DESNOS Among The Sri Lankan War Veterans

By Ruwan M. Jayatunge -

Prolonged armed conflict in Sri Lanka has created higher rates of mental ailments among the combatants and a significant number of veterans have been diagnosed with complex form of PTSD. The veterans with malignant form of anxiety have a wider range of clinical symptomatology with sever psychosocial impairments. 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) that was described by Dr. Judith Herman in 1992.

According to Herman (1992) Complex post-traumatic stress disorder (C-PTSD) is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma in the context of either captivity or entrapment that 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 then the traditional PTSD which is illustrated in the Diagnostic and Statistical Manual of Mental Disorders and the victims experience  loss of control, disempowement , 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 the 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 some of the associated features of PTSD, although more recent evidence concur that DESNOS and PTSD may be distinct disorders and DESNOS represents a potential public health problem. The DESNOS has been found to be associated with sever functional impairments affecting cognition and emotions especially the impaired emotion processing capacities.  It has extreme post-traumatic intrusive symptomatology. The DESNOS is one of the debilitating disorders that has a poor therapeutic outcome.  DESNOS was conceptualized to describe the, alterations in 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) postulates 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 need more case investigations and research. The manifestation of DESNOS related symptoms may be 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 report distressing symptoms. Culture affects individuals and communities shaping their world view. Culture has a profound influence on how psychological trauma is perceived by the person and how it’s being 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. Despite the fact that PTSD is institutionally framed it had different labels. In the European war theater 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 researches 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 aetiology 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 less 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 the heaviness in their chest and tension in the head. Many Sri Lankan combatants believe that repeatedly talking about distressing experiences are 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 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 the adult life. Many researchers suspect strong correlation between early childhood trauma and DESNOS. Ford et al. (1998) indicate that 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. Many research concur that early physical abuse and 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 if could also affect their adult life. 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 house maids every year leaving their children with relatives. This has resulted 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 prior to age 10, increases adult vulnerability to stress disorders.

During the Eelam War (1983 – 2009) many youth from the lower social-economic strata joined the military and a large number of them had experienced childhood traumas such as physical -sexual abuse, neglect, maternal or paternal deprivation and the impact of severe poverty.  People who joined the military forces from the endangered villages in the North Central Province had witnessed the brutal realities of the Eelam War as little children. These villages became under the constant attack by the LTTE and many had witnessed mass killings and mass burials. Many of them had lost relatives.
A study that was done between 2002-2006 allowed 824 Sri Lanka Army soldiers to be screened for PTSD. 56 of the combatants were found to have full blown symptoms of PTSD and 6 of them with partial PTSD. Of those tested positive for PTSD, 30 of the them had experienced severe childhood trauma (Fernando & Jayatunge , 2013).

Military veteran survivors of childhood trauma have prevalent problems with affect regulation, impulse regulation, relational engagement 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

Psychologically overwhelming experience caused by war is a form of complex trauma that could occur repeatedly and escalates over its duration. War is a traumatic experience in many ways. It could harm the psychological integrity of the participant. During the Eelam War in Sri Lanka a large number of combatants experienced traumatic events that shook their foundations of beliefs about safety. They were exposed to combat for long periods and some had spent over 10 years in the operational areas constantly facing hostile enemy attacks. War was a cumulative traumatic experience for most of them. These life-threatening events changed their psychological makeup negatively.

Many Sri Lankan combatants with complex PTSD had been exposed to cumulative traumas in the battle field and in the civilian life. For instance Lance Corporal SX46TX who witnessed the land mine explosion in Mannar in 1998 became a psychological casualty and his mental health condition became even worst after witnessing a large number of dead bodies at the Matara Hospital in 2004 following Asian Tsunami. Similarly Lieutenant BX34XT who was diagnosed with acute PTSD after witnessing traumatic battle events in Paranthan Jaffna in 1999 became overwhelmed in 2006 by witnessing the devastating effects of the suicide bombing at the Army Headquarters Colombo.

Following repeated traumatic combat events many were struggling with upsetting emotions. In the Sri Lankan armed conflict psychological first aid or debriefing / systematic counseling were not introduced to the war front for long years and many psychological casualties of the Eelam War   did not complain about their difficulties until they found it unbearable. Many soldiers relived their war related frightening memories for long periods and became numbed and disconnected. A considerable number of Sri Lankan combatants had experienced various dissociative reactions at the war front. Many of them ended up with PTSD and DESNOS.

The war veterans with past trauma exposure but who are asymptomatic at present could be a risk group. Numerous studies have indicated delayed reactions of 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 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 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 , despair are prominent.

