke Sinhala fluently tortured them relentlessly. Sometimes he used to sing Sinhala songs and tortured the POWs. The POWs became extremely frighten when they heard his singing voice. He was released in 2002 during the ceasefire agreement between the Sri Lankan Government and the LTTE. Although Constable HXC is a free man today he has numerous psychological and physical symptoms. He left the Police department and now working as a security guard in a private firm.

Lance Corporal U

Lance Corporal U became a POW in July 1991 during the operation Balawegaya (Operation Power force) one of the largest amphibious operations conducted by the Sri Lankan armed forces. He was wounded during the battle and captured by the enemy. Until his release in March 1995 he was subjected to inhuman treatment. He struggled with depression and anger. He had always been angry at his captors. He was beaten a number of times and threatened to be killed

Lance Corporal U was deprived of sanitation, light and proper medical treatment. He was kept in a small cell with 40 other prisoners. They had no enough space and practically every prisoner suffered skin infections. The sick and wounded were left in their own excrement for many days. Some days they were given rotten food and while they were having meals the guards used to disturb them with loud noises etc. They were not allowed to take showers for months. Finally they decided to go on a hunger strike. After continuous interventions by the ICRC the LTTE agreed to release him with a group of other prisoners.

After coming home Lance Corporal U reported back to his unit. Gradually his sleeping pattern and the appetite started to change. He felt more alienated. He had loss of interest and pleasure in daily activities, multiple somatic complaints, loss of libido and had repeated thoughts to commit suicide. He was diagnosed with Depressive Disorder. Although he was treated with medication (anti depressants) his condition was aggravating. He was troubled by intrusive memories, emotional numbing, nightmares, startling reactions and avoidance of reminders. In 2003 he was diagnosed with PTSD. Lance Corporal U was treated with EMDR and his symptoms had been reduced to a significant level. Today he is almost symptoms free and leading a productive life.

Mr. N

Mr. N - a civilian worked as a cook in the Poonareen Camp. When the LTTE attacked the Poonareen camp in 1993, 241 soldiers, including 8 officers, were killed in the fighting. Nearly 200 combatants were captured alive. (The plight of these captives is still unknown. The Military Authorities believe that these POWs had been murdered by the LTTE)

When the LTTE cadres advanced towards his sector Mr N hid inside the building complex and later found by them. He was beaten vigorously and threatened to be killed on the spot. They put a gun to his head and threatened to pull the trigger.Mr. N was in extreme fear. He was mistakenly identified as an officer of the Sri Lanka Army and he was transported to one of the LTTE base camps. For a long period the LTTE believed that Mr. N was an officer in disguise.  Therefore he was subjected to numerous physical and mental torture to extract crucial information. Finally the Red Cross intervened and established his correct identity.

For nearly nine and half years, he lived his life a prisoner under the LTTE. He was homesick and practically every day prayed for his freedom.  For a long time he lived with uncertainty without knowing what his future would be.  When the Sri Lanka Air Force attacked the LTTE camps, their guards used to ill-treat them severely. Mr N’s condition significantly improved when he met another POW – Capt Boyagoda from the Sri Lanka Navy. Capt Boyagoda gave him courage and strength to face the callous conditions. Along with the other POWs, he spent the time discussing their release and writing letters to home via the ICRC.

He was released on the 30^th of September 2002. After his release, he gradually developed stress related physical symptoms such as headaches, backaches which did not subside to painkillers. He was unable to sleep. At nights, he was awake and thinking of the past. He often had melancholic feelings, and troubled by emotional anaesthesia.  He could not feel the happiness of becoming a free man. His emotions were dead. Mr. N was losing the will to live. Several times, he planned to commit suicide.  Finally he was able to receive counselling, medication and psycho social support that improved his condition.

Sailor P.K.I. Pitiyakumbura

Sailor P.K.I. Pitiyakumbura of the Sri Lanka Navy became a POW in November 2006 when his Navy Dvora attacked by the Sea Tigers in the Point Pedro seas. He was kept in different LTTE Sea Tiger bases under brutal conditions. He spent almost two and a half years as a prisoner of war. He was rescued by the Sri Lanka Army 59 Division troops in Vellamullaivaikkal area in 2009. 

The LTTE Interrogators and the Prison Guards

Most of the ex POWs concur that the LTTE Interrogators and prison guards were unsympathetic towards them and treated inhumanly. They often acted on impulses- hate and prejudice. Most of them derived sadistic satisfaction torturing prisoners. According to the statements given by the ex POWs when a prisoner screamed in pain the torturers intensified the torturous method that they inflicted on him. 

Interrogators used numerous physical and psychological torture methods to extract information. They questioned the prisoner for long hours depriving him of sleep. During the interrogations if they found any discrepancies in the POW’s statement he was severely beaten, electrocuted or subjected to extreme mental torture. 

The POWs were often beaten with rods. Beatings sometimes continued for several hours. When a prisoner is tied with a rope by hands and feet behind the back helplessly lying on the ground, he was beaten by a group of guards. They used to beat him with wooden poles or PVC pipes. They continued beating until the prisoner loses consciousness Some POWs succumbed to death.

Cutting the body with sharp razors was another punishment that had been used by the tormentors. Multiple superficial cuts were made on the prisoner’s body and then he is thrown in to a cell. The victim bleeds for a long time and suffers dehydration. He is not given water for several days.  Mostly the victims lose consciousness inside the prison cell. After a few days the body becomes swollen due to infection. Only a very few survived after this mode of torture.    

According to some of the POW s the interrogators used Chili powder that is made from the plant   Capsicum annuum to torture prisoners. Chili powder was applied on prisoner’s sensitive bodily areas such as eyes, anal cavity and in foreskin.  It gave the victim an unbearable burning sensation. The pain lasted for several days. Sometimes the prisoners were forced to inhale Chili smoke.

Torturing the POWs with electric shocks had been reported. Electrodes were placed in the oral cavity or other sensitive parts of the body and then non lethal electrical shock had been released by using a portable generator.  The victims often suffered convulsions and lost consciousness.  In addition heated iron wires were used to burn the prisoners. These torturous methods caused severe disfigurements.

POWs with severe bodily scars and disfigurements were never released and later killed by the prison guards. Their bodies were burnt with sugar in order to incinerate the skeletal parts. 

In spite of all these negative reports some of the POWs agree that there were kind LTTE cadres who treated the POWs in a humane way. When Lance Corporal P was severely beaten and left in handcuffs in his prison cell out of compassion one guard brought him water.  Lance Corporal U revealed that when he was given rotten food by hardcore members some guards secretly gave food to him from their rations. When there were no senior cadres some taught him Tamil and spoke with him ordinary things in life.  Mr N states that some of the LTTE cadres spoke with him nicely sometimes revealing their love affairs etc.

