Ruwan M. Jayatunge, M.D. PhD
The enduring armed conflict in Sri Lanka has led to an alarming increase in mental health disorders among former combatants, with a notable proportion of veterans being diagnosed with complex forms of Post-Traumatic Stress Disorder (PTSD). Many of these individuals experience severe anxiety that manifests through a diverse array of clinical symptoms, resulting in significant psychosocial challenges. This group of veterans often falls under the diagnostic criteria for Disorders of Extreme Stress Not Otherwise Specified (DESNOS), a classification that encompasses the intricate and multifaceted nature of their trauma. The concept of Complex PTSD, as articulated by Dr. Judith Herman in 1992, highlights the profound impact of prolonged exposure to traumatic events, emphasizing the need for specialized therapeutic approaches to address the unique experiences and needs of these veterans.
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 results in the lack or loss of control, helplessness, and deformations of identity and sense of self. C-PTSD is distinct from but similar to PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder.
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.
The DESNOS has more distinctive features than traditional PTSD which is illustrated in the Diagnostic and Statistical Manual of Mental Disorders and the victims experience loss of control, disempowerment, loss of self-worth, loss of sense of self, lack of trust, and enduring personality changes more profoundly. According to the clinical findings of Nemčić-Moro, Frančišković , Britvić, Klarić & Zečević (2011) PTSD and DESNOS can occur in comorbidity, which is in contrast with the ICD-10 criteria.
Psychological symptoms and psychophysical problems of war victims are much more complex than those described in the diagnostic criteria for PTSD. Ford (1999) indicates that DESNOS was described in the DSM-IV as one of the associated features of PTSD, although more recent evidence concurs that DESNOS and PTSD may be distinct disorders and DESNOS represents a potential public health problem. The DESNOS is associated with severe functional impairments affecting cognition and emotions, especially impaired emotion processing capacities. It has extreme post-traumatic intrusive symptomatology. DESNOS is one of the debilitating disorders that has a poor therapeutic outcome. DESNOS was conceptualized to describe the alterations in the functioning of individuals exposed to chronic trauma (Blaz-Kapusta, 2008).
Lundy (1992) highlights that traditional thinking about PTSD has focused on the traumatic quality of external rather than internal events. PTSD still remains an under-researched anxiety disorder, and the mental health experts debate about the cultural impact and the symptoms of PTSD. Gil & Caspi (2006) postulate that, despite the large body of research on predictors and risk factors for PTSD, a comprehensive understanding of the development of the disorder remains elusive. On the other hand, DESNOS is more elusive than PTSD and needs more case investigations and research. The manifestation of DESNOS-related symptoms may not be identical and each culture has its unique way of presenting the pathology.
Extreme Trauma and the Cultural Impact
Culture affects the ways of describing thoughts and feelings and reports distressing symptoms. Culture affects individuals and communities, shaping their worldview. Culture has a profound influence on how psychological trauma is perceived by the person and how it is interpreted. Understanding trauma in the cultural context is highly important, and culture influences healing and resilience.
The concept of trauma (especially PTSD) has psychological, sociological, political, and economic implications. Although PTSD is institutionally framed, it has had different labels. In the European war theatre, it was called Shell Shock; in the United States, it became the Vietnam Syndrome; and in Sri Lanka, it earned the title Palai Syndrome.
Although a large number of studies indicate that posttraumatic stress disorder (PTSD) is a universal phenomenon, some of the cardinal symptoms associated with PTSD could vary from culture to culture. Many researchers question whether the etiology and maintenance of PTSD are culturally similar. In some cultures, psychological distress is pronounced in different ways. Replicating standard studies, Jobson & Kearney (2009) showed that trauma survivors with PTSD from independent cultures reported more mental defeat, alienation, permanent change, and fewer control strategies than non-PTSD trauma survivors from independent cultures.
Traumatic life events can be simple or complex in nature and result in simple or complex forms of posttraumatic adaptation. Similarly, cultures can be simple or complex in nature with different roles, social structures, authority systems, and mechanisms for dealing with individual and collective forms of trauma……….. The nature of how cultures deal with the social, political, and psychological consequences of trauma raises the issue of the availability of therapeutic modalities of healing and recovery (Wilson, 2007).
The Sri Lankans knew the impact of combat trauma for centuries. The ancient scripts vividly describe the mental agony of the sufferers. In Sri Lanka, PTSD-like symptoms are often expressed in different psychological and somatic routes. The victims frequently complain of heaviness in their chest and tension in their head. Many Sri Lankan combatants believe that repeatedly talking about distressing experiences is a sign of weakness, and many try to repress their awful memories of war. The victims of war trauma often use religious and cultural beliefs (such as the concept of Karma, reincarnation, and astrology) to buffer the negative implications.
The Impact of Early Life Trauma on Combatants
A large body of research has shown that childhood trauma forms a serious risk for mental health problems in adult life. Many researchers suspect a strong correlation between early childhood trauma and DESNOS. Ford et al. (1998) indicate that a history of early childhood trauma was prevalent and highly correlated with Disorders of Extreme Stress Not Otherwise Specified (DESNOS) in a sample of veterans in inpatient treatment for chronic posttraumatic stress disorder.
Childhood abuse has a damaging effect on brain development. Childhood trauma can have an impact on an adult’s mental health, and it affects social and psychological functioning. Much research concurs that early physical abuse and the manifestation of numerous other subsequent social and psychological problems, including mental health problems. Horwitz A, Widom C, McLaughlin J, et al (2001) indicate that men who were abused and neglected as children have more dysthymia and antisocial personality disorder as adults than matched controls.
Maternal and paternal deprivation during childhood could cause separation anxiety in children and could also affect their adult lives. According to the Foreign Employment Bureau, Sri Lanka has nearly a million citizens working in the Middle East, most of them as housemaids. Over 100,000 women workers go abroad to work as housemaids every year, leaving their children with relatives. This has resulted in separation anxiety among the children. Breslau, Chilcoat, Kessler & Davis (1999) point out that prior traumatic experience, particularly violent experience, abuse, or catastrophe when young or separating or divorcing parents before age 10, increases adult vulnerability to stress disorders.
During the Eelam War, which spanned from 1983 to 2009, a significant number of young individuals from economically disadvantaged backgrounds enlisted in the military. Many of these youths carried the weight of traumatic experiences from their childhoods, having endured various forms of abuse, neglect, and the absence of parental figures, all exacerbated by the harsh realities of extreme poverty. Those who joined the armed forces often hailed from vulnerable villages in the North Central Province, where they had been exposed to the harrowing consequences of the conflict from a tender age. These communities were frequently targeted by the Liberation Tigers of Tamil Eelam (LTTE), leading to the traumatic witnessing of mass killings and the grim practice of mass burials. The impact of such violence was profound, as many of these young recruits had lost family members, leaving them with deep emotional scars that would shape their identities and experiences in the military.
Between 2002 and 2006, a comprehensive study was conducted to assess the prevalence of post-traumatic stress disorder (PTSD) among 824 soldiers of the Sri Lankan Army. The findings revealed that 56 of these combatants exhibited full-blown symptoms of PTSD, while an additional 6 soldiers were identified as having partial PTSD. Notably, among those who tested positive for PTSD, a significant correlation was observed, as 30 individuals reported having endured severe trauma during their childhood. This research highlights the profound impact of early life experiences on mental health outcomes in military personnel, underscoring the importance of addressing both combat-related and pre-existing psychological issues in the context of military service (Fernando & Jayatunge, 2013).
