PTSD

PTSD – Sri Lankan experience By Dr Ruwan M Jayatunge

Post-traumatic stress disorder – Over View

PTSD or Post-traumatic 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 – 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 behaviour) 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 a 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 (eg, torture, rape). The likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increases.

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 post-traumatic 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 Front made an unsuccessful attempt to overthrow the Government by launching an islandwide attack of police stations. According to K. M. de Silva, a renowned historian, 1971 JVP insurrection perhaps, was the biggest revolt by young people in any part of the world in recorded history.

The revolt was brutally crushed and more than 12,000 youths were killed. (figures estimated by Fred Halliday). More than 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 1971 Insurrection.

After the 1971 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 percent them did not join the second 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 1971 uprising and some were still experiencing the post-traumatic 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 soldiers including Lt Vass Gunawardana in Tinnevely, Jaffna. Soon after this incident, the mob attacked civilians, killing and looting their property. The 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 post-traumatic memories of 1983. Prof Daya Somasundaram in the Journal of Mental Health Systems 2007, estimates that 14 percent of the Tamil population living in the Northern Sri Lanka suffer from PTSD.

The insurgency in 1988/89

The JVP launched its second 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

The Tsunami disaster inDecember 2004 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 three to four weeks after the tsunami disaster in Sri Lanka 14 percent to 39 percent of children had PTSD and in another study, 41 percent of adolescents and approximately 20 percent of those adolescents’ mothers had PTSD four 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 percent.

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 billion. 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.

Based on our rough estimations 8 percent to 12 percent 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 percent) alcohol abuse (3.5%), Somatoform Disorders (7.89 percent) and psychiatric illnesses such as Schizophrenia Acute Transient Psychotic Disorders etc (9.4 percent).

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 post-traumatic 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 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 to 15 years with short intervals. This factor too has increased psychological casualties in the military.

Even though the war is over, its psychological repercussions have not ceased. The war stress especially, the post-traumatic reactions of the Eelam war, will echo on society for another generation unless we take necessary psychosocial measures to heal the combat trauma.

Shell shock to Palaly syndrome-II

Palaly is a well-known area in Jaffna and it is famous for the Palaly Air Base. Most of the soldiers go to the Northern Peninsula via Palaly airbase. Therefore, Palaly is a part of them. Palaly is in their memories, sometimes in their intrusions. Palaly syndrome describes various clinical and psychosocial ailments experienced by the Sri Lankan combatants and in the final scores how it affects the society at large.

Shell shock to Palaly Syndrome was a long way for the soldiers.

In the early years of WW1 Shell Shock was believed to be the result of a physical injury to the nerves. Shell Shock term was coined by the British Pathologist Col. Fredrick Mott. He regarded Shell Shock as an organic condition produced by miniature hemorrhages of the brain. Shell Shocked soldiers exhibited symptoms of extreme fear, shaking, psychogenic blindness, psychogenic paralysis and sometimes aphonia. The Army was less sympathetic to the ordinary soldiers with Shell Shock. Official figures said that 304 British soldiers were court-martialed and executed. Between 1914 and 1918, the British Army identified 80,000 men as suffering from Shell Shock.

During the World War 2 traumatic reaction to combat was identifies as War Neurosis or Chronic Fatigue Syndrome. 10% of US Servicemen developed combat exhaustion in the WW2. Nearly 1363,000 soldiers were given medical discharges and 39% had Chronic Fatigue Syndrome.

During the Korean War the term section 8 was widely used to describe causes of psychological combat trauma. Those who had been diagnosed with section 8 were dealt with in a very situational manner.

The term PTSD or Post Traumatic Stress Disorder emerged soon after the Vietnam War. PTSD has been found in 15% of 500,000 men who were in Vietnam. There are estimated 50,000 veterans suffering from full blown symptoms of PTSD. At least half a million Vietnam veterans lead lives plagued by serious war related readjustment problems.

A new form of battle stress began in Sri Lanka mainly after 1983. Many Psychiatrists point out that number of psychiatric illnesses have been increased as a result of the Northern Conflict. For a combat soldier in World War 2 who served for 4 years the average time spent in actual combat was approximately 40 days. In Vietnam soldiers spent an average of about two thirds of their 12 or 13 month tours over 250 days in combat. But in Sri Lanka a large number of soldiers have spent 10-15 years in combat with short intervals.

For nearly three decades, Sri Lanka experienced a social calamity as a result of an armed conflict and people were deeply traumatized. The echoes of the war trauma will affect Sri Lanka for generations. Although the origin and the history of this conflict is very complicated and carries many versions and explanations, after all it is a collective trauma for the Islanders indeed. The North and South suffered from this conflict creating a large number of physically and psychologically traumatized people. War trauma is still hounding the Sri Lankan society rising as social violence, political violence, political extremism, criminal activities, domestic violence, suicides, homicides, alcohol and drug abuse, cruelty to children and various other forms.

Combat Related PTSD in Sri Lanka

PTSD is a relatively newly defined disorder with an old history. According to the Western chronological records the first patients of PTSD were recorded in 1666. These records were based on Samuel Pepy’s diary which describes the bizarre behavior pattern of the survivors of the Great Fire of London. Samuel Pepy vividly portrayed the nightmares, intrusions and flashbacks experienced by these survivors. In 1876 American Civil War doctor Mandez Da Costa published a paper diagnosing Civil War veterans with PTSD like symptoms which he called Irritable Heart.

Although the Western World recorded PTSD in 1666 the King Seethawaka Rajasinghe the 16th century monarch of Sri Lanka believed to be suffered from combat related PTSD. King Seethawaka Rajasinghe (born in 1580 AD) was a great warrior who came to the battle field at the age of 16. He fought against the Portuguese invaders and witnessed many deaths and destructions. He was a fearless fighter who used effectual war tactics and overpowered the fully equipped and fully trained Portuguese war machine. Following the long years of combat he was exhausted and definitely suffered from battle fatigue.

In the later years the King Seethawaka Rajasinghe showed outburst of anger, irritability, deep mistrust, alienation, emotional numbing and various other PTSD related symptoms. There were clear personality changes in him. With these changes the great liberator launched a chain of terror against his own people creating a deep void in the hearts and minds. Hence the King Seethawaka Rajasinghe lost his due respect in the history. But no one can argue his courage and tactics which he demonstrated in the battle field. The invincible 16th century super power was in the verge of a defeat in front of his sward. But what went wrong? Did combat related PTSD affect him?

The history shows that the King Seethawaka Rajasinghe experienced a number of PTSD symptoms. On one occasion, he gathered 100,000 soldiers and attacked the Portuguese Fort in Colombo. The Portuguese were desperate. Fear and famine fell upon them. Despite the attacks, the Portuguese were able to get external naval support from Goa. The battle was a fiasco and the King became furious. He suspected most of his Generals and assassinated them one by one. King Seethawaka Rajasinghe poisoned his right wing man Wicramasinghe Maha Senevi then Weerasundara Bandara. These Generals helped him in numerous battles. He was under a deep suspicion and believed in a conspiracy theory.

He acted as a tyrant and used brutal methods to punish people. He never felt any remorse or compassion. The King Seethawaka Rajasinghe even killed his own father Mayadunne which can be interpreted as a reaction following emotional anesthesia. Emotional anesthesia or emotional numbing is a distinctive feature of PTSD. In the later years he turned against the religion (which can be interpreted as avoidance also a cardinal symptom in PTSD). He embraced Hinduism and murdered thousands of his subjects who refused to follow Hinduism. The King Seethawaka Rajasinghe destroyed Buddhist temples and killed Buddhist monks by drowning.

His emotions were unstable. Very often, he acted with sudden rage. Gradually he made him self alienated. He had no close associates and the King became an isolated and a broken man. After many battles, he was physically and mentally worn out. Many aristocrats had left him because they could not stand his false accusations and outrageous behavior. The Great warrior had become another victim of combat stress.

Shell Shocked Sri Lankan Combatants

During the World War 2 a small contingent of Sri Lankan soldiers attached to the British Army served in Italy , Singapore , Egypt and Burma. Some were exposed to active combat or witnessed the horrors of the WW2. Some historical data suggest that a few Sri Lankan veterans suffered from Shell Shock during the WW2. The renowned Sri Lankan novelist Mr. W.A Silva in one of his short stories described the plight of a local soldier who had Shell Shock features.

D an American Illness?

Some have expressed the view that PTSD as developed in the West should not be imposed on countries with different cultures. Even though the concept of PTSD came from the West, it was common and could be seen in many countries irrespective of cultural differences.

Psychological stress reactions to traumatic events occur in diverse societies and cultures. (Post-Traumatic Stress Disorder: Cross-Cultural Aspects -Padmal De Silva Department of Psychology, Institute of Psychiatry UK). Human response to trauma is universal but the cultural context of the trauma is an imperative dimension. The meaning of trauma is often culturally specific. Cultural factors may also influence the manner in which PTSD symptoms are manifested. Therefore culture based assessment had to be introduced. In addition, the specifications of the Sri Lankan conflict should be taken in to considerations. These specifications were prolonged combat exposure, lack of psychological first aid soon after the combat, lack of social support system and on the other hand as the positive specifications- the usage of traditional healing methods, the impact of religion must not be forgotten.

The US Veteran Administration found 50,000 US servicemen soon after the Vietnam War. For many years, Sri Lankan authorities considered PTSD was an American illness, which could never affect Sri Lankan soldiers. Some expressed the view that we should not dig in to unnecessary issues like combat related PTSD which can lead to litigation and compensation. Therefore deaf and blind policy was adopted for the official convenience. But during this period combat stress increased in large numbers. Most of them were undiagnosed and untreated.

The Echoes of Palaly Syndrome

War is a multi-layered, multi-factorial phenomenon, which is filled with gruesome acts of violence. In a war not only the combatants even the civilians undergo a tremendous amount of combat stress. Stresses are unavoidable in a situation like war. Therefore people who lived in war zones become vulnerable. Their psychological makeup change rapidly.

War is a wholly human-made catastrophe, which is a gigantic process of social and self-destruction. As Plato once said “only dead have seen the end of the war. This means the psychological scars following combat can stay behind for many years. It can change the psychological markup of a person making him more dysfunctional. As the Salvadorian psychologist Martin-Baro(1990) wrote of his own country, what was left traumatized were not just Salvadorian individuals , but Salvadorian society. This expression is totally applicable to Sri Lanka. Many combatants, civilians as well as members of the rebel group have become the victims of Palaly Syndrome.

The Country was in an armed conflict for thirty years and during that period the society was severely traumatized and if necessary psychosocial rehabilitation is not provided the war trauma would harm the spirit of the Nation. During the past years, psychological needs of the combatants were not properly addressed. Much attention was paid to the physical injuries rater than psychological damages. Effective rehabilitation was not conducted and the repercussions of the mismanagement of combat trauma are visible even today.

Following the Sri Lankan conflict a large number of civilians, members of the Armed Forces and the LTTE carders have been killed. Total deaths estimate over 70,000 lives. Many have become permanently disabled. A large numbers carry psychological scars of the war with them and suffer silently. Some have sublimated their anxiety and stress to the family members and to the society. Hence, war trauma has become a vicious cycle.

The Sri Lankan society has experienced and still experiencing the echoes of the Palaly Syndrome. Many distressing and heartbreaking stores reveal the magnitude of combat trauma in the country.

A Distinguished Officer Turned in to a Serial Murder

Major Anuruddha Wijebahus’s story could be described as one of the horrifying stories of Palaly Syndrome. Anuruddha Wijebahu was a bright student from a leading school in Kandy. After completing his school education, he joined the Kothalawala Military Academy and passed out as an infantry officer. He was attached to the VIR or Vijayaba Infantry Regiment. Anuruddha Wijebahu served in the operational areas experiencing numerous combat related stresses. Gradually his psychological make up changed and there were clear personality changes in him. Major Anuruddha Wijebahus’s became cold-blooded serial killer and murdered a number of innocent men. His last victim he took to the Manthottam camp and drugged him. Then he chopped off the victim’s body, put the remains in to a barrel, and set fire. Later he was caught and while in the custody, Major Anuruddha Wijebahu committed suicide.

The Story of Army Jine

Army Jine was brave soldier from the Sri Lanka Commando unit who had exceptional combat skills. Affected by the combat stress his conduct became intolerable. Hence, Jine became AWOL. While in AWOL Jine committed highway robberies, murders and rapes. He lived in the jungle and with the survival tactics, which mastered, Jine evaded the law and enforcement authorities for a long time. According to some reports, Jine had committed nearly 27 rapes. Eventually he was gun downed by the Police.

Kadawatha Madura

Madura was a top sportsman in the Army who was mishandled by his superiors. Many occasions he was harassed and Madura underwent harsh work related stress. Following unbearable work related atmosphere he became AWOL and joined the underworld. Madura organized several armed robberies and he was engaged in extortions mainly in Kadawatha. Madura was shot dead in Kadawatha town while he was confronted by the Police.

Wambotta the ex Army Soldier

Kitulgamaralalage Ajit Wasantha alias Wambotta was born in Embilipitiya. In 1993, he joined the Army, enlisting as a member of the 3rd Sinha Regiment. After sometime, he left the Army and formed a criminal, gang, which consisted of over 50 heavily armed military deserters. Since Vambotta had the powerful political backing and political patronage, the Police found it extremely difficult to make any arrests. The gang led by Wambotta had done over ten murders and a number of extortions. The notorious gangster Wambotta was ambushed and killed by another underworld gang at Aswatte in Kosgama

A Lady Accountant killed by a Deserter

At Mutwal a lady accountant from a private firm was murdered and her 12 year daughter was raped by an army soldier in 2008. The perpetrator became AWOL several months before the crime. He waited near her house then entered and committed the crime. The victim was assaulted with a blunt weapon to her head and she succumbed to the injuries.

A Lady Doctor was shot by a Disabled Soldier

A lady doctor named Dr Miss Indunil from Bandagiriya Central Dispensary was shot by a disabled soldier from the Commando Regiment. According to the internal sources, the disabled soldier who was wounded in the battle had not received appropriate rehabilitation and psychological mode of management was affected by posttraumatic stress. Following an argument with the lady doctor he went in to a sudden rage and shot her.

A Brigadier was charged with shooting of his wife

A Brigadier who had served in the North and participated in numerous military operations was arrested by the Police for murdering his wife. According to the investigations, the suspect had used his service pistol to commit the murder.

The SF Rider who became a Criminal

Lance Corporal Harshana Nuwan was an expert motor cycle rider in the Special Forces who participated in SF operations in the North. He encountered copious battle stress, which he could not cope with. Often he was charged with disciplinary infractions and to evade the punishments he became an absentee. While hiding from the military police Lance Corporal Harshana Nuwan organized several bank robberies in which he used his riding skills. He was nick named as Son Baba by the underworld. He masterminded several contact killings and abductions. The Police took an immense effort to track him down.

An Army Sergeant Plants a Bomb in a School Van

An army explosives expert was arrested for alleged involvement in the Kurunegala school van explosion which left one 12-year-old school girl dead and 11 injured in 2009. According to the initial investigations indicated that the army sergeant had smuggled two kilos of C-4 explosives out of the Minneriya camp and planted them on the van around midnight in an apparent bid to kill the owner-driver, whom he suspected of having an illicit affair with his wife.

War Trauma and Social Violence

The 30 year armed conflict in Sri Lanka has produced a new generation of veterans at risk for the battle stress. Over 150, 000 members of the armed forces had been directly or indirectly exposed to traumatic combat stress. There had been nearly 18 major military operations conducted by the Armed Forces from 1987 to 2001 and when the conflict aggravated in 2006 new military operations were launched. A large number of combatants were exposed to hostile conditions. Following the traumatic combat stress, many combatants suffered from anxiety reactions that could be manifested as social aggression.

Psychosocial Rehabilitation of the Affected Veterans

The magnitude of combat trauma in Sri Lanka cannot be ignored. Most of the psychological scars are unhealed and it can affect the person as well as society. These psychological and emotional traumas were resulted from witnessed killings, handling human remains, exposing to life and death situations, 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 as well as their family members and the society at large.

The combatants gave an enormous contribution to end the war in Sri Lanka. Their blood and sweat were used by the politicians for their glory and at the end of the day the combatants received nothing except so called the Ranaviru Upahara which consisted of empty words. There should be an effective rehabilitation for the combatants affected by the Palay Syndrome. For long years, the veterans did not gain adequate rehabilitation and their battle stresses increased risking not only the combatants also their family members. In the final account, these stresses affect the entire society.

Combat Trauma in the Post War Era

There were many examples from other countries that reveal how combat trauma affected in the post war era. For example soon after the American Civil War, traumatized solders formed an extremist movement that called KKK which engaged in racial violence. Many American volunteers who participated in the Spanish Civil War engaged in social violence and some Lincoln Brigade soldiers became top criminals. Post Vietnam War caused a vast social chaos in USA. Similarly, many Afghanistan veterans of the Red Army engaged in organized crimes during the Perestroika era in the former USSR.

