Professor Daya Somasundaram / Dr Ruwan M Jayatunge
Prolonged armed conflict in Sri Lanka has created higher rates of mental
ailments among the Army personal and members of the LTTE. A significant number
of people have been diagnosed with complex forms of PTSD aka Malignant PTSD.
These individuals with malignant forms of anxiety have a wider range of
clinical symptomatology with severe psychosocial impairments. These people
would fit into the diagnostic category of DESNOS (Disorders of extreme stress
not otherwise specified) or Complex Post-Traumatic Stress Disorder (C-PTSD) /
Malignant PTSD that was described by Dr. Judith Herman in
1992. Complex PTSD has been recognised as a new diagnosis in the
International Classification of Diseases 11th Revision (ICD-11).
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. (DESNOS), characterised by alterations in regulating
affective arousal with difficulty in modulating anger, self-destructive and
suicidal behaviour and impulsive and risk-taking behaviour.
They have chronic characterological changes with alterations in
self-perception: chronic guilt and shame; feelings of self-blame or
ineffectiveness and of being permanently damaged; a tendency to victimize
others and alterations in systems of meaning such as despair and hopelessness
or loss of previously sustaining beliefs (Jong, 1997).
Sri Lanka's Armed Conflict and Its Impact on the Victims
A three-decade-long armed conflict in Sri Lanka has created higher rates
of psychological problems among the victims. They were at high risk of
developing war-related psychopathology. The armed conflict between government
forces and the Liberation Tigers of Tamil Eelam has resulted PTSD and DESNOS
(C- PTSD). DESNOS has caused considerable impairments in psycho-social
functioning among the affected individuals. These people often experience
multiple mental health problems. Most of the victims have not received adequate
treatment and some cases are still undiagnosed. Lack of availability of mental
health services is one of the barriers to treat war victims and
ameliorating their distress.
C- PTSD Among the Sri Lankan Combat Veterans
A significant number of Sri Lankan soldiers suffered severe war trauma
during the Eelam War that lasted from 1983 to 2009. It changed the
psychological makeup of soldiers. A large number of combatants underwent
traumatic battle events outside the range of usual human experience. These
experiences include constantly living in a hostile battle-ravaged environment,
seeing fellow soldiers being killed or wounded and sight of unburied
decomposing bodies, handling human remains, hearing screams for help from the wounded,
and helplessly watching the wounded die without the possibility of being
rescued etc. The affected combatants with war trauma experience problems in
their living, working, learning, and social environments. War trauma has
drastically impacted their mental health and long-term functioning. Some of the
Sri Lankan combatants with full blown PTSD showed a wider range of clinical
symptomatology with sever psychosocial impairments and these veterans would fit
in to the diagnostic category of DESNOS (Disorders of extreme stress not
otherwise specified) or Complex Post Traumatic Stress Disorder (C-PTSD).
C- PTSD Among the ex LTTE Carders
The Liberation Tigers of Tamil Eelam (LTTE) - a Tamil militant
organization and they attacked the Sri Lankan armed forces with modern weapons.
The LTTE used numerous unconventional methods to fight the Sri Lankan Forces
using child soldiers and suicide bombers. Many surviving members of the former
LTTE either now live in Sri Lanka or live abroad. Most of these ex-militants
joined the movement as children and throughout the war, they underwent the
harsh realities of war trauma. A significant numbers of ex LTTE members suffer
from malignant PTSD. These victims live with rage, guilt, alienation and
suicidal ideation. They lack social skills and unable to form families due to a
lack of parental skills and intimacy. Some affected by addiction problems.
