Dr. Neil J Fernando / Dr. Ruwan M Jayatunge
Abstract
From 1983 to 2009,
the Sri Lankan Army engaged in an extended conflict known as the Eelam War,
which saw a significant number of soldiers deployed in combat zones for
prolonged periods. This relentless exposure to warfare led to a considerable
incidence of combat stress among the troops. It was crucial to examine the
effects of combat trauma on soldiers. Between March 2002 and December 2006, a
clinical study was conducted involving 824 Army personnel who were referred to
the psychiatric unit at the military hospital in Colombo due to various
battle-related physical and psychological issues, as well as disciplinary infractions.
Each soldier underwent a structured
face-to-face interview conducted by the Consultant Psychiatrist of the Sri
Lanka Army, utilizing the PTSD Check List based on the DSM-IV criteria. The
assessment focused on their combat experiences, personal circumstances, and
current mental health status. Out of the 824 servicemen evaluated, 56 were
diagnosed with full-blown Post-Traumatic Stress Disorder (PTSD), while an
additional 6 exhibited partial PTSD symptoms. Those suffering from PTSD faced
numerous psychosocial challenges that adversely impacted their military
performance, family relationships, and social dynamics. The identified issues
included low life satisfaction, a suboptimal state of physical well-being, diminished
motivation, suicidal thoughts, substance abuse, social isolation and instances
of domestic violence. To address these complex problems, affected combatants
received a combination of pharmacological treatment and psychological therapies
aimed at alleviating their symptoms and improving their overall well-being.
Key
Words:
Sri Lankan Army Servicemen, Eelam War, Post-Traumatic Stress Disorder
Introduction
The protracted armed
conflict in Sri Lanka, lasting three decades, has given rise to a new cohort of
veterans who are increasingly vulnerable to chronic mental health issues
stemming from their extensive exposure to warfare. Over 100,000 personnel from
the Sri Lanka Army experienced combat situations, either directly or indirectly,
during this tumultuous period. Many of these soldiers faced traumatic events
that are far beyond the realm of typical human experience, including enduring
life in a war-torn environment, fear
stemming from threats of enemy assaults, witnessing the deaths and
injuries of fellow soldiers, handling human remains, and hearing the desperate
cries of the wounded, all while feeling powerless to provide assistance. Such
harrowing experiences have profoundly altered their psychological well-being.
As the conflict
escalated, particularly during the Eelam War, the Sri Lankan military engaged
in nearly 20 major military operations against insurgents from 1987 to 2009,
deploying its full combat strength for over 25 years. The culmination of this
conflict came in May 2009, when the Sri Lankan government announced a decisive
victory over the LTTE, or the Liberation Tigers of Tamil Eelam. However, this
military success was accompanied by substantial social repercussions, as both
combatants and civilians continue to grapple with the psychological aftermath
of the war. A considerable number of soldiers have been diagnosed with
Post-Traumatic Stress Disorder (PTSD), highlighting the enduring impact of
combat trauma on their lives.
The
Sri Lankan Armed Conflict
The armed conflict
in Sri Lanka was distinct from other global conflicts, characterized by its
specific dynamics and underlying issues. This protracted struggle primarily
involved the Sri Lankan government forces and the Liberation Tigers of Tamil
Eelam (LTTE), a rebel group advocating for racial separation. Initially marked
by small-scale guerrilla attacks, the conflict escalated into a full-scale war
that predominantly affected the northern regions of the island. From 1976 until
its end in 2009, the LTTE executed numerous assaults on both military and
civilian targets, resulting in significant casualties and injuries. The group
gained notoriety as one of the most formidable terrorist organizations
worldwide, leading to its designation as a banned entity in several countries,
including the United Kingdom, the United States, India, and Canada.
Employing modern
weaponry and unconventional tactics, such as the use of child soldiers and
suicide bombers, the LTTE posed a considerable challenge to the Sri Lankan
military, which was compelled to mobilize its entire force for nearly three
decades. The conflict, known as the Eelam War, became one of the
longest-running conflicts in contemporary history. The war left behind a legacy
of profound psychological trauma, manifesting as paralyzing anxiety, grief, and
hopelessness among the affected populations. The Eelam War also resulted in a
significant number of soldiers suffering from combat-related stress, yet the
psychological impact on these combatants has received minimal attention.
Tragically, the mental scars inflicted by the conflict have not been adequately
addressed, and the lingering effects of combat trauma continue to haunt those
who served.