Loss of the Pre-traumatic Personality Structure

It has been known to the 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 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 behavior 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 the post trauma personality. After exposing to traumatic battle events soldiers could have a negative outlook on their buddies, platoon leaders, commanding officers, the military and sometimes with 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 interview.
Daud and colleagues (2008) on 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 behavioral vulnerabilities.
Lieutenant BXSCX35X who witnessed the death of seven of his platoon members in Paranthan Jaffna and later diagnosed with full blown symptoms of PTSD found noticeable changes in his personality. Some of the changes were evident to his wife and to his close friends. After the battle trauma he became more introverted and used to respond and act unexpectedly without realizing the repercussions. In one of the events he assaulted a bus driver for high speed driving. He became awfully hostile and had a number of arguments and fights with people. Lieutenant BXSCX35X could not stand any criticism or a negative comment after he became psychologically unwell. His emotions became unstable and often felt depressed. Several times he contemplated self-harm and suicide. He felt that the world is against him and most of the people are plotting to harm him. He could not trust his commanding officers and always questioned his orders. Lieutenant BXSCX35X who was a brave and a disciplined soldier felt unexplainable fear most of the times after he became a psychological casualty of the Eelam War. He used to avoid wounded people, anything related to blood and combat films.

Rifleman Mx38 was trapped in the enemy lines for two days felt extremely frightened. He was hiding inside a pit and observed enemy movements. Every moment he thought that the enemy would find him and then torture and kill him. When he found an opportunity to escape , he slowly scrolled towards the outer perimeter of his camp and alerted the friends. He was able to return to his platoon without any physical injury. But within a short period he had fear feelings, nightmares, avoidance and later referred for psychiatric services and diagnosed with PTSD. With the development of PTSD drastic personality changes were observed in Rifleman Mx38.  He had significant impulsivity, intense fear, overly involved in safety measures, irritability and OCD type of behavior. When he crossed the roads Rifleman Mx38 used to have a ritualistic behavior that gave him a sense of safety and relief.

Rifleman Sn34 became psychologically wounded after facing traumatic battle events in the Operation Yale Devi that was launched in 1993 to destroy the LTTE Sea Tiger strongholds at Kilali. The enemy launched a surprised attack on the advancing column resulted 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 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 explain 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 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 cold make him excessively frightened.

Altered Self Perception

According to the Social Psychologist Daryl Bem people come to know their own attitudes, beliefs, and other internal states by inferring them from their own behavior and the circumstances under which they occur (Bem, 1972). Combatants with complex PTSD have altered self-perception and their interpretation of events are distorted. Following dreadful past experiences their primary appraisal is often altered and they apprehend events as life threatening. Therefor the affective response could be negative.

Skinner (1957) believed that Self-perception is an individual’s ability, to respond differentially to his own, behavior and its controlling variables, is a product of social interaction. War trauma could change healthy interactions and transform the victim in to a pathological level that has unhealthy interactions. Maksakis (1996) describes that upon victimization of trauma the PTSD sufferers could go in to 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 behaviors, childish emotions, withdrawal and dependency.

The combatants affected by severe war trauma often have distorted beliefs. Some do not trust the support services, health care system and even their therapists. They could have   sense of re-victimization and over concern about their safety and wellbeing. Some go to the extent of making   attempts to victimize others. In addition loss of beliefs and loss of coherent sense of self are very much evident among them.

Bombardier AXTX36 – a known PTSD patient presented with distinct changes in self-perception. He was in combat for 14 years and during 1988 – 89 JVP uprising served as an interrogator. He used to question suspects to extract information and used vigorous torturing methods. He became obsessed with torture and sometimes derived satisfaction hearing his victims’ screams.

By 2000 his mental health started fading and he was troubled by intrusions, nightmares and flashbacks. When he relived the disturbed reminiscences sometimes he could hear the screaming of his victims. He had marked depression and frequently talked about his death.

Bombardier AXTX36’s self-perception changed drastically with 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 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 sometimes tried to assault them. Bombardier AXTX36 became aggressive and emotionally numbed. He lost the ability trust anyone.  Sometimes he blamed his senior officers, and 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.

Alterations in Systems of Meaning

Psychological trauma alters the long-held beliefs and changes the perception of world and universe. When the belief system changes thoughts, words, and actions too change accordingly.

Sergeant NXX48CX was a devoted religious person and after becoming a PTSD patient he lost faith in his religion and refused to attain any kind of religious services. After experiencing numerous battle traumas he perceived that the world is an evil place and no human action could change it. He repeatedly stated that the Universe is governed by the negative and evil forces that cause eternal destruction. He strongly held the view that he did not cause any harm to anyone and it was absurd that he became a psychological casualty of the war. He felt that the negative forces had caused his misery.