Psycho Social Problems Experienced by the POWs   

Psychosocial problems, such as behavioural, emotional, and occupational problems, are highly prevalent among the POWs. For many ex POWs being a prisoner of war often means that one’s life has changed sometimes beyond repair. Some of them suffered permanent psychological damages as a result of torture and degradation. Many are still hounded by their past memories of the LTTE torture chambers. They are at special risk for reduced physical and emotional well-being.   

POWs are torture victims. Torture profoundly disrupts the senses and personality (Reyes, 2007). It can cause severe form of psycho-trauma. The symptomatology associated with torture trauma will vary with respect to learned patterns of coping and the particular ethnic, political, and spiritual perspectives through which an individual views the experience. It must be interpreted accordingly, in terms of both the culture of origin and the relocation setting, when formulating therapeutic interventions (Gorman, 2001).    

The tortured POWs are impacted by traumatic reminiscences. They relive their past traumas. The repeated recollection of traumatic memories is a central component of the phenomenological response to traumatic events (McFarlane, 2010).   When traumatic events occur, by definition they are frequently beyond the victim’s control. In addition, certain inadequate coping responses are frequently present as victims attempt to take charge of their lives in the aftermath (Flannery, 1999). Antonovsky (1979) indicate that sustaining an important commitment in life is enhanced by a sense of coherence of the world. 

The POWs with their past traumatic experiences perceive that the world is unsafe and unpredictable. They lose the sense of coherence of the world. They have profound sense of alienation and loneliness.  It   erodes the ability to make and maintain healthy attachments.     It has been noticed that a significant number of POWs have disconnected from the social support networks. Their social environment is rigorously fragmented. The internalized disorders that they suffer have caused lack of strong bonds to societal institutions and weaken the community and social ties. It impairs their ability to function as member of the society.   The POWs diagnosed with PTSD found with trauma-related anger and hostility. Anger directed against the self or others is always a central problem in the lives of people who have been violated and this is itself a repetitive re-enactment of real events from the past. (van der Kolk, 1989). 

They have intense perception of their perpetrators. Some have preoccupation with hurting perpetrator and planed revenge. Often they displace their anger and frustration on family members. Many have the feeling of being permanently damaged and wasted.   Averse life experiences and maladjusted cognitive and behavioural processes have caused wide-ranging psycho social problems among the ex POWs.  Although human spirit is resilient many POWs of the Eelam war found it difficult to re adjust to the post war Sri Lankan society.   Returned prisoners of war were not treated as war heroes. Majority of them left the military or the police service. Their long term torture and degradation have never been examined appropriately and majority of them did not receive proper rehabilitation and health benefits.    

Shame and Guilt

War captivity situation become deleterious even for the core self of the person ( Urlić et al., 2009).  It can cause severe Psychological distress making the POW more dysfunctional.

The POWs have higher level of shame and guilt. Shame is the most personal and private of all feelings (Rustomjee , 2009) and  according to Gilbert (2003) Shame experiences can cause significant threat to the (social) self. Often the POWs maintain persistent traumatic silences.  It has become a disconnecting experience for them. Shameful feelings are at the very basis of the psycho traumatised -persons' withdrawal, depression, suicidal attempts, and even psychotic answer (Urlić et al., 2009).  

A POW evidently becomes an instrument of his tormentors. For the perpetrators torture becomes an expression of hate and prejudice. The violence inflicted on prisoners of war by its personnel as the product of indoctrination in brutality which is decomposed as blind obedience to authority, abuse of subordinates by superiors, and  extreme differences in social status (Brown,1998). As reported by the former POWs of the Eelam War the members of the Tiger Organization Security Intelligence Service (TOSIS) used vicious physical and psychological methods to extract information from them.

The LTTE used proficient psychological methods to break the morale of the combatants. Sometimes psychological manipulation was used as a key method.  Following isolation and psychological anguish often the captees established traumatic bonding with their captors. Some of the POWs had to collaborate with the enemy due to high pressure but many resisted.

The POWs were held in contempt by their captors. They underwent humiliation. Some guards frequently used derogatory remarks. Sometimes the guards used to urinate on the detainees. When the LTTE lost their cadres in a battle the guards became exceptionally brutal.

The POWs were disconnected from the outside world and they felt that they were abandoned by the military. They lived in an extreme world of darkness. Frequently they were displayed as proof of victory and subjected to ideological indoctrination. The POWs were allowed to take showers once or twice a month. Hence sanitation became a huge problem. Many of them suffered from skin rashes like scabies. There was no privacy in their prison cells. They had no toilets except poorly covered toilet buckets infested with flies. POWs had to use the toilets in front of all the others. Sometimes they were stripped naked and searched by the guards.

Water supply was limited and they were only given a small amount of water per day. The food was unpalatable and also given in very small quantities.  There was no scope for their biological needs. Most of the POWs were in their young age and the desire for sexual contact was suppressed under these traumatic circumstances. However some of the ex-POWs later revealed that sometimes at nights they used to engage in masturbation. According to the ex-POWs the erotic feelings gave some self soothing effect and it temporarily helped them to forget their suffering.

The POWs had little choices when they lived under their captors. They were monitored round the clock and had no time to rest, relax or recuperate. Anxiety, boredom, confusion impacted them daily basis. Shame and guilt repeatedly became excruciating. Sometimes the interrogators deliberately used very young child soldiers (as young as 12 – 15 years old) to beat the POWs. They were beaten with clubs. For senior non-commissioned officers it became a shameful episode.

 Many trauma survivors believe that their choices during the traumatic event were unjustified, even though their actions during the event might have been the best choice at the time. Also some trauma survivors may believe that their actions violated their own standards of right and wrong, due to negative outcomes, even if their actions at the time were consistent with their moral standards (Bratton, 2010).

Shame and guilt affected the POWs in greater degrees. When an individual experiences both distress and a feeling of responsibility for causing the traumatic event he is significantly troubled by guilt (Kubany & Manke ,1995).Guilt may intensify or complicate trauma (Nader et al., 1990).  

According to Alexander McFarlane Professor of Psychiatry at the University of Adelaide (Personal communication, 2014) traumatic stress fundamentally disrupts psychobiology that has long lasting effects, particularly for individuals such as POWS. This impact is also very much about the idea of being captured, defeated and compromised. These impacts are not about biology but about shame. This then has a biological consequence through the constant reminders it brings.

After coming home some of the former prisoners of the Eelam War still fight back shame and guilt. They have negative self-appraisals following the failure to fulfill their military obligation and ended up as a POW. Some have guilt that they had to collaborate with the enemy under the extreme conditions. Most of the traumatic memories are associated with the experience of trauma-related guilt. Some are confronted with ethical and moral challenges.  

