The Functional Impairments of Combat Related PTSD

I am tired and fed up. I have been fighting this war a long time. I have been killing Germans since 1937, then there is no end to them. You shoot a man 200 yards he is just a moving target. You kill him with a knife you are close enough to smell him. I smell them in my sleep. - Brown the Butcher of Barcelona – The Guns of Navarone

by Dr Ruwan M Jayatunge

(June 06, Ontario, Sri Lanka Guardian) PTSD often results in the impairment of the person’s ability to function in social and family situations. There are number of impartment associated with PTSD.

Major dimensions of maladaptive behavior in combat stress

Warfare has placed great stress on combatants. Death grief and social disorganization have been inevitable accompaniments of war. Violent conflict is part of social experience and memory (Davis1992). Combat can produce distrait reactions.

There are major dimensions of maladaptive behavior in combat stress.

Affective- anxiety, depression, irritability

Motivational- low productivity

Cognitive- confusions

Interpersonal-conflicts and withdrawal

Biological- associated with somatic complaints

Cognitive impairments

PTSD has been associated with cognitive impairments involving memory and attention. The affected individuals have poor mental function associated with confusion, forgetfulness and difficulty concentrating. The impairment affects many areas of thought and action; language, attention, reasoning, judgment. Many research concur that PTSD is associated with general learning and memory impairments. (Learning and memory impairment in PTSD: relationship to depression- Louisa Burriss, Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, South Carolina)

Difficulties in parenting

Many of the skills children acquire are fundamentally dependent on their interactions with their parents. Parent-child interactions are crucial in child development especially the developments including self-esteem, academic achievement, cognitive development and behavior. PTSD patients find difficulties in parenting. Many PTSD patients are unable to express love since there are troubled by emotional anesthesia.

Sergeant KP8 a known PTSD patient described his inability to enjoy his role as a father in following manner…..

Since I became ill, I my 8-year-old daughter detached from me. She was highly frightened when I went in to tantrums and had quarrels with my wife. Once I got very angry and dashed plates and cups, which were on the table. She started crying and hid under the bed. In the past years, she used to sleep with us, but I wake up for a slightest sound with terror and overwhelming reaction. I have fears that I might harm her when I experience flashbacks of the battlefield. I am unable to express my love for her and my feelings may be dead. I have become a cold father.

Domestic Violence

Family violence is a widespread problem that occurs among the combatants with PTSD. They use force to inflict injury, either emotional or physical, upon their spouses. Many combatants sublimate their rage. Domestic violence is a form of sublimation and transformation of anger. Based on our study out of 56 Sri Lankan soldiers with PTSD 13 of them frequently physically abused their spouses. Beatings and house property damage were common among them. Their anger and rage were focused towards their wives. They were irritable and hostile in family affairs.

There are many types of abuse that take place as part of domestic violence. These are emotional abuse, physical abuse and verbal abuse. They have gradual withdrawal from day to day activities. There are marked personality changes which affect their function as an active member in the society as well as in the family circle. Often they break family commitments, both major and minor. They become impulsive, numbed and inhibited. These features affect to have a successful family life and positive parenting. Men with PTSD commonly have sexual dysfunctions. This may be due to the anxiety and depression that they suffer. A part from the illness long term use of antidepressants also can cause erectile dysfunctions. Some males become suspicious and have sexual jealousies. This factor too escalates family violence.

Many combatants with PTSD admit that when they go in to tantrums they over punish their children. Children often live in fear and despair. The physical abuse take place inside the family system and rarely mothers admit that the beatings were done by their husbands. When the children are hospitalized for physical abuse mothers always, conceal the physical beatings in order to evade child protection laws.

Once a soldier with PTSD went in to flashbacks and he strangulated his little daughter. The girl was choking and luckily neighbours came and rescued her. In another incident, a PTSD father became annoyed when his eight year old son could not solve mathematical sums and he beat his son with a cricket bat. Later the child was admitted to the hospital and treated for three weeks.