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 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 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 are constantly affect their emotions. The victims are troubled by rage, despair, guilt, shame, and self-loathing. Some victims have alexithymia or 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, in particular problems modulating anger (Chemtob, Hamada, Roitblatt, & Muraoka, 1994). When emotions are dysregulated the combatants become highly reactive and with a 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 its intensity. They are unable to understand and distinct the emotions that they experience. They are unable to control emotions, and regulate it situationally appropriate manner.

Some suspect affect dysregulation has some close links with the process of pathological dissociation. Pathological dissociation has been identified as one of the key features in DESNOS. Chu et al. (1999) states that affect dysregulation are extremely common in dissociative disorders.

Lance Corporal NHXX36X served 16 years in combat and underwent numerous combat related traumatic events. He was diagnosed with PTSD in 2004. Lance Corporal NHXX36X showed extreme hostility, difficulty to control anger, inappropriate anger frequently escalating into physical confrontations, instability in interpersonal relationships, self-loathing, difficulties engaging in goal-directed behavior and lack of emotional clarity. Lance Corporal NHXX36X frequently had angry outbursts and often physically abused his wife and children. Sometimes he used military punishments (including a punishment which is popularly known as Irshi Position that is very common punishment mode among the soldiers in the Sri Lanka Army) on his wife and children. Out of rage he used to destroy house property including the TV set. Several times he was arrested by the police for assaulting his neighbors.

Numbing of Responsiveness

Numbing of responsiveness or loss of affect has been recorded among the soldiers who have been diagnosed with PTSD. Emotional numbing (emotional anesthesia) symptoms are part of avoidance cluster of the PTSD symptomatology. Often they distant their feelings from others and they are unable to feel happiness, unable to be content, unable to form emotionally secure attachments.

Numbing of responsiveness, which may be registered as depression, as anhedonia and amotivational states, as psychosomatic reactions, or in dissociative states, is tonic and part of the patients’ 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 defense against remembering painful affects. 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 inability to emotionally connect with others. Many have restricted emotions and emotional detachment.

After witnessing deaths of his platoon members and handled human remains Corporal KXX46LX experienced PTSD symptoms. He had marked emotional numbness and could not feel happiness. He often described his emotions as a dead end. He could not derive satisfaction from any pleasurable activity which gave him joy before he became ill. Happiness did not last even for a small period and he was emotionally not responsive. Corporal KXX46LX was unable to express or feel love for his children.

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). The dissociative disorders are usually associated with trauma and Combat soldiers who were exposed to distressing battle events could go in to 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 unreal and unfamiliar. Some describe it as a sensory fog or spaced out.

Psychogenic amnesia, (dissociative amnesia) had been reported among the Sri Lankan combatants who experienced extreme form 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 witnessed the death of seven soldiers in Paranthan Jaffna following a mortar blast in 1999. He was physically unharmed but witnessing this dreadful event he went in to shock. He lost his orientation. He could not remember what happened after the blast and how he ended up at the Psychiatric Unit Military Hospital Colombo. There was a significant memory gap.

Confusion and emotional distress related to the amnesia have been noticed among the 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 a defense mechanism and an attempt to move away from reality. Putnam (1992) calls Dissociation as the escape when there is no escape. Dissociation could delay the 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 went in to a severe dissociative reaction during a combat operation in 1998 (without any physical wound or without any medication / substance) and felt himself was disconnecting from the battle ground. He could not hear the gun shots or blasts sounds. He felt that he was acting in a movie and he had no control over his motion. He had no any idea about time and space. When he regained his sensors Cpl. VXX43X realized that the soldiers on his left flank had advanced further and enemy had started attacking them with mortars.

Corporal AXX39SX has served 17 years in the operational areas facing extreme form of battle stress. He was experiencing posttraumatic symptoms and for a long time he had no way of getting psychological help. He did his military duties suppressing his mental distress. On one occasion he went in to a dissociative fugue and walked in to the enemy lines. When he was found by a friendly group of soldiers Corporal AXX39SX had thrown his weapon and was wondering about in hostile territory. He did not have any idea how he left his bunker and ended up near enemy lines.
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 became extremely overwhelmed when a LTTE female carder threw a grenade at him. Fortunately, the grenade did not explode, but for several minutes Lieutenant SXX32VC was in inexplicable fear for his life. This was an incident he was not able to forget, subsequently experiencing ongoing nightmares as well as intrusive memories. About six to eight months later, Lieutenant SXX32VC began to notice drastic changes in his speech, especially his accent. When he spoke Sinhala it had a noticeable Tamil accent.  Lieutenant SXX32VC was dismayed to learn that his speech was affected to the extent that he was unable to communicate.

