PTSD Sri Lankan experience

“In July 1983, communal riots broke out following the ambush and killing of 13 Sri Lankan Army soldiers including Lt Vass Gunawardana in Tinnevely Jaffna. Soon after this incident, the mob attacked Tamil civilians killing and looting their property. The communal riots in 1983 created a massive collective trauma and many victims suffered posttraumatic stress.”
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By Dr Ruwan M Jayatunge

Posttraumatic Stress Disorder- Over View

(December 07, Colombo, Sri Lanka Guardian) PTSD or Posttraumatic Stress Disorder is a cluster of psychological Symptoms that can follow a psychologically distressing event. The typical symptoms of PTSD occur after recognizable stress or traumatic event that involved intense fear and horror. PTSD denotes an intense prolonged and sometimes delayed reaction to an extremely stressful event.

The Columbia University Encyclopedia describes post-traumatic stress disorder (PTSD) as a mental disorder that follows an occurrence of extreme psychological stress, such as that encountered in war or resulting from violence, childhood abuse, sexual abuse, or serious accident. The stressful event is usually followed by a period of emotional numbness and denial that can last for months or years. After that period, symptoms such as recurring nightmares, “flashbacks,” short-term memory problems, insomnia, or heightened sensitivity to sudden noises may begin. In some cases, outbursts of violent behavior have been observed.

The diagnosis of PTSD first appeared in 1980 in the DSM or Diagnostic and Statistical Manual of Mental Disorders. According to the DSM -4 PTSD has been described as an Anxiety Disorder and the essential feature of Posttraumatic Stress Disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.

The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) The characteristic symptoms resulting from the exposure to the extreme trauma include persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness and persistent symptoms of increased arousal. The full symptom picture must be present for more than 1 month and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced by a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life-threatening disease. The disorder may be especially severe or long lasting when the stressor is of human design (e.g., torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.

Post-traumatic stress disorder is marked by clear biological changes as well as psychological symptoms. These symptoms can impair the surfer’s daily life massively. It is associated with impairment of the person’s ability to function in social or family life including occupational instability, cognitive problems, marital problems and difficulties in parenting. PTSD is complicated by the fact that it frequently occurs in conjunction with depression, alcohol and substance abuse.

Natural and Man Made Disasters Experienced by Sri Lankans

After the independence in 1948, Sri Lanka experienced a series of man made and natural disasters that affected the mental health of the population. These disasters had caused waves of PTSD in Sri Lanka. Most of the posttraumatic reactions were not identified or not diagnosed and sufferers lived with the symptoms for a long time sometimes in their entire life span.

1971 Insurrection

The 1971 uprising that was led by the JVP or the People's Liberation made an unsuccessful attempt to overthrow the Government by launching an island wide attack of the Police stations. According to K.M. de Silva a renowned historian 1971 JVP insurrection perhaps, the biggest revolt by young people in any part of the world in recorded history.

The revolt was brutally crushed and over 12,000 youths have been killed. (figures estimated by Fred Halliday) . Over 18, 000 were arrested and kept in various prisons and detention centers. The suspects were often tortured and some were kept in terrible conditions under the Jaffna Hammond Hill prison. A large number of suspects as well as civilians underwent traumatic condition because of the 71 Insurrection.

After the 71 insurrection, the Government appointed a team of experts to rehabilitate the young rebels, headed by Dr Leel Gunasekara who did a commendable service. Their psychosocial needs were addressed and a large number of suspects were successfully rehabilitated. Today the participants of the 71 insurrection lead productive lives and 95% them did not join the 2nd revolt in 1988/89.

Despite the psychosocial fulfillment of the rebels, the mental health parameters were not deeply addressed and during 2008 - 2009 I have interviewed a large number of participants of the 71 uprising and some were still experiencing the posttraumatic reactions even after 38 years. Many of them had intrusions, avoidance and emotional numbing.

1983 Communal Riots

In July 1983, communal riots broke out following the ambush and killing of 13 Sri Lankan Army soldiers including Lt Vass Gunawardana in Tinnevely Jaffna. Soon after this incident, the mob attacked Tamil civilians killing and looting their property. The communal riots in 1983 created a massive collective trauma and many victims suffered posttraumatic stress. After the 1983 riots, a large number of traumatized youth joined various Tamil militant groups and fought against the Government Forces. Tens of thousands fled to Western Countries and to India. Thousands are still living with the posttraumatic memories of the 83. Prof Daya Somasundaram in the Journal of Mental Health Systems 2007 estimates that 14% of the Tamil population living in the Northern Sri Lanka suffer from PTSD.

The Insurgency in 1988/89

JVP launched its 2nd Insurgency during the time 1988/89 which cost the lives of over 60,000 people. The 88/89 terror period marked by killings of civilians as well as destruction of national assets. Unspeakable atrocities were committed against humanity during this terror period and the nation went through its darkest phase. The Insurgency in 1988/89 created a bulky numbers of PTSD in the country. Some psychological studies indicate that a vast amount of victims as well as perpetrators of the 88/89 insurgency suffer from malignant PTSD.