Lance Corporal P has served seven years in the combat zone. He sustained a gun shot injury to the right leg. After he came home he could not get a sound sleep. He had nightmares with startling reactions. To avoid his sleep difficulties and intrusions he consumed alcohol practically every night. He became depressed and aggressive. Lance Corporal P used to physically abuse his children and the spouse. Several times he became AWOL. For nearly 3 years he went undiagnosed and untreated. Subsequently he was referred to the Psychological Unit Military Hospital Colombo and diagnosed with combat related PTSD. After 6 months of successful medication and psychotherapy program Lance Corporal P was free of his PTSD symptoms. Today he is having a productive life.

Occupational Problems

Soldiers who suffer from PTSD have occupational problems. Their productivity is weakened. They are detached from co-workers. Soldiers with combat stress have dysfunctional infractions at the work places. Traumatized soldiers develop their own peculiar defenses to cope with intrusions and increased psychological arousal. One officer who was diagnosed with PTSD felt uneasy and often manifested startling reactions when soldiers come and halt with a salute. The noise made him frightened. Therefore, he used to be away from others. Another soldier who had trepidation of uniforms felt uneasy when he comes to the camp. The irritability and spontaneous rage make them more socially isolated. They deliberately keep away from people in order to avoid confrontations. They easily get provoked. Some have homicidal tendencies.

Private WX6 sustained a gun short injury to the face in the Operation Ranagosa in 1999 became more and more dysfunctional. He had intense rage, suspicion and homicidal ideas. He frequently had conflicts with the soldiers and officers in his unit. In 2002 following a work related dispute Private WX6 planned to kill six of his platoon members including the platoon sergeant. His movements became suspicious and he was not issued firearms. Later Private WX6 was referred for psychological counseling and work related disputes were resolved avoiding a major disaster.

Compulsive Exposure

Some traumatized individuals have a compulsive urge to expose to situations reminiscent of trauma. Professor Bessel A. Van der Kolk in his outstanding publication on Traumatic Stress (Gilford Press 1996) gives numerous examples. This is a common feature among the Sri Lankan combatants too. Many combatants believed to be suffering from combat trauma have joined the private security firms, working with politicians and engage in violence during election periods, or working with the mob. Repetition cause further suffering for the victim and for the people around them. (Van der Kolk 1996).

Cpl FC8 was psychologically devastated when he witnessed the deaths of three of his platoon members in Silavathura and later developed PTSD symptoms. He left the military prematureally and joined with a local politician. During 1999, Infamous Wayamba PC election Cpl FC8 engaged in many election related violence that was instigated by his political master.

Private AX4 experienced a numerous traumatic combat events from 1996 to 2001 became AWOL and joined with an underground criminal gangue that committed several bank robberies. Several years he was evading the police and the CCMP. In 2005 when the criminal gangue attempt to rob a bank in Mathara district, they were arrested by the Police. Today Private AX4 is serving a prison term.

Capt KF9 lost his leg in the Northern territory as a result of an anti personal land mine which was called Jonny Batta. He underwent bellow knee amputation and transferred to a non-combat unit. After serving several yeas in a non-combat environment, he became distressed and wanted to go to the war front. He had marked posttraumatic features with intense rage. He was affected by severe hype arousal and traumatic reminiscences. After leaving the Army, he joined a private security firm and worked for several years. His occupational difficulties were intensifying and once he had a sever conflict with the Police and arrested for assaulting a Police Officer.

Suicide and Deliberate Self-Harm

Studies estimated that patients suffering from PTSD have up to a seven-fold increased incidence of suicide, and four-fold increased risk of death from all external sources (Bullman and Kang, 1994). A significant number of soldiers have committed suicide in the battlefield During the Eelam War. In addition, considerable amounts of uncompleted suicides have been recorded. Suicide is a complex event. There are biological, psychological and sociological causes of suicide and suicidal behavior. Among the 824 combatants referred to the Psychiatric Unit Military Hospital Colombo during 2002 Aug – 2005 March 22 of them had suicidal attempts. These combatants had used various methods such as self-poisoning, shooting, hanging and in one case a planned road traffic accident.