Bromberg (1998) views Dissociation as a precious psychic, survival tool that arises from the need to separate and compartmentalize aspects, of traumatic experience 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 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 the operational area for 9 years and firsthand experienced combat trauma. He witnessed how his unit members got killed following enemy fire, mortar blasts and 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 in to 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 and 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.

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 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 joined the Army in 1985. Soon after his basic training he was posted to serve in the Jaffna Fort. During this time the Jaffna Fort was occupied by the Sri Lanka Army and the enemy constantly attacked the Fort with mortars. Day and night he heard the sounds of explosions. The enemy had surrounded the Fort. These events had caused severe distress and anxiety in Sergeant NX42HX.

In 1997 Sergeant NX42HX served in the Paranthan forward defense line. This was a difficult period for them following monsoon rains. The monsoon rains caused many difficulties. Evacuations and reinforcements became to a standstill. One night the enemy attacked their defense line.  The soldiers were able to secure the forward defense line launching a counter attack. After a five hour battle many soldiers perished and many became wounded. He witnessed the deaths of a number of soldiers. Although Sergeant NX42HX remained unhurt his psyche was severely damaged.   After some time Sergeant NX42HX  had multiple somatic complaints, his physical symptoms aggravated with stress, also he had decreased coping abilities, associated symptoms like anxiety and depression, startling reactions, and poor response for analgesics with long term treatment failure.

van der Hart et al. (2000) describe somatoform dissociation as 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 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 poor response to typical medical treatments.

Private NXS32W experienced maternal deprivation as a child and following financial difficulties joined the military. He has served 7 years in the operational areas facing many life and death events. He handled human remains and became utterly devastated. Several of his friends died in action leaving a deep sadness inside. Gradually he experienced intrusions, nightmares and startling reactions. In 2002 He was referred with right sided hemiplegia He was seen by a Physician and a Neurologist His EEG and CT brain and other investigations were normal and organic causes were eliminated. Private N was recovered after hypnotherapy.

Sexualized Behaviors 

Sometimes sexualized behaviors are evident among the 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 engage 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 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 behaviors 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 to blame their victims for the rape.
Private AXJ43SX – a known PTSD patient admitted that he was troubled by sexual, compulsivity and urges to fulfill voyeuristic impulses. He told his therapists that he used to derive satisfaction by sadistically hurting his wife during copulation. Following increased libido and sexual violence he had marital problems. In addition he had legal involvement resulting from sexual behavior. Private AXJ43SX described such behaviors came to dominate him after he became a psychological casualty of the war.

Sense of Foreshortened Future

Combatants with complex PTSD do not have specific life goals or motivation 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 very experienced and effective field operator from the Commando Unit became psychologically unstable after experiencing traumatic battle events at Thoppigalla. Once he found two of his friends were dead in a bunker. The enemy had killed them by slitting their throats. Another occasion one of his buddies died in front of his eyes following a sniper bullet. After experiencing harrowing battle events he had fear feelings, nightmares intrusions flashbacks and avoidance. He was diagnosed with full blown PTSD in 2002 by the Consultant Psychiatrist of the SLA. After his mental health became compromised Sergeant AXC38RX could not see any bright future for him. He became totally demotivated and had no any interest to follow further training or to do special military courses. His body pains and headaches did not allow him to do sports or to engage in physical exercises which he used to do regularly. The depressive feelings made him isolated and he stopped associating people. He was not interested in his married life and the child and felt that his life was going to end soon.

Self-Harm

Self-harm, 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 one self , burn, throw one self against vehicles, swallow things , head banging , reckless and risk taking behaviors etc. Farber (2000) points out that when facing with life-threatening psychological trauma people exhibit radical changes in eating behavior and may become, self-injurious. Self-harm have 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 patent’s total self-experience (Farber, 2006).

L/Cpl FWX sustained gunshot injury to the left leg. After he became wounded L/Cpl FWX experienced intrusions and was troubled by startling reactions. He was constantly troubled by the disturbing combat related memories. Once he consumed a large amount of alcohol and slept on a 20 feet high parapet wall knowing that it was too risky. After a while he fell asleep and as he anticipated  he fell down and sustained a fractured femur.