Military veteran survivors of childhood trauma have prevalent problems with affect regulation, impulse regulation, relational engagement self- self-efficacy and self-esteem, and pathological dissociation. These symptomatic and functional impairments are precisely the core constituents of DESNOS. (Bremner, Southwick, & Charney, 1995).
Traumatic Combat Exposure
The experience of war can lead to profound psychological distress, manifesting as a complex form of trauma that often intensifies over time. This traumatic impact is multifaceted, significantly undermining the mental well-being of those involved. For instance, during the Eelam War in Sri Lanka, numerous combatants encountered harrowing events that fundamentally challenged their perceptions of safety and security. Many of these individuals were engaged in combat for extended periods, with some spending over a decade in active conflict zones, perpetually under the threat of enemy assaults. As a result, the cumulative nature of these traumatic experiences profoundly altered their psychological states, leading to lasting negative effects on their mental health and overall psychological resilience. The relentless exposure to life-threatening situations not only eroded their sense of safety but also reshaped their emotional and cognitive frameworks, leaving enduring scars that would affect their lives long after the conflict had ended.
Numerous Sri Lankan combatants suffering from complex PTSD have endured a series of traumatic experiences both on the battlefield and in their civilian lives. A poignant example is Lance Corporal SX46TX, who was profoundly affected after witnessing a land mine explosion in Mannar in 1998. This initial trauma was compounded in 2004 when he encountered the harrowing sight of numerous deceased individuals at the Matara Hospital following the catastrophic Asian Tsunami, leading to a significant deterioration in his mental health. Similarly, Lieutenant BX34XT, who received a diagnosis of acute PTSD after experiencing traumatic events during battles in Paranthan, Jaffna, in 1999, found himself overwhelmed in 2006. This was due to the horrific aftermath of a suicide bombing at the Army Headquarters in Colombo, which further exacerbated his psychological distress and highlighted the long-lasting impact of such cumulative traumas on the mental well-being of those who have served in conflict zones.
The aftermath of repeated traumatic experiences in combat left many individuals grappling with intense emotional distress. During the prolonged Sri Lankan armed conflict, the absence of psychological first aid, debriefing, or systematic counselling at the front lines meant that numerous psychological casualties of the Eelam War remained silent about their struggles until their suffering became unbearable. Many soldiers found themselves trapped in a cycle of reliving harrowing memories associated with their wartime experiences, leading to a state of emotional numbness and disconnection from their surroundings. A significant number of Sri Lankan combatants exhibited various dissociative reactions while engaged in combat, which ultimately contributed to the development of conditions such as Post-Traumatic Stress Disorder (PTSD) and Disorders of Extreme Stress Not Otherwise Specified (DESNOS). This lack of timely psychological support not only exacerbated their mental health issues but also hindered their ability to reintegrate into civilian life after the conflict.
The war veterans with past trauma exposure but who are asymptomatic at present could be a risk group. Numerous studies have indicated delayed reactions to combat trauma. In a study among Vietnamese refugees, Silove, Phan& Bauman (2009) found that people who were exposed to more than three traumatic events had a heightened risk of mental illness after 10 years compared to people with no trauma exposure.
DESNOS Symptomatology
According to Yehuda (2002), approximately 10% to 25% of adults who are exposed to an extreme stressor may develop simple acute stress disorder and PTSD. Complex trauma generates complex reactions like DESNOS, which is not adequately described in the DSM–IV (Courtois, 2004). DESNOS has a wide range of symptomatology. DESNOS is conceptualized as a constellation of chronic problems with the regulation of self, consciousness, and relationships that is not formally recognized as a diagnostic entity (American Psychiatric Association, 1994).
The victims of prolonged repeated trauma could suffer from DESNOS, and they can have a wide range of symptoms. Among the symptoms are emotional dysregulation (persistent sadness and explosive anger), cognitive dysfunctions (impaired memory and attention), pathological dissociation, hopelessness, shame and guilt, distorted perceptions, mistrust, isolation, loss of sustaining faith, and despair are prominent.
Loss of the Pre-traumatic Personality Structure
It has been known to researchers that psychological trauma can cause dramatic personality changes. ICD-10 introduced a diagnostic category of Enduring Personality Change After Catastrophic Events (F62.0), which includes features such as hostility and a mistrustful attitude toward the world, social isolation, a feeling of emptiness and hopelessness, irritability, and estrangement. Personality changes following combat trauma have been reported from many battle fronts. Soldiers diagnosed with DESNOS have marked personality changes.
Allport (1961) defines personality as: “The dynamic organization within the individual of those psychophysiological systems that determine his characteristic behaviour and thought.” Beltran, & Silove (1999) show that a substantial portion of trauma experts working in the field of human-engendered violence recognize the possibility that certain traumas can result in personality change.
There is a significant difference between pre-trauma personality and post-trauma personality. After exposure to traumatic battle events, soldiers could have a negative outlook on their buddies, platoon leaders, commanding officers, the military, and sometimes on the government. They lose the sense of trust and ability to view the world as a safe place. Southwick et al. ( 1993) indicate that Combat veterans have been found to have particularly high rates of borderline, avoidant, and obsessive-compulsive personality disorders when assessed by structured interviews.
Daud and colleagues (2008) in their study “Trauma, PTSD and personality: the relationship between prolonged traumatization and personality impairments ” found prolonged torture experiences or early trauma exposure may impair personality formation by enhancing the effects of cognitive, affective, and behavioural vulnerabilities.
Lieutenant BXSCX35X, who experienced the harrowing loss of seven soldiers during the conflict in Paranthan Jaffna, subsequently faced a profound transformation in his mental health, culminating in a diagnosis of severe post-traumatic stress disorder (PTSD). This psychological turmoil manifested in significant alterations to his personality, which were particularly noticeable to his wife and close friends. Following the traumatic events of battle, he became increasingly withdrawn, often reacting impulsively and without consideration for the consequences of his actions. One notable incident involved an aggressive confrontation with a bus driver over reckless driving, highlighting his escalating hostility and propensity for conflict. The lieutenant's inability to tolerate criticism or negative feedback further exacerbated his emotional instability, leading to frequent bouts of depression and thoughts of self-harm or suicide. He developed a pervasive sense of paranoia, feeling as though the world conspired against him, which eroded his trust in his commanding officers and left him questioning their directives. Once a courageous and disciplined soldier, Lieutenant BXSCX35X now grappled with an unshakeable sense of fear, prompting him to avoid situations involving injury, blood, or even combat-related media, as he struggled to navigate the psychological aftermath of the Eelam War.
Rifleman Mx38 found himself ensnared within enemy territory for two harrowing days, engulfed by an overwhelming sense of fear. Concealed in a makeshift pit, he meticulously observed the movements of enemy forces, each passing moment amplifying his anxiety as he feared discovery, torture, and death. When a fleeting opportunity for escape presented itself, he cautiously made his way toward the outer perimeter of his camp, successfully alerting his comrades and returning to his platoon without any physical harm. However, the psychological scars of his ordeal soon manifested, leading to persistent feelings of dread, recurrent nightmares, and a tendency to avoid situations reminiscent of his traumatic experience. Subsequently, he was referred for psychiatric evaluation, where he was diagnosed with post-traumatic stress disorder (PTSD). The onset of PTSD brought about profound changes in Rifleman Mx38's personality; he exhibited marked impulsivity, heightened anxiety, an obsessive focus on safety, irritability, and compulsive behaviors. Notably, he developed a ritualistic pattern when crossing roads, engaging in specific actions that provided him with a fleeting sense of security and relief amidst the turmoil of his mental state.