Private HX67 was deployed in Kokkuthuduwai in the height of the Eelam war and he felt that his life was in danger. His platoon was in the jungle, they had minimal facilities and continuous heavy rain made things worst. Private HX67 shot his leg with his weapon and forced evacuation. He was immediately taken to the hospital and treated. After his recovery Private HX67 had to face disciplinary charges.

Sergeant LX54 witnessed a number of traumatic events in the North. He witnessed the death of his platoon members and handled human remains. By 2002, Sergeant LX54 had no life interests. He had an intense death wish. Once he went to the armory, took a T-56, and placed it under his chin. The soldiers who were on duty grabbed the weapon. Subsequently he was referred for psychological therapies. Sergeant LX54 was treated with SSRI and CBT. After the treatment, he became free of suicidal ideas.

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 had manifested dissociative reactions; symptoms of acute PTSD in the height of the battle were not treated or referred to psychological therapies. When the symptoms aggravated with malignant PTSD they were referred to the Psychiatric Unit Military Hospital Colombo.

Hence we can give a case example. Corporal T had nightmares, intrusions and disorientation during the operation Jayasikuru or the Victory Assured in 1997. He became distressed and asked for medical attention. He was taken to the nearest MSD and treated with analgesics. With the difficulty that he experienced he was sent back to the battle front. After two weeks he lost his voice or in other words he had a dissociative reaction of psychogenic aphonia. Still he was not sent for any kind of treatment. After many months he became depressed and threatened to commit suicide. Then he was posted to Anuradhapura where there was no active combat, but had to handle dead bodies and human remains. Only in 2002 he was referred to the Psychological therapies. By this time, Corporal T had developed chronic PTSD with severe functional impairments.

Kessler’s Phenomena

According to Kessler 16% of PTSD patients can have psychotic features. When the PTSD sufferers are affected by the psychosis, they seem to the loss of contact with reality. They are affected by hallucinations, delusions and though disorders.

Private SK67 was actively involved in combat and on one occasion, he and a small team of soldiers trapped behind the enemy lines for over 3 days. By 2003, his mental condition was failing and he experienced passivity feelings, ideas of reference, thought broadcasting, thought insertion and disorganized thinking pattern. He was diagnosed with Schizophrenia by a Psychiatrist of the North Colombo Teaching Hospital. When a re assessment done by Dr Neil Fernando and the team in the same year found that key symptoms of PTSD such as hypervigilance , avoidance nightmare etc in Private SK67.

Recruit SD45 developed an abnormal reaction after wounded by a MBI (Mortar Blast Injury) to the left shoulder. His flashbacks were wrongly interpreted as visual hallucinations and distress reaction was misinterpreted as manic features. After a detail assessment, this soldier was diagnosed as having PTSD.

Delayed Reactions of PTSD

Currently the definition of delayed-onset PTSD encompasses symptoms that surface only up to 6 months following an event. Sometimes PTSD can emerge many years after the original trauma. According to Dr Michael Robertson, the director of the Mayo-Wesley Centre for mental health at Taree in NSW, a large numbers of older veterans are presenting nightmares and intrusive memories of the war. Some are experiencing these features for the first time in their lives. For some World War II veterans, memories of the war can still be upsetting more than 50 years later.

Late onset trauma plagues war veterans in a devastating manner. Those who are in their old age now troubled by the disturbing war memories. The delayed reaction, could be triggered by a subsequent stressful event

In a study of 147 Dutch veterans who had fought in the Resistance against the Nazis in WW2, it was found that forty years after the end of the war over half of these people are still suffering from PTSD and 4% showed no symptoms at all.

( Hovens, Falger 1992)

A new study of Joseph A. Boscarino, PhD, from the Geisinger Center for Health Research, in Danville, Pennsylvania that assessed New Yorkers exposed to the events of September 11, 2001 provides additional evidence that posttraumatic stress disorder (PTSD) can surface up to 2 years after the event in individuals with preexisting emotional or social problems. Dr. Boscarino and colleagues interviewed a random sample of English- and Spanish-speaking adults who were living in New York City on the day of the World Trade Center (WTC) disaster. At baseline, they conducted 2368 diagnostic interviews by telephone about between October and December 2002. At 1-year follow-up, they interviewed 1681 of the original sample.