L/ Cpl SCX34X a known PTSD patient with severe affect  dysregulation, poor impulse control and ignominy, speculated self-harm several times. On one occasion he jumped in front of a moving van and sustained severe injuries.

Suicidal Behavior

According to Afifi et al. (2008) numerous researches 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 the combatants with sever war trauma.

During the Eelam War (1983 -2009) a significant numbers of the Sri Lankan soldiers had committed suicide and some of the victims believed to have suffered from combat related stress. Psychological autopsies of some of the cases revealed that the victims had depression, posttraumatic stress, psychiatric illnesses, addiction issues, relationship problems and severe work related stresses. Most of these suicides could have been avoided with early interventions.

Private SXB29XC served in the operational areas and witnessed deaths following artillery / mortar attacks. A number of times he was caught under heavy fire. He experienced severe headaches, nightmares intrusions and flashbacks. Since he was participating in the Jayasikuru military operation he had no way of getting leave or no way of expressing his difficulties to his unit leaders. He suppressed his anxiety related symptoms for a long period. At a certain point he could not bear the suffering and Private SXB29XC walked to the enemy lines expecting sniper fire. One of his platoon members altered others and they found Private SXB29XC walking on the open territory. He was brought back to the camp and then severely punished. He was charged with abandoning the post. Later Private SXB29XC referred to the Military Hospital for treatment. Private SXB29XC was found with full blown symptoms of PTSD.

DESNOS and Psychotic Symptoms

According to our empirical investigations, some of the Sri Lankan combatants with complex PTSD found with psychotic symptoms in latter stages leaving us to question the relationships between PTSD and psychosis. Some researchers have speculated potential links between trauma and psychosis. Ellason & 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 underwent traumatic combat events at Palampiddi and became stunned. He saw how incoming mortars killed his fellow soldiers and how their bodies blown into pieces. Nearly ten months he had to serve with the platoon and could not come home for leave. They constantly faced hostile attacks. His mental health was severely compromised while serving in the operational area. Later he was diagnosed with PTSD. With progression of anxiety related symptoms Corporal JXXE36X gradually experienced psychotic symptoms as well. He was treated with atypical antipsychotics.

Corporal KXX38BX went in to acute stress reaction after witnessing the deaths of two of his buddies following a mortar blast. He had intrusive memories, flashbacks and severe avoidance of combat. Increasingly his mental health faded and he was found with PTSD and psychotic symptoms such as incoherent speech ,hallucinations and disturbed thoughts.
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 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 joined the Army in 1991 and served in the operational areas. In 1993 he was working as a signalman attached to the Senapura Camp. In the same year the LTTE attacked the camp and overran it killing a large number of soldiers. Lance Corporal P was captured alive by the enemy. During the attack he witnessed how the enemy killed his immediate superior officer Lt. …… with a mammoty. After killing the Lieutenant his eyes were taken out. Lance Corporal P witnessed this incident with horror and he was oozing with fear.

He was taken to one of the LTTE camps and heavily beaten. For nearly seven months he was kept in a small dark room in order to break his biological clock. While spending time in isolation he lost his orientation and sense of time. After psychologically breaking him he was subjected to physical torture. He was savagely beaten, electrocuted and constantly interrogated to get some classified radio signal codes. The interrogators had thought that he was an officer in disguise. Several times he was taken to slaughter grounds for mock executions. On one of the occasions one EPRLF prisoner who belonged to a different rebel group was shot in front of his eyes. Lance Corporal P had to spend nearly five agonizing years as a POW under the LTTE custody.

He was released in 1998 with the intervention of the International Red Cross. When he came home he could not feel happiness. His emotions were numbed and he had immense fear that the LTTE would capture him again. He had deep suspicion, intrusions, flashbacks, nightmares and suicidal ideation. Upon his release Lance Corporal P was never refereed for any psychological evaluation and for a number of years he was undiagnosed and untreated. His symptoms were aggravating and at certain point he suffered a severe dissociative reaction and became aphonic. In 2000 he was diagnosed as having full blown symptoms of PTSD. Over the years his anxiety disorder has developed in to a malignant form. He had numerous DESNOS related symptoms including affect dysregulation, suicidal preoccupation, amnesia, severe guilt and shame, inability to trust people, somatization, hopelessness and despair. In 2005 Lance Corporal P was medically discharged from the Army following his psychological disability.

