By Dr. Neil J Fernando and Dr Ruwan M Jayatunge –

The 30 year armed conflict in Sri Lanka has produced a new generation of veterans at risk for the chronic mental health problems that resulted following prolonged exposure to the war. Over 100,000 members of the Sri Lanka Army had been directly or indirectly exposed to combat situations during these years. There had been nearly 20 major military operations conducted by the Armed Forces from 1987 to 2009. A large number of combatants from the Sri Lanka Army were exposed to hostile battle conditions and many soldiers underwent traumatic battle events outside the range of usual human experience. These experiences include seeing fellow soldiers being killed or wounded and sight of unburied decomposing bodies, of hearing screams for help from the wounded, and of helplessly watching the wounded die without the possibility of being rescued. Following the combat trauma in Sri Lanka, a significant number of combatants were diagnosed with Post Traumatic Stress Disorder (PTSD).

The combat operations in the North and East had involved military personnel in major ground combat and hazardous security duty. A significant number of combatants had posttraumatic reactions soon after the traumatic combat events. Majority of these reactions were undetected and untreated. A large number of combatants of the Sri Lanka Army have been directly or indirectly affected by the armed conflict. These psychological and emotional traumas were resulted from witnessed killings, handling human remains, exposing to life and death situations, engaging and witnessing atrocities and numerous other battle stresses. This is a form of invisible trauma in the military. But it has direct implications on the mental health of the soldiers.

The Sri Lankan Conflict

Sri Lanka’s conflict had its own specifications. It was a conflict between the Government Forces and a rebel group better known as the LTTE. The Northern conflict was one of the longest conflicts of the 20th century. Sri Lankan military forces deployed its entire bayonet strength for nearly 30 years. The psychological trauma experienced by the military was colossal. The Eelam War in Sri Lanka had generated a considerable number of soldiers with combat related PTSD. Many victims are still undiagnosed and do not receive adequate psychological therapies.

Major Military operations conducted by the Sri Lanka Army

From 1987 to 2009, the Sri Lanka Army had conducted major military operations against the separatists.

 

Name of the operation	Year	Objective
Operation Liberation	1987	clear the areas in the Jaffna Peninsula
Operation Sea Breeze	1990	to save the Mulative camp
Operation Trivida Balaya	1990	to save the 6 SLSR (Sri Lanka Singha Regiment) who were trapped in the Jaffna Fort.
Operation Balawegaya	Jul 1991	to give back up support to the troops at Elephant Pass
Operation Valampuri –	1992
Operation Akunupahara	-1992
Operation Hayepahara-	1993
Operation Safe Passage-	1995
Operation Leap Forward-	1995
Operation Thunder Strike-	1995
Operation Rivirasa 1, 2 &3 –	1995	Main task was to liberate Jaffna
Operation Sathjaya-	1996
Operation Edibala	1997
Operation Jayasikuru-	1997
Operation Rivibala-	1998
Operation Ranagosa 1 , 2 & 3 –	1999
Operation Rivikirana-	2000
Operation Agnikeela	2001
Operation Mawilaru	2006
Battle of Thoppigala	2007
Northern offensive –	2009

 Combat Trauma

Psychological Trauma is defined by the American Psychiatric Association as an event or events that involved actual or threatened death or serious injury, or to a threat to the physical integrity of self or others. Examples include military combat, violent personal attacks, natural or manmade disasters and torture. (DSM 4 p.424) Combat trauma is a horrendous experience. During a trauma soldiers often become overwhelmed with stress and fear. Soon after the traumatic experience, they may re-experience the trauma mentally and physically. Due to the painfulness, they tend to avoid the reminders of the trauma.