Soon after a mass conflict like war, there is a tendency of political extremism and sometimes fundamentalism to emerge. In a post conflict, society social fabric is fragile, people are traumatized and they become easy targets to these extreme and damaging forces. Soon after the WW 1, Germany faced such a situation and NAZIS could exploit the collective trauma experienced by the German people. The Taliban fundamentalists grabbed the power at the end of the Afghan conflict. Hence, there is an impending risk that we face today and the Democratic forces have an absolute responsibility to restore peace and justice system in the Country

The major impact of war includes disintegration of the psychological well-being. Therefore, major psychosocial interventions are required to restore the damages caused by the war. Promotion of human rights and justice are the key way to reinstate the social equilibrium. The victims of war need psychosocial support and rehabilitation. Rehabilitation programs include education, vocational training, income generating projects, loans and housing that is tailored to the needs of the survivors and post disaster situation.

War Trauma Experienced by the Sri Lankan Combatants by Dr Ruwan M Jayatunge M.D.

Death is not an adventure to those who stand face to face with it
Erich Mariya Remarque – All Quiet on the Western Front

In the Sri Lankan conflict, the impact of war and extreme stress on civilian population has been highlighted over the years. However, war traumas experienced by the combatants were not adequately shown. Over the past few decades, some extreme reports had dehumanized the images of the combatants and publicized combatants as perpetrators of violence. But a very few realize that the war trauma affected the soldiers in tremendous proportions.

War is particularly traumatic for soldiers because it often involves close violence, including witnessing death through direct combat, viewing the enemy before or after killing them, and watching friends and comrades die. (Hendin H, Haas A. Posttraumatic Stress Disorders in veterans of early American wars. Psychohistory Review. 1984). After exposing to combat trauma soldiers are more likely to have psychological ailments predominantly stress related symptoms, problems with social relationships and various other problems.

The wounds that they received from war are not confined to the battlefield it frequently transformed to their domestic environment as well. Although studies are needed to systematically assess the mental health of members of the armed services, a very few studies were conduced during the last 30 years.

Research has also linked war trauma and physical health outcomes, ( Schnurr PP, Green BL. Washington, DC: American Psychological Association; 2004. Trauma and health: Physical health consequences of exposure to extreme stress) Researches have shown the co relation between cancer risk and battle stress. Therefore, the veterans of the Eelam War are at a health risk. Considering these facts the health authorities should take necessary action to minimize the mental and physical complications of the war trauma.

Despite fact that the full psychological effect of the war is impossible to estimate, at least the authorities should take measures to heal the psychological wounds caused by the War. Mental health of the soldiers who participated in the Eelam war in Sri Lanka is severely affected by the horrendous battle events that they witnessed. The most common mental health issue for soldiers is post-traumatic stress disorder and related symptoms of depression, anxiety, inattention, sleeping difficulties, nightmares, and survival guilt. Still we are unaware of what long-term effect did the war have on Sri Lankan soldiers.

The dedication and the courage of the armed forces cannot be underestimated and the Sri Lankan combatants fought one of the longest and deadliest armed conflicts in the world and they were able to gain a clear victory. Sri Lanka paid an immense price for the victory. As a result of the three-decade war, many soldiers became physical and psychological casualties. Unfortunately the society is gradually forgetting the scarifies made by these people.

Although many see war as a heroic effort, there are thousands of untold traumatic stories in the Eelam War. Some soldiers shared their traumatic stories with us and these stories reveal the magnitude of their suffering. These stories represent the true nature of combat trauma in Sri Lanka.

The psychological casualty of the operation liberation

The Operation Liberation or Wadamarachi Operation was conducted in 1987. It was the fist major military operation in Sri Lanka. Nearly 8,000 soldiers participated in this campaign. The most popular and the famous officer of the Sri Lanka Army the late Gen Denzyl Kobekaduwa commanded this military offensive against the LTTE. Now nearly 21 years have passed and many have forgotten this campaign. Up to date no one has scientifically studied the first military operation of Sri Lanka and its psychological effects.

Corporal Ax36 is one of the psychological casualties of Operation Liberation. During this battle, he faced many battle stresses. He was physically and mentally exhausted. After serving, a number of years in the Army Cpl Ax36 witnessed many traumatic events. He suffered nightmares, intrusions, hyperausal, and flashbacks. He was avoiding people and places related to his traumatic experiences and became emotionally numbed. In 2003, Cpl Ax36 was diagnosed with PTSD.

Corporal Ax36 describes his present emotional and physical ailments as follows.

I was one of the soldiers who took part in the Wadamarachi Operation in 1987. Our main aim was to liberate Jaffna Peninsula and destroy the LTTE positions. When we came near the Thondamanaru Bridge, the LTTE destroyed the bridge using explosives. We had to advance slowly. One of our soldiers died in front of my eyes as a result of a booby trap. I can still recall his face filled with blood. It was a horrific incident.

Needless to say that I was terrified by this event. Because I am a human although I wore a military uniform. I was shaken by the death and demolition. Even after many years, I still see these events in my dreams. To evade the nightmares I used to take alcohol and go to sleep. I cannot stand any loud noises, I become frightened and my heart started pounding. Often I try not to think about past events. When I see the TV if I see any combat related story or a pictures I disconnect my self with it. I hate to talk about past events especially those related to the war.

I have no strength in my body now. My joints are aching. I cannot even walk a mile. Premutually I have grown old. My mind is full of melancholic feelings. I am unable to feel happiness. For many years, I never experienced cheerfulness.

I am unable to concentrate and I am very forgetful. I have forgotten the names of my fellow soldiers who served with me in the same unit. Sometimes I feel that I have no reason to live. My family members avoid me because of my hot temper. Unlike early days, I cannot control my anger. I have been turned in to an irritable cold person. Several times, I thought of disappearing from this world. But according to my religion it is a sin. Therefore, I have resisted the idea of committing suicide.

Private K and Survival Guilt

There is a higher incidence of depression in veterans who had been in combat and lost a friend. Survival guilt is an especially guilt invoking symptom.

“Survivor guilt” is the term used to describe the feelings of those who, fortunately, emerge from a disaster, which mortally engulfs others. On an irrational level, these individuals wince at their privileged escape from death’s clutches. (Survivor Guilt in Holocaust Survivors and their Children -Aaron Hass).

Private K is a soldier who was severely troubled by the survival guilt. He joined the Army in 1992 and served in the North. While serving in the combat his buddy was shot in front of his eyes near the Punani station. He fell down and lost his consciousness. Although Private K wanted to help his friend, he could not reach the friend due to heavy fire. Along with the other soldiers, he attacked the enemy and eventually went near his friend. But he was dead. This incident made him so upset. He felt guilty that he could not help the buddy.

By 1997, he often experienced headaches, intrusions about his dead friend and showed a marked depression. He became irritable and gave a startling reaction to any slightest sound. Private K felt uneasy with the military duties and wanted to avoid military situations. In 2003, he was referred to the Military Hospital Colombo and diagnosed as having PTSD. Private K’s condition improved following drug therapy (SSRI) and psychotherapy (CBT and EMDR). By 2005, he was free of most of the PTSD symptoms. After cognitive restructuring, he got the insight and now Private K knows that he was not responsible for the death of his friend.

Did I bury him alive?

Private Lx26 became pitiful when he witnessed the death of his fellow soldier who got killed by a sniper shot. The troops had no means to bring the body back. After confirmation of death, Private Lx26 was ordered to bury the body. When he touched his friend’s body, he could feel the body warmth may be due to the hot Northern climate. Private Lx26 dug a pit and berried his friend’s body in the mist of sorrow. Then they advanced towards Omanthai. After a several days, Private Lx26 had an irrational and guilty feeling that he had buried his friend alive. He suppressed this painful feeling for a long time. Gradually it became a distressing thought, which he could not bear anymore. In 2003, he experienced a severe depressive reaction following survival guilt. He had full-blown symptoms of clinical depression. He was treated with Rational Emotive Therapy in which his irrational and illogical ideas were confronted via a friendly and therapeutic mediation. After the therapeutic intervention, Private Lx26 was free from devastating psychological burden that he carried for long years.

My Sergeant died in my arms: says Private RS

I was born in a small village in Pollonarwa and often our village became the LTTE target. Several times the LTTE attacked our village slaughtering men women and little children. We had mass funerals after these attacks and most of the villagers felt utterly sad and insecure. As a child, I saw these horrendous things around me. At night, we did not sleep in houses, for security we slept in the jungle. I did not see a way out for these tremendous problems except joining the military. So I was determined to join the Army.

Our family had to face many financial hardships and that affected my education. I could not study further and I joined the Army. After my basic training, I served in Welioya and Vavunia.

In 1997, I participated in Jayasikuru (Victory Assured) operation and we were given a task to capture the Mankulam highway. We fought the enemy face to face. The gunfire lasted for nearly 3 hours. A commando unit came for our support and we were able to advance further. Sergeant L who was my senor NCO and my mentor was behind me. He taught me many combat skills. We always fought the enemy together. He used to cover me and I used to cover him. Both were lucky for many years. However in Mankulam he was hit by a bullet. Sergeant L was bleeding profusely. I helped to evacuate him. I carried him while praying for his life. His breathing became shallow. I could not reach the medics , half way he died in my arms.

After his death, my conscience blamed me for not saving him. I felt guilty. I wish I could take him to the Medical Point on time. If I did that, it could have saved his life. But I was late and Sergeant L died. I was troubled by this guilty feeling and combat related nightmares and various intrusions. My life became to a standstill. I was filled with sorrow and repulsion of combat events. I was disgusted with all these issues and once I wanted to shoot my self and end the suffering. Somebody or some power saved me from self-harm and showed the way towards life. Again, I saw light.

(Private RS was found with PTSD comorbid with depression. Following intensive treatment, he was able to recover. He became free of survival guilt that troubled him for a long time. Now he is serving in his unit without firearms and doing light duty. )

Rifleman Sn34 and Baptism of Fire

I became a psychological casualty at the Yale Devi operation says Rifleman Sn34 revealing his story thus.

…Operation Yale Devi was my first combat experience. We faced the enemy with courage. I witnessed a lot of traumatic incidents there. Our fellow soldiers died in front of my eyes leaving us in sorrow. On one occasion, the enemy gave us a surprised attack and we were scatted. I jumped in to a pit and waited all night long. It was a dark night. I saw the enemy collecting weapons from our bunkers. I was alone and feared my life. Because I knew, the enemy had no mercy. I had seen dead bodies mutilated by the enemy. I thought they would do the same thing to me if they could capture me. It was an awful idea. I had vivid mental pictures of my funeral and I saw my parents were crying. I did not want to be captured by the enemy and let them mutilate my body.

The entire night I was praying for my life and by dawn the reinforcements came and they rescued me. I was taken to the hospital. Although I had no physical injuries, my mind was deeply wounded. Nevertheless, doctors said I was ok. I felt something was wrong with me. I was sent to the battlefield again. I had fear feelings and every night I saw the same horrible dream. I saw my self trapped in a pit and the enemies were all over. Despite the fear and resentment, I did the duty that was requested from a soldier. My mental health was deteriorating and I had no salvage. Finally, I decided to become AWOL.

I went home as a completely changed person. The innocence of youth and affection towards the family members had gone away. They saw me as a frightened cold soul. My parents thought that some evil spirit had got in to my body and they did Thovilaya the ancient ritual to chase dark spirits to heal me. But it did not help. My memory was fading and I couldn’t sleep. Nightmares ruined me to the end.

My family arranged a marriage for me thinking that it would help me to get away from alienation. After my marriage, again I went back for duty. But I was a lost soldier. I was anxious performing military duties. I had intense fear of enemy attacks. The noise of the gunfire made me startle.

I went home after several months serving in the North. I had no happy feelings that I got a vacation after so many months fighting in the jungle. My emotions became numbed and no longer, I was interested in marital life. I became more and more hostile and physically abused my wife. Since I couldn’t have a sound sleep, I started indulging in alcohol. Practically day and night, I was drinking secretly. But it made me worst. It made me a monster. My wife was afraid of me. When I came home, she was shivering in fear. When I was angry, I destroyed the house property. Nothing gave me a relief.

Eventually I decided to talk to one of my senior officers whom we trusted. The officer listened to my grief and helped me to get psychological therapies. I was treated at the Psychotherapeutic unit at the Military Hospital Colombo for nearly 3 weeks as an inward patient. Then they got down me to the clinic and treated me. Counseling and medication helped me to get away from the trauma that I experienced for a long time. Today I am a new man who is not abusing alcohol and I love my family. I enjoy life and do not live in past memories.

The soldier who did not like to attain military funerals

I hate to participate in Military Funerals says Lance Corporal S who described his military life in following account.

In 1987, I was posted to Kurumbasevadi camp near the Palali Base Camp. There I faced the baptism of fire. In that camp, I served nearly one and half years and then sent to Welioya camp. I was at the forward defense line. At the Welioya camp, I witnessed many horrendous combat events. The enemy attacked us with heavy weapons killing my fellow soldiers. I saw how they were laying on the ground with bullet or shrapnel wounds. I collected the dead bodies and put it in to body bags. I was utterly devastated when collecting human remains.

In 1991, I served in a non-operational area but my official duty was to participate in funerals of our soldiers who died in action. When I was at these military funerals, I had various intrusions about the battlefield and my dead buddies. My heart was broken when I heard the mourning and wailing of the relatives. At one funeral, I saw a mother was crying for her dead son. He was a good soldier whom I knew. Her weep reverberated in my ear. I recalled the dead soldiers at Welioya , how they were laying on the sand some with opened eyes. Many weeks I could not sleep.

I hated to participate in these depressing military funerals. However, my duty required such participations. In each funeral, I had flashbacks and deep sensation of sadness.

By 1998, I got a transfer to Mannar District. There while I was traveling by bus I met with a land mine explosion. I was wounded and treated at the hospital. Although my physical wounds healed, the fear I experienced at that event was re occurring. My mind was full of various battle events, military funerals and the land mine explosion, which I met in Mannar. I had nightmares and fear feelings. I became more irritable and sexually inactive.

My body became a source of pain. Every joint in my body started aching. When I experienced an unbearable headache, I could not stand noises. After the land mine explosion, I was again posted to the former camp in the non-operational are to fulfill funeral duties, which I hated. Regrettably, the senior officers gave no ear to my grievances. I was there for another one and a half years. During that time my illness progressesed rapidly and once I decided to commit suicide inside the camp. My unsuccessful suicide attempt alarmed the platoon officer and I was sent to the hospital. At the hospital, I was treated and given medication and psychological support. After months of treatment, my condition improved. Today I am doing light military duty in a non-operational area. But still I cannot see dead and war memorials.

(Lance Corporal S was diagnosed with PTSD by Dr Neil Fernando – Consultant Psychiatrist and treated with SSRI and EMDR. After intense therapy, his anxiety based symptoms reduced to a significant level)

In my dreams I see the enemy is attacking my bunker says Private Rx68 (A known PTSD patient)

….My memories are still filled with the events that took place on the 24^th of August 1993. Now for many years I still live with these horrendous memories. Practically every day I recall these events and it gives me pain and anguish.

On that dooms day at 12 o’clock midnight I was at the bunker. Two of my buddies who were with me had a rest while I was on guard. Suddenly I heard gunshots and one of our corporals shouted that the enemy is attacking the Janakapura North Camp. I awakened two of my buddies and asked them to be on alert. Within a few moments, a group of LTTE attacked our bunker.

I heard the scream at the adjacent bunker. The enemy attacked them with a hand grenade and I presumed that they had captured that bunker. So we were on our own and fighting the enemy. Three of us fired at the enemy from three different directions and we never wanted to surrender.

The enemy came towards us like an unceasing wave. I attacked the enemy with my LMG killing a dozen of them. One of my buddies near me sustained a gun shot and fell down. Hence, two of us had to face them.

We fired at them without giving any break. Suddenly they attacked my bunker with a RPG and the bunker collapsed. A large Palmyra log fell on to my head and I was semi conscious. My ears became locked and I felt bleeding from my head. I knew if we stayed there, we would be killed. Therefore, we came out from the wreck and crawled towards the center of the camp. While we were moving several LTTE carders came to capture us alive and I threw a grenade to escape.

When two of us went further, we met a group of our soldiers. We regrouped and attacked the enemy. The assault went for a long time, by dawn, the enemy withdrew from the camp leaving many casualties. Although I was injured and tired, I fought with my guys without dropping my weapon. In the morning, I was sent to the hospital for treatment.

I still recall how my friend at the bunker fell like a log after hit by a bullet to the head. We fought while he was gasping and we had no time to pay attention to him. He must have died within a few minutes. These memories hound me at nights. When I am half a sleep I see shadows, and I become vigilant. I always get a feeling that the enemy is crawling towards me. I fear that the enemy would attack with a RPG. Then I open my eyes and my heart starts to beat like an accelerated machine. Afterward for several hours, I am unable to sleep. Awake at night I am thinking about my friends who died in the battle. Then I feel that it was so unfair that I am alive and they are no more.