The Compulsion to Repeat the Trauma 

Clinical research indicates a tendency to compulsive repetitions of traumatic experiences (Horowitz, 1975). Many individuals re-create and repetitively relive the trauma in their present lives (Horowitz, 1976; Levy, 1998).  As indicated by Levy (1998) trauma survivors may also be drawn to establish relationships that are similar to past significant relationships because there is comfort in familiarity. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.    (van der Kolk, 1989). Compulsive repetition of trauma affects the survivor’s psycho social well being. 

As indicated by Cowls & Galloway (2009) people who have had traumatic life experiences may connect with work in an unhealthy way.  It corrodes their functionality further. According to Miller (1994) the process of trauma reenactment is cyclical and includes thoughts, feelings, and behaviour that can be interpreted at any point in the cycle. 

At one point the cycle could be interpreted as feelings of rage, shame, or fear causing an individual to inflict self-harm. At another juncture, it could be interpreted that self-harming causes disgust that results in further punishment, or finally, it could be interpreted that when an interpersonal relationship becomes too intimate the individual feels compelled to detach through self-harming behaviours. The self-abuse cycle serves to protect the trauma survivor as it keeps others at a distance (Trippany et al , 2006). 

In behavioural re-enactment of the trauma, the self may play the role of either victim or victimizer.  (van der Kolk, 1989). The occurrence of reenactments of past trauma has been found among a number of former POWs of the Eelam War. Often they play the role of victim and face daily activities with a learned helplessness. Many survivors have compulsion to repeat elements of the traumatic events. Some of the former POWs of the Eelam War have joined the security firms or work as personal bodyguards handling weapons and exposing themselves to a vulnerable atmosphere.    

Suicidal Ideation 

According to numerous studies suicidal behaviour has been found to relate to trauma exposure. War captivity is one of the most severe human-inflicted traumatic experiences with wide and substantial long-term negative effects with suicidal tendencies (Zerach, Levi-Belz & Solomon, 2013). Researchers believe that suicidal ideation among the ex-POWs connected with posttraumatic stress disorder (PTSD) that they suffer. According to Calabrese and colleagues (2011) soldiers with PTSD were at increased risk for suicidality. Past traumatic memories could impact the victim’s present condition negatively. Memories of abuse and trauma also may be encoded at the explicit, autobiographical level.  

Autobiographical memories and negative cognitions can be triggered by similar stimuli in the environment which in turn, then activate negative emotional responses associated with the memory (Myers, 2002).  

In addition to memories of abuse and trauma many former prisoners of war hugely impacted by self-blame and guilt. Combat guilt could be one of the significant predictors of both suicide attempts and preoccupation with suicide suggesting that guilt may be an important mediator (Hendin & Haas, 1991; Maguen & Litz, 2012). Miller, Martin, & Spiro (1989) indicate of a   study among former WW I1 prisoners of war and it was found that 57% of POWs imprisoned by the Japanese harboured suicidal thoughts and that 7% of POWs under the Germans had attempted suicide. 

PTSD is frequently comorbid with major depressive disorder, and when the two disorders co-occur, the risk for suicidal behavior is enhanced (Oquendo et al., 2013).  Combat veterans diagnosed with major depressive disorder and comorbid posttraumatic stress disorder have a risk for suicidality. Researching the risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U.S. Army,  Ramsawh and colleagues (2014) found that suicidality has independent associations with both PTSD and depression. Suicidal behaviour can be considered within the spectrum of risk-taking behaviours (Ortin et al., 2012). 

A number of risk-taking behaviours have been found among the ex POWs of the Eelam War. Some of them used to take unnecessary risks while crossing the busy streets.  Some were found with working in life threatening jobs. Addictive disorders are important risk factors for suicide. Indirect self-destructive behaviours such as severe alcohol or drug abuse with long term suicidal intentions were detected among some of the POWs.   

Traumatic over-arousal has been identified as one of the triggering factors. Traumatic over-arousal may arise from inner affective deluge with minimal external stimulation and it could trigger suicidal ideation. Suicidal crises are often marked by repetitions (flashbacks) of these affects as they were originally endured in  past traumatic experiences. Further, recurrent overwhelming suicidal states may retraumatize the victims (Maltsberger et al., 2011). 

       

POWs and Physical Health

There is longstanding interest in the effects of stress on health, due to the strain that it places on the adaptive capacity of individuals, which thereby leads to an increased risk of disease. (McFarlane, 2010). POWs were found with significant health problems.  Different physical illnesses are prevalent among the Sri Lankan ex-POWs. These physical ailments were resulted by physical beatings and detrimental prison conditions. They often complain of headaches, joint pains, muscle pains, fatigability, dyspepsia and lack of energy.

Defrin and colleagues (2013) highlight that torture survivors suffer from high rates of chronic pain and hypersensitivity in the previously injured regions. In addition, they indicate that torture appears to induce generalized dysfunctional pain modulation that may underlie the intense chronic pain experienced by torture survivors’ decades after torture.

Among former WWII POWs, risk of cardiovascular disease is related to having PTSD (Kang, 2006). A number of studies have suggested that PTSD has a direct relationship with the risk of developing hypertension (McFarlane, 2010). Systemic diseases such as Hypertension and Diabetes Mellitus were found in ex POWs in Sri Lanka. Persistent health problems have affected their day today activities.

Hunt et al., (2008) of the view that conditions of captivity and health concerns or emotional distress during captivity may contribute to long-term adverse health outcomes as measured by later life disabilities in individuals incarcerated as POWs. Creasey and colleagues (1999) found that Prisoner of War during World War II was associated with a higher prevalence of chronic disease and diminished functional performance in later life. They hypothesized that POW experience played a part in premature, abnormal, or unsuccessful aging in some individuals.

Researches indicate that ex – POWs have high mortality rates. Dent and colleagues (1989) found that mortality rates of the former Australian POWs due to disease or accidents are higher than in general population.

The long-term health consequences of the POWs have been researched in numerous armed conflicts around the world. Hunt and colleagues (2008) found that significant associations between later life disability and POW experiences. Conditions of captivity and health concerns or emotional distress during captivity may contribute to long-term adverse health outcomes.

Meziab et al (2014) indicate that POW status and PTSD increase risk of dementia in an independent, additive manner in older veterans.

Although physical health of the POWs of the Eelam war remains under-researched area physical health decline among the POWs of the Eelam War has been observed in a number of cases.   Longitudinal studies would be needed to investigate the health effects of the ex POWs in Sri Lanka.  