War is an institutionalized violence, which has intrinsic unique elements. It is a manmade disaster, which is very complex and multi-dimensional. War can be individual as well as a collective form of trauma. War disrupts the existing social structure and makes it very difficult for the usual social mechanisms to manage the consequences. The major impact of war includes disintegration of the psychological wellbeing. It create a specific calamity sub-culture often leads to generate vicious cycles. Some see war as a human malevolence and particularly difficult to cope with this manmade disaster. There were a number of psychological responses displayed by the combatants during and after the combat. These reactions vary from Acute Stress Reactions to Adjustment Disorders, Transient Psychotic Reactions, Depression and PTSD

Combat Related PTSD

The circumstance of war can produce a range of emotional, psychological and behavioral stress reactions among soldiers and officers that can lead to a condition known as PTSD (Post Traumatic Stress Disorder). The symptoms of PTSD were described in the context of war related trauma. PTSD is described in the Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition (American Psychiatric Association, 1994) DSM-4 as the development of characteristic symptoms following exposure to an extreme traumatic stressor. PTSD marked by cardinal symptoms of re-experiencing, avoidance and arousal was officially delineated in 1980 as a clinical diagnosis within the category of anxiety disorders.

PTSD Symptoms

Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories (flashbacks) or dreams occurring against the persisting background of a sense of numbness and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia and avoidance of activities and situations reminiscent of the trauma. The combatants with PTSD have the classic symptoms of sleep disturbance, psychomotor retardation, feeling of worthlessness, difficulty in concentrating etc.

Untreated and undiagnosed PTSD

As pointed out by Lipkin, Blank, Parson and smith (1982) many cases of PTSD go underreported because many Psychiatrists and Psychologists fail to ask about military experience or what happened to the person while in the military.

Suicide and Deliberate Self-Harm

A considerable number of soldiers had committed suicide in the battlefield in the past 30 years. Bunker suicides were reported from the North. In our study we have found that some soldiers had walked in to the enemy lines sometimes with a suicidal ideation and in some cases due to pathological dissociation. Also we found that a small fraction of soldiers shot their arms or legs in order to get evacuated during the war.

Alcohol and Substance Abuse

Alcohol and substance abuse can be interpreted as a negative stress coping action. For drugs to be attractive to a soldier there must be some underling unhappiness, sense of hopelessness or physical pain.. Alcohol was often abused to self medicate anxiety, depression, irritability and sleep disorders.

Psychological Management of Combat Stress

Controlling combat stress is often a decisive factor in victory and an essential feature in the post war era. Military Psychologists unanimously agree that treatment of combat stress should begin as soon as possible. There are several modes of psychological therapies that have been used to treat the Sri Lankan combatants suffering from PTSD. Cognitive Behavior Therapy (CBT) and EMDR (Eye Movement Desensitization and Reprocessing) are widely used to treat the Sri Lankan combatants. The combatants who were treated with EMDR gave favorable results and EMDR is one of the major psychological therapies in the Sri Lanka Army.

Risk Factors

PTSD could arise in the context of an event outside the range of usual human experience. It cannot occur without exposure to a traumatic event of sufficient magnitude. Research has suggested both shared unknown genetic factors and shared adversity and familial disturbance contributes to the risk of PTSD in veterans (Davidson, Swartz, Storck, Krishman, & Hammett, 1985; True et al., 1993). Macklin et al. (1998) found that lower pre-war intelligence predicted greater postwar PTSD in Vietnam veterans. Cognitive deficits could be a liability because they impact on problem solving and resourcefulness. Factors that reduce a person’s chances of developing PTSD include: higher cognitive ability; strong social supports; having a happy, safe childhood in a stable family; and an overall positive outlook/personality (McNally et al., 2003).

The estimated risk for developing PTSD for people who have experienced the following traumatic event is:

Witness killing 7.3%

Facing a gunshot injury 15.4%

Severe beating or physical assault 31.9%

Prisoner Of War 53.8%

Factors other than direct combat experience such as perceived danger and exposure to the violent and destructive aftermath of combat are important factors in the development of PTSD in a war zone. Traditional thinking about PTSD has focused on the traumatic quality of external rather than internal events.(Lundy 1992). However research in to the event characteristics which contribute to the experience of trauma emphasizes severity/ intensity of trauma degree of terror/ horror duration of impact: unexpectedness: presence of threat after the event: ratio of loss vs. available resources potential for prolonged alteration of the post disaster environment perceptions of control and cultural/ symbolic aspects of the event (Foy et al 1984 Lyons 1991)

There were numerous risk factors affected the Sri Lankan combatants during the 30 year war.