Sometimes I see battle events in my dreams. Often when the enemy attacks I am unable to return fire, my gun is jammed. Since I am unable to shoot the enemies, they are approaching me little by little. I can hear their voices scolding us in Tamil Punde Army Punde Army . I become helpless. I hear someone throws a grenade. My fear increases and I shout. Then I realize that it was another nightmare.

My family members are now used to my screenings at night. My great fear is when I am sleeping I might harm someone who is near me. Therefore, I often tell my wife and children not to be near me when I am sleeping. My life has changed dramatically and I am not the same person anymore. My emotions are numbed and I cannot cry for my dead friends.

The Story of Private UG

Private UG met with a blast injury in 1997 near the Thaladi camp. He was wounded and psychologically shattered by the blast. After several months of the injury he complained of sever headache, insomnia and fear feelings. Gradually he developed PTSD symptoms. Private UG found difficult to sleep and experienced nightmares related to the blast injury. He had fright feelings and always wanted to avoid the places and conversations related to the blast injury. Any slightest sound made him jumpy. He became irritated and could not control his anger. Often he experienced sexual dysfunctions and as a result of family turmoil, his wife left him. Following family problems and overwhelming anxiety, he tried to commit suicide.

When Private UG was referred for psychological therapies, he was treated with CBT and EMDR which minimized his PTSD symptoms. Today he is able to sleep without nightmares and intrusions hardly bother him. He does not get excessively angry as early. He has learnt to manage his anger without destructive behavior. The final follow up revealed that his wife had returned and Private UG is leading a productive life.

I was hiding in a hole in the ground: Rifleman Mx38

The night of the 27^th of September 1998 was the most terrible hours of darkness of my life. I was at the FDL in the Paranthan area. The LTTE attacked my bunker and they were managed to come very close. My friends had thought that I was dead and enemy had captured my bunker. Then they too attacked the bunker with their weapons. I was trapped facing enemy fire as well as friendly fire. Without many options, I decided to abandon the bunker. I crawled and moved away from the FDL. Then I found a pit and I was hiding in there. I heard the enemy’s movements and lot of gunfire. I thought this would be the end. Within a few moments, they would discover me and they would not think twice to kill me. I saw child solders moving towards the FDL with heavy weapons, then the LTTE female carders with AK 47 in their hands. Luckily, no one saw me or not expected me to be in a hole in the ground. I could hear heavy fighting and I decided to stay inside the pit. I was trapped there for several days. I had no food and my water bottle finished by the second day. On the third day, I was thirsty and I was compelled to dink my urine. By the fourth day, I had no alternative. I decided to move towards the FDL. I noticed that the defeated enemy retreating group by group. I took a cover and avoided them. It was a dark night and I made no noise. I was without food and water with severe exhaustion. I moved slowly.

When I came near the FDL I had to be vigilant not to receive friendly fire. I shouted at our soldiers. I told them my name, unit and my serial number. Then they recognized me with a surprise. They had thought that was killed or captured by the enemy. I was taken to the C/O and he admired my courage. I evaded death like a miracle. I was lucky to come alive. But this happiness lasted for few days. Often the fear and isolation that I experienced inside the ditch bothered me. I could not rest, every time I had to be on guard anticipating an invisible enemy. Days went by I was still feeling fear. When I went to an ambush I became restless I was looking at the front then my inner feeling said the enemy is behind you, I looked back, and no one was there. I could not concentrate my mind. It was a terrible mess and became an obsessive ritual to watch every direction for the enemy.

My head started aching and often I forgot things. Several times, I was warned by senior NCOs and Officers for leaving my weapon elsewhere. I could not concentrate or remember things. At nights, I was practically awake. A slightest sound made my heart oozing with fear. My heart started pounding giving me aches and pains. I had terrible nightmares. In my dreams, I saw I was trapped in a hole in the ground and surrounded by the enemy. I hated to go to sleep.

(Rifleman Mx38 was diagnosed with PTSD by Dr Neil Fernando Consultant Psychiatrist in 2001 and treated him with SSRI and Psychotherapy –CBT& EMDR. According to the 12^th April 2005 follow up he experienced no major PTSD symptoms. His sleep became normal and the startle reactions became minimal. No intrusions or flashbacks troubled him)

The story of Lance Corporal AS – The soldier who was living in isolation

I was happily married but things changed when I became wounded. In 1990, I was at the Thaladi Camp Mannar. There I saw fears battle. The LTTE attacked us with heavy weapons killing nearly 40 soldiers. With utmost difficulty, we were able to defeat the enemy. My heart cried when I saw the dead bodies of our fellow soldiers. We were like one large family. Prier to the attack we had meals together and made jokes about odd things. They have gone forever. When I put their bloodstained bodies to the body bags, I cursed the enemy.

After this event I became more isolated and had intrusive memories. There was no one to speak about my anguish. I became alienated. When I came home, my wife often asked what was wrong with me. However, I did not tell anything to her. Because it was a pointless effort to tell my sorrow to her and she would never understand what happened in the battlefield. Therefore, I silently lived with my grief. But I became more and more irritable.

In 1996 we went to Kodikamam and ambushed the enemy. There was no proper camp for us. We lived in abandon houses, which were ruined by the shellfire. It was a hostile ground. The enemy was everywhere. If you do a stupid mistake, you would sleep in a body bag. I was uncertain of my life. We lived day-by-day avoiding enemy fire and booby traps.

One day we accidentally walked to an ambush and the enemy fired at us in a close range. Eight of our men died in this attack and they died in front of my eyes. We too attacked the enemy and eventually managed to escape. But we had to leave the bodies due to the advancing hostile forces. I still feel guilty for leaving their bodies. Indeed it was a terrible time. During these years, I saw many dead soldiers as well as the members of the LTTE. Some bodies were decomposed or mutilated. I saw large monitors eating dead bodies. The things I have seen confirmed me that there is no glory in death for sure. Once I saw a dead body of a staff sergeant (he was known to me), the enemy had shot his eyes. It was a horrible image to see, a dead body without eyes and instead of the eyeballs, I could see the deep bullet wounds. For many years, that image was deposited in my mind. I even had bad dreams.

When I came home these battle events started rooming around my mind. I wanted to be left alone. But my wife wanted to know what’s wrong with me. I was not interested in sex life. I was avoiding my wife. She thought I was having an illegal affair. I could not stand her accusations. I became depressed and could not tolerate noise. When my children played and shouted I became extremely angry. I punished them severely. When my wife protested, I used to beat her too. One day I smashed the TV and chased everybody out of the house.

My family was suffering with me. When I came home, I used to physically abuse my wife for a slightest argument. She felt uneasy during my presence. Even the children feared me as if I am a monster. Little by little, I was losing my family. When the physical abuse escalated, my wife went to her parent’s house with the children. I was all alone and I started abusing alcohol.

My nights became more and more disturbed. I experienced battle events in my dreams and relived painful moments. Sometimes I could hear gunshots, artillery fire and helicopter sounds. I was trapped in reality and illusion. I had a deep loathe when I saw military vehicles and uniforms. I was afraid of going back to the battlefield. I never knew what fear was but now my body shivers even for a slightest sound like a firecracker.

My wife refused to come back then I became more depressed. I wanted to end suffering by shooting my self. Once I was on duty at the Army camp I took a weapon to take my life. A senior NCO jumped and grabbed the weapon. Then I was produced before my Office in Command. I thought I had to face charges violating military discipline. Instead of punishing me, they sent me to the Military Hospital. There I was treated and the doctors were kind enough to arrange an open interview with my family. The doctors convinced my wife to come back and finally she agreed.

With treatment, I was able to control my anger. My intrusions and nightmares diminished and gradually I became a productive person. Now for over two years, I live with my family and I do not abuse them.

I lost my voice in the height of the battle – Lance Corporal W

Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, or dissociative reaction. Psychogenic aphonia is a conversion symptom, which arises following an unconscious psychological conflict. There were many soldiers who lost their voices without any organic factors in the Eelam War. These soldiers mainly had overwhelming combat stress factors, which led to their aphonic condition. Lance Corporal W who is a known PTSD Patient described how he lost his voice in the mist of the war.

I joined the military in 1995 and faced many battle events. In 2000, I went to serve in the Pallei camp where the LTTE attacked us with mortars. I was shattered by the sound of this mortar fire. I felt profound breakdown inside my body. Every time I took cover to incoming mortars. I could feel the shockwave. I saw how our soldiers sustained injuries. I still recall one event in which a soldier succumbed to a mortar blast. His bowels came out and blood splashed all over. It was a cruel and painful death. I was always on guard for incoming mortars. When that zooooo…..noise comes I always took cover. I knew what was going to happen in next moment. Mortar comes with that sound and gives a terrible blast. If you don’t go down you would be hit by shrapnels. Although I was extra careful, I was not lucky. Once I sustained minor injuries as a result of a mortar attack. Shrapnel pierced my thigh. I was hospitalized and treated for a few days.

Pallei experience was a horrendous experience for me. I was not sure of my life and often lived in uncertain situations. However, I was lucky to be alive and returned from Pallei. Then I served in relatively a favorable environment. In 2003, I re-experienced Pallei events and I frequently had nightmares. My fellow soldiers did not like me because I used to scream at mid night with fear. Some though that I was smoking cannabis. One night when I was sleeping, I saw an incoming mortar I cried for help but there was no sound. I became speechless. . Ever since, I could not speak and I lost my voice.

(Lance Corporal W was aphonic for several weeks and underwent psychotherapy. He was treated with hypnotherapy and was able to re gain the voice. His PTSD condition lasted for a long time. Medication and CBT helped him to minimize the prevailing condition)

I had walked to the enemy lines: Private SK

“I was confused and did not know what I was doing. I had walked to the enemy lines. Luckily, a team of Special Forces saved me. When they found me, I had dropped my weapon and wondering towards the enemy lines. I don’t remember how I left my defense point or where I have dropped my T56. I was taken to the camp and produced before Col ….. I was heavily questioned. Later they blamed me for abandoning my post and losing the weapon. I was severely punished for that offence. “

(Private SK had gone in to a psychogenic fugue state following over whelming battle stress. He could not recall what really took place on that day. He served at Nadunkarni and witnessed the death of four soldiers as a result of an artillery fire. He saw how their bodies had been blown in to pieces and instantly he was shocked. After this incident, he gradually became a victim of combat related PTSD which was undiagnosed and untreated. He had dissociative features as well. Several times, he went in to fugue states and in the final event, he had walked to the enemy lines. After he was rescued Private SK was refereed to the Psychological Treatment Center at the Military Hospital Colombo. At the center, he underwent series of psychological assessments and cyber testing method to elicit autonomic arousal. He was diagnosed as having PTSD. Private SK was treated with SSRI and SPDT (Short Term Psychodynamic Therapy). With the treatment, his mental state improved)

POW s with PTSD

There are a number of POWs of the Eelam War who still carry the psychological scars. Most of them suffer from DDD Syndrome which was delineated by Farber Harlow in 1956. The DDD Syndrome consists of debility, dependency and dread. POWs often show depression, apathy suspicion and fear. Some have large memory gaps and still feel guilty about their POW days.

Lance Corporal U has served 17 years in the Sri Lanka Army. During the Balawegaya operation, he sustained a gun short injury to his leg and became immobile. When the enemy advanced, he could not move and hence he became a prisoner. When he was captured, he was severely beaten and threatened to kill. But one of the LTTE regional leaders stopped the beatings and sent him for medical treatment.

When the medical treatment was over, he had to undergo vigorous interrogations. He was tortured to get information about his Camp and its inner structure and guard points. He was handcuffed and kept in painful positions for long time. Frequently his guards physically assaulted and humiliated him. However, Lance Corporal U admits that there were some members who were kind to him and brought food sometimes.

From July 1991 to March 1995 L/Cpl U spent his life as a POW facing torture, humiliations and uncertainty. He was kept in a very small cell with forty other prisoners. They had no space to move. The prisoners were allowed to take a bath once in two weeks or sometimes longer that that. Many suffered skin infections. Their meals were not served regularly. Following the intolerable conditions, the prisoners launched a hunger strike and eventually he was released in March 1995 after the interference by the ICRC.

Although Lance Corporal U became a free man, he often suffered from an unexplainable fear. The POW days memories hounded him severely. Some nights he used to wake up with fear thinking that he is still in the LTTE prison cell. He was depressed and surrounded by guilty feelings. In order to avoid nightmares he was indulging alcohol. More he used alcohol more he became depressed. He often physically abused his spouse. Lance Corporal U began to avoid everything related to his traumatic experiences.

He was suspicious about the surroundings. He lost the ability to trust and feel intimate. He was affected by emotional anesthesia. He had flashbacks and sometimes he could not distinguish reality from fantasy. His physical strength was weakening and slightest exertion gave him an immense body pain. In 2003, he was diagnosed as having PTSD.

The Cook of the Poonareen Camp

Mr. N -a civilian worked as a cook in the Poonareen Camp. When the LTTE attacked the Poonareen camp in 1993, many lost their lives. to evade the enemy he was hiding inside the building complex and later found by the LTTE carders. He was beaten and threatened to kill on the spot. He was mistakenly identified as an officer in disguise. He was subjected to numerous physical and mental torture. Eventually the Red Cross intervened and established his correct identity.

For nearly nine and half years, he lived his life a prisoner under the LTTE. He was homesick and practically every day prayed for his freedom. For long time he lived with uncertainty without knowing what his future would be. When the Air Force attacked the LTTE camps, their guards used to ill-treat them severely. His condition significantly improved when he met another POW – Capt Boyagoda from the Sri Lanka Navy. Captain Ajith Boyagoda became a POW when his naval ship ”Sagarawardene,” was attacked by the Sea Tigers in 1994. Capt Boyagoda gave him courage and strength to face the callous conditions. Along with the other POWs, he spent the time discussing their release and writing letters home via ICRC.

He was released on the 30^th of September 2002. After his release, he gradually developed stress related physical symptoms like headaches, backaches which did not subside to painkillers. He was unable to sleep. At nights, he was awake and thinking of the past. He often felt melancholic feelings, and troubled by emotional anesthesia. He could not feel the happiness of becoming a free man. His emotions were dead. Mr. N was losing the will to live. Several times, he planned to commit suicide.

He was referred for psychological therapies and in the assessment, many somatoform features were found in him. Despite the traumatic symptoms, he positively responded to psychological and drug therapies. Gradually he was able to get away from his melancholic feelings, intrusions and psych somatic troubles. He was lucky to receive a lot of psychosocial support, even a house donated by the Ceylinco Group. Today Mr. N is very much symptoms free and living a productive life.

Combatants with Partial PTSD

According to Kulka partial PTSD is a sub diagnostic constellation of symptoms that was associated with significant impairment. They have sufficient features of re-experiencing and hyperarousal with insufficient features of avoidance and numbing and comorbid alcohol abuse or dependence.

Cpl Tx3 was a member of the Army Special Forces engaged in a number of military operations. He often worked with the long-range reconnaissance patrols (LRPP). Cpl Tx3 met with numerous hostile enemy conditions, which affected him psychologically. On one occasion, they deeply penetrated the enemy area. He was with a five-man team and they operated silently. Suddenly he met with two LTTE female carders face to face and none of them fired. Cpl Tx3 was in a dilemma situation if he had fired at the two LTTE female carders his team would have been in a great danger. Unbelievably two women despaired in the jungle. He was confused and dazed for a while and was able to return safely.

For many years, this incident stuck in his mind. He always questioned him self “why didn’t they shoot? With these intrusive thoughts, he re-experienced combat events that occurred in the North. He would give a startling reaction to any loud noise and became vigilant all the time. Despite the posttraumatic features, he was not avoiding combat situations. Therefore, the avoidance feature was not seen in Cpl Tx3. There was supportive evidence to prove that Cpl Tx3 suffered from partial PTSD.

Lance Corporal Ax4

Lance Corporal Ax4 who was diagnosed as having partial PTSD, expresses his combat experience thus.

“In 1992 I was posted to Kitz Island. My own brother served with me in the same unit and I was not comfortable with it. Therefore I requested for a transfer and I was asked to serve in Kajuwatta Mannar. While I was serving in Kajuwatta camp one day I got a message saying that my brother was killed in action at Keramalei. Although I was given leave to attain my brother’s funeral when I went home, the funeral was over. But I attained religious activities after his funeral.

When my leave was over, I had to report back to the camp. My mother was devastated over my brother’s death. When I went to say goodbye to her she asked me to stay with her. But I had to report to duty. So I left home. While I was traveling to the camp, again I got a message near Puttalam stating that I should report home immediately. My inner mind told me that some bad thing had occurred. When I went home, I met with another disaster. My mother had committed suicide. I was relentlessly shattered. I lost my brother and now my mother. This time after her funeral, I did not report to work and became AWOL. After several months, I decided report to duty and this time I was posted to a rescue mission at Poonareen. In this mission I sustained a mortar blast injury and taken to the hospital.