Impact on Mental Health 

Physical and psychological torture inflicted to the POWs has an atrocious impact on their mental health. Most empirical research indicates that the psychological impact of trauma suffered by war captives is severe and persistent (Hourani, 2002).  Many psychiatric signs, symptoms, and defense mechanisms have been reported by POWs retrospectively during debriefings (Ursano & Rundell, 1990). 

Captives suffer from some mental or behavioural disorders even after freedom that can limit conformity of them to society and their social roles ( Najafi et al., 2007). The ex POWs often have the feelings of being trapped and un-empowered. van der Kolk et  al,  (1996) indicate that traumatized persons with posttraumatic conditions have become "stuck" on the trauma and its sequelae. Following psychological entrapment they show signs of confused thought processes with disorientation. The ex-POWs continue to feel entrapped by their PTSD symptoms that tie them to their captivity memories while still experiencing foreshorten future, even years after the war ( Zerach,  et al, 2013).  

As reported by Eberly and Engdahl (1991) American former prisoners of war had moderately elevated lifetime prevalence rates of depressive disorders and greatly elevated rates of posttraumatic stress disorder (PTSD). The degree of stress caused by these experiences depends on the physical conditions, the psychological experience, degree of maltreatment, interpersonal issues, and the individual and cultural appraisal of events (Biderman, 1967;  Ursano & Rundell,  1990). 

Solomon and collagues (1994) assessed the long-term impact of war captivity and combat stress reaction on rates of posttraumatic stress disorder (PTSD) in Israeli veterans of the 1973 Yom Kippur war and found that small but significant proportions of the POWs and veterans with combat stress reaction were still suffering from PTSD almost two decades after the war. Kluznik , Speed,  VanValkenburg &  McGraw (1986) found a lifetime PTSD rate of 67%   In a group of American POWs. These disorders have the same prevalence in captives of all countries (Boehnlein et al., 2007).  The POW s of the Eelam War underwent torture in extreme proportions. 

The LTTE regularly used solitary confinement to psychologically break down the captured servicemen. Hence they could extract vital information about the internal configuration of the military camps, artillery gun positions, troop movements etc from the captives. Although the solitary confinement was a popular method of the perpetrators it caused huge mental health consequences among the POWs. As indicated by Grassian (2006) solitary confinement that is the confinement of a prisoner alone in a cell for all, or nearly all, of the day with minimal environmental stimulation and minimal opportunity for social interaction can cause severe psychiatric harm.  As a result of the physical and psychological torture the POWs of the Eelam War suffer from symptoms, disability, and maladjustments. War captivity is a recognized pathogenic agent for both posttraumatic stress disorder (PTSD) symptoms and disorder of extreme stress not otherwise specified (DESNOS) symptoms, also known as Complex PTSD (Zerach et al., 2013). 

Complex traumas are implicated in attachment orientations and PTSD symptoms even many years after captivity (Solomon, 2008). Some of the Sri Lankan POWs show positive symptomatology of DESNOS or Complex Post Traumatic Stress Disorder (C-PTSD) that was described by Dr. Judith Herman in 1992.  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 that result in the lack or loss of control, helplessness, and deformations of identity and sense of self. The Eelam war ended in 2009 and most of the ex POWs are now reaching their middle age.  Research data indicate that aging veterans experience mental health concerns. Rintamaki and colleagues (2009)   found Traumatic memories and clinical levels of PTSD persist for WWII POWs as long as 65 years after their captivity in World War II prisoners of war. Aging ex-POWs who develop psychiatric symptomatology should be considered a high-risk group entering a high-risk period in the life cycle. It is important to monitor ex-POWs and provide them with appropriate medical and psychological treatment as they age (Solomon et al., 2013).   

 Alcohol and Substance Abuse among the POWs Making the transition from prison cell to home had been a severely overwhelming experience for most of the POWs. The POWs returning home have high rates of alcohol and substance abuse.  The ex-POWs consume alcohol and other substances to suppress traumatic war-related memories, escape flashbacks and to achieve a combat nightmare-free sleep. However Alcohol and Substance Abuse have become a risk factor for morbidity and mortality. In their 30-year follow-up of American prisoners of war (POWs) of World War II and the Korean conflict Page et al (2000) found evidence of increased cirrhosis mortality.   Alcohol and drug addiction denotes individual risk factors in war trauma.  About 84% of those suffering from PTSD may have comorbid conditions including alcohol or drug abuse (Javidi & Yadollahie , 2012). 

A study done with a group of Vietnam veterans McFall and colleagues (1992) found that reexperiencing and avoidance/numbing components of PTSD were more strongly associated with drug abuse and    physiological arousal symptoms of PTSD were more highly correlated with alcohol abuse. Alcohol and Substance Abuse have been reported among some of the Sri Lankan ex POWs. Binge and hazardous drinking and cannabis abuse have become a significant health related problem. Alcohol and Substance abuse frequently co-morbid with posttraumatic stress disorder (PTSD) that is experienced by the POWs. Nevertheless associations between alcohol and other substance abuse problems and post-traumatic stress disorder among the Sri Lankan POWs remain understudied.     

Marital Problems

War has deleterious effects on both ex-POWs and their wives (Solomon et al., 2009). POWs experience higher levels of marital problems. Previous exposure to combat trauma could impactfamily dynamics negatively.  The effect of imprisonment and release on family members and the family system itself can be profound and enduring or minor and transient (Ursano & Rundell, 1990).    

According to Dekel (2007) the wives of POWs reported significantly higher levels of distress and growth than did the wives of the controls. Dekel & Solomon (2006) state that PTSD is related to decrease marital satisfaction, increased verbal aggression, and heightened sexual dissatisfaction among former POWs. They emphasize that marital problems of former POWs are more related to PTSD than to their captivity.

Zerach and colleagues (2010) investigated the marital problems of ex-POWs of the Yom Kippur War and found an association between the traumatized ex-POW's capacity for intimacy and both their sexual satisfaction and dyadic adjustment. O'Donnell and colleagues (2006) examined the relationship among posttraumatic stress disorder, depression, and intimate partner relationship aggression in a community sample of World War II male military former prisoners of war. According to the researchers sixty percent of these POWs reported verbal aggression in their marriages, and 12% endorsed physical aggression. 

War captivity on parenting has been discussed among numerous ex – POW groups. Zerach and colleagues (2012) found lower levels of positive parenting in ex-POWs.      A significant numbers of the ex POWs of the Eelam War experience intra-familial conflicts. They experience numbing of emotions, loss of libido, erectile dysfunctions and difficulty in modulating sexual behaviour. The social and emotional deficits associated with their past trauma often contribute to marital problems. Relationship difficulties, domestic violence, problems with emotional intimacy, distressed relationships in the community have been observed. When family violence intensifies children often become victims. Often they witness inter-parental violence which has a strong detrimental impact on them. Catani et al (2008) found a relationship between war violence and violent behaviour inflicted on children in their families in Sri Lanka.