2) Corporal JXXX32T
Corporal JXXX32T participated in the military offensive Operation Ranagosa in 1999 and underwent extremely traumatic combat events. Numerous times he faced life and death situations and his life was at stake. After the operation he became severely distressed and troubled by survivor’s guilt. His mental health started fading gradually. He had severe headaches and signs of pathological dissociation. Several times he tried to commit suicide and later referred for a psychological evaluation. Corporal JXXX32T was diagnosed with full blown symptoms of PTSD. Apart from his major PTSD symptoms he was found with affect dysregulation, modulation of anger, chronic suicidal preoccupation, dysphoria , severe sexual dysfunctions, repressed combat memories (amnesia) and alterations in self-perception.

3) Lance Corporal  LX31CXX
Lance Corporal LX31CXX used to interrogate suspects for number of years and he was severely troubled by his past experiences. He had frequent nightmares and a strong obsession with blood. He used to see a bleeding skull in his dreams practically every night. In 2002 he was diagnosed as having full blown symptoms of PTSD. He poorly responded to medication and psychotherapy.

Despite the treatment his anxiety symptoms grew and developed in to a malignant stage. There were marked alterations in regulation of affects and impulses in him. He became extremely hostile and frequently had homicidal ideas and fantasies. He became severely depressed and preoccupied with contemplating suicide. Once he tried to end his life consuming pesticides. Although he was in a sexually active life period he had no interest in sex or in a marriage. A number of self-destructive behaviors have been observed in Lance Corporal LX31CXX and he had the habit of crossing the roads disregarding incoming traffic. Later LX31CXX revealed that he was anticipating a fatal road traffic accident.
His memory became weak and he was unable to concentrate for a long time. He could not recall some of the important events that took place in the past. He often went in to dissociative episodes especially Depersonalization. He was highly worried that he could harm his sisters children while re experiencing traumatic memories in a dissociative stage. LX31CXX experienced numerous somatic ailments that did not subside for painkillers. There were drastic changes in his personality and belief systems. He could not trust anyone even his therapists.

4) Private CX29VX
Private CX29VX experienced childhood trauma following neglect, poverty and maternal deprivation. He was raised by his grandmother and after her death by his uncles. He had spent most of his childhood in an endangered village in the Polonnaruwa District. This village constantly became under the attacks of the LTTE. Many times the LTTE carders attacked his native village and killed men women and children with machetes. During these attacks he lost some of his relatives. He witnessed mass burials after these slaughters and lived with fear and uncertainty.
After finishing his school education Private CX29VX joined the Army and served in the operational areas. He was an efficient soldier and was selected for special training. While performing special operations he experienced many traumatic combat events. In front of his eyes his buddies got killed and a number of occasions he handled human remains. After serving 12 years in the military his mental health became unstable. Private CX29VX had fear feelings, nightmares, hyperausal, intrusive memories, numbing of emotional feelings and marked avoidance. He was diagnosed with combat related PTSD in 2003.

By 2004 he became more and more isolated and extremely withdrawn and alienated himself from others.  He felt guilty over the wounded buddies that he had to leave in the battle field and who never returned home. He had self-blame and chronic sense of guilt and stigma. He had deep external cynicism and often felt that his life was wasted and life has no meaning. He was troubled by hate and he was preoccupied with revenge. He had deep suspicion and was unable to control his anger and several times arrested by the police. He started abusing alcohol in order to evade the night terror.   Private CX29VX had low capacity to sustain positive emotional states. He became extremely self-destructive. He continuously started victimizing people around him especially his family members. He was found with the symptoms of somatization and pathological dissociation.

Treatment Measures

In Sri Lanka a number of treatment methods are used to treat the 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 serve agitation and suicidal behavior.

Psychotherapies are widely used in major hospitals and rehabilitation centers in Sri Lanka. Client Centered (Rogerian) Counseling, Cognitive Behavior Therapy, Family Therapy are widely used by trained therapists. Empirical data concur that EMDR has been an effective mode to treat the 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 a remarkable therapeutic success after treating with EMDR (Jayatunge ,2008)

The traditional healing methods are frequently used by the 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 are often used. Spiritual therapy and meditation are another important methods to treat war victims since ancient days. Chanting Pirith for blessings and numerous types of mediations are prescribed to treat the war victims. Mindfulness meditation, meditation of loving kindness help the 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, USA, Canada and United Kingdom.

The LTTE with their ground naval and air power launched massive attacks against the government forces and sometimes aiming 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 forced militarily defeated the LTTE.