“After I was discharged from the hospital I participated in Rivirasa operation. We walked up to Kilinochi facing hostile enemy attacks. A lot of buddies died in front of my eyes. At Kilinochi the enemy attacked us with mortars. I sustained injuries and I was bleeding. I asked others to help me. No one came to help me and I felt fear. Then I saw a sergeant passing near me and I asked him to help me. But he left me just giving a glance. I was helpless and in pain. I gathered my entire energy and scrolled towards Elephant Pass. On the half way, a group of soldiers helped me. They put me in a cab and took me to the nearest Med Aid Point. There I lost my consciousness and when I opened my eyes I was at Anuradapura hospital.”

“I was treated several weeks at the Anuradapura hospital and then discharged. I realized that I was experiencing some distressing past events and these intrusive memories troubled me. I could not tolerate sudden noises. My mind was full of traumatic events that I experienced in the resent past. Some nights I could not sleep and I was having a severe headache. When I am with physical and emotional pain, I become restless. I am not afraid of the battle. As a soldier, I can go to the war front at any time. The war does not scare me anymore”

My commanding officer was hit in front of my eyes: Private SN

Private SN who was shattered by war stress expresses his past experience in the following manner……

At Mallakam (1995) the LTTE attacked us with RPG. I stood near my commanding officer. I fired at the enemy with my T56, killing two of them, then a mortar exploded near us. I saw my commanding officer wounded and bleeding heavily. His uniform was soaked with blood. I expected help form our buddies. When I looked at the right flank, I saw no one. I shouted for help. Then another mortar exploded near me. I too sustained injuries. Blood came from my left ear. I had no strength to help my commanding officer. While he was lying on the ground I crawled towards the rear side. I had severe guilty feelings for abandoning him on a hostile ground. But I had no option. When I was crawling, I met some of our soldiers. Then I shouted at them “the CO is wounded get him soon”

So they went to rescue him. I went further. I could not crawl anymore. I lost my energy. The world was trembling in front of my eyes. I could hear the gunfire artillery explosions and the incoming mortar sounds. My eyes were covered with a dark strip. I lost consciousness. When I opened my eyes, I was at the Palali Hospital.

I was treated at the hospital for nearly one and half months. When I was discharged from the hospital, I went back to my unit. I realized that my personality was changing little by little. I was a daring soldier. But the events at Mallakam changed my life. Day and night, my mind was full of these events. Gunfire, black smoke, incoming mortars, images of the enemies and the wounded commanding officer etc were vivid mental pictures that were ruminating inside my mind. I became more vigilant. I could not sleep at nights. I used to wake up for a slightest sound. These sounds gave me fear. When I was disturbed by a slightest sound, I felt a burning sensation in my chest.

Many nights I saw combat events that occurred at Mallakam. I used to get up in the middle of the night with fear and sweat. Gradually I became depressed and felt that my life was wasted. I wanted to commit suicide. One day when I was at the bunker alone, I tried to release the pin of a hand grenade. Then I saw the eyes of my wife. I put the grenade aside.

My world was upside down. I did not like to stay in the operational areas. I felt uneasy when I saw military uniforms and vehicles. I disliked participating in ground operations. But I had no option. I was compelled to fulfill military duties. I went with my platoon secretly suppressing my fear and avoidance. My symptoms were aggravating. I was about the explode.

Finally, I told my fears to one of my unit leaders. He listened to me for a long time and said “you need medical treatment”. So I went to the military hospital seeking salvage. I was referred to the psychiatric unit and treated for nearly three months. I received drug therapy and psychotherapy. My symptoms reduced little by little. Then I felt much easy. Today I am dong light duty. But I have not completely freed from Malakam events. Occasionally I see the twinge face of my commanding officer.

The Jonny Batta that changed a young life

Private Hx26 became a victim of an anti personnel mine in the North and underwent B/K amputation. He became shocked when his foot had blown off from the ankle and for a long period, he relived this traumatic incident. After he met with the injury, his life fell a part. The girl who promised to marry Private Hx26 left him. He could not adjust to the life with a prosthetic foot. He became more and more alienated and stopped associating people. His life was limited to a wheel chair.

Although he was recommended rehab therapy Private Hx26 did not actively participate in rehabilitation program. Once he made an unsuccessful attempt to jump to the pool at the rehab center with his wheel chair. After his attempted suicide, Private Hx26 was referred for psychological therapies and he was diagnosed with PTSD.

Private Hx26 ’s therapeutic schedule consisted of drug therapy as well as counseling. After 6 weeks of inward treatment, his suicidal ideation changed and he was gradually came to terms with his disable condition. Private Hx26 underwent further psychotherapy and finally he gave his consent to undergo the rehabilitation program with the Psychiatrist’s supervision. He selected a handicraft profession- shoemaking and successfully completed it. Two year follow-up revealed that Private Hx26 is free of PTSD symptoms.

The EPS debacle was my worst experience

The Elephant Pass debacle that occurred in 2000 due to poor leadership and inefficient strategic evacuation plan led to loss of many lives. It was a tactical withdrawal of the Elephant Pass camp but it was carried out in the hot sunny afternoon. Many soldiers died of dehydration and heat stroke. During the EPS debacle, 359 military personnel were killed, 349 were listed as Missing in Action and some 2500 were injured. Corporal K described the events that took place between the 21^st of April 2000 and 22^nd of April 2000.

On the 21 of April 2000, I was at the FDL of the Elephant Pass Camp. We were told that the evacuation order would be given at any moment. The following day at about 10.30 am, the enemy attacked the Elephant Pass camp with heave artillery. While the enemy was attacking our soldiers withdrew towards Kilali lagoon. There we met Brigadier Percy Fernando who was brave officer and he tried to re organize us and launch an attack then to go for a safe withdrawal. We assaulted the enemy and moved toward Paleii. The LTTE attacked us with mortars and their snipers targeted our offices and signalmen. I saw Brigadier Percy Fernando sustained a gun shot injury. It was a disastrous moment. Brigadier Percy was a brave soldier who did not abandon us. Some cowardly behaved senior officers saved their skin and got away leaving us to the enemy. But Brigadier Percy Fernando stayed with us and gave us leadership until the end. When he fell down, I knew that we were doomed.

We were tired and exhausted. Many of our soldiers could not walk. Hot sun and dry wind absorbed our energy. I felt thirsty but my water bottle was empty. Many of us had no sufficient water. We were walking like zombies in the hot sand. Some drank salty water from the lagoon. Some began to sing songs as they lost their minds. Many fell down with exhaustion and never got up.

While we were moving enemy attacked us with mortars. Many soldiers were dying without water and facing enemy attacks. We had to walk fast to avoid the enemy fire. There was no air cover for us. Some fainted in front of my eyes. I knew they would never return home. One solder became insane. He was singing and dancing asking for a cup of tea. Wounded soldiers asked us to carry them. But we all were worn out and had no energy to carry a fellow soldier. We were on our own and every man for himself. It was an egoistic moment that I cannot forget until my last day.

My energy was ending. I could not carry the ammunition pack. I had to throw my belongings. Finally, I threw my weapon which was my savior for a long time. I walked in the hot son with other soldiers. All I needed was water. My head was dizzy and I fell down. I saw the hot Sun. There were no clouds in the sky. Many soldiers passed me by but no one helped me. I knew if I stayed there, I would be dead soon. I gathered energy and again, I stated to crawl avoiding enemy attacks. Panicked solders trampled me and ran towards Pallei. On my way, I saw many dead bodies.

One soldier grasped my boots. He was wounded and bleeding. He pleaded me and these very words still echoes in my mind. He said I am dying and I don’t want you to carry me, then he gave his name and address and asked me to convey his death to his parents. I still cannot forget this incident. I didn’t know who he was and by the time I came to Paleii I was unconscious. I too suffered a heat stroke and later recovered. I have forgotten his name and the address. I could not convey the message to his relatives up-to-date. But I still remember his face filled with utter despair. “

The acute PTSD victim of 2005 ceasefire

Signalman Px54 met with a claymore mine explosion in Jaffna in December 2005. He sustained minor injuries to the left hand as a result of this explosion. But 13 of other soldiers died in this incident. Signalman Px54 witnessed the hurtful death of two privates and a sergeant. These events change the psychological equilibrium in Signalman Px54 and he was diagnosed with acute PTSD . This is how he describes the event that drastically changed his psyche.

“That was a horrible event indeed. We went to Jaffna town by a truck. I was in the middle and holding my weapon. Suddenly I heard a large noise. The soldiers in front of me fell down. Than I realized that, it was an enemy attack. Despite the ceasefire agreement they attacked us with claymore mines and then with small arms. When the enemy attacked, our driver sustained injuries. But he was able to keep the vehicle stable and we kept on going further. There was a large tire inside the truck then I took a cover. While I was lying down two wounded solders asked for water from me. But there was no water. We had to travel a few more kilometers to the nearest camp. Another wounded sergeant crawled near me and said something. His mouth was full of blood. Within a minute or two, he became motionless. His eyes were opened and he was dead. When the truck entered the nearest camp, I rushed to help the wounded men. Most of them were dead including two soldiers who asked for water. I felt really sorry for them. I could not help these soldiers even to give a cup of water.”

The soldier who became overwhelmed after killing the enemy

Sergeant Sx78 served nearly ten years in the operational areas exposing to heavy combat. He faced fierce battle events defending the Jaffna Fort. The Jaffna Fort was under siege and the enemy attacked them with heavy weapons. The operation “Midnight Express” was launched to rescue troops that were trapped inside the Fort. During the confrontation, he killed five of the enemy carders. After some years, he predominantly preoccupied with the thoughts that were related to these killings. Although they came to kill us, they too human beings says Sergeant Sx78.

“They were poor village boys like us who had no many options in life. They were indoctrinated, poisoned with hatred and directed to attack us. We had no alternative except firing at them. I in a war things are intense, either you or the enemy. If you don’t kill him he will kill you. Anyhow, these Tamil youths had parents like us, they too had expectations. All ended sadly. Some one in somewhere may be still missing them. I know killing is bad. It is a violation of the first Buddhist precept. I was compelled to do that act.

Sergeant Sx78 feels that one day he has to face the Karmic repercussions. His conscience was shattered and he became more religious. Sergeant Sx78 wishes to be a monk after his retirement form the Army.

The final days of the War

Lt Col ……… is an experienced field officer who participated in many operations. He shared his experiences on the final days of the Eelam War.

……….When we liberated Thoppigala I knew we were invincible. Others may have felt that. So we advanced further. The last days of Eelam War were hectic. The LTTE built a large sand walls and it was difficult to penetrate it following heavy fire. They were among the civilians creating a human shield. We had to be extra cautious not to harm civilians.

However, in a war civilian casualties are inevitable. For instance, how many civilians died in Iraq and in Afghanistan when the US forces retaliated the enemy? But I remember several events when the enemy attacked, our soldiers did not attack back due to the civilian factor. The outside world would never know about these facts.

I remember when the enemy fired from a bunker, one of our soldiers tried to attack the bunker with a Tomba gun. Another soldier stopped him saying that there were civilians near the bunker. They had to find other means to destroy the bunker without causing civilian casualties.

In another event, I saw soldiers carrying little Tamil children when the civilians broke the sand wall and came towards us. These humane stores were never told and only negative points were highlighted.

I agree, in a war atrocities are often committed and in every army you see people like William Calley who did the My Lai Massacre. I personally think that the media should comment on atrocities as well as humane stores of the war. Otherwise, there will no reconciliation at any point. After all man is not pure evil.

I have been living with the war for many years. I have seen perished soldiers, and dead LTTE carders. All these people were the children of this land. The final days of the war were traumatic. I saw human suffering. I have seen enough blood. Those who cry for war and glorify the war from Colombo should have been there. Then they would know what the war is really like.

I felt sorry for the Tamil civilians who followed a mirage. . When I first came to the North as a schoolboy at the age of 16, I was touched by the kindness of the Tamil people. The Jaffna people were cultured and educated. They had a great civilization that cherished with non-violence. When the conflict erupted in early Seventies, things changed drastically. Then I had to come to the North in a combat fatigue.

Tamil people in the North paid an immense price for the war. Their property were destroyed, children were forcibly recruited. They faced deaths and destruction. They lived under poverty. What happened to the millions of dollars that pumped by the NGO s and by the Tamil Diaspora to the North? The people of Wanni had no infrastructure, people were malnourished. If this money was used to develop the North, they could have built a little Singapore.

I am glad that the war is over. We must rebuild the North and work for the ethnic harmony. We must forget our petty racial differences and work for peace with our Tamil brothers. Otherwise, within 20 years there will be another bloody war…………

Conclusion

Many people in Sri Lanka still debate about who should be given credit for ending the war. Is it to MR, or to SF or to Gota? No doubt that all these persons gave their utmost support to end the war. But without the dedication, sacrifice, sweat and the blood of the combatants, it could not have been achieved. Therefore, the Nation has a moral responsibility to look after the wellbeing of the soldiers who fought in the Eelam War.

(LankaWeb)

US soldiers in Iraq can find stress deadlier than enemy

In the early hours of September 14, US sergeant Joseph Bozicevich allegedly drew his rifle, aimed and shot to death two of his superiors on a military base south of the Iraqi capital.

According to several US media reports, Bozicevich, 39, allegedly killed staff sergeant Darris Dawson 24, and sergeant Wesley Durbin 26, because he could not bear being berated by them.

A US military statement said that “a US soldier is in custody in connection with the shooting deaths. He’s being held in custody pending review by a military magistrate.”

Dawson’s step-mother Maxine Mathis later told newspaper in Pensacola in Florida that before the shooting he had complained to her and spoken of the impact the Iraq war was having on many young soldiers.

“Momma, I’m not so afraid of the enemy. I’m afraid of our young guys over there, because they’re so jumpy and quick to shoot,” Mathis quoted Dawson as saying.

Trauma, stress, fatigue, depression and tensions linked to family problems are taking their toll on US soldiers deployed in Iraq and are often more threatening than the Islamist insurgents they are expected to fight.

“We know that the stress of war, which includes repeated and long deployments, is having an effect on our soldiers and their families,” said Colonel Elspeth Cameron-Ritchie, a military psychiatrist based at US army medical command in Fort Detrick, located at Frederick, Maryland.

The wars in Iraq and Afghanistan have increased the number of US soldiers suffering Post-Traumatic Stress Disorder (PTSD), leading to higher rates of suicides and divorce, according to military reports.

Nearly a fifth of American soldiers deployed in Iraq suffer PTSD, according to the US military’s battlemind.army.mil website.

The cases of PTSD increased by almost 50 percent in 2007 among American soldiers who served in Iraq and Afghanistan, the US military said.

For Cameron-Ritchie “PTSD has gone up as the length of deployment has gone up, so we reported that to our leadership who has been able to reduce the length of deployment.”

The Bush administration has cut down the duration of deployment from 15 months at the start of 2007 to 12 months.

At the same time experts are examining ways of dealing with PTSD.

“We have a lot of programmes and strategies in place to minimise the effect of war. We made a commitment to raise the number of psychiatrists, social and mental health workers,” Cameron-Ritchie told AFP by telephone from her US headquarters.

An increase in the levels of divorce and suicide among soldiers are among the key concerns of the military.

A military report on the mental health of soldiers in Iraq and Afghanistan issued in May 2008 notes that “the suicide rate remains high on both theatres, higher than the normal rate in the army.”

The divorce rate in the US army at large rose from 2.3 percent in 2001 to 3.5 percent in 2008, according to military figures.

“Nearly 20 percent of soldiers deployed in Iraq say they have concerns or experience marital problems,” according www.battlemind.army.mil.

Specialist Shawn Woodward is among those whose marriage has collapsed.

“I’m going back to Massachusetts, to get a divorce, go back to college, start a new life,” Woodward said at the Speicher base north of Baghdad.

“There are many, many in this situation in the army. Deployments brings lots of stress on families.”

Of the nearly 4,490 US soldiers killed in Operation Freedom — in and outside Iraq — 862, or 19 percent were not killed by enemy fire, according to the independent website icasualties.com.

It did not specify if they were died due to accidents, illness, suicide or friendly fire.

Some killings of Iraqi detainees by US soldiers have also been linked to PTSD such as the murder in May of Ali Mansur Mohammed who was first shot to death and then his face badly burnt by an incendiary device.

First Lieutenant Michael Behenna and Staff Sergeant Hal Warner have been both accused of premeditated murder, assault, making a false official statement and obstruction of justice in connection with Mohammed’s killing.

The pair faced pre-trial hearings separately in September and now await a decision of whether they will face a court martial for murder.

US soldiers have alleged in testimonies that Mohammed was killed to avenge two men who were killed in an attack a month earlier.

“I didn’t know what to do. I was afraid, like you are afraid when you don’t control part of the situation,” one of Behenna’s deputies, Sergeant Milton Sanchez said.

A US officer, speaking on condition of anonymity, told AFP the case was “pretty clear.”

“It’s a classic PTSD that came after the bomb attack,” the officer said.

“The soldiers have so much stress and responsibilities, and they are so young, sometimes it just pops up.”