Rifleman Sn34 experienced profound psychological trauma as a result of the harrowing events he encountered during Operation Yale Devi, which commenced in 1993 to dismantle the LTTE Sea Tiger strongholds located in Kilali. During this operation, the enemy executed a sudden and devastating assault on the advancing military column, leading to the tragic loss of hundreds of soldiers. The LTTE employed a relentless barrage of mortars and rocket-propelled grenades, creating chaos and destruction on the battlefield. Amidst this turmoil, Rifleman Sn34 witnessed the deaths of several of his comrades, an experience that left an indelible mark on his psyche. Additionally, the enemy's onslaught resulted in the capture of some of the wounded soldiers, further compounding the sense of despair and helplessness that permeated the ranks of the advancing troops.
After this dreaded battle, Rifleman Sn34 found himself engulfed in a cloud of despair regarding his future. The memories of the conflict haunted him, replaying in his mind like a relentless loop, each recollection triggering a wave of anxiety. Startle responses became a significant source of distress, leaving him in a constant state of unease. Lacking access to professional help or a means to articulate his psychological suffering, he endured the weight of his post-traumatic symptoms in silence for an extended period. Over the years, a pervasive mistrust developed within him, not only towards individuals but also towards the very systems designed to provide support. This growing suspicion led to heightened vigilance around unfamiliar faces, prompting him to withdraw from social interactions entirely. The once-brave soldier, who had been honored for his valour, now found himself paralyzed by fear, avoiding new experiences and succumbing to lethargy. Even the innocuous sound of a firecracker could send him into a panic, starkly contrasting the confident demeanour he had once exhibited before the trauma.
Altered Self Perception
According to social psychologist Daryl Bem, people come to know their own attitudes, beliefs, and other internal states by inferring them from their own behaviour and the circumstances under which it occurs (Bem, 1972). Combatants with complex PTSD have altered self-perception, and their interpretation of events is distorted. Following dreadful past experiences, their primary appraisal is often altered and they apprehend events as life-threatening. Therefore, the affective response could be negative.
Skinner (1957) believed that Self-perception is an individual’s ability to respond differentially to his own behaviour and its controlling variables, which is a product of social interaction. War trauma could change healthy interactions and transform the victim into a pathological level that leads to unhealthy interactions. Maksakis (1996) describes that upon victimization of trauma, PTSD sufferers could go into a condition known as assumption-shattering in which the victim grapples with issues of vulnerability, negative self-image, and the perception of a disorderly world and exhibits signs of immature behaviours, childish emotions, withdrawal, and dependency.
The combatants affected by severe war trauma often have distorted beliefs. Some do not trust the support services, the health care system, and even their therapists. They could have a sense of re-victimization and concern about their safety and well-being. Some go to the extent of making attempts to victimize others. In addition, the loss of beliefs and a coherent sense of self are very evident among them.
The Bombardier AXTX36 case involves a patient with a well-documented history of post-traumatic stress disorder (PTSD), who exhibits significant alterations in his self-image. This individual served in combat for an extensive period of 14 years, during which he played a pivotal role as an interrogator amid the tumultuous backdrop of the 1988-89 Janatha Vimukthi Peramuna (JVP) uprising. His responsibilities included extracting critical information from suspects, a task he approached with extreme measures that often involved brutal torture techniques. Over time, he developed an unhealthy fixation on the act of torture, to the extent that he occasionally found a disturbing sense of gratification in the anguished cries of his victims. This complex interplay of trauma, guilt, and distorted self-perception underscores the profound psychological impact of his experiences in combat and interrogation.
By the year 2000, his mental well-being began to deteriorate significantly, leading to a series of distressing experiences characterized by intrusive thoughts, haunting nightmares, and vivid flashbacks. During these episodes, he often found himself re-experiencing traumatic memories, at times perceiving the anguished cries of his victims echoing in his mind. This relentless cycle of recollection contributed to a profound sense of depression, which he openly discussed, frequently expressing thoughts about his own mortality. The weight of his past actions seemed to cast a long shadow over his psyche, leaving him in a state of turmoil and despair.
The self-image of Bombardier AXTX36 underwent a profound transformation with the emergence of his symptoms. He experienced a significant decline in self-esteem, perceiving himself as a sinner and a wrongdoer deserving of punishment from Karmic forces. He openly identified as a villain, expressing a desire for all manner of blasphemies to befall him. In his despair, he often claimed that he was no longer human, asserting that the essence of his humanity had vanished long ago. He even encouraged others to use derogatory terms when addressing him, revealing a troubling need for self-deprecation. In a troubling turn, he began to disclose details of his past interrogative work to strangers, fully aware that he would not receive any sympathy in return. When, contrary to his expectations, individuals did express compassion, he reacted with irritation and, on occasion, aggression, even attempting to physically confront them. This emotional turmoil led to a state of heightened aggression and emotional numbness, eroding his ability to trust those around him. He oscillated between blaming his senior officers, his parents, and himself for his suffering, ultimately succumbing to a bleak outlook on the future. In moments of despair, he contemplated suicide, reflecting the depth of his anguish and hopelessness.
Alterations in Systems of Meaning
Psychological trauma alters long-held beliefs and changes the perception of the world and universe. When the belief system changes, thoughts, words, and actions change accordingly.
Sergeant NXX48CX was a deeply religious individual whose faith was profoundly shaken after he became a patient suffering from post-traumatic stress disorder (PTSD). The harrowing experiences he endured on the battlefield led him to a bleak perception of the world, one in which he believed that evil predominated and that no human effort could alter this grim reality. He often expressed the conviction that the Universe was under the sway of malevolent forces, which he felt were responsible for an unending cycle of destruction and despair. Despite his own suffering, he maintained that he had never inflicted harm upon others, finding it utterly irrational that he should emerge as a psychological casualty of war. In his view, it was these negative forces that had orchestrated his anguish, leaving him disillusioned and estranged from the very faith that once provided him solace.
Affect Dysregulation
Aronson et al.(2005) view that emotions result from people’s interpretations and explanations of their circumstances, even in the absence of physiological arousal. In PTSD, interpretations and explanations of circumstances are not healthy, and the sufferers perceive stimuli from the outside world as dangerous and threatening.
The combatants with complex PTSD have extreme emotions and often they find it difficult to regulate their emotions and react in a socially acceptable manner. The horrific past experiences could constantly give feelings of terror and dread. Re-experiencing traumatizing events and avoidance of reminders of the trauma constantly affect their emotions. The victims are troubled by rage, despair, guilt, shame, and self-loathing. Some victims have alexithymia or an inability to express feelings with words.
The researchers believe that PTSD is associated with heightened emotional intensity and reactivity. Heightened negative affect intensity and the tendency to negatively evaluate emotions may be associated with the development and maintenance of posttraumatic stress symptoms. (Tull , Jakupcak , McFadden & Roemer, 2007).