During this prolonged armed conflict over 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 in 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 under studied or disregarded and there was no psychological first aid to the troops until the war trauma gravely affected the military and the 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 the 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 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 psychotherapies. 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 outcome after treating 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 combat trauma reactions and do the 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 the traumatized combat veterans to achieve recovery. Psychosocial Rehabilitation practices help war veterans re-establish normal roles in the community, independence and their 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

References

Abbey, A., McAuslan, P. A. (2004). Longitudinal examination of male college student’s perpetration of sexual assault. Journal of Consulting and Clinical Psychology. 72:747–756.
Afifi, T.O., Enns, M.W., Cox, B.J., Asmundson, G.J.G., Stein, M.B., & Sareen, J. (2008). Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. American Journal of Public Health, 98, 946-952.
Allport, G.W. (1961). Pattern and growth in personality. New York: Holt, Rinehart, and, Winston.
American Psychiatric Association. (2000). Diagnostic and, statistical manual of mental disorders (4th revised ed.)., Washington, DC:
Aronson, E., Wilson, T.D., & Akert, R.M. (2005). Social psychology, 7th ed. Upper Saddle River, NJ: Pearson Education, Inc.
Beltran, R. O., & Silove, D. (1999). Expert opinions about the ICD-10 category of enduring personality change after catastrophic experience. Comprehensive Psychiatry, 40, 396–403.
Bem, D. J. (1972). Self-Perception Theory. In L. Berkowitz (Ed.), Advances in Experimental Social Psychology (Vol. 6, pp.1-62). New York: Academic Press.
Blaz-Kapusta, B. (2008). Disorders of extreme stress not otherwise specified (DESNOS) — a case study. Archives of Psychiatry & Psychotherapy, 10(2), 5-11.
Bremner, J., Southwick, S., & Charney, D. (1995). Etiology of posttraumatic stress disorder. In M Mazure (Ed.), Does stress cause mental illness (pp. 68-104). Philadelphia: Saunders.
Bromberg, P. (1998). Standing in the Spaces: Essays on Clinical Process, Trauma, and, Dissociation. Hillsdale, NJ/London: The Analytic Press.
Chemtob, C., Hamada, R., Roitblat, H., & Muraoka, M. (1994). Anger, impulsivity, and anger control in combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 62, 827-832.
Chu, J. A., Frey, L.M., Ganzel, B.L., & Matthews, J.A. (1999). Memories of childhood abuse:, Dissociation, amnesia, and corroboration. Americal Journal of Psychiatry, 156, 749-755.
Courtois, C.A. (2004) Complex Trauma, Complex Reactions: Assessment and Treatment. Psychotherapy: Theory, Research, Practice, Training. 41(4): 412-425.
Dalenberg, C.J. (1999). The management of dissociative symptoms in PTSD patients. NC-PTSD Quarterly, 8(2), 27-29.
Daud, A., Klinteberg, B., Rydelius ,P.A., (2008). Trauma, PTSD and personality: the relationship between prolonged traumatization and personality impairments. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18298618

Elklit, A.,  Christiansen, D. (2009). Predictive factors for somatization in a trauma sample. Clinical Practice and Epidemiology in Mental Health, 5, 1–8. doi:10.1186/1745-0179-5-1
Ellason, J. W., & Ross, C. A. (1997). Childhood trauma and psychiatric symptoms. Psychological, Reports, 80, 447–450.

Farber, S. (2000). When the Body Is the Target: Self-Harm, Pain, and Traumatic Attachments., Northvale, NJ: Jason Aronson.

Farber, S.K. (2006).The Inner Predator: Trauma and Dissociation in bodily self-harm. retrieved from http://www.apadivisions.org/division-39/sections/childhood/farber.pdf

Fernando,N.J., Jayatunge,R.M. (2013). Combat Related PTSD among the Sri Lankan Combatants. (in press)

Foa, E. B., & Hearst-Ikeda, D. (1996). Emotional Dissociation in Response to Trauma: An Information Processing Approach. In L. Michelson & W. Ray (Eds.), Handbook of Dissociation (pp. 207-226). New York: Plenum Press.

Ford, J. D., & Kidd, P. (1998). Early childhood trauma and disorders of extreme stress as predictors of treatment outcome with chronic posttraumatic stress disorder. Journal of Traumatic Stress, 11(4), 743-761.

Ford, J.D. (1999). Disorders of extreme stress following a war-zone military trauma: Associated features of posttraumatic stress disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67, 3-12.

Friedrich WN, Jaworski TM, Huxsahl JE, Bengtson BS. Dissociative and sexual behaviors in children and adolescents with sexual abuse and psychiatric histories. J Interpers Violence. 1997;12:155–171.

Gil S, Caspi Y. (2006) Personality traits, coping style, and perceived threat as predictors of posttraumatic stress disorder after exposure to a terrorist attack: a prospective study.Psychosom Med. Nov-Dec;68(6):904-9.