(AFP)

Preparing for the Next Crisis: When the Troops Come Home by Stephen Long

I sincerely hope the Government of Sri Lanka is looking past the destruction of the LTTE to the day when the troops finally come home. This will be a joyous time of celebration, no doubt, but it will also be a time of crisis: what are you going to do with the excess force in the military? You will reduce the size of your army, of course, but what are you going to do with the men and women who served you so valiantly and rid your country of terrorists?

This is a problem faced by all nations who find themselves in similar situations after the war is over. Julius Caesar faced it. In the last century America faced it four times, and is facing it again with the returning Iraqi war veterans. In the case of America, they botched it badly after Vietnam, and they are botching it again with Middle East returnees. Here in Los Angeles it is heartbreaking to go Downtown to the skid row area around 5th and Maple Streets and see the large numbers of homeless and drug-addicted men and women – many of whom were heroes in both Vietnam and in Iraq/Afghanistan.

I am well aware that the Government’s complete attention is on winning the war, as it should be. Victory over the terrorists is so close, and it needs to be the primary focus of the moment. But governing a country means looking beyond the immediate to the future – at least five years ahead, if possible. You’re probably going to have 100,000 troops returning to Colombo and the rural areas, and a huge percentage of them will be unemployed, maimed, traumatized, and maybe all three.

I would suggest immediately forming a task force that would examine this looming situation before it becomes a crisis. The finest minds in the country need to focus on creating jobs for these soldiers, planning for their rehabilitation, training counselors to deal with their trauma, and establishing programs that will help them re-enter the society for which they fought so bravely.

This is not an easy job, but it is imperative that the issue be addressed now – before the last battle bullet is fired and the final battle is won. The last thing you want is an angry mob of dissatisfied veterans protesting that the Government has nothing to offer them for their valiant service. Caesar was deathly afraid by the specter of his soldiers returning to Rome and staging a revolt. Such a possibility in Sri Lanka is not outside the realm of possibility if plans aren’t put into the works immediately. Imagine the morale-builder it will be for the troops if they know that their Government is thinking of their future – now. This will give them the will to fight harder and stronger for the peace that is just around the corner.

My second suggestion is to examine a very interesting phase of American history. When the stock market crashed in 1929 the bottom fell out of an era of party and prosperity. The then president, Herbert Hoover, did nothing to avert a crisis over the deep unemployment that ensued. He didn’t think the government should get involved in helping out during an economic crisis.

When one of my political heroes, Franklin Delano Roosevelt, stepped into the White House in 1932 he saw the potential disasters that could result due to the legions of unemployed. After all, the Russian Revolution wasn’t that long before, and it was still fresh in his memory. The possibility of revolution sent chills of angst through his gifted mind.

Roosevelt’s admirable solution was to create the New Deal, which was a large, powerful, and effective bundle of social programs designed to keep the unemployed working – and to use the down-cycle of Depression as an opportunity to build and strengthen America’s infrastructure. With the exception of Social Security, the Federal Housing Authority, and the TVA most of the New Deal organizations had a shelf life limited to the time of economic recovery, and were disbanded when no longer needed.

Here are a few successful examples of New Deal programs that the Government of Sri Lanka may want to examine for possible implementation in the motherland.

o The Civilian Conservation Corps (CCC) was established in 1933 in every state and territory in the US. This organization was made up of the sons of unemployed fathers – victims of the Depression. At its peak in 1935 it had 500,000 employees in 2,650 work camps. It provided labor for a wide variety of Government Agencies including: Department of Interior, Department of Agriculture, Army Corps of Engineers, National Parks Service, Bureau of Forestry, Soil Conservation Service, General Land Office, and others. Employees of the CCC put up telephone and power lines, built logging and fire roads, engaged in tree planting, bee keeping, archaeological excavation and even furniture manufacture. Evening classes were held in most camps, and courses were offered in general academics as well as vocational training. Congress ceased funding it in 1942 when it needed all those boys to fight in World War II.

o The Federal Housing Administration (FHA) was created to combat the housing crisis of the Great Depression. The FHA was designed to regulate mortgages and housing conditions, and still exists to this day.

o The Home Owner’s Loan Association was established in 1933 to assist in the refinancing of homes. Between 1933 and 1935 over one million homeowners were saved from foreclosure by this program.

o The Public Works Administration was another department set up to create jobs during the Great Depression.

o The Social Security Act was passed to protect America’s senior citizens from poverty.

o The Works Progress Administration (WPA) was created in 1935 and had a positive impact on the entire country. The WPA built roads, buildings, and other massive infrastructure projects. It officially ended in 1943 after keeping millions of men and women at work throughout America until they were needed for the war effort.

o The Tennessee Valley Authority (TVA) built dams for hydro-electric power and created lakes and parks for recreational use. Today the TVA still supplies more electricity than any other hydro company in the United States – keeping the growing Southeast in lights.

In addition to examining New Deal programs the Government of Sri Lanka should also consider the following:

o Worldwide Nursing Shortage. Men and women in Sri Lanka could be trained as nurses and medical assistants for the growing demand in America, Japan, Europe and other regions where the aging population has created a huge shortage of skilled personnel in this field. The compassionate, caring nature of Sri Lankans could be put to good use. Male and female returning soldiers would be perfect candidates for these important jobs.

o UN Peacekeeping Efforts. Skilled Sri Lankan soldiers could be sent by the UN to peacekeeping fronts in Africa, the Middle East, Eastern Europe, and other areas where they are sorely needed and where they could put their high-level skills in warfare to excellent use.

o Middle East Labor. Unskilled labor is sent by Sri Lanka, Indonesia, Philippines, Thailand and other countries to the Middle East, which currently has an insatiable need for humans due to high economic growth rates and an enormous construction boom. Sri Lankans go abroad with no training whatsoever, which puts them at risk for employee abuse, neglect, rape, and other violations of their human rights. Domestic servants don’t even know how to clean house or answer the telephone, which makes their employers angry. We don’t want to hear any more stories of cruelty – like sending maids to the desert to tend goats. Pre-emigration training programs would be a great help to assist these unfortunates who find the need to leave their home country to survive. Our last wish would be for returning soldiers to spend their lives as construction laborers and domestics in the Mid East, but if they decide to go abroad, please prepare them appropriately for their work.

o Other Labor Shortages. Look abroad and find out what other skilled labor shortages exist in the world, and set up training programs accordingly.

o Overseas Investment. Identify industries and specific companies from abroad that could be attracted to Sri Lanka to build factories and take advantage of the countries abundance of both skilled and unskilled labor.

The think tank I am suggesting could develop a number of projects that would benefit returning troops as well as Sri Lanka, but there is an urgent need to act quickly. No one would want to hear about the soldiers on the front prolonging the war for fear of losing their jobs due to peace. Let them know you are planning for their return, and announce projects now that would give them an incentive to fight harder and end the conflict sooner. Give them the good word that their Government is going to provide for them with employment opportunities, and chances to better their lives after the war.

Programs in the New Deal cost American taxpayers a lot of money at a time when they could least afford it. The Government of Sri Lanka will have to be creative and figure out how they will get their similar programs financed. In spite of the global economic crisis funds are still available overseas for assistance from both private and public sources. Get your new programs designed and written up now so you can apply for quick funding. It takes time for governments in the United States, Japan, Korea, and others to get them through the bureaucratic red tape and approved. Let’s not forget our NGO and INGO friends and hold them to their peace-loving word. Let them go to work on new projects that involve the returning soldiers for the country’s benefit. When the war is over and they’re back on the side of the Government, give these organizations a good reason for staying in Sri Lanka.

You have to act now to bring these ideas “down to the ground” and make them a reality. Think smart and stave off a potential disaster. You owe it to your men and women of the armed services to reward them for putting their lives at risk for their country. Welcome them home with honor and hope for the future.

(Asian Tribune)

The Mental Health Issues of the Sri Lankan War Widows By Dr Ruwan M Jayatunge

If men were the principle casualties of the War, these widows represent its collateral damage.- Ed Payne: “Collateral Damage

One harsh reality of the war is that the every soldier killed in war leaves behind grieving relatives. It has been a reality since the Trojan War.

The women who were left widows as a result of the Sri Lankan conflict are facing radically altered circumstances. There are estimated thousands of War widows and war-affected family members from the Tri Forces who still experience grief reactions. Many widows are in the 22 to 35 age group and with the death of their husbands; these women have become a psychologically and socially vulnerable group. Most of the women who underwent severe emotional pain still have not completely recovered. Many have become the victims of pathological grief. They are unable to work through their grief despite the passage of time. With the widowhood, they experience identity change, role adjustment and change in social status.

Many researches concur that the mental trauma of the war widows can last for long years. Julie E. Byles of the University of Newcastle Australia developed and evaluated a brief measure of depression for use within a population of older Australian war veterans and war widows. Derived from the Geriatric Depression Scale (GDS), the 12-item GDS-Veterans is designed to include items that most closely represent the thoughts and feelings of older veterans in relation to their war experiences. The scale was administered to 1,620 veterans and widows concurrent with the 36-item Medical Outcomes Study Short Form (MOS SF-36) quality of life measure. Of those surveyed, 13.5% indicated that they often or always worry about things that happened during the war, indicating that this item tapped an important dimension for many of the veteran population.

Depressive reactions are common among the Sri Lanka war widows. In 2005, 86 Sri Lankan war widows were clinically interviewed based on Beck’s depression scale and depression was diagnosed in 23. Ten war widows said that they had contemplated suicide after they lost their husbands. (Psychological Management of Combat Stress – A Study Based on Sri. Lankan Combatants. Ruwan M. Jayatunge)

The war widows of the other conflictive areas in the globe are facing similar consequences. The conflict in Iraq had recorded high numbers of war widows. The Iraqi war has made widows of an estimated 740,000 women and left many others fatherless ( Olga Ghazaryan, Oxfam’s regional director for the Middle East) After 1991, many Iraqi war widows became sole wage earners, often going hungry to feed their children; possibly 60% suffered from psychological problems, with physical manifestations such as weight loss and difficulty breast-feeding (Hoskins, 1997).

Death of a close family member is a highly stressful event. According to Homes and Rahie stress scale the loss of a family member carries the highest stress level. In the psychological context, a traumatic experience like sudden death of a relative can cause long lasting negative effects.

In the conservative Asian societies, widows face social, economic and legal handicaps. Widow as its name denotes associated with some form of socio-cultural stigma and humiliation. They are considered as bad omen in many Sri Lankan rural areas. They are marginalized by their own communities. These factors affect their self-esteem. In some events, the accusations were made by the in laws stating that the husband’s death occurred because of the unluckiness of the wife and they are partially answerable for the husband’s death. They experience lack of social support and loss of their social possession in their own family circles.

The war widows face a number of mental health problems. They have suffered bereavement as a result of the violent deaths of their husbands and these traumatic memories hound them for long years. They are often subjected to extreme forms of discrimination and physical, sexual, and mental abuse. Therefore, widowhood represents a form of “social death” for these women. Their plight and vulnerability lead to numerous psychological ailments.

Many of the widows carry the memories of their late husbands. They are emotionally troubled by the loss and grief. In the overall view the large percentage of women are having following psychological features.

1- intrusive memories about their dead husbands
2- fear and uncertainty about the future
3- self pity
4- low self esteem
5- sleep disturbances
6- irritability
7- displacement of anger
8- emotional numbing
9- feelings of guilt for being happy

10- Psycho physiological reactions such as persistent headaches, backaches, without any medical basis and these symptoms do not respond to painkillers.

Many Sri Lankan widows have a tendency to experience and communicate psychological distress in the form of physical symptoms. Some have multiple unexplained somatic symptoms. Most often, the complaints involve chronic pain and problems with the digestive system, nervous system, and reproductive system. These young war widows who have suppressed their biological needs following the cultural pressure and family honor often-manifest conversion reactions.

People who experience severe symptoms of separation distress also tend to suffer from certain symptoms of traumatic distress. Psychiatric comorbidity or the presence of multiple disorders is common following bereavement. In 1997, a series of studies of independent samples of bereaved people and found that elements of separation distress and traumatic distress form a single cluster, and that this cluster is distinct from depressive and anxiety symptom clusters.

In a study by Gabriel Silverman and colleagues (2000), traumatic grief, PTSD, and major depressive episode were found to overlap with each other to similar degrees. Of those with traumatic grief, 47 percent also received a diagnosis of major depressive episode, 33 percent met criteria for PTSD, and 40 percent had traumatic grief.

As described by Prigerson (Prigerson H.G. Complicated grief: when the path of adjustment leads to a dead end. Bereavement Care 2004) individuals who meet the diagnostic criteria for prolonged grief disorder have been shown to be at an increased risk of developing clinically distinct posttraumatic stress disorder, generalized anxiety disorder, major depressive disorder as well as suicidal ideation.

Bereavement is the reaction to the loss of a close relationship. Bereavement is defined as a state of sadness or loneliness. Sometimes these reactions are prolonged and affect the women who have lost their husbands. The violence of war does not end with the return to peace for those living closest to former combatants. Following is the experience of a war widow whose husband died in the operation Jayasikuru in 1997.

When I heard the death of my husband, my entire world collapsed. He was a Lance Cpl in the Army and we were living in his house with his mother and two unmarred sisters.

I still have a fragmented memory of the funeral. Some events I cannot remember. My three-year daughter who had no clue about father’s death asked various questions. I did not know what would happen to the daughter and me after my husband’s death.

After several months, my mother in law and husband’s two sisters started passing negative comments. They blamed me for his death. They implied that I was unlucky and since I came to their house, the things changed negatively. Even the neighbors avoided me.

I had to go to Panagoda the Army pay and pension branch to get my dead husbands’ pension. They said he was a volunteer and it would take some time and gave me papers to fill up. I had no idea how to do the paper work. I asked my cousin brother to help me. The day I went to his house with the daughter to get the paper work done my mother in law came up with false accusations and blamed me for seeing men soon after the husband’s death. She humiliated me and demanded

the full pension of my husband saying that I have no financial rights.

I had no place to go and my parents died when I was small. My relative had no financial ability to look after me and my daughter. Therefore, I had no other option living with the husband’s relatives facing humiliations every day. When I received my husband’s pension, my mother in law took it. We were given only food.

Every month I had to go to the Grama Niladari to confirm that I am still a widow and not remarried. When I went to get sign, the document he used to pass inappropriate jocks and once tried to touch my hand. I scolded him and left the office. Ever since, he delayed signing my papers.

I became depressed and when the daughter went to sleep, I cried alone. If not for her, I would have committed suicide ending this suffering. My mind preoccupied with the events of my husband’s funeral. I had the mental pictures of the coffin, his dead body, ceremonial uniform, and many more things. I had mental pictures of these miserable events. Constantly I had fear feelings and uncertainty of future. My memory started fading and I could not concentrate. Gradually I have become a living dead………….

Mrs AT87 had been married only for seven months when her husband became MIA (missing in action). This is her story.

……..When my husband went missing in action, I was 30 years old. We had been married for seven months. As a young widow, I had to face the challenges of life. I waited for him many years but he did not return. Every day was a painful anticipatory day for me. I went to many army camps, to the ICRC and even went to the North during the ceasefire era in search of my husband. There was no news about him. My relatives urged me to marry again but I refused. I still cannot believe that he is dead. I hope one day he would come back…..

Mrs. HK34 faced severe hardships with the death of her husband who was a full corporal in the Army. She was driven out from the husband’s family accusing that she was unlucky. She was living in a small house with her four years old son. Her neighbor – a middle-aged man tried to help her with different motives in his mind. When his intentions were reveled Mrs. HK34 did not speak to him and avoided him. Then he started spreading malicious rumors about her in the village. The villagers especially the women humiliated her publicly. Some nights stones were thrown to her house. As Mrs. HK34 believed, her neighbor was behind all these mock incidents. When the troubles intensified, she decided to leave the village but she had no place to go.

The conflict in Sri Lanka has generated a large number of war widows in the North and East. Widows in the North and East province totaled 49 612 in March 2002, and female-headed households numbered 19787 in the five NEP districts in 2000. (Sri Lanka NEP, 2003). Many women are living in abject poverty and despair.

The mental health consequences of war: gender specific issues described by Marianne C Kastrupi thus,

Many women may in war be faced with the main responsibility for care giving in the family, with the destiny of their husbands unknown and new and unfamiliar duties placed on them. If the household is facing disaster, this may overload women’s capacity to cope; as preoccupation with the needs of the family may lead to that they are not able to consider their own needs, especially if they become widows. Mental health consequences of war: gender specific issues. (Marianne C Kastrupi – Transcultural Psychiatry Centre, Psychiatric Department, Copenhagen, Denmark)

The late Air Chief Marshall Harry Goonetilleke conducted a valuable psychosocial assisting project for the war widows of Sri Lanka under the Ranaviru Family Counselling Association. This project helped the war widows to reconstruct their lives and gain confidence. He believed that there should be a permanent rehabilitation policy for the war widows at the national-level. Until his death in 2008, Air Chief Marshall Harry Goonetilleke actively engaged in the rehabilitation work of the Sri Lankan war widows.
Mrs. KL342 was able to face her destiny with courage and determination after her husband’s premature death that occurred in the Eelam war.