During the Eelam War Sri Lankan soldiers served in the operational areas facing constant hostile attacks sometimes over 12 months. On most occasions, they were exposed to prolonged combat without knowing the date of transfer to non-operational areas or release from the active service. A large parentage of combatants served in the operational areas with uncertainty. There was no Vietnam type Date of Return from Overseas (DEROS) that allowed official release of combat.

Some of the socioeconomic factors too contributed to generate high rates in PTSD. During the height of the war, youth from the lower socio economic levels and with low education joined the Army and many of them had experienced childhood traumas that drastically affected their psychological makeup. These groups were psychologically vulnerable and some could not withstand the battle stress.

During the war, there were no full time military Psychiatrists to treat the soldiers. Lack of experts in military psychology in Sri Lanka has made psychological trauma management painstakingly difficult. The military had no qualified psychotherapists to treat combat trauma. Combat related stress reactions went undiagnosed and untreated for a number of years. When cases were diagnosed, the affected soldiers had gone in to malignant PTSD.

Psychological Assessment and PTSD

Psychological Assessment can provide valuable information to clinicians regarding trauma exposure, PTSD symptoms and associated features, and treatment process and outcome. PTSD is a multifaceted disorder with a number of associated features, including guilt, anger, depression, substance abuse and other anxiety based conditions. Careful psychological assessments are required to determine the presence and severity of the range of adverse reactions to trauma.. Semi-structured interviews such as the Structured Clinical Interview for DSM-3-R, the Clinician Administered PTSD Scale and the Structured Interview for PTSD, can help establish the presence and severity of disorder PTSD as well as psychometrically sound questionnaires with established norms such as the Mississippi Scale for Combat –related PTSD.

The standard Studies

According to Dr. Terry Keane who reviewed the epidemiological studies on PTSD(1990) estimates that 15.2% of all male and 8.5% of all female Vietnam veterans currently suffer from PTSD- approximately 450,000 veterans in all. A national study of American civilians conducted in 1995 estimated that the lifetime prevalence of PTSD was 5% in men and 10% in women. The studies of veterans conducted years after their service ended have shown a prevalence of current PTSD of 15 percent among Vietnam veterans and 2 to 10 percent among veterans of the first Gulf War.

The Sri Lankan PTSD Study

Studies are needed to systematically assess the mental health of the members of the armed services who had participated in the warfare. There were no published studies of the PTSD rates among the Sri Lankan military personnel.

From August 2002 to March 2006, 824 members of Army infantry and services units who were referred to the Psychiatric ward Military Hospital Colombo were interviewed. This study was conducted while the soldiers were still on active duty. The study group included 824 soldiers/ officers and informed consent was obtained and the methods used ensured participants’ anonymity. These soldiers were administered the PTSD Check List based on DSM 4 with a structured interview. This schedule designed from similar trauma questionnaires used elsewhere in the world to detect PTSD. The DSM-IV diagnostic criteria for PTSD require that a minimum number of symptoms from each cluster be present (one or more re-experiencing symptoms; three or more avoidance/numbing symptoms; two or more hyper-arousal symptoms) and that they coexist for at least 1 month after the trauma and are associated with significant distress or functional impairment (Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC, American Psychiatric Association, 1994).

The presence or absence of PTSD was evaluated with the use of the PTSD Checklist. Results were scored as positive if subjects reported at least one intrusion symptom, three avoidance symptoms, and two hyperarousal symptoms that were categorized as at the moderate level, according to the PTSD checklist. In addition to these measures, on the survey participants were asked whether they were currently experiencing stress, emotional problems, problems related to the use of alcohol, or family problems.