Halepota, A. A., & Wasif, S. A. (2001). Harvard Trauma Questionnaire Urdu translation: The only cross-culturally validated screening instrument for the assessment of trauma and torture and their sequelae. Journal of the Pakistan Medical Association, 51(8), 285–290.

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

Hamner, M.B. (2011). Psychotic Symptoms, in Posttraumatic Stress, Disorder. Retrieved from http://focus.psychiatryonline.org/data/Journals/FOCUS/4332/foc00311000278.pdf

Herpetz, S. (1995). Self-injurious behavior: Psychopathological and nosological characteristics in subtypes of self-injurers. Acta Psychiatr. Scand. 91: 57-68.

Horwitz A, Widom C, McLaughlin J, et al (2001).  The impact of childhood abuse and neglect on adult mental health: a prospective study. J Heal Soc Behav 42:184- 201.

Jayatunge, R.,M. (2008). EMDR Sri Lankan Experience , Sarasavi Publishers Colombo.

Jobson, L.,   O’Kearney, R. (2009). Impact of Cultural Differences in Self on cognitive appraisals in Posttraumatic Stress Disorder. Behavioural and Cognitive Psychotherapy, 37(3), 249-266.
Lipowski ZJ (1988). “Somatization: the concept and its clinical application”. Am J Psychiatry 145 (11): 1358–68.
Lommen, M.J.J. & Restifo, K. (2009). Trauma and posttraumatic stress disorder (PTSD) in patients with schizophrenia or schizoaffective disorder. Community mental health journal, 45, 485-496.
Lundy, M. S. (1992). Psychosis-induced posttraumatic stress disorder. American Journal of, Psychotherapy, XLVI, 485–491.

Luxenberg, T., Spinazzola, J., & van der Kolk, B. A. (2001). Complex Trauma and Disorders of Extreme Stress (DESNOS)Diagnosis, Part One: Assessment. Retrieved from http://www.traumacenter.org/products/pdf_files/DESNOS.pdf
Matsakis A (1996) I Can’t Get Over It: A Handbook for Trauma Survivors, California, New Harbinger Publications Inc.
Moskowitz, A. (2003). Dissociation and violence. Retrieved from http://www.hawaii.edu/hivandaids/Dissociation_and_Violence__A_Review_of_the_Literature.pdf

Morrison, A. P., Frame, L., & Larkin, W. (2003). Relationships between trauma and psychosis: A review and integration. The British Journal of Clinical Psychology,42, 331–351.
Nemčić-Moro, I., Frančišković, T., Britvić,D.,Klarić,M.,& Zečević, I . (2011) Disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans with posttraumatic stress disorder: case-control study.Croat Med J. 52(4): 505–512.
Putnam, F. (1992). Discussion: Are alter personalities fragments or fiction?, Psychoanalytic Inquiry 12, 95-111.
Silove, D., Phan, T., Bauman, A. (2009). Long term effect of psychological, trauma on the mental health of Vietnamese refugees resettled in Australia: a, population-based study. Lancet :360: 1056-62.
Skinner , B. F. Verbal behavior. New, York: Appleton-Century-Crofts, 1957.
Southwick, S.M., Yehuda, R., & Giller, E.L., (1993). Personality disorders in treatment-, seeking combat veterans with, posttraumatic stress disorder. American, Journal of Psychiatry, 150, 1020-1023.
Tull MT, Jakupcak M, McFadden ME, Roemer L. The role of negative affect intensity and … J Nerv Ment Dis. 2007 Jul; 195(7):580-7.
Van der Hart, O., Van Dijke, A., Van Son, M. & Steele, K. (2000). Somatoform dissociation in traumatized World War I combat soldiers: A neglected clinical heritage.
van der Kolk BA, Saporta J. (1991).The biological response to psychic trauma: mechanisms and treatment of intrusion and numbing. Anxiety Res. ;4:199–212.

Wenzel T, Sibitz I, Kieffer W, Strobl R. (1999). Capgras syndrome and functional psychosis in 2 survivors of torture. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10364730
Wilson, J.,P. (2007). The lens of culture: Theoretical and conceptual perspectives in the assessment of psychological trauma and PTSD. New York, NY: Springer Science.
Yehuda, R. (2002). Posttraumatic stress disorder. New England Journal of Medicine, 346, 108-114.
Zucker, M., Spinazzola, J., Blaustein, M., & van der Kolk, B. A. (2006). Dissociative symptomatology in posttraumatic stress disorder and disorders of extreme stress. Journal of Trauma and Dissociation, 7(1), 19-32 .