…………. When I heard the terrible news of my husband’s death in the war front, I was utterly devastated. For many months, I was in a denial stage and could not believe that he would never come back. Somehow, I had to gather strength for the sake of my two little children. I knew that being a widow in a deeply conservative society is not easy. But I had no alternative and with courage I faced the consequences.

Ranaviru Family Counselling Association offered me strength and guidance. At the meetings, I saw women like me who were struggling to survive. I learned new skills and started to work in an income-generating project. While working and attending my children’s work my emotional trauma reduced. But the deep sorrow was always with me. I had to be the sole breadwinner of the family; I had to be responsible for my children. I was determined to live a life with dignity.

During the cease-fire in 2002, a group of war widows from the North visited us. Their husbands were LTTE carders who died in the battle. When I saw them, I had angry feelings. I thought for a while probably one of the husbands of these women had killed my husband. My heart stated beating rapidly. I saw they were looking at us. Simultaneously I thought they would be having the same feelings about us. That moment I realized that anger and hatred offer nothing but destruction. My anger dropped to the zero level. We welcomed them, the women from the opposite side but who share the same grief as us. We all are victims of the war no matter of racial differences. After all our teats and suffering had no ethnic difference. We spoke with these women and exchanged ideas. Soon we became friends. We cried together for the memories of our dead husbands who left us so unexpectedly. At the end of the day, we parted like sisters. Some of these women still write to me and we are good friends…….

Mrs. GF54 lost her sense of purpose in life when she underwent a pathological grief reaction following her husband’s death in 2001 during the Operation ‘Agni Kheela’. She was extremely focused on the loss and reminders of her husband, problems accepting the death, preoccupation with sorrow, inability to enjoy and moving on with life, trouble carrying out normal routines, withdrawing from social activities. She was treated with medication and EMDR, which gave optimum results. Today Mrs. GF54 s rationally facing her life. She is self employed and building a house for her and for the children.

Professor Rachel Tribe and Padmal De Silva (Senior Lecturer in Psychology at the Institute of Psychiatry, University of London) in their research paper – Psychological intervention with displaced widows in Sri Lanka highlight the importance of integrating coping strategies self-help principles changing perceptions, attitudes and stereotyped beliefs when improving mental health issues of the Sri Lankan women who widowed following extreme traumatic events. As they recommend the cultural and socio-political issues should be taken in to consideration.

As a matter of fact a very few governments and non-government organizations view widows as a special category with individual problems and special status. Therefore, war widows are marginalized in many communities around the world.

The higher levels of stress and mental illness among women, common in many post conflict societies, may be even higher in Sri Lanka due to the prolonged war. The war widows carry extra burden than the average women in the Sri Lankan society. Apart from their traumatic experience, daily stressors such as poverty, family conflict, health problems, unemployment, social isolation and harassments exert a significant effect on their stress levels. Some widows take care not only of their children but often of their extended family as well.

The mental health interventions of the war widows should be followed with the specific cultural contexts and not contradicting religious believes of the victims. The war widows need strength-based psychosocial interventions. Welfare and rehabilitation of widows are essential with teaching coping strategies, facilitating education and job training for the socially shunned widows. The measures are needed to help women to transform their new skills into financial independence and sustainability and strengthen women’s existing skills and to introduce new skills in traditional and non-traditional fields.

There must be a permanent rehabilitation policy for the war widows at the national-level that helps widows to build a new life regain confidence and gently adjust to a new life. The children of these war widows should have a secure and dignified future as their fathers always expected. It is the duty of the Nation to repay their dues to these families who have become the invisible victims of the Eelam war.

( Sri Lanka Guardian)

Combat related PTSD in Sri Lanka by Dr. Ruwan M Jayatunge M.D.

Psychological and Sociological Aspects

Sri Lankan society is shattered by hate and brutalization as a result of the 20 year conflict. Combatants as well as a large numbers of civilians including members of the LTTE have undergone a tremendous amount of stress for the last two decades. There hve been large military operations where the combatants were directly exposed to hostile conditions. Exposure to extreme stress is unavoidable in combat. Some were physically as well as psychologically wounded. The shock wave of combat echoes the Sri Lankan society. The war trauma has been sublimated in to the society. Attention must be paid to the psychosocial scars of the war.

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 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. 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.

To meet DSM-IV criteria for PTSD, the soldier must have been exposed to an “extreme” stressor, and the soldier’s response to that stressor must include a specific number of symptoms from each of three broad categories: re-experiencing, avoidance/numbing, and increased arousal.

Human response to trauma is universal but the cultural context of the trauma is an imperative dimension. The meaning of trauma is often culturally specific. Cultural factors may also influence the manner in which PTSD symptoms are manifested. Therefore culture based assessment had to be introduced. In addition, the specifications of the Sri Lankan conflict were taken in to considerations. These specifications were prolonged exposure, lack of psychological first aid soon after the combat, the usage of traditional healing methods, the impact of religion and social support systems etc.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 post traumatic Stress Disorder. This disorder can develop in individuals without any predisposing conditions, particularly if the stressor is especially extreme

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 I paternal deprivation) or subjected to childhood trauma. Their psychological makeup has 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. In addition two insurrections occurred in the South that crippled the nation. The first youth unrest in 1971 caused direct clashes with the military and police. The results were traumatic. More than 18,000 youth from the South were killed. 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 second uprising took place in 1987 and continued until 1988. In 1987 a group known as the Patriotic Liberation Organization emerged. They forced service personnel to give up their jobs by issuing death threats. Some soldiers and their family members were massacred by the Patriotic Liberation Organization and soon the military defended themselves with arresting suspected youth. Some got killed. During this social turmoil a considerable amount of soldiers became psychologically affected by committing and witnessing atrocities.

Combatants suffering from combat stress easily go in to negative stress coping methods like alcohol abuse and violence. Alcohol and substance abuse is evident among the combatants suffering from war trauma. Those veterans who experienced prolonged exposure to heavy combat are especially vulnerable. Soldiers abuse substances such as drugs, alcohol, and tobacco for varied and complicated reasons When we interviewed 56 combatants with full blown symptoms of PTSD we found five (8.9%) of them are severely addicted to alcohol. They were found positive with alcohol related symptoms and their liver function tests were affected. They consumed large amounts of alcohol in order to avoid sleep disturbances and eliminate scary nightmares. The heavy drinking may also seem to relieve anxiety and block out intrusive memories associated with combat events. But the truth is excessive drinking can disturb the natural sleep process, interrupting REM dream patterns; the veteran may become more vulnerable to the symptoms of PTSD.

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 wives. Many combatants sublimate their rage. Domestic violence is a form of sublimation and transformation of anger.

Out of 56 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. 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.

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 defences 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.

Most of the combatants with PTSD have psycho somatic ailments that prevent them from strenuous work. They easily get tired. Following fatigability their can not fulfill duties like good old days. This phenomenon was described in the Old Sergeant’s Syndrome where brave and physically strong men became frightened and weak soldiers.

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)

For treatment procedures of combat related PTSD in Sri Lanka medications and psychotherapy are used. Therapeutic relationship with the patients is the often the foundation of effective treatment. Therefore therapists maintain good rapport with the patients. Drug therapy is an essential component of PTSD treatment. Serotonin Reuptake Inhibiters like fluoxatine! paroxatine are often used. These drugs provide symptomatic relief
CBT or Cognitive Behaviour Therapy plays a key role. CBT is an approach that focuses on improving mood by modifying dysfunctional thinking and behaviour. CT for PTSD typically begins with an introduction of how thoughts affect emotions and behaviour. Early treatment, new skills to identify and clarify patterns of thinking are taught using techniques such as recording thoughts about significant events, identifying distressing trauma-related thoughts, and converting such dysfunctional thought patterns into more accurate thoughts.

The recent studies lend empirical support for the use of cognitive-behavioral therapy (CBT) and EMDR in treating combatants with PTSD. EMDR or Eye Movement Desensitization and Reprocessing is a psychotherapy treatment that was originally designed to alleviate the distress associated with traumatic memories (Shapiro, 1989a; 1989b).EMDR facilitates the accessing and processing of traumatic memories to bring these to an adaptive resolution (Shapiro, 2001). EMDR is considered to be an effective treatment for PTSD and Sri Lankan combat veterans (uncontrolled study; 18 males) showed significant improvements from pre- to post treatment following EMDR.

Group therapy deals with “isolation, alienation, and diminished feelings Also it helps the survivor” feelings in participants. In group settings the combatants are able to discuss their pent up feelings and able to realize that they are not isolated and that others have similar experiences and problems.

(Daily Mirror)

Blinded by war: Injuries send troops into darkness By Gregg Zoroya

Two days before a 10-mile race here, Army 1st Lt. Ivan Castro is explaining how he will run tethered to another soldier — one who can see.

As he speaks, his wife lovingly extends her right hand to Castro’s face, fingers outstretched. But Evelyn Galvis pauses inches away.

“I used to be able to reach out and touch him, caress him, without telling him first, ‘I’m going to touch your face,’ ” she says. Now, “if I just reach out and touch him, he’ll startle.”

Castro, 40, a paratrooper with the 82nd Airborne Division, is one of more than 1,100 veterans of Iraq and Afghanistan — 13% of all seriously wounded casualties — to undergo surgery for damaged eyes. That is the highest percentage for eye wounds in any major conflict dating to World War I, according to research published in the Survey of Ophthalmology.

It’s a reflection of how eye injuries have become one of the most devastating consequences of a war in which roadside bombs, mortars and grenades are the most commonly used weapons against U.S. troops. Brain injuries and amputations have long been the focus of the damage such weapons are inflicting, but the Army has acknowledged in recent weeks that serious eye wounds have accumulated at almost twice the rate as wounds requiring amputations.

Body armor that protects vital organs and the skull is saving lives. But troops’ eyes and limbs remain particularly vulnerable to the blizzard of shrapnel from such explosions.

Each explosion unleashes large metal shards and thousands of fragments, says Army Col. Robert Mazzoli, an ophthalmological consultant to the Army surgeon general. “Those small missiles are generally innocuous if they hit the (protected) forehead, face (or) chest but are devastating when they hit the eye,” he says.

Surgical facilities are kept close to the fighting, so troops can be treated in minutes. Partial or total vision has been restored in most cases involving eye injuries, military statistics show. But hundreds of troops have been left with impaired vision, and dozens have been blinded.

Troops in Iraq routinely wear protective eyewear, but it doesn’t always work. When a roadside bomb in Baghdad blew a hole through the heavily armored vehicle carrying Army Sgt. Luis Martinez last April, the force from the blast stripped off his helmet, headset and goggles. After the dust settled, Martinez, 38, could see nothing out of his left eye and only streaks of blood in his right. He waited for help, terrified about the damage to his eyes.

“That was the first thing I asked” hospital personnel, the National Guard soldier recalls. ” ‘Am I going to be blind?’ “

Surgeons later restored vision to his right eye, although bits of glass are embedded there. He remains blind in his left.

“At least God was kind enough to protect me, to keep my right eye and see my family,” says Martinez, of Vega Alta, Puerto Rico, who is married and the father of three.

Formidable challenges await troops who return home blind or with serious eye injuries. In the most severe cases, they will struggle to cope emotionally and financially.

About 70% of all sensory perception is through vision, says R. Cameron VanRoekel, an Army major and staff optometrist at Walter Reed Army Medical Center in Washington. As a result, the families of visually impaired soldiers wrestle with a contradiction: The wounded often have hard-driving personalities that have helped them succeed in the military. Now dependent on others, they find it difficult to accept help.

Because the Pentagon has no rehabilitation services for the blind, the path to recovery often leads directly to the Department of Veterans Affairs. The VA operates 10 centers across the country for blind rehabilitation that teach visually impaired veterans how to function in society. The centers have 241 beds, and it takes an average of nearly three months to get in. Iraq and Afghanistan casualties go to the front of the line, says Stan Poel, VA director of rehabilitation services for the blind. So far, 53 have enrolled in the blind rehabilitation programs, the VA says.

The department plans to open three more centers beginning in 2010, Poel says.

‘He has no light in his life’

Even now, more than a year after her husband’s return from Iraq, Connie Acosta is taken aback to find her home dark after sunset, the lights off as if no one is there.

Then she finds him — sitting in a recliner in their Santa Fe Springs, Calif., house, listening to classic rock. Sgt. Maj. Jesse Acosta was blinded in a mortar attack 22 months ago. He doesn’t need the lights.

That realization often makes Connie cry. “You kind of never get used to the fact that he really can’t see,” she says. “He has no light in his life at all.”

The tiny piece of shrapnel that blinded Acosta, 50, an Army reservist, father of four and grandfather of three, was precise in its destruction.

On the morning of Jan. 16 last year, Acosta led soldiers on a 3-mile fitness run across Camp Anaconda in Balad, Iraq. Suddenly, insurgents attacked the camp with mortars.

Acosta remembers that he stopped, turned to yell at his soldiers and then dived for cover.

“Bam! That was it,” he recalls. “Lights out.”

An explosion about 60 feet away sent a piece of shrapnel — perhaps three-quarters of an inch long — through his left eye. It struck his brain and came out his right eye.

“It was a perfect hit,” Acosta says.

Rushed to the Air Force Hospital at Anaconda, he spent seven hours in surgery. Army Maj. Raymond Cho, an ophthalmologist, removed Acosta’s right eye and carefully reassembled his left one.

“I didn’t want him waking up missing both eyes and wondering for the rest of his life, ‘Gosh, could they have saved at least one?’ ” Cho says. “So he knows that we did everything we could.”

Acosta regained consciousness as he was being returned to the USA. In Germany, a doctor told him that his right eye was gone and his left eye, although stitched together, likely would never see light.

“He said, ‘You’re going to have to start a whole new life from here on,’ ” Acosta recalls.

“I go, ‘So I won’t be able to see my kids? My grandkids? Nobody? I won’t be able to see blue skies?’

“He said, ‘Nope.’

“I just sat there. What could I do?

“A lot of things went through my mind,” Acosta says. “Am I going to be accepted this way? Am I going to be rejected? I was pretty independent all my life, and I did everything. So it was pretty tough.”

VA plans more clinics

Pentagon doctors can rebuild eyes, reconstruct eye sockets and nurse casualties back to health, but soldiers with serious vision problems who want to learn how to adapt into civilian life must rely on VA centers that also serve the elderly and other veterans.

The VA plans to invest $40 million this fiscal year to create 55 outpatient clinics across the nation, providing rehabilitation for veterans learning to cope with partial vision, says James Orcutt, the VA’s director for ophthalmology.

The department also is taking part in two clinical trials focusing on artificial vision, says Ronald Schuchard, director of the Atlanta VA rehabilitation research and development center. The trials involve implanting silicon chips in eyes. The chips act as receptors that can transform light into electrical signals that can be transmitted to the brain. It is cutting-edge research, Schuchard says.

However, Orcutt says, “I think we’re a long way from a practical use of some of these.”

At the VA’s rehab centers for the blind, specialists teach orientation and mobility skills. Visually impaired veterans learn to use a white cane, public transportation and perform daily routines. They also are offered computer instruction and the use of special scanners for reading text. They are assessed and treated, if necessary, for psychological readjustment to their sight loss.

The VA does not provide guide dogs, but it helps link veterans with guide-dog schools that commonly provide a dog and training virtually free to veterans, Poel says.

Iraq veterans sometimes find the VA blind rehab programs, which cater largely to elderly veterans, to be a poor fit for a younger generation. Army 1st Lt. Castro says he felt somewhat out of place during rehab at a VA facility in Augusta, Ga.

After the Army sent Jesse Acosta to a VA center for the blind in Palo Alto, Calif., for rehabilitation in January 2006, he and his wife became unhappy with the facility, describing it as having a “nursing home” atmosphere. It is a five-hour drive from his home.

“It did not fit my needs,” Acosta says.

He left the VA after a few months and was accepted, free of charge, into the Junior Blind of America rehab program near his home in Santa Fe Springs. Last month, he completed training with his new guide dog at The Seeing Eye school in Morristown, N.J., and now has Charlie, a German shepherd.

All that is left, Acosta says, is figuring out the rest of his life.

He has fought a medical discharge from the Army until his medical care is complete. Ultimately, he will earn disability income for his wounds. Acosta was an energy technician with Southern California Gas before he was called to active duty.

He is still with the company, though unpaid, and a different job awaits him — one tailored to his disability, Connie Acosta says. It’s unclear whether Jesse will want it, she says.

“We’re hoping for the best,” she says. “He’s the type that constantly has to be kept busy. We always have an agenda. I have a calendar going constantly with things happening.”

It begins when they wake, and he wants to know the weather and the color of the sky, she says. Nothing in the house can be moved; he’s memorized the location of every chair and table.

He has his routines and chores, including weightlifting in the backyard or fiddling with the fuel pump on the 1969 Dodge Dart. (He fixed it.) Daughter Brittany, 14, is mustered into duty to operate the computer for her father until she pleads for a break.