Symptoms that have been present for 1 to 3 months are termed acute, whereas those that persist beyond 3 months are considered chronic. The development of symptoms 6 months or more after the trauma is termed delayed onset. Similar criteria have been set forth by the World Health Organization (World Health Organization: The ICD-10 classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland, World Health Organization, 1992)

The Results

This was a convenient sample that was referred to the Psychiatric Unit Military Hospital Colombo. Mainly the referrals were done by the medical officers of the OPD, Consultants in the Medical and Surgical units, Palaly Military Hospital, Victory Army Hospital Anuradhapura and other military treatment centers. The affected combatants had behavioral problems, psychosomatic ailments, depression and anxiety related symptoms, self-harm, attempted suicides, alcohol and substance abuse, and misconduct stress behaviors. The sample consisted of 824 combatants of the Sri Lanka Army.

Results were presented from an epidemiologic investigation of PTSD among the Sri Lanka Army soldiers and officers. PTSD rate is 6.7% following analysis of questionnaire from 824 combatants.

PTSD	No
Full blown	56
Partial	6

Exposure to combat was significantly greater among those who were deployed in the North and East of Sri Lanka. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after serving in the above mentioned areas.

 

Risk factor        

                                                       No

Those who have served in the operational areas (for more than 3 years)	45
Sustained grievous injuries –	15
Sustained none grievous injuries –	22
Witnessed Killing-	49
Past attempted suicides-	17
childhood trauma	30

Results suggest that exposure to active combat may be responsible for stress reactions such as PTSD among the combatants.

Among the 824 combatants referred to the Psychiatric Unit Military Hospital Colombo during the period August 2002 to March 2006, 22 of them had suicidal attempts. Among the methods used were self-poisoning, shooting, hanging and in one case a planned road traffic accident. Cannabis was the major substance that was abused. Three soldiers were found to be abusing heroin.

Results indicate early detection of PTSD symptoms, early treatment, and psychosocial care is important moderators in the attenuation of PTSD.

Conclusions

This study provides an initial look at the mental health of members of the Sri Lanka Army who were involved in combat operations. There was a strong reported relation between combat experiences, such as being shot at, handling dead bodies, knowing someone who was killed, or killing the enemy, and the prevalence of PTSD. Findings indicate that among the study groups there was a significant risk of mental health problems especially regarding combat related PTSD. According to our rough estimations, nearly 10% to 12% of the members of the armed forces are suffering from combat related stress. A number of combatants who suffered acute PTSD in the height of the battle were not treated or referred for psychological therapies.

Although the War is over the psychological repercussions caused by the Eelam War can still hound the combatants. The World War 2 and Vietnam experience had provided ample evidence of the late manifestations of combat related PTSD. Therefore screening, case identification, effective treatment and psychosocial support should be provided to the combatants. This study would give an insight to the policy makers in the military and care providers in the mental health sector to deal with combat trauma in Sri Lanka effectively.

References

1. APA- American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association
2. Davidson J.R.T & Foa E.B (1991) Diagnostic issues in PTSD Considerations for DSM-
3. Davidson J, Swartz M, Storck M, Krishnan R and Hammett E – A diagnostic and family study of posttraumatic stress disorder – America Journal of Psychiatry 1985; 142:90-93
4. Herman .J (1992) Trauma and Recovery. New York Basic Books
5. Jayatunge R (2004) PTSD Sri Lankan Experience , ANL Publishers Colombo
6. Lipkin .J Blank A. Parson E, and Smith .J -Vietnam Veterans and Posttraumatic Stress Disorder (retrieved fromhttp://psychservices.psychiatryonline.org/cgi/content/abstract/33/11/908
7. Litz .B -The Unique Circumstances and Mental Health Impact of the Wars in Afghanistan and Iraq , PTSD Support Services February 12, 2011
8. Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press.

Acknowledgement:

Sepal Thanks to T. M. E Dabrera ,Registrar in Community Medicine, Postgraduate Institute of Medicine, University of Colombo.