Tsunami Disaster 2004

2004 December 26th Tsunami disaster was the immense natural disaster faced by Sri Lankans in its recent history. Over 30,000 people lost their lives and nearly 545,715 people became displaced. Tsunami 2004 created a deep psychological impact on the affected population. It was found that 3 to 4 weeks after the tsunami disaster in Sri Lanka 14% to 39% of children had PTSD and in another study, 41% of adolescents and approximately 20% of those adolescents' mothers had PTSD 4 months after the event. (The Psychological Impact of the 2004 Tsunami- Dr. Matthew Tull -University of Massachusetts)

Another study done by Miriam J.J. Lommen Angelique J.M.L. Sanders and Nicole Buck (Maastricht University, Maastricht, The Netherlands) included 113 survivors of the 2004-tsunami on the south coast of Sri Lanka. The results indicated that fifteen months post-trauma the prevalence of PTSD was 52.2%.

Sri Lanka received numerous aids to combat the Tsunami disaster and psychological assistance offered by the EMDR HAP was commendable. A team of experts led by Dr Nancy Errebo treated a large number of psychological victims of the 2004 Tsunami Disaster in Sri Lanka.

30 year War in Sri Lanka

Sri Lankan conflict was one of the longest armed conflicts of the 20th centaury. Sri Lankan society was shattered by hate and brutalization as a result of the internal war which caused over 75,000 lives and destruction of property worth over billions. This prolonged conflict generated massive numbers of PTSD victims. Combatants as well as a large numbers of civilians including members of the LTTE had undergone a tremendous amount of stress for the last three decades.

There had been large military operations where the combatants were directly exposed to hostile conditions. Some were physically as well as psychologically wounded. The shock wave of combat echoes the Sri Lankan society for a long time. Although the war is over the psychosocial scars of the war will remain for a long time.

There are no empirical data that directly address the prevalence of PTSD among the Sri Lankan combatants. But the 3 year study (2002-2005) done by the author with the Consultant Psychiatrist of the Sri Lanka Army Dr. Neil Fernando reveals that combat related PTSD is emerging in Sri Lanka. In one separate study which was done with 824 Sri Lankan combatants, full blown symptoms of PTSD was found among 56 people. In other words 6.7% of combatants were severely affected by the combat stress. PTSD diagnosed done according to the DSM 4.

Based on our rough estimations 8% - 12 % of combatants are severely affected by combat stress and many of them are not under any type of treatment. According to the survey (done by Dr Neil Fernando / Dr Ruwan M Jayatunge) of psychosocial and mental health problems among the 824 combatants who were referred to the Psychiatric Unit Military Hospital Colombo from August 2002 to March 2005 found a prevalence of conditions like PTSD (6.8%) depression (15.6%) alcohol abuse (3.5%), Somatoform Disorders (7.89%) and psychiatric illnesses such as Schizophrenia Acute Transient Psychotic Disorders etc (9.4%).

This may be the tip of the ice burg that is still able to be seen. This sample was referred to the Military Hospital Colombo for various psychiatric as well as stress and anxiety related conditions. Although this was not a randomly selected field sample it includes combatants who were exposed prolonged combat trauma. This survey discloses the bitter truth about the war and measures are needed to prevent further damage. A traumatized soldier can transform his stresses to his family and to the community. Hence, in the long run the whole country is affected by the repercussions of combat stress. This would lead to a vicious cycle and the scares will remain for decades.

The American Psychiatric Association (2000) discusses risk factors that affect the likelihood of developing PTSD. Among the risk factors the severity, duration, and proximity of an individual’s exposure to the traumatic event are the most important factors affecting the likelihood of developing this disorder. There is some evidence that social supports, family history, childhood experiences, personality variables, and preexisting mental disorders may influence the development of posttraumatic Stress Disorder. This disorder can develop in individuals without any predisposing conditions, particularly if the stressor is especially extreme.

One can point out several risk factors that affected the Sri Lankan combatants and which played a crucial role in developing PTSD. The authorities have not identified combat stress as a vital factor that should be dealt with effectively. Lack of experts in military psychology as well as the lack of funds has made psychological trauma management painstakingly difficult.

Some of the socioeconomic factors too contributed high rates in PTSD following combat related stress. During the height of the war youth from the lower socio economic levels joined the Army and some of them have faced severe economic hardships, affected by the Middle East syndrome (maternal deprivation) or subjected to childhood trauma. Their psychological makeup had been changed negatively and they were psychologically vulnerable. In one study among the 56 Sri Lankan combatants who suffered from PTSD 30 of them had experienced childhood trauma.

As Lt. Gen Gerry D Silva- former Commander of the Sri Lankan army points out that Sri Lanka army is the only army in the world whose full binate strength has been mobilized for two decades. A large numbers of soldiers have served in the operational areas for 10-15 years with short intervals. This factor too has increased psychological casualties in the military.

Even though the war is over the psychological repercussions of war was not ceased. The war stress especially the posttraumatic reactions of the Eelam war will echo the Sri Lankan society for another generation unless we take necessary psychosocial measures to heal the combat trauma.

-Sri Lanka Guardian