Affect dysregulation has been described as a cardinal feature of chronic war zone-related PTSD, particularly problems modulating anger (Chemtob, Hamada, Roitblatt, & Muraoka, 1994). When emotions are dysregulated, the combatants become highly reactive and with the slightest provocation, they could act violently without any rational consideration. Combatants affected by severe PTSD find it difficult to respond to their emotions, regardless of their intensity. They are unable to understand and distinguish the emotions that they experience. They are unable to control emotions and regulate it a situationally appropriate manner.
Some suspect that affect dysregulation has some close links with the process of pathological dissociation. Pathological dissociation has been identified as one of the key features of DESNOS. Chu et al. (1999) state that affect dysregulation is extremely common in dissociative disorders.
Lance Corporal NHXX36X dedicated 16 years to military service, during which he experienced a multitude of traumatic events related to combat. In 2004, he was diagnosed with post-traumatic stress disorder (PTSD), a condition that profoundly affected his behavior and relationships. He exhibited severe hostility and struggled to manage his anger, which often escalated into physical confrontations. This volatility extended to his personal life, where he faced challenges in maintaining stable interpersonal relationships and grappled with feelings of self-loathing. His difficulties in pursuing goal-directed activities and a lack of emotional clarity further compounded his struggles. Tragically, these issues manifested in frequent outbursts of anger, leading to instances of physical abuse towards his wife and children. In some cases, he resorted to military-style punishments, such as the Irshi Position, a disciplinary method commonly used in the Sri Lankan Army, to exert control over his family. His rage also destroyed household property, including significant items like the television. His aggressive behavior led to multiple arrests for assaults on neighbors, highlighting the extent of his challenges in coping with the aftermath of his military experiences.
Numbing of Responsiveness
Numbing of responsiveness or loss of affect has been recorded among soldiers who have been diagnosed with PTSD. Emotional numbing (emotional anesthesia) symptoms are part of the avoidance cluster of PTSD symptomatology. Often, they distance their feelings from others, and they are unable to feel happiness, unable to be content, and unable to form emotionally secure attachments.
Numbing of responsiveness, which may be registered as depression, anhedonia and amotivational states, psychosomatic reactions, or in dissociative states, is tonic and part of the patient’s baseline functioning. It interferes with the ability to explore, remember and symbolize, which are essential to finding good meaning. Throughout the literature, numbing is all too unquestioningly described as a psychological defence against remembering painful effects. Below, we will argue that numbing is a core, biologically based symptom of PTSD (van der Kolk & Saporta, 1991)
Combatants with war trauma report restrictions in their emotional experience. After facing trauma, they lose interest in once pleasurable activities and find themselves inability to emotionally connect with others. Many have restricted emotions and emotional detachment.
Corporal KXX46LX, having endured the traumatic loss of his fellow platoon members and the harrowing task of dealing with human remains, found himself grappling with the debilitating effects of post-traumatic stress disorder (PTSD). He experienced profound emotional numbness, rendering him incapable of feeling joy or happiness, which had once been integral to his life. Describing his emotional state as a dead end, he struggled to find satisfaction in activities that had previously brought him pleasure. The fleeting moments of happiness he once enjoyed were now elusive, leaving him in a state of emotional unresponsiveness. This profound disconnection extended to his relationships, as he found himself unable to express or even feel love for his children, further deepening his sense of isolation and despair.
DESNOS and Pathological Dissociation
Dissociation is defined in the Diagnostic and, Statistical Manual of Mental Disorders DSM-IV) as “a disruption in the usually integrated functions of consciousness, memory, identity, or perception, of the environment” (APA, 2000). Dissociative disorders are usually associated with trauma, and Combat soldiers who were exposed to distressing battle events could go into dissociative reactions. It is reasonable to believe that there is a strong link between combat trauma and dissociation, and many combatants with PTSD have dissociative features. Moskowitz (2003) states that PTSD and dissociative disorders not only have some symptoms in common but may also share etiology.
Zucker et al. (2006) highlight that the symptoms of PTSD include dissociative experiences, such as amnesia for aspects of the trauma, and dissociative flashback episodes. They further state that one of the DESNOS domains, alterations in attention or consciousness, includes amnesia, transient dissociative episodes, and depersonalization.
According to the APA, Depersonalization is an anomaly of self-awareness that consists of a feeling of watching oneself act, while having no control over a situation. They feel detached from their own thoughts and emotions and disconnected from one’s body. The combatants who had experienced derealization often feel that the environment around them was unreal and unfamiliar. Some describe it as a sensory fog or being spaced out.
Psychogenic amnesia (dissociative amnesia) had been reported among the Sri Lankan combatants who experienced extreme forms of war trauma. Some could not recall the entire incident but had some fragmented memories about the traumatic incident. In all cases, organic brain damage or substance abuse had been excluded.
Lieutenant BX34XT experienced a traumatic event in 1999 when he witnessed the deaths of seven soldiers due to a mortar explosion in Paranthan, Jaffna. Although he emerged physically unscathed, the psychological impact of the incident was profound, plunging him into a state of shock. In the aftermath, he found himself disoriented and unable to recall the sequence of events that transpired following the blast. This disconnection from reality left him with a significant gap in his memory, and he could not piece together how he ultimately arrived at the Psychiatric Unit of the Military Hospital in Colombo. The experience marked a turning point in his life, highlighting the often-overlooked mental toll of warfare on those who serve.
Confusion and emotional distress related to amnesia have been noticed among trauma survivors. Many soldiers with combat trauma have impaired concentration and memory. Halepota & Wasif (2001) believe that the cataclysmic impact of the trauma events on an individual’s personal life often impedes the ability of the survivor to share his or her experiences.
Some experts believe that dissociation is a form of defense mechanism and an attempt to move away from reality. Putnam (1992) calls Dissociation the escape when there is no escape. Dissociation could delay information processing and recovery. Foa & Hearst-Ideka (1996) postulate that dissociative symptoms are attempts at mental escape from the overwhelming and dysphoric consequences of the trauma and, subsequently, of the memory of the trauma. They believe that this maladaptive process hinders the psychological processing of the trauma.
Corporal VXX43X experienced a profound dissociative episode during a combat operation in 1998, an occurrence that transpired without any physical injury or the influence of medication or substances. In that moment, he felt an unsettling detachment from the chaos of the battlefield, as if he were merely an observer in a film rather than an active participant. The sounds of gunfire and explosions faded into silence, leaving him in a disorienting void where the concepts of time and space lost all meaning. When he eventually regained his senses, the stark reality of the situation struck him: the soldiers positioned to his left had pushed forward, and the enemy had begun to launch mortar attacks against them, highlighting the perilous nature of his surroundings and the urgency of the moment.
Corporal AXX39SX has dedicated 17 years of his life to serving in operational zones characterized by intense and extreme battle stress. Throughout this time, he grappled with posttraumatic symptoms, yet he found himself without access to the psychological support he desperately needed. In fulfilling his military responsibilities, he often suppressed the mental anguish he was experiencing. This internal struggle culminated in a particularly alarming incident when he entered a dissociative fugue state, inadvertently crossing into enemy territory. When a group of friendly soldiers eventually located him, Corporal AXX39SX was found disarmed and aimlessly wandering in a hostile environment, completely unaware of how he had left his bunker and arrived at such a perilous location.
Dissociative experiences could cause severe dysfunctions among the combatants. According to Dalenberg (1999), among the PTSD symptoms, dissociative experiences are often the most emotionally disturbing to the patient. Sometimes, Pathological dissociative reactions are culture-specific and cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. Numerous dissociative symptoms that were not specified in the DSM had been found among the Sri Lankan combatants.