Treatment Measures

The Sri Lankan armed conflict lasted for thirty years. On average Sri Lankan POWs spent five to nine years under captivity. According to Andersen (1975) typical Vietnam POW being in captivity about six or seven years and their period of confinement was considerably longer than that of the prisoners of World War II and the Korean War. This highlights the magnitude of psycho trauma experienced by the Sri Lankan ex POWs.

The ex POWs remain as a highly vulnerable group. They suffer from a large array of physical and psychological symptoms that has links with the POW experience. According to Ursano & Rundell,(1990) the prisoner of war experience is greatly influenced by the environmental and socio-cultural factors of the particular captivity setting. Therefore their trauma has to be understood by psychological, social, cultural, and spiritual levels.

War captivity has pronounced independent effects on current depression and PTSD among the ex POWs of the Eelam War. Psychiatric and psychosomatic morbidity play an important part in their treatment schedule.

Turnbull (1992) states that debriefing after initial release from captivity is considered as a standard treatment. After the preliminary stage complete assessment has to be done and appropriate treatment should be provided.

Medication treatments can be effective in PTSD acting to reduce its core symptoms, and should be considered as major part of the treatment (Stein et al., 2000). The treatment of PTSD focuses on cognitive behavioural therapy and the use of selective serotonin reuptake inhibitors (McFarlane, 2010). According to Baldwin (2006) the serotonin-noradrenaline reuptake inhibitors (SNRI), venlafaxine, milnacipran and duloxetine are efficacious in relieving anxiety symptoms within depression, and some have proven efficacy in certain anxiety disorders. Emilien and colleagues (2000) state that Tricyclic antidepressants are generally thought to be effective in alleviating symptoms, including nightmares, depression, sleep disorders and startle reactions.

Psychotherapy is an essential part in the treatment plan.  According to Mendes et al (2008) CBT, exposure therapy and cognitive therapy are effective in the treatment of PTSD. Foa and colleagues (2009) highlight the efficacy of EMDR in treating PTSD. EMDR has been successfully used to treat a number of Sri Lankan ex POWs diagnosed with PTSD and Depression. (Jayatunge, 2008).

Treating the ex POWs with complex PTSD or DESNOS (disorder of extreme stress not otherwise specified) could be challenging. Exposure to recurring and extreme stressors and extensive toll of war captivity has made these victims a psychologically fragile group. Their symptoms such as emotional dysregulation, altered self-perception, modulation of anger pathological dissociation, inability to trust, deep suspicion, avoidance and sense of betrayal could deter the therapeutic outcome.

As indicated by Luxenberg , Spinazzola and van der Kolk  (2001) DESNOS has persistent biological, emotional, interpersonal, and social components that all must be assessed and addressed in treatment.Recognizing DESNOS in traumatized groups is important for conducting therapeutic interventions (Nemcic-Moro et al., 2011).  Ford and colleagues (2005) describe a three-phase sequential integrative model for the psychotherapy of complex posttraumatic self-dysregulation: Phase 1 (alliance formation and stabilization), Phase 2 (trauma processing), and Phase 3 (functional reintegration). As they indicate technical precautions designed to maximize safety, trauma processing, and reintegration.   

Maxfield (2014) denotes that EMDR can be used to treat complex PTSD. According to Korn & Leeds (2002) Forgash & Copeley (2008) and   Korn (2009) EMDR can be clinically applied in cases of complex PTSD.

Rehabilitation and providing social support help in long term recovery of the POWs. Several studies suggest that the older, more educated, married, less-combat-experienced New Zealand Vietnam War POWs who received post-release social support faired better than their counterparts (Vincent et al., 1994; Page et al., 1991; Hourani et al., 2002). Dent et al (1987) and Venn and colleagues (1991) point out that factors such as employment and higher socioeconomic status may be protective against depression among former POWs. 

The Psychosocial rehabilitation of the war affected Sri Lankan combat veterans is significantly crucial (Jayatunge, 2014). The ex-POWs need appropriate psychosocial rehabilitation and support.Psychosocial Rehabilitation practices help them re-establish normal roles in the community, independence and their reintegration into community life. 

  Restoring Posttraumatic Growth 

Although traumatic events jeopardize physical and psychological equilibrium giving rise to a wide range of physical and mental health complications an alternative perspective proposes that trauma has a salutogenic effect (Tedeschi & Calhoun, 2004; Dekel et al, 2012). Sometimes aftermath of trauma opens a new line of thinking about trauma’s effects (Keidar , 2013).  It could    pose significant challenges to individuals' way of understanding the world and their place in it (Tedeshi et al., 2004). This insight could be used as a potential Posttraumatic growth. Restoring Posttraumatic growth in ex POWs is tremendously important and it is therapeutic for them.  Individuals can develop a positive outlook and further experience positive psychological changes in the wake of traumatic events (Tedeschi et al., 2004; Dekel et al, 2012).

  

Dekel and colleagues (2012) of the view that individuals experiencing PTSD, particularly when it is enduring, have the potential for positive psychological change. Tedeschi and Calhoun (1995) hypothesized that positive psychological changes can occur following a potentially traumatic event as post traumatic growth and it can be allied with increased character strengths. They further state that post traumatic growth could be directed towards improved relationships with others, openness to new possibilities, and greater appreciation of life, enhanced personal strength, and spiritual development.Posttraumatic growth is not simply a return to baseline from a period of suffering; instead it is an experience of improvement that for some persons is deeply meaningful (Tedeshi & Calhoun, 2004).

 Conclusion 

The POWs of the Eelam War have become an under-studied population. Although they experience severe psychological and psychiatric problems a very few studies to date have examined psychological sequelae of the ex POWs.  The POWs of the Eelam War were exposed to prolonged and repetitive traumas. It has caused serious psychological consequences among them. Torture and imprisonment have left these victims permanently scarred. They remain as a chronically traumatized population. They experience a wide variety of physical and psychological symptoms which impact their functionality and psychosocial wellbeing. In addition these survivors encounter   adjustment difficulties to civilian life. Many of the ex POWs have a lower health-related quality of life.   

A large number of ex POWs continue to show the positive symptomatology of   PTSD and Depression. Some POWs have symptoms characteristic of DESNOS (disorder of extreme stress not otherwise specified). They need trauma-focused psychological treatment. Some of the Sri Lankan POWs treated with medication (anti depressants), CBT and EMDR showed significant symptom release. Regrettably mistrust sense of betrayal, trauma reminders and triggers, alienation and a sense of foreshortened future have distanced many victims from the support services. Their mental health needs are often not being met. Therefore an effective treatment programs should be provided to these victims. They need culturally congruent psychological /psychiatric treatment including holistic psychosocial rehabilitation. Special health care is recommended to address the problems of ex POWs. The health care system should actively seek the survivors and provide support. In addition it is important to assess current and long-term psychological and psychiatric sequelae of war trauma of the POWs of the Eelam War.