“Taking care of Jesse has been an experience,” Connie Acosta says. “He’s a sergeant major in the Army, and they’re tough people. He’s a tough person to live with and then, worse, being blind.

“Sometimes, he can be demanding. And I deal with it. I’m used to making sure that everything’s in line. That he’s got everything. And that’s basically all I’ve got to do.”

‘I want to feel productive’

Castro thought he knew how his life would play out.

A former Army Ranger who had worked his way out of the enlisted ranks to earn an officer’s commission, Castro commanded a scout reconnaissance platoon and dreamed of becoming a Special Forces team leader.

Instead, the last thing he would ever see was the colorless expanse of an Iraqi roof in Youssifiyah, Iraq.

A mortar round landed a few feet away from him there on Sept. 2, 2006. The blast killed two other soldiers from the 82nd Airborne Division and sent shrapnel tearing into Castro’s left side. The explosion damaged a shoulder, broke an arm, fractured facial bones and collapsed his lungs. Doctors amputated part of a finger.

The blast also drove the frame of his protective eyewear into his face. When Castro regained consciousness days later at the National Naval Medical Center in Bethesda, Md., his wife, Evelyn, sat at his bedside. She told him his right eye was gone, but doctors hoped to salvage vision in his left.

The surgeons later removed one last piece of shrapnel from that eye. When they took off his bandages and flashed a light for Castro to see, he thought the eye was still covered. “That’s when he told me, ‘Ivan, you’re not going to be able to see again,’ ” Castro recalls. “I swore (it was like) I was standing between the World Trade Center and the two towers had just come down on my shoulders.”

From that moment on, through convalescence and rehabilitation, Castro would struggle to regain a measure of independence.

Castro has become an advocate of rehabilitation funding for the blind, visiting members of Congress. After the 10-mile race in October, he ran the Marine Corps Marathon three weeks later, finishing in 4 hours and 14 minutes.

He concedes that he needs his wife’s help. Evelyn Galvis gave up her career as a bilingual speech pathologist in Fayetteville, N.C., to help her husband. She supervises his medical care and drives him around.

She guides him through crowds, keeping him aware of raised edges in the walkway and steps. She reads his menu in restaurants and tells him where the food sits on the table. She watches him memorize his hotel room, starting from the doorway and circling within the four walls to keep account of beds, the tables, the wastebasket, the bathroom.

“My husband used to be a very independent individual,” she says.

Castro hopes to stay in the military.

The Army has let several amputees stay in the ranks as well as one blind captain, who will be an instructor at West Point Military Academy after completing post-graduate education. Castro awaits word on his future; the Pentagon won’t comment on his situation.

“There’s a world in front of me I can’t predict or envision because I haven’t been there yet. I haven’t lived this yet. I haven’t lived blind,” he says. “All I ask is to stay in the Army and finish out my years … I want to feel productive.”

The only good news for now is when he sleeps, Castro says.

“I’ve had dreams where I know I’m blind and, guess what? I’ve regained my vision,” he says. Reality floods back each morning.

“There’s not a night that I don’t pray and ask God, when I wake up, that I wake up seeing.”

BRAIN INJURIES ALSO DANGER TO VISION By Gregg Zoroya

Glenn Minney lost most of his sight from a combat explosion. But it wasn’t just the injuries to his eyes that cost him his vision it also was damage to his brain.

Minney, then a Navy corpsman, was wounded when a mortar landed near him in Haditha, Iraq, in 2005. The blast threw him 30 feet. His back struck a metal railing, whipping his head backward. He lost his right eye. Vision in his left eye is impaired from physical injury and brain damage, he says.

An emerging threat from the fighting in Iraq and Afghanistan is damage to the brain that affects vision, Pentagon and Department of Veterans Affairs medical researchers say. This type of injury could mean that there are thousands of veterans with undiagnosed vision problems, says Tom Zampieri, of the Blinded Veterans Association.

Doctors didn’t find Minney’s neurological damage until after he left the military and was screened for brain injuries by the VA. “The public doesn’t know the true extent of these (brain) injuries,” says Minney, 40, married and the father of two. He’s now a patient advocate for the VA in Frankfort, Ohio.

Concerns about eye injuries have prompted federal legislation that would create a $5 million Pentagon-based center for research and treatment of injured eyes. It also would create a registry to track eye wounds.

Minney suffered severe vision loss. Researchers are finding that less-severe vision problems also can occur among troops who suffer minor brain concussions from combat, particularly exposure to a blast. “There are a lot of patients who have suffered mild to moderate brain injuries. Upon initial examination their eyes looked healthy, but they were still reporting problems with their vision,” says R. Cameron VanRoekel, an Army optometrist at Walter Reed Army Medical Center in Washington.

Gregory Goodrich, a research psychologist at VA facilities in Palo Alto, Calif., had similar findings in a study of 101 Iraq and Afghanistan war veterans with mild traumatic brain injuries. Many are still in the service.

Goodrich found that 40% to 45% of the patients suffered vision loss even though their eyes were physically healthy. The biggest problem was an inability for both eyes to operate precisely together. This can lead to eye strain and blurred vision.

Left undiagnosed, it can also hamper vocational or educational training and aggravate depression and post-traumatic-stress disorder, Goodrich says. Veterans may need an eye care specialist and corrective eyewear, he says.

But Goodrich fears that routine eye examinations may not uncover the problems. “In many cases, we’re seeing active-duty troops, and they want to get back and join their units,” he says. “So they don’t want to hear that there’s something they need to go get treated for.”

(USATODAY)

How to Use Meditation to Treat PTSD

Scientists say that meditation can improve blood pressure, diminish insomnia and keep the mind sharp. When you are triggered and began reliving your trauma, having an established meditation practice is wonderful tool. One of the greatest benefits of meditation is learning to “quiet the mind,” which can be especially difficult when fear strikes. This is why meditation can be such an important practice. There are many different ways to meditate. We are going to use a visualization that will come in helpful when you start to panic.

Instructions

Find time to meditate everyday, such as when you first wake up in the morning or right before bedtime.
If you are a beginner, you will want to start slow. If you live with someone, let them know you will need 5-10 minutes to yourself A gentle reminder, such as a sign, isn’t a bad idea either.
Prepare your space. If you choose, light incense, candles and put on some soft music. Dim the lights. While this is not necessary, having a ritual associated with your daily meditation help prepare your mind for what’s to come.
Minding your posture, sit on a chair or cushion. Keep your spine straight and head tilted slightly forward. If you can, try to maintain a half-smile on your face.
Close your eyes and breathe in deeply through your nose, filling your belly with air. As you breathe in, let go of any tension you have in your muscles. Take ten slow deep breaths.
Imagine that you are walking down a flight of steps, with a door at the bottom. Each time you take a breath, you descend one step.
As you come to the bottom of the steps, you try to open the door and realize its locked. You look down at your chest and notice that you are wearing a key around your neck.
Using the key, you unlock the door and step inside. You are in your favorite place. When you are here, nothing bothers you and you feel powerful, safe and protected.
You sit here for as long as you feel comfortable. When you are ready, you walk back out the door and lock the door behind you, making sure the key is safely around your neck.
As you ascend the ten steps home, you notice that a calm has washed over you. You take one step per breath as you climb, opening your eyes when you get to one.
Give yourself a couple of minutes to stretch and slowly readjust yourself to your surroundings. Hang on to the feeling of calm you have acquired, always remembering that you carry the key to unlock that door anytime you like.

Tips & Warnings

As a beginner, it will be difficult to keep your mind from wandering. Don’t get frustrated. Just start again. Everyone’s mind wanders. The important part is to keep at it.
Even if you can’t “see” what you’re imagining, keep at it. It takes time to develop these skills.
You may want to tape this meditation and listen to it so you don’t have to read it every time.
Use a shorter version of this meditation when you are triggered. You may want to change the number of steps or have the door sitting wide open when you arrive. Do whatever feels comfortable.
Don’t give up! Go gentle on yourself.
Do not try to force yourself to stop thinking. This will only make you think more. When you realize you are lost in thought, simply start counting again and bring your focus back to your breath.
Don’t give up if you get off-track! Just start back as soon as you remember.

User perspective of the effectiveness of meditation in treating Post-Traumatic stress disorder

Meditation has helped the most Meditation was difficult for me to learn, but has ultimately been what has helped me the most.

It was difficult for me to start meditating because I suffered from panic, anxiety and depression related to PTSD. I needed a lot of help–I took the Mindful Meditation class at Kaiser (offered at many hospitals), and that gave me the support I needed to start.

Meditation helps because when I’m having a flashback of the trauma, I am no longer in the present. Meditation helps me to return to the moment, to be aware of what is going on now.

I have to do lots of self-care–massage and bodywork, support from other people, therapy. But I feel meditation is the key to everything–what helps me remember what is good in my life now, and what it is that I really need in order to heal. Sometimes it’s so hard to get through the moment when I’m feeling emotional–I just focus on my breathing and use the meditation skills to return to the present. It’s taken practice for me to get to a point where I can do this.

I see meditation as a long-term tool that I feel will help any one suffering from PTSD–just be patient, and know that it may take some time to really experience the benefits.

Trauma of war hits troops years later

In internet chat rooms, veterans ask if anyone else is having a similar experience. “I had an incident where a small Iraqi boy had his leg blown off. His screams haunt my thoughts. Is what I am experiencing normal?” asks IraqCowboy. “They gave me sleeping pills, but it doesn’t stop the nightmares,” says Chucky. “The doctor says my husband has PTSD,” posts Sam. “Does that count as a combat-related illness?”

What is now known as PTSD, or post-traumatic stress disorder, was called shell shock back in the days of the first world war. Sufferers have harrowing flashbacks, and alternate between emotional numbness and outbursts of rage, guilt and depression. Previously well-adjusted soldiers suffer impaired memory and attention, insomnia and anxiety, and are more likely to take drugs and alcohol later in life. That much is well recognised.

What is less well known is that PTSD can trigger physical as well as psychological ill health. And as the US agonises over how long its soldiers should stay in Iraq, New Scientist has pieced together evidence showing that veterans will be paying the price of combat for decades to come. Recent and soon-to-be published research reveals that soldiers who fought in theatres as diverse as Vietnam and Lebanon are not only more likely to die from an accident on their return, but are also twice as likely to develop cardiovascular disease, diabetes and even cancer later in life. And these problems are particularly likely to afflict troops who experience the close-quarters fighting taking place in Iraq.

Last year researchers from the US Centers for Disease Control and Prevention (CDC) revisited more than 18,000 Vietnam veterans who had been subjects of a detailed health survey in 1985, to see who had died and how. For the first five years after their return home, men with combat experience appeared more likely to have died of accidents, overdoses and the like. After that, they seemed no more at risk than comrades who had spent the war in non-combat roles (Archives of Internal Medicine, vol 164, p 1908).

The CDC study took no account of whether the soldiers were suffering from PTSD. But now Joseph Boscarino of the New York Academy of Medicine has re-analysed the 1985 data to assess which men were suffering from the condition. That analysis, to be published in Annals of Epidemiology, reveals stark differences in death rates persisting 30 years after the end of the Vietnam conflict. All men with PTSD, whether from combat experience or not, were more likely to die from “external causes” such as accidents, drugs or suicide. But men who developed PTSD as a consequence of combat were also more likely to die of heart disease and, surprisingly, various kinds of cancer.
“The link between combat stress and cancer risk surprised us, and it isn’t explained by differences in smoking”

“Other studies have found a link between heart disease and stress, but this is the first time there has been such a direct association with PTSD so many years later,” Boscarino told New Scientist. “The cancer surprised us, and it isn’t explained by differences in smoking.”

People with PTSD may experience long-term changes in various immune reactions, and in levels of the stress hormone cortisol and chemicals such as adrenalin and dopamine that underlie fight-or-flight reflexes, Boscarino says. He found a direct relationship between the amount of combat exposure and the reduction in cortisol levels. “The excess deaths in both PTSD groups show that stress can kill,” he says. “But the much greater effect among the combat veterans shows there is something especially bad about that.”

He is not alone in his conclusion. In March this year Yael Benyamini and colleagues at Tel Aviv University in Israel reported that among Israeli veterans of fighting in Lebanon in 1982, those who developed PTSD are now twice as likely to have high blood pressure, ulcers and diabetes, and five times as likely to have heart disease and headaches, as those who did not develop the disorder (Social Science and Medicine, vol 61, p 1267). “PTSD is the key mechanism that leads from the trauma to poorer health,” they say.

“Iraq is similar to Vietnam, with roadside bombs, ambushes and the civil insurgency”

Other studies have found clear associations between war-related PTSD and cardiovascular disease in veterans of the second world war, the Korean war, and recent conflicts in Croatia and Lebanon.

Last year, a study by US army scientists at the Walter Reed Army Medical Center in Silver Spring, Maryland, concluded that some 18 per cent of US veterans from Iraq could be affected by PTSD, which would translate to around 60,000 people so far (The New England Journal of Medicine, vol 351, p 13). And the more firefights Iraq veterans experienced, the more likely they were to have PTSD.

Boscarino is a Vietnam veteran, and he predicts that levels of PTSD in Iraq veterans will be similar to those seen in troops who fought in Vietnam. “It’s a similar war, with the roadside bombs, ambushes and the civil insurgency.”

“The link between combat stress and cancer risk surprised us, and it isn’t explained by differences in smoking”

Timely psychological help might mitigate the problem. Yet The Walter Reed group found only a third of Iraq veterans with PTSD were getting help from a mental health professional a year after their return. British soldiers get no routine mental health screening before or after deployment, though 1 in 10 troops airlifted out of Iraq for medical reasons had mainly psychological problems.

In February, the General Accounting Office of the US congress reported that the Department of Veterans Affairs had not fully met any of the recommendations its own advisers have been making, in some cases since 1985, for improving treatment of PTSD, such as checking whether screening and counselling are being implemented.

(New Scientist magazine)

Post Traumatic Stress Disorder (PTSD – War Trauma)

It has been estimated that 30% of Vietnam war veterans, 10% Gulf war veterans, 6% to 11% Afghanistan war veterans and 12% to 20% of veterans of the Iraq war have suffered from Post Traumatic Stress disorder. This is an anxiety disorder that can develop after exposure to one or more terrifying events.

The history of PTSD date back to the early 1800′s where military doctors began diagnosing soldiers with “exhaustion” following the stress of battle. This “exhaustion” was characterized by mental shutdown due to individual or group trauma. Around this time there was a syndrome in England called ‘railway spine’ or ‘railway hysteria which bares a resemblance to what we call PTSD today. This was found by people who had been in the catastrophic railway accidents of that time.

In World War I and II the term ‘shell shock’ and combat fatigue’ were terms to describe veterans who exhibited stress and anxiety after being in combat. The official designation of “Post Traumatic Stress Disorder” did not come about until 1980 when the Third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published.

This anxiety disorder occurs when you are afraid and your body activates the fight or flight response. This reaction to fight releases adrenaline, which is responsible for increasing your blood pressure and heart rate as well as increasing glucose to muscles (to allow you to run away quickly in the face of immediate danger). However when this danger has gone your body begins to go through a process that shuts down the stress response and this process involves the release of another hormone known as cortisol. If your body doesn’t generate enough cortisol to shut down the stress reaction you may continue to feel the effects of adrenaline. Trauma victims who develop post-traumatic stress disorder often have higher levels of other stimulating hormones (catecholamines) under normal conditions in which the threat of trauma is not present. These same hormones kick in when they are reminded of their trauma.

Military Post Traumatic Stress Disorder is a very serious disorder with symptoms such as self harm, anger, violence and drug addiction as well as depression. All of these are common symptoms of Military Post Traumatic Stress Disorder and sadly affects thousands of soldiers every year who have serviced in the armed forces. Treating Military Post Traumatic Stress Disorder is done through psychotherapy and basic counselling but can take a lot of time and patience.

Sadly a number of people who are experiencing and suffering from Post Traumatic Stress Disorder, also known as ‘war trauma’, is said to hugely increase in the next few years due to the number of soldiers who are fighting in areas such as Helmand and Basra. There are concerns that the Iraq war is producing more cases of Post Traumatic Stress Disorder than any other conflict in decades, one of the main reasons for this is that the violence has been so widespread and exposure to it so constant over long periods of time. The suicide bombers, roadside mines and the constant threat of attack within the Iraq war poses a unique challenge to the mental health of the soldiers who are serving in it.

If you are one of those suffering and are thinking of claiming compensation for you suffering then you should do so right away. It is your civil and legal right to claim compensation for injuries psychological and mental. No-one should suffer in silence.

(www.articlesbase.com)

Not Specific to Combat, Research Project Studies Use of Tibetan Meditation to Treat PTSD

Although not specifically directed towards combat veterans and PTSD, a research study is currently evaluating whether Tibetan meditation has benefit for PTSD sufferers. Miami and Ohio State university researchers will use an ancient technique to address a modern problem. With a $98,000 grant from the Ohio Department of Mental Health, Deborah Akers, Miami visiting assistant professor of anthropology, will work with co-researchers from Ohio State on a project titled “Treatment of Trauma Survivors: Effects of Meditation Practice on Clients’ Mental Health Outcomes.”Akers and co-researchers Moyee Lee, professor of social work, and Amy Zaharlick, professor of anthropology, will investigate the impact of Tibetan meditation on victims of post-traumatic stress disorder (PTSD). The project began this month and will continue for two years.