Lieutenant SXX32VC found himself engulfed in an overwhelming sense of dread when a female cadre from the LTTE hurled a grenade in his direction. Miraculously, the device failed to detonate, yet for several agonizing minutes, he was gripped by an inexplicable terror for his life. This harrowing experience left an indelible mark on his psyche, leading to persistent nightmares and intrusive memories that haunted him long after the incident. Approximately six to eight months later, Lieutenant SXX32VC began to observe significant alterations in his speech patterns, particularly a pronounced shift in his accent. When he attempted to communicate in Sinhala, it was now tinged with a distinct Tamil inflection, a change that left him both bewildered and disheartened. The extent of this transformation was so profound that it severely hindered his ability to express himself, compounding the psychological toll of his earlier trauma.
Bromberg (1998) views Dissociation as a precious psychic survival tool that arises from the need to separate and compartmentalize aspects of traumatic experiences while maintaining the attachment to those who have neglected or abused them.
Dissociative Flashback Driven Violence
Many experts suspect a relationship between PTSD and violence. Some identify dysfunctional anger and violent behavior as comorbidities of PTSD. It has been reported that combatants who were diagnosed with complex PTSD had committed violence while experiencing flashbacks and had no clear sense of their acts. Such a phenomenon had been reported elsewhere.
Freedman and Sadock (1980) described flashbacks as ‘episodes of visual distortion, time expansion, physical symptoms, loss of ego boundaries, or relived intense emotions, lasting usually a few seconds to a few minutes, but sometimes longer.
Private SXXT31 served in a combat zone for nine years, during which he endured significant psychological trauma. He witnessed the deaths of his fellow soldiers due to enemy fire, mortar explosions, and artillery strikes, experiences that left him deeply affected, particularly when it came to handling the remains of his comrades. Over time, the cumulative weight of these harrowing events took a toll on his mental health, leading to severe transient headaches and memory loss. By 2002, he was diagnosed with full-blown post-traumatic stress disorder (PTSD), characterized by persistent nightmares and intrusive flashbacks. These flashbacks often transported him back to the traumatic moments of his service, causing him to disconnect from reality. In one alarming incident, he experienced a dissociative flashback during which he inadvertently squeezed the neck of his five-year-old daughter, mistaking her for a threat. His wife, noticing the distressing situation, quickly intervened and alerted their neighbors, who helped save the child from suffocation. Although the girl was hospitalized and eventually recovered, Private SXXT31 was left in a state of profound distress and guilt upon realizing what had occurred, as he had no recollection of the incident and was horrified to learn that he had harmed his own daughter.
Somatization
Somatization is defined as a tendency to experience and communicate psychological distress in the form of somatic symptoms (Lipowski,1988). These somatic symptoms have no organic causes. Psychologically traumatized veterans may suffer from different combinations of symptoms, including somatization. Elklit & Christiansen (2009) express the view that the relationship between trauma and somatization appears to be mediated by posttraumatic stress disorder (PTSD).
There are significant numbers of Sri Lankan combatants who were exposed to combat for a long period and suffer from posttraumatic symptoms and somatization. These psycho-somatic ailments show poor responses to the medication. Some of these symptoms have no medical basis. Therefore, these symptoms are often taken as elements of malingering.
Sergeant NX42HX enlisted in the Army in 1985, embarking on a journey that would test his resilience and fortitude. Following the completion of his basic training, he was assigned to the Jaffna Fort, a strategic location that was under the control of the Sri Lanka Army at the time. The atmosphere was fraught with tension, as the fort was frequently targeted by enemy forces who launched relentless mortar attacks. The sounds of explosions echoed through the air, both day and night, creating an environment of constant peril. Surrounded by adversaries, Sergeant NX42HX faced not only the physical dangers of combat but also the psychological toll of living under such duress, which led to significant distress and anxiety as he navigated the challenges of military life in a conflict zone.
In 1997, Sergeant NX42HX was stationed at the Paranthan forward defense line during a particularly challenging time, exacerbated by the aftermath of the monsoon rains. These torrential downpours not only disrupted supply lines but also halted evacuations and reinforcements, leaving the soldiers in a precarious situation. One fateful night, the enemy launched a fierce assault on their position. Despite the overwhelming odds, the soldiers managed to hold their ground and initiated a counteroffensive. The ensuing five-hour battle was brutal, resulting in significant casualties among the ranks, with many soldiers losing their lives and others sustaining serious injuries. Although Sergeant NX42HX emerged physically unscathed, the psychological toll of witnessing such violence and loss was profound. In the weeks that followed, he began to experience a range of somatic complaints, with his physical symptoms intensifying under stress. His ability to cope diminished, leading to the emergence of anxiety and depression, as well as startling reactions to everyday stimuli. Furthermore, he found that traditional pain relief methods were ineffective, and long-term treatment yielded little success, leaving him grappling with the invisible scars of war.
van der Hart et al. (2000) describe somatoform dissociation as a lack of normal integration of sensorimotor components of experience ( hearing, seeing, feeling, speaking, moving, etc). The phenomenon of “somatoform dissociation” was found among a number of Sri Lankan war veterans suffering from a severe form of PTSD. Their symptoms are characterized by numbness, paralysis, psychogenic seizures, persistent body pains, dyspepsia, sexual dysfunctions, etc., without any organic causes, and these symptoms have a poor response to typical medical treatments.
Private NXS32W faced significant challenges from an early age, having endured maternal deprivation during his childhood. In the wake of financial hardships, he decided to enlist in the military, where he dedicated seven years to service in operational areas, confronting numerous life-threatening situations. Throughout his deployment, he was tasked with handling human remains, an experience that left him profoundly affected and emotionally shattered. The loss of several close friends in combat further deepened his sorrow, contributing to a growing sense of grief and trauma. Over time, he began to experience intrusive thoughts, recurrent nightmares, and heightened startle responses, which indicated the toll that his experiences had taken on his mental health. In 2002, he was referred for medical evaluation due to the onset of right-sided hemiplegia. Following consultations with both a physician and a neurologist, a series of diagnostic tests, including EEG and CT scans, returned normal results, effectively ruling out any organic causes for his condition. Ultimately, Private N found relief and recovery through hypnotherapy, which helped him address the psychological scars of his past experiences.
Sexualized Behaviors
Sometimes, sexualized behaviors are evident among combatants with complex PTSD. Some psychologically traumatized war veterans were found with behaviors such as sexual preoccupation, spending money and time on pornographic material and on prostitutes, sexual aggression- committing marital rape, engaging in sexual violence – rape and sexual assaults, child abuse, voyeurism, exhibitionism, frottage, bestiality, etc.
Sexual behavior and concerns are also related to a childhood history of sexual abuse (Friedrich, Jaworski, Huxsahl &Bengtson, 1997). The combatants with a past history of childhood physical, sexual, and emotional abuse (as well as physical and emotional neglect) could engage in sexual violence. These actions could be disastrous to the victim as well as to the perpetrator. The extreme forms of sexualized behaviours have serious consequences for targets, including physical and psychological harm. Abbey et al. (2004) indicate that sexually violent men, especially multiple offenders, are more likely to lack empathy or have remorse for their victims and blame their victims for the rape.
