Challenge before post-war Sri Lanka

Post traumatic stress disorder:

Dr Neil J Fernando / Dr Ruwan M Jayatunge

Continued from December 11

Standard studies

According to Dr Terry Keane who reviewed the epidemiological studies on PTSD(1990) estimates that 15.2 percent of all male and 8.5 percent 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 percent in men and 10 percent 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.

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. Therefore, this study is the only one that is available so far.

From August 2002 to March 2006, we have interviewed 824 members of Army infantry and services units who were referred to the Psychiatric ward Military Hospital Colombo. This study was conducted cross-sectionally, while the soldiers were still on active duty. The study group included 824 soldiers/ officers and obtained informed consent 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. (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.

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.

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 (Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC, American Psychiatric Association, 1994).

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 presented sample that was referred to the Psychiatric Unit Military Hospital Colombo. Mainly the referrals were done by the medical officers of the OPD, various Consultants in the Medical and Surgical units, Palaly Military Hospital, Victory Army Hospital Anuradhapura and various 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 presented sample was consisted of 824 combatants of the Sri Lanka Army.

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 were significantly higher after serving in the above mentioned areas. Among the 824 referrals PTSD was identified in 62 combatants. (56 with full blown symptoms and 6 with partial PTSD)

Total Number of PTSD patients - 56

*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

Results were presented from an epidemiologic investigation of PTSD among the Sri Lanka Army soldiers and officers. Analysis of questioner data from 824 combatants PTSD rate recoded as 6.7 percent. Results suggest that exposure to active combat may be responsible for stress reactions such as PTSD among the combatants. Additional results indicate early detection of PTSD symptoms, early treatment, and psychosocial care is important moderators in the attenuation of PTSD.

Untreated and undiagnosed PTSD

As pointed out by Lipkin, Blank, Parson and smith (1982) many cases of PTSD go underreported because of great many Psychiatrists and Psychologists fail to ask about military experience or what happened to the person while in the military. We have found a number of combatants who suffered acute PTSD in the height of the battle were not treated or referred for psychological therapies.

Hence we can give a case example. Corporal T had nightmares, intrusions and disorientation during the operation Jayasikuru in 1997. He became distressed and asked for medical attention. He was taken to the nearest MSD and treated with analgesics. With the psychological difficulties that he experienced he was sent back to the battlefront. After two weeks, he lost his voice or in other words, he had a dissociative reaction of psychogenic aphonia.

Still he was not refereed for any kind of treatment. After many months, he became depressed and threatened to commit suicide. Then he was transferred to Anuradhapura where there was no active combat, but had to handle dead bodies and human remains. While serving in Anuradhapura his condition was deteriorating. Dispite the fact that Cpl T was experiencing PTSD symptoms for many years only in 2002; he was referred for Psychological therapies. By this time, Corporal T had developed chronic PTSD with plentiful psychosocial impairments.

Suicide and deliberate self-harm

A number of soldiers had committed suicide in the battlefield. In addition, a considerable amount of uncompleted suicides had been recorded. 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.

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. In our study, we found cannabis was the major substance that was abused. Three soldiers were found to be abusing heroin. 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.

Conclusion

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 percent to 12 percent of the members of the armed forces are suffering from combat related stress. Although the War is over the psychological repercussions caused by the Eelam War can still hound the combatants.

The WW2 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.