Methodology
This research was
carried out by the Visiting Psychiatrist of the Sri Lanka Army, with the
approval of the Medical Advisor of the Sri Lanka Army Medical Corps. Spanning
from March 2002 to December 2006, the study involved a thorough screening of
824 Sri Lankan Army personnel from infantry and service units who were referred
to the Psychiatric Ward at the Military Hospital following various stress-related symptoms and disciplinary infractions. Notably, this investigation took
place while the soldiers remained on active duty. The participants were
primarily referred by medical officers from the outpatient department, as well
as consultants from both medical and surgical units at Palaly Military
Hospital, Victory Army Hospital in Anuradhapura, Colombo, Panagoda and various
other military healthcare facilities.
The servicemen
exhibited a range of psychological issues, including behavioural disturbances,
psychosomatic disorders, symptoms of depression and anxiety, self-harm
tendencies, suicide attempts, substance abuse, and stress-related misconduct.
The sample comprised 824 individuals, predominantly male (806), with a small
female representation (18). Throughout the study, strict client safety
protocols were adhered to, ensuring that informed consent was obtained and that
the anonymity of participants was maintained. Each soldier underwent a
structured face-to-face interview utilizing the PCL-4 (PTSD Checklist for
DSM-4) is based on the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV), which was published in 1994. (American Psychiatric Association, 2000).
This assessment tool was adapted from similar trauma questionnaires employed
globally to effectively identify cases of PTSD.
Results
Study results among the Sri Lankan Army soldiers and officers were as follows:
The PTSD rate was 6.7% following analysis of the questionnaire from 824
combatants.
PTSD Full criteria
56 / Partial PTSD 6
The level of exposure to combat was notably higher for individuals deployed in
the northern and eastern regions of Sri Lanka. Consequently, a significant
proportion of participants in the study exhibited responses that met the
criteria for major depression, generalized anxiety disorder, or post-traumatic
stress disorder (PTSD) after their service in these areas.
Among the 824 Sri
Lankan combatants assessed, 135 individuals, representing 16.38%, were
diagnosed with Adjustment Disorder. Additionally, 129 combatants, or 15.65%,
were found to have Depressive Disorder. The study also identified 78 individuals,
accounting for 9.46%, with various psychiatric conditions, including
Schizophrenia, Bipolar Affective Disorder, and Acute Transient Psychotic
Disorder. Furthermore, 65 combatants, or 7.88%, were diagnosed with Somatoform
Disorder, while 89 individuals, representing 10.8%, were identified with
Dissociative Disorder. The assessment revealed that 27 combatants, or 3.27%,
suffered from Traumatic Brain Injury, and 29 individuals, accounting for 3.51%,
were diagnosed with Alcohol Abuse and Dependence, as well as Substance Abuse
Disorder.
The combatants with full-blown symptoms of PTSD
were found to have with following associations:
|
Those who have served in the operational areas (for
more than 3 years)
|
45
|
|
|
Sustained grievous injuries –
|
15
|
|
|
Sustained non-grievous injuries –
|
22
|
|
|
Witnessed Killing-
|
49
|
|
|
Past attempted suicides-
|
17
|
|
|
Experienced childhood trauma
|
30
|
|
Research indicates that the experience of active combat can significantly contribute to the development of stress-related disorders, including post-traumatic stress disorder (PTSD), among those who have participated in such intense and often life-threatening situations. The psychological impact of engaging in combat is profound, as individuals are frequently exposed to traumatic events that can overwhelm their coping mechanisms. This exposure not only affects their mental health during and immediately after their service but can also lead to long-term psychological challenges. The symptoms associated with PTSD, such as flashbacks, severe anxiety, and emotional numbness, can severely disrupt the lives of combatants, making it essential to understand the relationship between combat exposure.
Discussion
The recognition of
posttraumatic stress disorder (PTSD) as a distinct diagnostic category emerged
with the publication of the Diagnostic and Statistical Manual (DSM-III),
largely influenced by the clinical observations of Vietnamese war veterans
(Dadic-Hero et al., 2009). In contrast, despite the onset of the Sri Lankan
armed conflict in the early 1980s, PTSD remained largely unacknowledged as a
significant mental health issue affecting soldiers for an extended period
(Jayatunge, 2014).
This study
represents the first investigation into combat-related PTSD within the Sri
Lankan context, offering a foundational understanding of the psychosocial
challenges faced by combatants involved in the Eelam War. Notably, the research
was conducted while many of these individuals were still actively serving in
the military, underscoring its relevance and timeliness. Structured interviews
were carried out in the Sinhalese language, allowing for a comprehensive
assessment of each combatant's military deployment history. In certain
instances, the study also involved discussions with commanding officers and
family members, ensuring that cultural dimensions of trauma were adequately
addressed.