Private AXJ43SX, a recognized patient suffering from post-traumatic stress disorder (PTSD), openly acknowledged his struggles with sexual compulsions and voyeuristic urges. In therapy sessions, he revealed that he had previously found gratification in inflicting pain on his wife during intimate encounters. This behavior escalated alongside his increasing libido and tendencies toward sexual violence. This troubling pattern not only strained his marital relationship but also led to legal repercussions stemming from his sexual conduct. Private AXJ43SX articulated how these destructive behaviors took control of his life, attributing their emergence to the psychological toll he experienced as a result of his wartime experiences.
Sense of Foreshortened Future
Combatants with complex PTSD do not have specific life goals or motivations to pursue them. They do not wish to advance their military career, to have a family or children (if married, no interest in family matters and family advancements) and often make negative predictions about their health and lifespan.
Sergeant AXC38RX, a highly skilled and seasoned field operator from the Commando Unit, experienced a profound psychological decline following a series of traumatic events during combat at Thoppigalla. The horrors he witnessed were particularly haunting; on one occasion, he discovered two of his comrades brutally murdered in a bunker, their throats cut by enemy forces. In another instance, he helplessly watched as a sniper's bullet claimed the life of a close friend right before his eyes. These traumatic experiences left him grappling with severe psychological repercussions, including persistent nightmares, intrusive thoughts, flashbacks, and a strong desire to avoid reminders of the battlefield. In 2002, a Consultant Psychiatrist from the Sri Lankan Army diagnosed him with full-blown Post-Traumatic Stress Disorder (PTSD). As his mental health deteriorated, Sergeant AXC38RX found it increasingly difficult to envision a hopeful future, leading to a profound sense of demotivation. He lost interest in pursuing further training or participating in specialized military courses, and physical ailments such as chronic pain and headaches hindered his ability to engage in sports or exercise, activities he once enjoyed. The weight of his depression isolated him from social interactions, causing him to withdraw from relationships, including his marriage and responsibilities as a parent. Ultimately, he felt a pervasive sense of despair, believing that his life was nearing its end.
Self-Harm
Self-harm is defined here as deliberate and voluntary physical self-injury that is not life-threatening and is without any conscious suicidal intent ( Herpetz, 1995). The types of self-harm reported were: taking excessive numbers of medication, cutting oneself, burning, throwing oneself against vehicles, swallowing things, head banging, reckless and risk-taking behaviors, etc. Farber (2000) points out that when faced with life-threatening psychological trauma people exhibit radical changes in eating behavior and may become, self-injurious. Self-harm has been reported among a number of Sri Lankan combatants with malignant PTSD.
Self-harm allows the individual to adapt to the most horrific of circumstances without becoming psychotic and without killing himself or, someone else, and in that way serves an invaluable defensive function. But it is, far more than a defense, and more than a symptom. It is the behavioral, component of a part of the self with a set of needs, feelings, and perceptions that have been dissociated from the patient’s total self-experience (Farber, 2006).
L/Cpl FWX suffered a gunshot wound to his left leg, which marked the beginning of a series of psychological and physical challenges. Following his injury, he found himself grappling with intrusive thoughts and heightened startle responses, symptoms that are often associated with combat trauma. The memories of his experiences in battle haunted him relentlessly, contributing to a growing sense of distress. In a moment of poor judgment, he consumed a significant amount of alcohol and chose to sleep on a precarious 20-foot-high parapet wall, fully aware of the inherent dangers. Unfortunately, his decision led to a predictable outcome; he eventually lost consciousness and fell, resulting in a fractured femur. This incident not only exacerbated his physical injuries but also highlighted the profound impact of his mental state on his decision-making.
L/Cpl SCX34X, who has been diagnosed with post-traumatic stress disorder (PTSD), exhibits significant challenges related to emotional regulation and impulse control, often accompanied by feelings of shame and humiliation. His mental health struggles have led him to contemplate self-harm on multiple occasions, reflecting the depth of his distress. In a particularly alarming incident, he impulsively stepped in front of a moving van, resulting in severe injuries that underscored the gravity of his condition. This incident not only highlights the urgent need for comprehensive mental health support but also raises concerns about the potential risks associated with untreated PTSD and its impact on behavior.
Suicidal Behavior
According to Afifi et al. (2008), numerous studies indicate that there is a correlation between psychological trauma and suicidal behaviors. In addition, there is evidence that traumatic events such as childhood abuse and other types of trauma may increase a person’s suicide risk.
The prevalence of suicidal thoughts, suicide planning, and suicide attempts is significantly higher among combatants with severe war trauma.
The Eelam War, which spanned from 1983 to 2009, witnessed a troubling phenomenon: a considerable number of Sri Lankan soldiers took their own lives, with many believed to be grappling with the psychological aftermath of combat. Investigations into these tragic cases, often referred to as psychological autopsies, uncovered a range of mental health issues among the victims, including depression, post-traumatic stress disorder, various psychiatric conditions, substance abuse, interpersonal relationship difficulties, and overwhelming work-related pressures. The findings suggest that a significant portion of these suicides could have been prevented through timely and effective interventions aimed at addressing the mental health needs of soldiers. The implications of these revelations highlight the critical importance of mental health support systems for military personnel, particularly in the wake of intense and prolonged conflict.
Private SXB29XC served in active combat zones, where he witnessed the devastating effects of artillery and mortar attacks, including the loss of fellow soldiers. Frequently exposed to intense gunfire, he endured significant psychological distress, manifesting as severe headaches, nightmares, intrusive thoughts, and flashbacks. During his involvement in the Jayasikuru military operation, he found himself unable to take leave or communicate his struggles to his superiors, leading him to suppress his anxiety for an extended period. Eventually, the weight of his suffering became unbearable, prompting him to walk toward enemy lines, seemingly inviting sniper fire. A fellow platoon member noticed his perilous actions and alerted the rest of the unit, who quickly retrieved him from the open terrain. Upon his return to camp, he faced harsh disciplinary measures for abandoning his post. Subsequently, Private SXB29XC was referred to the Military Hospital, where he was diagnosed with full-blown symptoms of post-traumatic stress disorder (PTSD).
DESNOS and Psychotic Symptoms
According to our empirical investigations, some of the Sri Lankan combatants with complex PTSD were found with psychotic symptoms in the latter stages, leaving us to question the relationships between PTSD and psychosis. Some researchers have speculated potential links between trauma and psychosis. Ellison & Ross (1997) suggest that psychosis may emerge as a reaction to trauma. PTSD with secondary psychotic features (PTSD-SP) is an emerging diagnostic entity (Hamner,2011).
There is much speculation about the relationship between traumatic life events and, the development of psychosis, particularly its association with childhood sexual abuse, physical abuse, or interpersonal violence (Morrison, Frame, & Larkin, 2003).
Lance Corporal JXXE36X experienced traumatic combat situations during his deployment in Palampiddi, which left him in a state of shock. Witnessing the devastating impact of incoming mortar fire, he saw his comrades fall victim to the violence, their bodies tragically torn apart. For nearly ten months, he remained with his platoon, unable to return home for leave, as they continuously faced aggressive assaults from hostile forces. This relentless exposure to danger took a significant toll on his mental well-being, ultimately leading to a diagnosis of post-traumatic stress disorder (PTSD). As his anxiety symptoms intensified, Corporal JXXE36X began to exhibit signs of psychosis, prompting medical intervention. He was subsequently prescribed atypical antipsychotic medications to help manage his condition and alleviate the distressing symptoms he was experiencing.