Case Studies
1)
Rifleman Sn34 became psychologically wounded after facing traumatic battle
events in Operation Yale Devi which was launched in 1993 to destroy the LTTE
Sea Tiger strongholds at Kilali. The enemy launched a surprise attack on
the advancing column resulting in the deaths of hundreds of soldiers. The LTTE
attacked them with mortars and Rocket Propelled Grenades. Rifleman Sn34 saw the
deaths of a number of his fellow soldiers. The enemy captured some of the
wounded men. After this dreaded battle, Rifleman Sn34 had a pessimistic
outlook on the future. He had ruminations about the battle events. He relived
these experiences. Startle reactions troubled him significantly. He had no way
of receiving treatment or no way of explaining to anyone his psychological
anguish. For a long period, he lived with his posttraumatic symptoms. Over the
years he felt that he was unable to trust people or the system. He became
extremely vigilant during the presence of unknown people. He stopped
associating with people and became socially isolated. He was demotivated to
initiate new events and felt lethargic and withdrawn. He became an extremely fearful
person. Prior to the traumatic event, he was decorated for bravery but after
the battle trauma, the sound of a firecracker could make him excessively
frightened
2)
Private SXXT31 served in the operational area for 9 years and firsthand
experienced combat trauma. He witnessed how his unit members got killed
following enemy fire, mortar blasts, artillery attacks etc. and became
severally overwhelmed while handling human remains. After experiencing these
events over a long period, he suffered severe transient headaches and loss of
memory. By 2002 he was diagnosed with full-blown symptoms of PTSD. He was
frequently troubled by nightmares and flashbacks. When he experienced
flashbacks, he used to re live the traumatic event and often became
disconnected from reality. Once Private SXXT31 went into a dissociate flashback
and he had squeezed the neck of his five-year old daughter. When the little
girl was suffocating, his wife accidentally noticed the dreadful event, alerted
the neighbors and saved the little girl from Private SXXT31’s strong grip. The
girl was immediately hospitalized and later recovered. Private SXXT31 became
extremely distressed and felt guilty after realizing that he tried to strangle
his own daughter. He had no memory of the incident and did not realize how he
grabbed the daughter’s neck.
3)
Bombardier AXTX36’s self-perception changed drastically with the onset of
symptoms. He lost his self-esteem and viewed himself as a sinner and a
perpetrator who deserved to be punished by the Karmic forces. I am a villain he
openly said and he wished all the blasphemes to fall upon him. He frequently
said that he is not a human anymore and the human part of him had gone a long
time ago. He urged other people to call him derogatory names. He started to
reveal his past interrogative work even to unknown people on the street and
never expected a word of sympathy from them. When people sympathized with him
he became extremely annoyed and sometimes tried to assault them.
Bombardier AXTX36 became aggressive and emotionally numbed. He lost the ability
to trust anyone. Sometimes he blamed his senior officers, his parents,
and sometimes, even himself, for his anguish and suffering. He had no
hopes for the future and several times planned to commit suicide.
4)
A 23-year-old male presented at the psychiatric clinic at the Teaching Hospital
Jaffna, with complaints of insomnia, numbness of the head, and flashbacks of
dead friends. He had joined the militant group at the age of 14 and underwent
extensive training. As he lost his friends one by one on missions, he became
more withdrawn and preoccupied with thoughts of his dead friends. He also led a
very tense life during active duty. He developed a hatred for people whom he
was led to believe were traitors and who passed information to his enemies. He
caught 3 people whom he considered informants and tortured them by slowly
cutting them to pieces while they screamed. He then threw these pieces onto the
nearby road. After this, he began to be obsessed with the sight of blood and
hearing his victims screaming in pain. He also had nightmares of dead comrades
being blown to bits. His insomnia worsened, and he began to take Diazepam. He
became addicted and started taking up to 40 mg at a time. He introduced this to
the other boys. He also had a severe headache accompanied by numbness of the
head. His drug abuse habit was detected by his superiors, who put him on
punishment, where he was physically beaten and kept in detention. He is
obsessed with the urge to torture and to see blood. When he was asked to draw a
picture, he chose a dark red crayon and drew blood drops, a hanging man, a
knife stained with blood, a grave and ghosts.
Treatment Measures
The main treatments for DESNOS (C- PTSD) are psychotherapy and
medication. Trauma-focused cognitive behavioral therapy, Eye movement
desensitization and reprocessing (EMDR) and Dialectical behavior therapy (DBT)
are highly recommended as psychological therapies. Studies recommend
multicomponent therapies starting with a focus on safety, psychoeducation, and
patient-provider collaboration, and treatment components that include
self-regulatory strategies and trauma-focused interventions (Maercker
et.al.,2022). These interventions are alleviating the patient's distress
in several psychological and physical domains.
Psychological interventions improve C- PTSD symptoms. It is essential to
provide more efficient and comprehensive therapies to the individuals with war
trauma, and the psychiatric and rehabilitation services should work in
collaboration to achieve success. The victims with war trauma need psychosocial
rehabilitation to recover. Warren (2002) is of the view that addressing the
broader emotional, social and economic needs of survivors is a critical aspect
of the rehabilitation process.
The Health Ministry should provide sufficient training to the doctors to
identify war trauma symptoms and do referrals effectively. Psychosocial
Rehabilitation should be incorporated to help traumatized combat veterans to
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 victims
to live a full and meaningful life.