Personal Communications

1)      Professor Sharon Dekel Tel-Aviv University. Instructor in Psychology Harvard Medical School · Department of Psychiatry

2)      Dr. Louise Maxfield, Psychologist, EMDRIA Approved Consultant, London Health Sciences Centre London, ON, Canada

3)      Professor Alexander McFarlane -Director of the Centre for Traumatic Stress Studies, Professor of Psychiatry The University of Adelaide

Acknowledgements

1)      Dr. Neil J Fernando – Former Consultant Psychiatrist of the Sri Lanka Army

2)      Dr. Andrew P . Levin- Adult and Forensic Psychiatry 141 North Central Avenue Hartsdale, NY

3)      Dr. Michael Odenwald -The University of Konstanz Germany

References

Andersen, R.S.(1975). Operation homecoming: psychological observations of repatriated Vietnam prisoners of war.Psychiatry.38 (1):65-74. 

Antonovsky, A. (1979). Health, stress, and coping. San Francisco: Jossey-Bass.

Baldwin, D.S.(2006).Serotonin noradrenaline reuptake inhibitors: A new generation of treatment for anxiety disorders.Int J Psychiatry Clin Pract.10 Suppl 2:12-5. doi: 10.1080/13651500600637056.

Biderman, A.D. (1967).Life and death in extreme captivity situations. In: Appley MH, Trumbull R, eds. Psychological Stress: Issues in Research. New York: Appleton-Century-Crofts. 242–277.

Boehnlein JK,  Kinzie JD, Ben R,  et  al. (1985).  One year  follow  up  study  of  PTSD  among campaign concentration Camps. Am J Psychiatry. 142(8):956‐9.  

Bratton, K.L. (2010).    Shame, Guilt, Anger, and Seeking Psychological Treatment among a Trauma Exposed Population .Retrieved from: https://www.myptsd.com/c/gallery/-pdf/1-106.pdf

Brown, R.L. (1998).Kenpeitai: Japan’s Dreaded Military Police Somerset, England: Sutton. pp. 9-10. 

Calabrese, J.R., Prescott, M., Tamburrino, M., Liberzon, I,. Slembarski, R., Goldmann, E., Shirley, E., Fine, T., Goto, T., Wilson, K., Ganocy, S., Chan, P., Serrano, M.B., Sizemore, J., Galea, S. (2011).PTSD comorbidity and suicidal ideation associated with PTSD within the Ohio Army National Guard.Clin Psychiatry.1072-8. doi: 10.4088/JCP.11m06956. 

Catani ,C., Jacob, N., Schauer, E., Kohila, M., Neuner, F.(2008).Family violence, war, and natural disasters: a study of the effect of extreme stress on children's mental health in Sri Lanka. BMC Psychiatry. 2;8:33. doi: 10.1186/1471-244X-8-33.

Costa, D.L.(2012). Scarring and Mortality Selection Among Civil War POWs: A Long-Term Mortality, Morbidity and Socioeconomic Follow-Up. Demography.  49(4): 1185–1206. doi:  10.1007/s13524-012-0125-9.

Cowls, J., Galloway, E.(2009). Understanding how traumatic re-enactment impacts the workplace: assisting clients' successful return to work.Work.33 (4):401-11. doi: 10.3233/WOR-2009-0889.

Creasey, H ., Sulway, M.R., Dent, O., Broe, G.A., Jorm, A., Tennant, C.(1999).Is experience as a prisoner of war a risk factor for accelerated age-related illness and disability? J Am Geriatr Soc. 47(1):60-4.

Defrin,R.,   Ginzburg,K.,    Mikulincer,M.,    Solomon, Z. (2013).The long-term impact of tissue injury on pain processing and modulation: A study on ex-prisoners of war who underwent torture. European Journal of Pain. DOI: 10.1002/j.1532-2149.2013.00394.

Dekel, R., Solomon, Z.(2006). Marital relations among former prisoners of war: contribution of posttraumatic stress disorder, aggression, and sexual satisfaction. Fam Psychol. 20(4):709-12. 

Dekel, R.(2007).Posttraumatic distress and growth among wives of prisoners of war: the contribution of husbands' posttraumatic stress disorder and wives' own attachments. Am J Orthopsychiatry.  77(3):419-26.

Dekel, S., Ein-Dor, T., & Solomon, Z. (2012). Posttraumatic growth and posttraumatic distress: A longitudinal study. Psychological Trauma: Theory, Research, Practice and Policy, 4, 94-101.

Dent, O., Tennant, C.C., Goulston, K..J.(1987). Precursors of depression in World War II veterans 40 years after the war. Nerv Ment Dis. 175(8):486-90.

Dent, O.F., Richardson, B., Wilson, S, (1989).  Postwar mortality among Australian World War II prisoners of the Japanese.   Med J Australia.150(7):378‐82.

Eberly, R.E.,    Engdahl, B.E.(1991). Prevalence of Somatic and Psychiatric Disorders Among Former Prisoners of War. Hosp Community Psychiatry.42 (8):807-13.   

Emilien, C., Penasse, G., Charles, D., Martin, L., Lasseaux, A., Waltregny G.(2000).Post-traumatic stress disorder: Hypotheses from clinical neuropsychology and psychopharmacology research. Int J Psychiatry Clin Pract.4(1):3-18.

Farber, L.E., Harlow, H.F., West, L.J.  (1957). 'Brainwashing, Conditioning and D.D.D.' Sbciometry 20, 271-283.

Flannery,R.B. (1999).Psychological Trauma and Posttraumatic Stress Disorder: A Review. Retrieved from http://www.ncccism.com/upload/psychological%20trauma%20and%20posttraumatic%20stress%20disorder.pdf

Foa, E., Keane, T., Friedman, M., & Cohen, J. (2009). Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies. New York: Guilford.

Ford, J.D., Courtois, C.A., Steele, K., Hart, O.v., Nijenhuis, E.R.(2005).Treatment of complex posttraumatic self-dysregulation. J Trauma Stress.  18(5):437-47.

Forgash, C., & Copeley, M. (Eds.). (2008). Healing the heart of trauma and dissociation with EMDR and ego state therapy . New York: Springer.

Friedman, M.J., Schnurr, P.P., McDonagh-Coyle, A.(1994). Post-traumatic stress disorder in the military veteran. Psychiatr Clin North Am. 17(2):265-77.