Corporal KXX38BX experienced a profound acute stress reaction after witnessing the tragic deaths of two comrades due to a mortar explosion. This traumatic event triggered a cascade of psychological symptoms, including intrusive memories and vivid flashbacks that haunted him relentlessly. As a result, he developed a pronounced aversion to combat situations, leading to a significant decline in his mental well-being. Over time, his condition deteriorated further, culminating in a diagnosis of post-traumatic stress disorder (PTSD) accompanied by psychotic symptoms. These manifestations included incoherent speech, unsettling hallucinations, and disordered thought processes, all of which severely impacted his ability to function and engage with the world around him.
Lommen & Restifo (2009) are of the view that Psychosis and PTSD can both be part of a spectrum of responses to a traumatic event. There have been many reports from various parts of the world that survivors of war trauma or torture have been found with complex PTSD and psychosis. Wenzel et al. (1999) vividly describe the case histories of two patients suffering from Capgras syndrome along with schizoaffective disorder and posttraumatic stress disorder after prior experience of prolonged torture.
Sri Lankan Combat Veterans with Complex PTSD
1) Lance Corporal P
Lance Corporal P enlisted in the Army in 1991, dedicating himself to service in various operational theatres. By 1993, he was stationed as a signalman at the Senapura Camp, a critical location during a tumultuous period. That same year, the camp came under a devastating assault by the LTTE, resulting in a catastrophic breach that led to the deaths of numerous soldiers. In the chaos of the attack, Lance Corporal P was captured by enemy forces. The harrowing experience left an indelible mark on him, particularly as he witnessed the brutal execution of his commanding officer, Lieutenant [Name], who was killed in a gruesome manner. The enemy not only took the Lieutenant's life but also committed the atrocity of removing his eyes, an act that filled Lance Corporal P with profound horror and paralyzing fear. This traumatic event would haunt him, serving as a stark reminder of the brutal realities of war and the fragility of life in combat zones.
He was forcibly taken to one of the LTTE camps, where he endured severe beatings. For nearly seven months, he was confined to a small, dimly lit room, a tactic designed to disrupt his biological clock and disorient him. This prolonged isolation eroded his sense of time and reality, leading to a psychological breakdown. Once they had shattered his mental resilience, the torment escalated to physical torture. He was brutally beaten, subjected to electric shocks, and relentlessly interrogated in an effort to extract classified radio signal codes. The interrogators, convinced he was an undercover officer, subjected him to mock executions, heightening his terror. On one harrowing occasion, he witnessed the execution of an EPRLF prisoner from a rival rebel faction, a chilling reminder of the brutality surrounding him. Lance Corporal P ultimately endured nearly five excruciating years as a prisoner of war under the custody of the LTTE, a period marked by relentless suffering and despair.
In 1998, he was released from captivity through the efforts of the International Red Cross, yet upon returning home, he found himself devoid of joy. His emotional state was severely dulled, overshadowed by an overwhelming fear of being recaptured by the LTTE. This pervasive anxiety manifested in deep-seated suspicions, intrusive thoughts, flashbacks, and nightmares, alongside troubling suicidal thoughts. Despite the severity of his condition, Lance Corporal P was not referred for psychological evaluation following his release, leaving him undiagnosed and untreated for several years. As time passed, his symptoms worsened, culminating in a significant dissociative episode that rendered him unable to speak. By 2000, he was diagnosed with full-blown post-traumatic stress disorder (PTSD). Over the years, his anxiety disorder evolved into a more malignant form, characterized by a range of symptoms associated with Disorders of Extreme Stress Not Otherwise Specified (DESNOS). These included difficulties in regulating his emotions, persistent suicidal thoughts, memory loss, profound feelings of guilt and shame, an inability to trust others, physical manifestations of psychological distress, and a pervasive sense of hopelessness and despair. Ultimately, in 2005, Lance Corporal P was medically discharged from the Army due to his psychological disability, marking a significant turning point in his life.
2) Corporal JXXX32T
Corporal JXXX32T was actively involved in the military offensive known as Operation Ranagosa in 1999, where he encountered profoundly traumatic experiences during combat. Throughout the operation, he found himself in numerous life-threatening situations, which left an indelible mark on his psyche. Following the conclusion of the operation, he struggled significantly with intense feelings of distress and survivor's guilt, leading to a gradual decline in his mental health. He began to experience debilitating headaches and exhibited symptoms of pathological dissociation. In his despair, he attempted suicide on several occasions, prompting a referral for a psychological evaluation. The assessment revealed that Corporal JXXX32T was suffering from severe post-traumatic stress disorder (PTSD), characterized by a range of debilitating symptoms. In addition to the hallmark signs of PTSD, he was also diagnosed with affect dysregulation, difficulties in managing anger, chronic suicidal ideation, persistent feelings of dysphoria, significant sexual dysfunction, repressed memories of combat (amnesia), and alterations in his self-perception, all of which contributed to his ongoing struggle with mental health.
3) Lance Corporal LX31CXX
Lance Corporal LX31CXX spent several years conducting interrogations, a role that left him deeply scarred by the traumatic experiences he endured. The weight of his past haunted him, manifesting in frequent nightmares that plagued his sleep, often featuring a haunting image of a bleeding skull. This recurring vision became a symbol of his inner turmoil, reflecting the psychological scars he carried. In 2002, he was diagnosed with severe post-traumatic stress disorder (PTSD), a condition that significantly impacted his daily life. Despite seeking help through medication and psychotherapy, his response to treatment was disappointing, leaving him to grapple with the persistent shadows of his memories and the obsessive thoughts that revolved around blood. The struggle to find relief from his symptoms only added to his distress, creating a cycle of anxiety and fear that he found increasingly difficult to escape.
The treatment he received failed to alleviate his anxiety symptoms, which escalated to a severe and malignant level. This deterioration was evident in his emotional regulation, as he exhibited significant changes in how he managed his feelings and impulses. His demeanor became increasingly hostile, accompanied by frequent thoughts and fantasies of violence. Concurrently, he sank into a deep depression, becoming consumed by suicidal ideation. In a desperate attempt to escape his pain, he once ingested pesticides in a suicide attempt. Despite being in a phase of life where sexual activity was common, he found himself devoid of any interest in sexual relationships or the prospect of marriage. Lance Corporal LX31CXX displayed numerous self-destructive behaviors, notably his reckless habit of crossing streets without regard for oncoming traffic. He later confided that he was, in fact, anticipating a fatal accident, suggesting a troubling acceptance of his own potential demise.
His cognitive faculties began to deteriorate, leading to a significant decline in his ability to focus for extended periods. This impairment manifested in his inability to remember key events from his past, which further compounded his distress. He frequently experienced dissociative episodes, particularly characterized by feelings of depersonalization, leaving him feeling detached from reality. A pervasive fear consumed him, as he worried that during these episodes, he might inadvertently cause harm to his sister's children while reliving traumatic memories. Additionally, LX31CXX suffered from a range of physical ailments that proved resistant to pain relief, further complicating his condition. These challenges were accompanied by profound shifts in his personality and belief systems, eroding his capacity to trust others, including his therapists, which left him feeling isolated and vulnerable.