The prevalence of
PTSD within military populations is well-documented, attributed to the high
frequency and nature of traumatic experiences encountered in combat zones
(Romanoff, 2006). Research by Clancy et al. (2006) indicates that factors such
as age, extensive combat exposure, and both pre- and post-military traumas
contribute to heightened PTSD symptoms.
Sri Lankan
combatants experienced prolonged exposure to combat, surpassing the durations
faced by veterans of World War II, Vietnam, Korea, and the Gulf War. As a
result, a significant number of these soldiers have developed PTSD and other
trauma-related mental health disorders, with many cases remaining undiagnosed.
Combat exposure
significantly alters the psychological landscape of military personnel. Those
who have faced the traumas of war are particularly vulnerable to developing
post-traumatic stress disorder (PTSD), as highlighted by Friedman et al.
(1994). Research by Collie and colleagues (2006) suggests that nearly 30% of
individuals who have served in combat zones may experience PTSD. Furthermore,
combatants often grapple with a range of mental health issues, including
depression, traumatic brain injury, and substance abuse, as noted by Kane et
al. (2013). Gaylord (2006) emphasizes that combat veterans are susceptible to
the adverse effects associated with deployment. The current study reveals that
a striking 80.35% of combatants diagnosed with PTSD had spent over three years
in combat zones, indicating that the length of exposure to combat is a
significant risk factor for developing this debilitating condition.
In addition to the
challenges faced by combat veterans, the prevalence of PTSD is also notably
high among adult survivors of childhood trauma, including sexual and physical
abuse. Research conducted by Ehring and colleagues (2014) underscores that
early adversities, such as emotional neglect, parental loss, and abuse, are
critical risk factors for the emergence of various psychiatric disorders in
adulthood, including PTSD, as supported by findings from Anda et al. (2006) and
Burri et al. (2013). The current study further reveals that 53.57% of soldiers
diagnosed with PTSD reported having endured adverse childhood experiences, such
as physical and sexual abuse, neglect, and the loss of parental figures,
highlighting the profound impact of early trauma on mental health outcomes in
later life.
The National
Vietnam Veterans Readjustment Study, which took place between 1986 and 1988,
revealed that the lifetime prevalence of post-traumatic stress disorder (PTSD)
among Vietnam veterans was 31% for men and 27% for women, with current
prevalence rates at 15% and 9%, respectively, according to the Department of
Veterans Affairs (2007). In contrast, the estimated rates of PTSD among
veterans of the Iraq and Afghanistan conflicts are approximately 11% and 18%,
respectively, although these figures are believed to be underreported (Hoge et
al., 2004; Nacasch et al., 2010).
A recent investigation into Sri Lankan combatants shows a
significantly lower rate of PTSD, recorded at 6.7%, compared to veterans from
Vietnam, Iraq, and Afghanistan. This difference may be due to various cultural
and religious influences that serve as protective factors against developing
PTSD. These elements not only provide solace but also help in finding meaning
in traumatic experiences and encourage quicker post-traumatic growth and
recovery after trauma. However, it is important to note that the
sample in this study was not randomly selected; rather, it consisted of
individuals who were referred for treatment and psychological evaluations.
Consequently, the findings may not accurately represent the broader reality of
combat trauma within the Sri Lanka Army, suggesting that the actual prevalence
of PTSD could be significantly higher, with rough estimates indicating rates
between 12% and 16% among soldiers.
In this research, six soldiers were identified
as having partial PTSD. The term "partial PTSD" is used in the
literature to describe individuals who do not fully meet the diagnostic
criteria for PTSD but still exhibit significant symptoms (Kulka, Schlenger,
& Fairbank, 1990; Gudmundsdottir & Beck, 2004). Stein and colleagues
(1997) note that those with partial PTSD may be missing one or two of the three
necessary avoidance or numbing symptoms, as well as one of the two required
hyperarousal symptoms. Breslau, Lucia, and Davis (2004) emphasize that PTSD is
typically associated with the most severely affected trauma victims, who can be
clearly differentiated from those with subthreshold PTSD. However, Dickstein et
al. (2013) point out that individuals exhibiting subthreshold PTSD symptoms are
at an elevated risk for psychological and functional impairments, including a
higher likelihood of suicidal thoughts.
Among the six Sri
Lankan soldiers diagnosed with partial PTSD, significant functional impairments
were evident, manifesting as difficulties in marital relationships, parenting,
and overall quality of life. Sri Lankan
soldiers returning from war encounter a range of psychosocial challenges.