Delayed PTSD reactions in Sri Lankan veterans

Some of the Sri Lankan veterans too have shown delayed-onset PTSD reactions. They have manifested posttraumatic features many years after original trauma. Combat trauma experienced by them may result in long-term sequelae.

Sergeant TH7 was an experienced combatant who participated in numerous combat operations in the North. During 1988 / 89 insurgency period, his platoon was deployed in the Southern part of Sri Lanka to fight the left wing Sinhala rebels who launched attacks against the Government. In the height of the conflict, the rebels attacked the Army killing several soldiers. This incident escalated to fathomless atrocities.

In 1989, Sergeant TX7 and his group arrested some of the suspects and eliminated them. Sergeant TX7 tortured one of the suspects who believed to have masterminded the attack on soldiers. He shot the suspect, poured petrol while the victim was alive. Then set fire. When the victim was on fire, he made an unsuccessful attempt to grab Sergeant TX7. Sergeant TX7 narrowly escaped the fire and he became shocked and utterly frightened. Then he aimed his firearm towards the blazing man and fired several shots. Then the suspect died instantly. After a few weeks, he completely forgot the incident.

In 2002, thirteen years after this incident one night Sergeant TX7 s wife tried to light the Kerosene lamp while they were having dinner. Then she accidentally dropped it and the lamp exploded. His wife s clothes caught the fire. She was on flames. Immediately Sergeant TX7 …….. water to his wife and extinguished the fire. She went unharmed. But Sergeant TX7 was utterly devastated.

When his wife was on fire immediately 1989 incident came into his mind. Instead of his wife he saw the JVP suspect who tried to grab him a moment before the death. From that night, he had nightmares of the original incident and continuous intrusive memories. Sergeant TX7 was startled and he was gradually turned in to different person. He became depressed and started abusing alcohol. He lost the life interests. Once he planned to commit suicide. He went to the railway station and walked along the railway tract. When the train was a few meters away, he changed his mind and jumped off.

Sergeant TX7 was diagnosed with PTSD by Dr Neil Fernando – Consultant Psychiatrist in late 2002 and treated with medication and psychotherapy. (EMDR and CBT). By 2003, he was free of most of the PTSD symptoms.

Lt Col XXD participated in the Operation Balawegaya in 1991 and faced heavy fire by the enemy. In front of his eyes, several soldiers died following sniper fire. Although he took a key, effort to prevent the enemy advance Lt Col XXD sustained a gun short injury to the leg. He thought that he would be dead as his fallen soldiers. While lying on the battlefield his thoughts were about his home, parents, wife and the children.

He was bleeding profusely and the other combatants took a greater effort to evacuate him immediately. He was transferred to Palaly hospital and then air lifted to Colombo.

The doctors took massive effort to save his leg and eventually the operation became successful. He recovered his physical injuries soon and went back to his unit. His physical and mental health was stable.

In 2003 he suffered DVT or Deep Vein thrombosis and experienced unbearable pain. While he was in physical pain he had flashbacks of the 1991 Operation Balawegaya events, how he sustained a gun shot injury, how he was lying on the ground etc. he even saw the late General Denzel Kobbekaduwa in his flashbacks. He became restless and had a PTSD attack.

After he was treated for the Deep Vein thrombosis his pain subsided, but he was hounded by the battle events. He experienced intrusive memories, flashbacks and startling reactions. His sleeping pattern changed and in order to avoid nightmares he started to work until late nights. Lt Col XXD adopted a workaholic attitude to evade disturbing ruminations. After sometime he was physically and mentally exhausted. His system could not cope any more. Then he had a second attack, which manifested as an aggressive fearful reaction. Lt Col XXD was treated with SSRI and relaxation therapies for a long time and gradually his posttraumatic symptoms subsided.