Challenges before post-war Sri Lanka:

Post traumatic stress disorder

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 Eelam War. Over 40,000 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 etc. Following the combat trauma in Sri Lanka, a significant number of combatants were diagnosed with PTSD.

Major military operations

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

1) Operation Liberation - (1987) -The overall plan for Operation Liberation was to clear the areas in the Jaffna Peninsula. This operation was half way stopped due to the Indian involvement.
2) Operation Sea Breeze - This operation was launched to save the Mulative camp 1990
3) Operation Trivida Balaya - Main objective was to save the 6 SLSR (Sri Lanka Singha Regiment) who were trapped in the Jaffna Fort. 1990
4) Operation Balawegaya - July 1991 Elephant Pass camp came under attack and Operational task was to give backup support to the troops at Elephant Pass.
5) Operation Valampuri - 1992
6) Operation Akunupahara - 1992
7) Operation Hayepahara - 1993
8) Operation Safe Passage - 1995
9) Operation Leap Forward - 1995
10) Operation Thunder Strike - 1995
11) Operation Rivirasa 1, 2 and 3 - 1995 (Main task is to liberate Jaffna)
12) Operation Sathjaya - 1996
13) Operation Edibala - 1997
14) Operation Jayasikuru - 1997
15) Operation Rivibala - 1998
16) Operation Ranagosa 1, 2 and 3 - 1999
17) Operation Rivikirana - 2000
18) Operation Agnikeela - 2001
19) Operation Mawilaru 2006
20) Battle of Thoppigala 2007
21) Northern offensive - 2009

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 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. 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 man-made 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 man-made 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 well-being. 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 man-made 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. 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 persons 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 gun shot injury - 15.4%
Severe beating or physical assault - 31.9%
POW - 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 into 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 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 into malignant PTSD.

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 DEROS that allowed official release of combat. Some of the socio-economic 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. Among the 56 Sri Lankan combatants who were diagnosed with combat related PTSD 30 of them had experienced childhood trauma. Psychological assessment

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.

It's clear that assessment of war zone PTSD is longer than assessment of other trauma syndromes. 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 Mississipi Scale for Combat-related PTSD.

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.

Combat operations

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. More than 100,000 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.

To be continued