Geneva Convention, Geneva Convention Relative to the Treatment of Prisoners of 

War. Geneva, 12 August 1949, Article 85.  Retrieved from 

http://www.icrc.org/ihl.nsf/FULL/375?OpenDocument  

Gilbert, P. (2003). Evolution, social roles and the differences in shame and guilt. Social Research, 70, 1205–1230.

Gorman, W. (2001). Refugee Survivors of Torture: Trauma and Treatment Professional Psychology: Research and Practice. Vol 3232. No. 5, 443-451

Grassian, S. (2006).Psychiatric Effects of Solitary Confinement. Madrid v. Gomez, 889F.Supp.1146 .

Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. American Journal of Psychiatry, 148, 586-591.

Herman, J.L. (1992). Trauma and recovery. New York: Basic Books.

Hickman, J.(2008).What is a Prisoner of War For ? Scientia Militaria, South African Journal of Military Studies, Vol 36.doi: 10.5787/36-2-50.

Horowitz, M.J.  (1975).Intrusive and Repetitive Thoughts After Experimental Stress A Summary. Arch Gen Psychiatry. 32(11):1457-1463. oi:10.1001/archpsyc.1975.01760290125015.

Horowitz, M.J. (1976). Stress Response Syndrome. Northvale, NJ, Jason Aronson.

Hourani, L.L., Hilton, S.M. (2002).The Long-Term Psychiatric Sequelae of the Prisoner of War Experience: Findings From Operation Homecoming Vietnam Veterans. Retrieved from file:///C:/Users/rjayatunge/Downloads/ADA419718.pdf

Hunt, S.C., Orsborn, M., Checkoway, H., Biggs, M.L., McFall, M., Takaro, T.K. (2008).Later life disability status following incarceration as a prisoner of war.Mil Med.173(7):613-8.

Javidi, H., Yadollahie, M.(2012). Post-traumatic Stress Disorder.Int J Occup Environ Med. 3(1):2-9.

Jayatunge, R. (2008) . EMDR Sri Lanka experience: (Psychological trauma management through EMDR in Sri Lanka , Sarasavi Publishers Colombo.

Jayatunge, R.M. (2014). Shell Shock to Palali Syndrome. Sarasavi Publishers . Colombo.

Kang, H.K., Bullman, T.A., Taylor, J.W.(2006). Risk of selected cardiovascular diseases and posttraumatic stress disorder among former World War II prisoners of war.Ann Epidemiol. 16(5):381-6.

Keidar, M. (2013).  Conceptualization of Post Traumatic Growth in the Work of Expert Trauma Therapists .Retrieved from https://digital.lib.washington.edu/researchworks/bitstream/handle/1773/23355/Keidar_washington_0250O_11866.pdf?sequence=1

Kluznik, J.C., Speed, N., VanValkenburg, C., McGraw, R. (1986). Forty-year follow-up of United States prisoners of war. Am J Psychiatry.143:1443–1446.  

Korn, D. L. (2009). EMDR and the treatment of complex PTSD: A review. Journal of EMDR Practice and Research, 3(4), 264-278. doi:10.1891/1933-3196.3.4.264.

Kubany, E. S.,  Manke, F. P. (1995). Cognitive therapy for trauma-related guilt:  Conceptual bases and treatment outlines. Cognitive and Behavioral Practice, 2, 27-61.

Levy, M. S. (1998). A helpful way to conceptualize and understand reenactments. journal of Psychotherapy Practice and Research, 7, 227—235.

Luxenberg, T., Spinazzola, J., and van der Kolk, B.A. (2001). Directions in Psychiatry, 21, pp.373-393. Long Island City, NY: The Hatherleigh Company, Ltd.

Maguen, S., Litz, B.,(2012). Moral injury in veterans of war. PTSD Res Quart.23(1):1-6. - See more at: http://www.psychiatrictimes.com/articles/reactivation-ptsd-symptoms-resulting-sandy-hook-media-exposure/page/0/2#sthash.jNdeIIvy.dpuf

Maltsberger, J.T., Goldblatt, M.J., Ronningstam, E., Weinberg, I., Schechter, M. (2011).Traumatic subjective experiences invite suicide.J Am Acad Psychoanal Dyn Psychiatry. 39(4):671-93. doi: 10.1521/jaap.2011.39.4.671. 

McFall ,M.E., Mackay, P.W., Donovan, D.M. (1992).Combat-related posttraumatic stress disorder and severity of substance abuse in Vietnam veterans. J Stud Alcohol.53(4):357-63.

McFarlane, A.C.(2010).The long-term costs of traumatic stress: intertwined physical and psychological consequences. World Psychiatry. 9:3–10.

Mendes, D.D., Mello, M.F., Ventura, P., Passarela Cde, M, Mari Jde, J.(2008).A systematic review on the effectiveness of cognitive behavioral therapy for posttraumatic stress disorder.Int J Psychiatry Med. 38(3):241-59.

Meziab, O., Kirby, K.A., Williams, B., Yaffe, K., Byers, A.L., Barnes, D.E. (2014). Prisoner of war status, posttraumatic stress disorder, and dementia in older veterans. Alzheimers Dement. 2014 Jun;10(3S):S236-S241. doi: 10.1016/j.jalz.2014.04.004.

Miller, D. (1994). Women who hurt themselves: A book of hope and understanding. New York: Basic Books. 

Miller, T W., Martin, W., & Spiro K. (1989). Traumatic stress disorder: Diagnostic and clinical issues in former prisoners of war. Comprehensive fsychiatry, 30, 139-148.

Ministry of Defence: Tamil Tigers executed and burnt Sri Lankan soldiers taken as prisoners of war: 2010(Ministry of Defence and Urban Development Website). Retrieved fromhttp://www.defence.lk/new.asp?fname=20101126_01

Myers, J.E.B.,  Berliner, L., Briere, L., Hendrix ,C.T.,  Reid, T .,Jenny C. (2002).Treating adult survivors of severe childhood abuse and neglect: Further development of an integrative model.

Nader, K., Pynoos, R., Fairbanks, L., Frederick, C. (1990). Children's PTSD reactions one year after a sniper attack at their school. American Journal of Psychiatry. 147: 1526-1530.

Najafi, M., Akochkian,S., Nikyar, H.R. (2007).Being Child of prisoners of war: The Case of Mental  Health Status. Iran J Pediatr.Vol 18 ( No 2), Pp: 154-158.

Nemcic-Moro, I., Franciskovic, T., Britvic, D., Klaric, M., Zecevic, I.(2011). Disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans with posttraumatic stress disorder: case–control study. Croat Med J.52(4):505-12.

Neria, Y., Solomon, Z., Dekel R. (1998). An eighteen-year follow-up study of Israeli prisoners of war and combat veterans. JNerv Ment Dis. 186:174-182.