Pearrow and Cosgrove (2009) highlight that veterans often experience heightened
stress levels due to combat and the associated traumatic events, which can
severely disrupt their functioning both during active duty and upon
reintegration into civilian life. This pattern was similarly observed in Sri
Lankan soldiers suffering from PTSD, who displayed various work-related and
psychosocial dysfunctions. Issues such as domestic violence, substance abuse,
suicide attempts, and self-harm were prevalent among these individuals. The
symptoms stemming from combat trauma significantly affected their marital
relationships, vocational stability, and social interactions, underscoring the
profound impact of their experiences on their daily lives.
Individuals
diagnosed with post-traumatic stress disorder (PTSD) often experience a range
of comorbid psychiatric conditions, including depression, various anxiety
disorders, and issues related to alcohol or substance abuse and dependence, as
noted by Friedman et al. (1994). The presence of these comorbid disorders can
significantly hinder both the prognosis and treatment outcomes for those
suffering from PTSD, as highlighted by Abram et al. (2013). Epidemiological
studies reveal that a considerable majority of individuals with PTSD also
fulfill the criteria for at least one additional psychiatric disorder, with a
notable portion having three or more such diagnoses (Brady, 2000). In Sri
Lanka, combatants with PTSD have been observed to frequently present with other
psychiatric issues, including depression, substance use disorders, and, in some
cases, psychosis.
The primary
approaches to treating PTSD encompass both psychotherapy and pharmacological
interventions. Current guidelines advocate for psychotherapy to be the
first-line treatment for PTSD (National Collaborating Centre for Mental Health,
2005). Among the medications commonly prescribed, antidepressants, particularly
selective serotonin reuptake inhibitors (SSRIs), have been widely utilized
(Davidson, 2000; Davidson & Connor, 1999; Cukor et al., 2009). Notable
therapeutic interventions identified by Spinazzola, Blaustein, and van der Kolk
(2005) include prolonged exposure therapy, cognitive processing therapy, cognitive
restructuring, and eye movement desensitization and reprocessing (EMDR), all of
which have shown efficacy in treating PTSD.
In Sri Lanka,
combatants suffering from PTSD receive a combination of pharmacological
treatments, such as antidepressants, mood stabilizers, antipsychotics, and pain
relievers, alongside various psychotherapeutic approaches, including Cognitive-behavioural therapy (CBT), EMDR, and Rogerian therapy. The
pharmacological treatments aim to alleviate acute PTSD symptoms and improve sleep
quality. Rogerian Person-Centred Therapy provides a supportive environment for
combatants to express and process their repressed negative emotions, while
Cognitive Behavioral Therapy has been effective in enhancing their social
functioning. A study conducted in 2005 involving eighteen Sri Lankan combatants
treated with EMDR revealed that twelve participants experienced significant
clinical improvement after just five to six sessions of this therapy.
Among the
traditional therapies, Thovilaya has been identified as a conventional healing
method. It is a form of psychodrama geared to heal the patient as well as his
environment. Spiritual therapy also plays a vital role in treating soldiers
with combat trauma. Spiritual therapy, especially Buddhist psychotherapy, helps
the war victims to find meaning and achieve post-traumatic growth.
In Sri Lanka, a
considerable number of former combatants have reintegrated into civilian life
without undergoing any prior screening, leading to various readjustment
challenges. The psychosocial rehabilitation of these war veterans has been
acknowledged as an essential aspect of recovery in the country. To effectively
meet the diverse needs of combatants affected by the war, a comprehensive array
of interventions is necessary, encompassing social, educational, occupational,
behavioural, and cognitive strategies.
Conclusion
This study marks
the first investigation into combat-related posttraumatic stress disorder
(PTSD) in Sri Lanka, focusing specifically on soldiers from the Sri Lankan Army
who served during the Eelam War. A total of 824 soldiers were subjected to
clinical interviews utilizing the PTSD Checklist for DSM-4, which identified 56
individuals exhibiting full-blown PTSD symptoms. The findings underscore the
emergence of combat-related PTSD as a pressing mental health concern for these
veterans. Those grappling with the aftermath of war-related trauma encounter
significant difficulties across various facets of their lives, including
personal relationships, job performance, and social engagements. The long-term
effects of such trauma have profoundly impacted their mental health and overall
functionality. To effectively address and alleviate the consequences of combat
trauma in Sri Lanka, it is imperative to implement targeted interventions.
Additionally, further research is crucial to thoroughly assess the extent of
combat-related trauma among these veterans, ensuring they receive the essential
psychosocial support and treatment necessary for their recovery.
Acknowledgments
1)
Gen (Dr) Dudley Perera – The former
Medical Advisor -Sri Lanka Army Medical Corps
2)
Gen (Dr) Sanjeewa Munasinghe – Colonel
Commandant of the Sri Lanka Army Medical Corps
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