Combat-Related Psychotic Manifestations Among Sri Lankan Army Personnel

 

Dr. D.P.D Wijesinghe and Dr. Ruwan M Jayatunge

Sri Lanka underwent a prolonged armed conflict lasting 30 years, during which many combatants ended up with severe post-traumatic reactions (Jayasinghe & de Silva, 2024). Beyond post-traumatic stress disorder, a subset of soldiers exhibited temporary psychotic reactions, and some soldiers ended up in full-blown psychosis that was directly linked to the intense combat stress encountered during warfare. This particular manifestation of psychological distress has not been extensively explored within the medical literature.

PTSD and Psychosis are two different mental health conditions, but sometimes they can overlap. There are few studies that have found direct evidence for a link between PTSD and psychosis. Psychotic phenomena may also be a relatively common manifestation in patients with chronic PTSD (Seedat et al.,2003). Morrison and team (2003) provide evidence to support the relationship between trauma and psychosis.

Stress is a significant factor in many theories regarding the origins of psychotic disorders (Holtzman et al., 2012). Extreme battlefield conditions can precipitate the onset of Brief Psychotic Disorders in some soldiers. The severe trauma encountered by military personnel during combat may result in various psychotic disorders, such as Post-Traumatic Stress Disorder with Psychotic Features, Stress-Induced Schizophreniform Disorders, and Bipolar Disorder.

Investigating combat-induced psychotic manifestations in Sri Lanka Army personnel is essential as it highlights a significant and often overlooked aspect of psychiatric trauma that conventional PTSD frameworks do not adequately address. While much of the global military research tends to concentrate on symptoms such as anxiety, hypervigilance, and depression linked to traditional PTSD, a thorough examination of these psychotic manifestations is crucial for enhancing regional public health, advancing military medicine, and ensuring long-term societal stability.

 

Brief Psychotic Disorders Following Combat Trauma

In high-stress combat situations, certain soldiers may experience Brief Psychotic Disorders, or Brief Reactive Psychosis, which is marked by an abrupt and transient emergence of psychotic symptoms. Umbrasas (2010) highlights that extreme combat stress acts as a direct precipitant for Brief Psychotic Disorder (BPD) in vulnerable soldiers. This disorder can emerge following combat trauma, resulting in a significant disruption in the brain's ability to interpret reality due to the overwhelming stress encountered in such environments.

The mental resilience of soldiers is severely compromised by combat stress, which can lead to a complete breakdown of the brain's stress response. The amygdala, which plays a crucial role in processing fear, may become overstimulated, resulting in acute panic (van Wingen et al.,2011). Simultaneously, heightened levels of cortisol and adrenaline can impair the functioning of the prefrontal cortex, hindering logical reasoning and accurate reality assessment (Arnsten, 2009). Furthermore, an excessive release of neurotransmitters like dopamine and glutamate can distort sensory perceptions (Master, 2024), complicating the soldier's ability to effectively engage with their surroundings. Consequently, this condition can result in hallucinations, delusions, disorganized speech, or catatonic behavior, with episodes typically lasting from several days to less than a month (Bashir & Ahmad, 2023).  

Corporal KJX's experience illustrates the onset of Brief Psychotic Disorder in a soldier during wartime. Following a devastating mortar attack, he witnessed the violent deaths of two fellow soldiers, an event that left him horrified as he saw their brain matter exposed. This traumatic incident triggered an acute stress reaction, leading to a psychotic episode characterized by incoherent speech and unresponsiveness to verbal commands. Additionally, he exhibited signs of agitation and disorientation, becoming confused about his environment. Subsequently, he was transported to Palali Hospital, where he was diagnosed with Brief Psychotic Disorder. Remarkably, after three weeks, he regained his normal cognitive functions.  

  

Combat Related PTSD with Psychotic Features

Research conducted by Hamner and colleagues (2000) indicates that between 30% and 40% of combat veterans suffering from chronic PTSD exhibit psychotic symptoms. The Sri Lankan war theatre has seen numerous soldiers develop post-traumatic stress disorder (PTSD), a condition that has been further exacerbated by the emergence of psychotic symptoms. 

Post-Traumatic Stress Disorder (PTSD) is strictly classified as a trauma- and stressor-related disorder, not a psychotic disorder (Friedman, 2014). The experience of severe and persistent trauma can lead some soldiers with PTSD to exhibit psychotic symptoms, a consequence of significant neurochemical and cognitive strain. This overload arises from the intense stress associated with their traumatic experiences (Arnsten, 2009). 

According to Hamner and team (1999), combat stress causes PTSD with psychotic features by triggering a profound neurobiological and chemical collapse in the brain. Chronic combat stress leads to a physical weakening and down-regulation of the medial prefrontal cortex (mPFC) and the anterior cingulate cortex (Shin et al.,2011). In the absence of the regulatory function of the prefrontal cortex, the amygdala becomes hyperactive, resulting in a constant release of adrenaline and cortisol into the nervous system (Koenigs & Grafman, 2009). Prolonged exposure to elevated cortisol levels can cause hippocampal atrophy, damaging neurons in the hippocampus, which is crucial for contextualizing and time-stamping memories (McEwen,2007). Additionally, dysregulation of dopamine can trigger a series of failures in the brain's ability to accurately process reality (Kapur, 2003).  This neurobiological breakdown can cause psychosis.