O'Donnell, C., Cook, J.M., Thompson, R., Riley, K., Neria, Y.(2006).Verbal and physical aggression in World War II former prisoners of war: role of posttraumatic stress disorder and depression.J Trauma Stress.19(6):859-66.

Ortin, A., Lake, A.M., Kleinman, M., Gould, M.S. (2012). Sensation seeking as risk factor for suicidal ideation and suicide attempts in adolescence .J Affect Disord. ;143(1-3):214-22. doi: 10.1016/j.jad.2012.05.058.

Oquendo, M.A., Friend, J.M., Halberstam, B., Brodsky, B.S., Burke A.K., Grunebaum, M.F., Malone, K.M., Mann, J.J.(2013). Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior.Am J Psychiatry. 580-2.

Page, W.F., Engdahl, .BE, Eberly, R.E. (1999). Prevalence and correlates of depressive symptoms among former prisoners of war. J Nerv Ment Dis. 179:670-677. 

   

Page, W.F., Miller, R.N (2000).Cirrhosis mortality among former American prisoners of war of World War II and the Korean conflict: results of a 50-year follow-up. Mil Med.165(10):781-5.

Ramsawh, H.J., Fullerton, C.S., Mash, H.B., Ng, T.H., Kessler,R.C., Stein, M.B., Ursano, R.J.(2014).Risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U.S. Army.J Affect Disord.161:116-22. doi: 10.1016/j.jad.2014.03.016.

Reyes, H. (2007)The worst scars are in the mind: psychological torture. International Review of the Red Cross, No. 867.

Rintamaki, L.S., Weaver, F.M., Elbaum, P.L., Klama, E.N., Miskevics, S.A. (2009). Persistence of traumatic memories in World War II prisoners of war.J Am Geriatr Soc. 2009 Dec;57(12):2257-62. doi: 10.1111/j.1532-5415.2009.02608.x

Robson, D. , Welch, E., Beeching, N.J., Gill, G.V (2009).Consequences of captivity: health effects of far East imprisonment in World War II.QJM. 02(2):87-96. doi: 10.1093/qjmed/hcn137.

Rustomjee, S. (2009).The Solitude and Agony of Unbearable Shame. Group Analysis 42(2):143-155. 

Solomon, Z., Dekel, R., Zerach, G., Horesh, D. (2009). Differentiation of the self and posttraumatic symptomatology among ex-POWs and their wives. J Marital Fam Ther.35(1):60-73. doi: 10.1111/j.1752-0606.2008.00102.x.

Stein, D.J., Zungu-Dirwayi, N., van Der Linden, G.J., Seedat, S.(2000).Pharmacotherapy for posttraumatic stress disorder. Cochrane Database Syst Rev.(4):CD002795.

Silva, V.(2000). Sri Lankan prisoners of war undertake hunger strike for release. Retrieved from http://www.wsws.org/en/articles/2000/04/sri-a08.html

Solomon ,Z. , Neria, Y., Ohry, A., Waysman, M., Ginzburg, K.(1994). PTSD among Israeli former prisoners of war and soldiers with combat stress reaction: a longitudinal study.Am J Psychiatry. 1994 Apr;151(4):554-9.    

Solomon, Z., Dekel, R., Mikulincer, M(2008).Complex trauma of war captivity: a prospective study of attachment and post-traumatic stress disorder. Psychol Med.38 (10):1427-34. doi: 10.1017/S0033291708002808.

Solomon, Z., Greene, T., Ein-Dor, T., Zerach, G., Benyamini, Y., Ohry A. (2013).   The long-term implications of war captivity for mortality and health .J Behav Med.

Tedeshi, R.G., Calhoun, L.G. (2004). Posttraumatic Growth: Conceptual Foundation and Empirical Evidence. Philadelphia, PA: Lawrence Erlbaum Associates.

Tedeschi, R. G., Calhoun, L. G. (1995). Trauma and transformation: Growing in the aftermath of suffering. Thousand Oaks, CA: Sage.

The APSAC handbook on child maltreatment, 2 nd Edition. Newbury Park, CA: Sage Publications.

Trippany, R. L., Helm, H.M., & Simpson, L. (2006). Trauma reenactment: Rethinking borderline personality disorder  when diagnosing sexual abuse survivors. Journal of Mental Health Counseling, 28(2), 95-111. 

Turnbull, G. (1992). Debriefing British POW’s after the Gulf War and released hostages from Lebanon. WVF International Socio-Medical Information Center Newsletter.4:4–16.

Urlić, I., Strkalj-Ivezić, S., John, N.(2009).Trauma, shame and psychotic depression experienced by ex-POWs after release. Psychiatr Danub.21 Suppl 1:81-7.

Ursano, R.J., Boydstun, J.A, Wheatley, R.D.(1981). Psychiatric illness in U.S. Air Force Viet Nam prisoners of war: a five-year follow-up.Am J Psychiatry. 138(3):310-4. 

Ursano, R.J., Rundell, J.R.(1990). The prisoner of war.Mil Med.155 (4):176-80.

van der Kolk, B. (1989). The Compulsion to Repeat the Trauma: Re-enactment, revictimization, and masochism. Psychiatric Clinics of North America, 12, (2), 389-41.

van der Kolk, B. A., McFarlane, A. C., Weisaeth, L(1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society.  New York: Guildford. 

Venn, A.J., Guest, C.S. (1991). Chronic morbidity of former prisoners of war and other Australian  veterans. MedJAust.  155:705-707,710-712.

Vincent, C., Chamberlain, K., Long, N. (1994).Mental and physical health status in a community  sample of New Zealand Vietnam War veterans. Aust J Public Health. 18:58-62.

Zerach, G., Anat, B.D., Solomon, .Z, Heruti, R.(2010). Posttraumatic symptoms, marital intimacy, dyadic adjustment, and sexual satisfaction among ex-prisoners of war. J Sex Med. 7(8):2739-49. doi: 10.1111/j.1743-6109.2010.01784.x.

Zerach, G., Greene, T., Ein-Dor, T., Solomon, Z. (2012). The relationship between posttraumatic stress disorder symptoms and paternal parenting of adult children among ex-prisoners of war: a longitudinal study.J Fam Psychol.  26(2):274-84. doi: 10.1037/a0027159.

Zerach, G., Levi-Belz, Y., Solomon, Z.(2013). Trajectories of suicidal ideation and posttraumatic stress symptoms among former prisoners of war:A 17-year longitudinal study. Journal of psychiatric research.DOI:10.1016/j.jpsychires.2013.11.003.

Zerach, G., Solomon, Z.(2013).The relations between posttraumatic stress disorder symptoms and disorder of extreme stress (not otherwise specified) symptoms following war captivity. Isr J Psychiatry Relat Sci.50(3):148-55.