4) Private CX29VX
Private CX29VX endured a tumultuous childhood marked by trauma stemming from neglect, poverty, and a lack of maternal care. Raised initially by his grandmother, he faced further upheaval following her death, which led to his upbringing under the care of his uncles. His formative years were spent in a perilous village located in the Polattackonnaruwa District, a place that was frequently besieged by the Liberation Tigers of Tamil Eelam (LTTE). The village was a scene of relentless violence, with LTTE militants launching brutal attacks that resulted in the deaths of numerous villagers, including men, women, and children, often using machetes. These harrowing experiences left a profound impact on him, as he not only lost several relatives during these assaults but also bore witness to the aftermath, including mass burials that followed the atrocities. Living in a constant state of fear and uncertainty, he grappled with the psychological scars of his environment, which shaped his understanding of safety and community in a world fraught with danger.
After completing his education, Private CX29VX enlisted in the Army, where he was deployed to various operational areas. Demonstrating exceptional skill and dedication, he was chosen for specialized training that prepared him for high-stakes missions. Throughout his service, he encountered numerous harrowing experiences, witnessing the deaths of fellow soldiers and frequently dealing with the aftermath of combat, including the handling of human remains. After dedicating twelve years to military service, the psychological toll of these experiences began to manifest, leading to significant mental health challenges. Private CX29VX began to suffer from a range of symptoms associated with post-traumatic stress disorder (PTSD), including intense feelings of fear, recurrent nightmares, heightened arousal, intrusive memories, emotional numbness, and a strong tendency to avoid reminders of his traumatic experiences. In 2003, he was formally diagnosed with combat-related PTSD, marking a pivotal moment in his struggle to cope with the lasting effects of his military service.
By 2004, he increasingly found himself in a state of isolation, becoming profoundly withdrawn and distancing himself from those around him. The weight of guilt over the comrades he had to leave behind on the battlefield, who never made it home, burdened him heavily. This self-reproach was compounded by a persistent sense of guilt and societal stigma, leading to a pervasive cynicism about the world. He often perceived his existence as futile, grappling with feelings that life lacked any real purpose. Anger consumed him, fueled by a deep-seated desire for revenge, which he struggled to manage, resulting in multiple encounters with law enforcement. To escape the torment of night terrors, he turned to alcohol, seeking solace in its numbing effects. Private CX29VX exhibited a diminished ability to maintain positive emotional experiences, spiralling into self-destructive behaviours that adversely affected those around him, particularly his family. His psychological state was marked by symptoms of somatization and pathological dissociation, further complicating his already troubled existence.
Treatment Measures
In Sri Lanka, a number of treatment methods are used to treat war veterans with complex PTSD. Among the treatment methods, medication, psychotherapy, and indigenous treatments are prominent. A variety of medications are used to treat the victims of war trauma. Anti-depressants, Anxiolytics, Antipsychotics, and Mood Stabilizers are often used. Sometimes, Psychiatrists use ECT to control severe agitation and suicidal behaviour.
Psychotherapies are widely used in major hospitals and rehabilitation centers in Sri Lanka. Client-Centred (Rogerian) Counseling, Cognitive Behavior Therapy, and Family Therapy are widely used by trained therapists. Empirical data concur that EMDR has been an effective mode to treat combatants with complex PTSD. Many Sri Lankan war veterans with full-blown symptoms of PTSD with pathological dissociation and other complications were able to achieve remarkable therapeutic success after being treated with EMDR (Jayatunge,2008)
Traditional healing methods are frequently used by indigenous healers. The ancient ritual Thovilaya, which is a form of Psychodrama, is widely used to treat the sufferers. It creates action methods, role training, spontaneous dramatization, and group dynamics to alleviate illnesses. A benediction ritual, which is known as Dehi Kapima or ceasing the evil spirits and evil eye, is often used. Spiritual therapy and meditation are other important methods to treat war victims since ancient times. Chanting Pirith for blessings and numerous types of meditation are prescribed to treat war victims. Mindfulness meditation, meditation of loving kindness, helps PTSD victims to control anger, reduce anxiety and improve concentration.
Discussion
The combat trauma affected the Sri Lankan soldiers as early as 1981 and in 1983, with the intensification of the armed conflict, the military forces in Sri Lanka mobilized a large number of combatants to fight the rebel forces of the LTTE (The Liberation Tigers of Tamil Eelam), whose aim was racial separation. The LTTE was known as the world’s deadliest terrorist organization and it was banned by a number of Governments – India, Malaysia, the USA, Canada, and the United Kingdom.
The LTTE, with its ground naval and air power, launched massive attacks against the government forces and sometimes aimed at civilians. The LTTE used suicide bombers and a large number of child soldiers in their military cause. The conflict lasted till 2009, and the Sri Lankan armed forces militarily defeated the LTTE.
During this prolonged armed conflict, 90 000 people died and a large number of people became physically and psychologically disabled. Over 300 000 people from the Army, Navy, Air Force, Police, and the Home Guards were exposed to combat situations throughout the Eelam War. The combatants who were on the frontline of this conflict experienced traumatic battle events that were beyond the usual range of human experience. Many became the psychological casualties of the war.
From the early days of the armed conflict, the Military Forces had no effective way of managing combat trauma. Psychological ailments such as PTSD were understudied or disregarded and there was no psychological first aid to the troops until the war trauma gravely affected the military and society. A large number of soldiers deserted the army and many were believed to be affected by combat stress. The military suicides increased and according to military sources after the end of the military conflict in Sri Lanka from 2009 -2012 post-war period, nearly 400 soldiers had committed suicide.
As a result of war trauma in Sri Lanka, a large number of soldiers suffered from PTSD and complex PTSD, which is better known as DESNOS (Disorders of, Extreme Stress, Not Otherwise Specified) a condition characterized by three categories of symptoms: emotion dysregulation, dissociation and problems in physical health. The DESNOS is also marked by severe functional impairments affecting the victim’s private and social life. There are many combatants with undiagnosed complex PTSD and the majority of them are not receiving adequate treatment.
The combatants who have been diagnosed with PTSD and DESNOS receive drug therapy and various forms of psychotherapy. Some prefer to undergo indigenous traditional therapies. Among the psychological therapies, many Sri Lankan war veterans were comfortable with CBT and EMDR (Reprocessing Therapy) and many showed positive outcomes after treatment with these modes of psychotherapy.
It is essential to provide more efficient and comprehensive therapies to the combatants with war trauma and the psychiatric and rehabilitation services should work in collaboration to achieve success. The Health Ministry should provide sufficient training to the doctors to identify and combat trauma reactions and make referrals effectively. As future measures, evidence-based psychotherapy such as Cognitive Processing Therapy should be introduced to treat Sri Lankan war veterans. Cognitive Processing Therapy (CPT) is a 12-session therapy that has been found effective for PTSD, and many VA centers are successfully using this psychotherapeutic method to treat war-affected combat veterans. In addition, Psychosocial Rehabilitation should be incorporated to help traumatized combat veterans achieve recovery. Psychosocial Rehabilitation practices help war veterans re-establish normal roles in the community, independence, and reintegration into community life. These interventions help to manage behaviors, perceptions, and reactions and give the opportunity to the veterans to live a full and meaningful life.
Acknowledgements
1) Dr. Neil J Fernando: Consultant Psychiatrist of the Sri Lanka Army
2) Professor James Alcock -Department of Psychology, Glendon College, York University. Canada
2) Professor Onno van der Hart – the Department of Clinical and Health Psychology , Utrecht University, Netherlands
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