The following case study examines a Sri Lankan soldier, Corporal XLC, who participated in the Eelam War and subsequently developed PTSD with psychotic features. Having served in the operational area for several years, he was exposed to numerous traumatic combat experiences, which significantly impacted his mental health. By 2003, after more than five years of service, Corporal XLC's condition had severely declined, leading to a diagnosis of combat-related PTSD. In addition to the core symptoms of PTSD, he displayed signs of paranoid surveillance, extreme hypervigilance, and delusions characterized by feelings of depression and guilt. He also experienced traumatic replays, including auditory hallucinations of deceased comrades' voices and phantom sounds reminiscent of the battlefield, such as gunfire and helicopter sounds. On one occasion, he experienced environmental distortion, mistaking an old lorry near his residence for a Unicorn APC, a type of mine-protected personnel carrier developed by the Sri Lanka Army.

  

War Trauma and Schizophreniform Disorders

The emergence of Schizophreniform Disorder, or a complete schizophrenia-spectrum disorder, in soldiers after experiencing intense combat stress can be comprehensively explained by the Stress-Vulnerability-Sensitization Model (Stefanis et al.,2020). It is important to note that the onset of such disorders is not solely attributable to stress; rather, a pre-existing genetic predisposition is necessary (Van Os & Kapur, 2009). Extended exposure to the traumatic conditions of a combat environment can lead to lasting changes in the brain's biochemical pathways (Southwick et al.,2011). This includes dopaminergic hyper-reactivity, sympathetic overload, and a surge in cortisol levels. (Pruessner et al.,2014).  Chronic stress results in an excess of cortisol, which can inflict damage on critical brain regions such as the hippocampus and prefrontal cortex, ultimately contributing to dopamine dysregulation and the development of Schizophreniform Disorders among combatants (Grace, 2016). 

Lance Corporal PNXG's experience illustrates how combat stress can lead to Schizophreniform Disorder. As a seasoned combatant, he took part in Operation Liberation in 1987, where he encountered traumatic events, including the deaths of two fellow soldiers, which left him emotionally overwhelmed. Six months’ post-operation, he began to exhibit symptoms such as combat-themed delusions and paranoia, particularly when he saw airplanes. Additionally, he experienced trauma-echoing hallucinations, hearing the voices of his deceased platoon members, and developed a belief that his thoughts were being manipulated by the enemy to extract critical intelligence from his mind. His condition was further characterized by affective flattening and avolition, resulting in significant neglect of self-care.

 

Battle Stress and Bipolar Disorder

Clinical studies show a shockingly high presence of bipolar symptoms in heavily traumatized military cohorts. The experience of battle stress can lead some combatants to develop Bipolar Disorder due to the brain's adaptation to prolonged hyper-vigilance in active combat zones (Gordon et al., 2014).  This heightened state triggers a relentless release of dopamine and glutamate, enhancing focus, energy, and reaction times (Popoli et al.,2012). However, chronic exposure to combat stress inflicts lasting damage on the Hypothalamic-Pituitary-Adrenal (HPA) axis, which regulates the body's stress response, resulting in excessive cortisol levels in the bloodstream. Following such stress, the brain experiences significant emotional and chemical upheaval, with repeated traumatic events forging deep neurological pathways (Herman et al.,2016).  Over time, the brain becomes increasingly sensitive to stress, leading to emotional extremes that can occur without any external threat. Consequently, the internal mood-regulation system operates independently, oscillating between manic and depressive states. Additionally, sustained high cortisol levels contribute to the structural shrinkage of the hippocampus and prefrontal cortex, impairing the brain's capacity to manage emotional fluctuations and reinforcing the cycle of Bipolar Disorder (Tomaszewska & Nowak, 2025). 

Sargent BCX dedicated 12 years of service in the Army, primarily in operational areas, where he encountered gruesome battle experiences that significantly affected his mental health. This exposure led to a complex psychological profile characterized by severe mood fluctuations, marked by episodes of both manic and depressive phases. During the manic phase, he displayed explosive rage, restlessness, and grandiose beliefs. Conversely, in the depressive phase, he suffered from emotional numbness, survival guilt, social isolation, and suicidal thoughts.

 

Concluding Thoughts

A considerable number of military veterans from Sri Lanka endured extended deployments, often lasting as long as ten consecutive years, in intensely active operational areas located in the North and East during the protracted Eelam War, which spanned three decades. This prolonged exposure to combat situations has led to a significant prevalence of combat-related stress among these soldiers, with some experiencing severe psychotic manifestations directly linked to their wartime experiences. These psychotic disorders represent a particularly complex and serious form of trauma, arising from encounters with traumatic events that are far removed from typical human experiences. It is important to be vigilant not to miss psychotic symptoms in soldiers presenting with PTSD as early treatment directly improves long-term recovery and reduces symptoms by shortening the duration of untreated psychosis.

  

(Dr. D.P.D. Wijesinghe serves as a consultant psychiatrist and is also a visiting lecturer at the University of Wayamba) 

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