Researchers will work with a group of women diagnosed with PTSD who live in Amethyst House, a women’s treatment program for alcohol and drug addiction in Columbus. Tibetan monk Geshe Kalsang Damdhul of the Institute of Higher Buddhist Dialectics in Dharamsala, India, will assist as a meditation instructor. “Participants will be taught specialized meditation techniques and will be guided through meditation for a period of six weeks,” said Akers. Results could then provide a new option for treating other victims of PTSD, such as combat soldiers returning from war or victims of natural disasters such as Hurricane Katrina. “This project charts new ground, bringing a holistic perspective to the treatment of PTSD,” said Akers. She added that though meditation has been used in a variety of therapeutic settings in the West, such as reducing stress and coping with pain,its application in the treatment of mental illness, including PTSD, has not been extensively explored.

“Whereas in the West treatment of PTSD may require years of prescription medicine and counseling, the Tibetan approach has been successful within one to two years by focusing on the spiritual connection between the mind and the body that seems to allow the patient to process the trauma more effectively,” said Akers. “Moreover, unlike Western medical therapies, meditation is free and can benefit individuals who cannot afford extensive therapy or medicine over long periods of time. The Tibetan approach is empowering, as it offers PTSD patients an alternative and less invasive form of therapy and enables them to participate in their own treatment.” The project grew from a Miami summer field school program, “Peoples and Cultures of Tibet,” conducted in Dharamsala, the residence of the spiritual leader of the Tibetans, the Dalai Lama, and location of the Tibetan government in exile. During the field school, Akers and Miami students learned about how Tibetan monks minister to political prisoners and victims of torture who suffer from PTSD. Several Miami pre-med and anthropology students will assist in the Columbus project, gaining hands-on research experience.

“The PTSD research project and the summer field program in Dharamsala exemplify Miami University’s continuing interest in South Asia,” said Akers.

(www.healingcombattrauma.com)

Portrait of a US combat casualty

For Spc. Brett Christian, the morning of July 23 began ordinarily enough. He brushed his teeth and shaved. Then, climbing into the cab of his 21/2-ton diesel troop carrier not long after sunrise, the young soldier pulled into an Army convoy headed west out of the northern Iraqi city of Mosul.

Specialist Christian’s mission was routine. He and a couple of dozen other troops from the 101st Airborne Division were bound for a firing range to zero their weapons. As was his habit, the gregarious 27-year-old was trading jokes in the cab. In the turret behind him, the machine gunner scanned flat brick rooftops and dusty streets.

The five-vehicle convoy rumbled past some charred chassis and artillery shells cluttering a scrap-metal dump – the kind found on the outskirts of many Iraqi cities – and began rolling up a hill.

Then, mid-joke, Christian’s world exploded.

“As we crested the hill, I felt myself get hit with a bunch of glass and debris,” says Lt. Christopher Wood, who was sitting next to Christian in the cab. “I thought we were getting ambushed, so I turned to tell Christian to put on the gas. He was already dead.”

A standard mission. A sudden blast. A soldier lost – and no enemy in sight.

This is the kind of faceless battle that tens of thousands of US troops are bracing for in Iraq each day. For infantrymen like Lieutenant Wood who fought their way to Baghdad to topple the regime of Saddam Hussein, today’s terrorist-style ambushes are in some ways worse than major combat, when the enemy was more visible and predictable. More than 52 US servicemen have died in hostilities since heavy fighting was declared over on May 1.

“There’s a tangible air of frustration,” says Wood, whose hearing was impaired and left eye injured in the ambush. Six other soldiers suffered shrapnel wounds.

Fighting flares up
The Mosul region, after a period of relative quiet, has experienced a spate of attacks since the 101st joined with other US forces to surround and kill Uday and Qusay Hussein on July 22. Military intelligence officers are unsure exactly who the enemy is, but say strikes have grown in sophistication. That some motivated by cash or revenge are willing to attempt the attacks is no surprise, they say. As in many places in Iraq, this city of 2.3 million people is home to thousands of unemployed young men and ingrained patterns of violence: Gunfire erupts here nightly and residents fish in the Tigris River using hand grenades.

To be sure, US forces are aggressively flushing out weapons, money, and potential attackers while also scrutinizing their methods. In recent days, for example, soldiers with the 101st foiled a rocket-propelled grenade (RPG) ambush and uncovered caches of missiles and hundreds of RPGs and rounds of ammunition. Troops are also becoming more skilled at identifying and disabling the kind of improvised explosive device that killed Christian. For every deadly attack, many more fail.

Meanwhile, soldiers such as Wood who survive close calls are carrying on with their jobs – driven variously by duty, resentment, and the knowledge that they have no choice.

Inside a heavily fortified Mosul hotel that was gutted by looters before his infantry company moved in, Wood speaks about the attack – even its first desperate moments – with a tone of detached resignation.

Moments after the makeshift blast – most likely from artillery shells planted in the road median and ignited remotely by a waiting enemy – Wood struggled to see clearly and get his bearings. The troop truck kept rolling forward but Wood could not reach the brakes.

“We gotta get out of here!” the gunner yelled, kicking Wood in the back. So Wood bailed out and with the rest of the troops took up fighting positions. The gunner, in a state of shock, sprinted from the scene and off the road. Other soldiers found him 50 meters away, and he was later evacuated from Iraq – a casualty of mental more than physical trauma.

‘What are we doing here?’
Indeed, two days later, a group of Christian’s comrades from the 2nd Battalion, 502nd Infantry Regiment met for hours with a combat-stress team sent to help them vent their grief rather than bottle it up. “For them, it was like losing a family member,” said Lt. Col. David Lonnquist, a combat-stress expert with the 113th Medical Company.

Some soldiers cried, and others raised doubts. “There were a lot of questions like ‘What are we doing here?’” Colonel Lonnquist said. “That’s not clear to some people, whereas it is clear in combat.”

Back home in Cleveland, Christian’s mother, a single parent, was mourning, too. On hearing a radio report of the attack, Tess Christian knew intuitively her oldest son was gone. “It’s such a gut-wrenching feeling,” she told a local newspaper. He died on her birthday.

The attack also weighed on the minds of Wood and his men as they set out soon afterward on a night foot patrol in an anti-American neighborhood of Mosul. Wastewater ran in gutters through the narrow streets, and children emerged from dim alleys to throw rocks at the soldiers. Once, orange tracer rounds flew up from behind a building. Nearby, a man on a rooftop peered down at the patrol.

“That makes me uncomfortable as hell,” Wood said as he glanced around, his one eye bloodshot from the attack.

“I never trusted the population before and I’m even less trustful now and somewhat resentful,” he says. “We removed a totalitarian regime and are trying to set up a democracy, and still people want to do us harm.

“I can’t understand it. But,” he added, “it’s not for me to understand.”

It was already hot at 8:00 a.m the next day, when Christian’s fellow soldiers gathered at their Mosul camp to bid him farewell. Sunlight filtered through a camouflage awning, dancing on their shoulders. Before them stood a shrine of Christian’s boots, rifle, and helmet, along with his Bronze Star and a snapshot of him in his truck.

“We shouldn’t put question marks where God puts periods,” said Chris tian’s company commander, Capt. John Yorko, as if reading the men’s minds.

One of Christian’s closest buddies, Spc. Nathan Galante, recalled his friend’s infectious humor as well as his bravery, shown when he took the lead in a convoy of trucks that came under small-arms fire during the war. “We love you, Brett,” he said.

Then the company’s burly first sergeant led roll call, summoning Christian by his new rank of sergeant. He was due for promotion Aug. 1.

“Sergeant Christian….” he called out hoarsely.

“Sergeant Brett Christian…..

“Sergeant Brett Thomas Christian….” Shots broke the silence, and the sound of taps rose over the rooftops of Mosul.

(The Christian Science Monitor)

Basic Overview of Post Traumatic Stress Disorder by Jim Loughrey

Histories of the Vietnam War are beginning to abound more than two decades after our nation’s involvement in the conflict officially ended. Historical analysis is most often subjective to some extent — and always dependent on available information. History, as it is recorded, may change when new facts come to light. It also may change more subjectively when the times change and the opinions involved in the writing reflect a different view-point.

Think for a moment about how the veterans of the Vietnam War have been portrayed. The picture depends on who does the writing and when. Every Vietnam Veteran is a part of history — as nameless as any of us may always be, we did have a part in the making of this part of history. But as a group, how were and are we being pictured?

I think most people will agree that for years we were not portrayed very favorably at all. In movies and books and on television the initial, main role of the Vietnam Veteran was that of a psychopath and social misfit — a man brutalized and warped by a war most Americans had little use or respect for. When the writers needed a character who was insane, completely antisocial, dangerous to society, drug and/or alcohol addicted, guilt-ridden and vengeful, etc. ad nauseam, the Vietnam Veteran filled the need. If one needed a character who would evoke pity, the beaten, weak, suffering Vietnam Vet served once more –because our song was, many agreed, “When Johnny Comes Slinking Home”. Like the new guy in Hollywood, we had to start at the bottom with all the bad guy roles.

Why? Why wasn’t it like it was with our World War II and Korean War brothers? How come we weren’t allowed to start out playing the good guy, the hero, the indomitable spirit? The roles we were given in fiction were the same ones we played in reality as far as our news media were concerned, and hence, as far as our people were given to know. Headlines reporting Vietnam Vets shooting from rooftops were more saleable than those which would tell of veterans of our era forming businesses, getting professional degrees, or otherwise benefiting themselves and society. It was as if the World War II Veteran was one who went off to the terrible task of war and took along with him morality and honor, while the veteran of the Vietnam War was somehow something less who went off to war and brought back immorality and dishonor. In any event, if despicable or pitiful, we had become, at least, interesting. But while some people who write the news might be given to exploitation and a certain degree of selective myopia, there usually is at least something of truth or reality in the reporting as an element of justification. Wasn’t it true that some of us did, indeed, do some of the things we as a group became famous for?

Certainly. But few asked why. It is apparent that very few people wished to know what caused the difference in behavior, compared to that of veterans of other wars, or wondered if such behavior might be attributable to only a very small segment of the Vietnam Veteran populous. A very tired and disillusioned America was not yet recovered enough from Vietnam to deal with the problems of its youngest war veterans; or countrymen felt they had difficulties enough of’their own, perhaps, or they simply were not aware that the problem was any more complex than it seemed. The result was that the seemingly obvious was taken as explanation enough. Hence, when anyone needed an explanation at all, we were known to suffer what became known as Post-Vietnam Syndrome. The term — which had no scientific meaning — was adopted by both veterans and the public.

Today we speak of PTSD in Vietnam Veterans. Today veterans are getting help and getting better, all because they suffer from a medically recognized condition: PTSD. But for far too many people — veterans and non-veterans of the Vietnam War — “PTSDII is nothing more than a substitute for IIPVS”. The problem has been given the legitimacy of official and professional recognition, but that has not necessarily led to any more understanding — either by veterans of Vietnam or by their countrymen. As in the days of IIPVS”, many veterans do not know what their problem is or what they need or can do to solve it, nor do other Americans understand what PTSD really means and why it exists. Consequently, too many veterans are still blamed for things that are not at all their doing or fault. They are still sometimes looked down upon when in reality they deserve to be praised and honored. And America cheats itself as long as it erroneously and unjustly rejects a part of itself.

We need to concern ourselves with PTSD for everyone’s ultimate benefit. But first it is necessary to know and comprehend what PTSD is, means, and does. Following is a brief discussion of PTSD that does not require a professional degree to understand. It only demands one care enough to read it and do so with an open mind, not with comfortable bias.

And what’s required of the Vietnam Vet who is having serious emotional and mental problems is something even greater: courage. The courage many of us already know he had in his war. To heal will demand courage because healing is change. Sometimes even hell can get to be comfortable and change will look like just too much to ask. Too much to try. But that is what is necessary and there is no other way.

Many of us suffer from a disease that perpetuates itself with a vicious cycle effect: the disease is one of a lack of change and part of the disease itself is an unwillingness to seek change. There is a similarity between this disease and the disease of alcoholism. Alcoholics, many believe, suffer from a type of insanity; the insanity makes them drink and the drinking affects the brain, hence the mind, and causes insanity. The disease we’re discussing here is called PTSD.

PTSD stands for Post-Traumatic Stress Disorders. Put simply, this is a set of disorders common in people who are reacting to severe trauma with the reactions occurring or continuing after the stressful event. PTSD is not, therefore, a set of mental disorders found only in Vietnam Veterans. Who suffers from the disease is determined by what was the stressful event or trauma. Survivors of rape or a life of child-abuse or some catastrophe as well as veterans of combat and associated experiences all may well eventually experience PTSD.

Our concern here, though, is PTSD as it relates to us, the veterans of the Vietnam War. And it’s only been in recent years that the term PTSD has been applied to the mental disorders many of us have been suffering. PTSD has been applied to us only since 1980 when the disorders were first included in the American Psychiatric Association’s DSM III — “Diagnostic and Statistical Manual III”.

The DSM serves as the text, the bible, for American psychiatrists and psychologists. The first Manual appeared in 1952; the DSM II with its new entries and revisions was available in 1968. PTSD as a term and a concept wasn’t documented until the DSM III.

There’s an old joke in chemistry: If Lavoisier discovered oxygen, what did people breathe before he discovered it? Similarly, from what did veterans of combat suffer before PTSD was discovered? Before Lavoisier, of course, people were breathing oxygen but just didn’t know what it is or what to call it. The history of combat veterans’ illnesses and maladjustments reflects a similar situation. One difference is that many labels have been used to describe the effects of combat on men and women over decades. Also, oxygen was, is and always will be just oxygen no matter what it is called. However, what was “wrong” with veterans of combat has been a matter of who judged the problem and when.

At first there were no specific explanations for Vietnam Veterans’ having the myriad problems they did; problems like a suicide rate described as 33% greater than the national average, disproportionately high incidences of chemical abuse and criminal convictions.

People who were against the war could point to the returning veteran who suffered such problems as proof of the veracity of their viewpoint: the Vietnam War was a disgusting and useless mess to which we had sent some of our most disgusting and useless people. The nature of the war was created by the nature of those who waged it. But more often we encountered antiwar sentiment that reversed this so that the immoral and disgusting war was the creator of immoral and disgusting people.

Likewise, supporters of the war used our condition to further their aims. We were proof positive of the Communist brutality and dirty tactics — all the more reason for our country to believe in the morality of its position. The war was disgusting because the enemy made it so and we were its gallant victims.

Sociopolitical motivations aside, people began to label us as sufferers of “Post-Vietnam Syndrome”. This label seems to have appeared sometime during the late sixties to early seventies.

PVS was more or less a term of convenience. It was a nebulous concept that purported to describe the ailments of the combat veterans of only this particular conflict. It was unique to us as if our behavior had never been seen in other veterans. As the war dragged on and this country wearied of the internal strife and lack of a victory, PVS began to be a derogatory term, especially as younger veterans and counterparts from other wars became less and less able to identify with each other.

The term Post-Traumatic Stress Disorders came about only after the effects of combat were truly studied scientifically and for the first time. So, before analyzing the nature of PTSD as it relates to combat veterans, a little history of its evolution would be informative.

Jim Goodwin, PhD reported in POST-TRAUMATIC STRESS DISORDERS OF THE VIETNAM VETERAN (Disabled American Veterans, 1980): “It was not until World War I that specific clinical syndromes came to be associated with combat duty. In prior wars, it was assumed that such casualties were merely manifestations of poor discipline and cowardice. However… during ‘The Great War’, the concept evolved that… exploding shells caused actual physiological damage, precipitating the numerous symptoms that were subsequently labeled -shell shock’. By the end of the war, further evolution accounted for the syndrome being labeled a ‘war neurosis’.

Until World War I, then, any soldier negatively responding to the stresses of combat would have been labeled just a coward. The studies done during that war, though, did not do much to alter opinion that it was somehow the fault of the soldiers that they ended up displaying mental disorders. Even though psychiatrists began to recognize combat as capable of producing such symptoms, it was still assumed that something had to be wrong with the soldiers character before combat stresses could have adversely affected him. Even though we’d moved from basic cowardice to “shell shock” and then on to “war neuroses”, the thinking continued on into World War II that a soldier had to have been “predisposed” toward such reactions … in other words, had to have had basic character defects.

According to Dr. Goodwin: “During the early years of World War II, psychiatric casualties had increased some 300 percent when compared with World War I, even though the preinduction psychiatric rejection rate was three to four times higher than WW I. At one point in the war, the number of men being discharged from the service for psychiatric reasons exceeded the total number of men being newly drafted-”

World War II thinking suggested that, if we’re going to assume that men had to possess “predispositional factors” in order to break down in combat, then we had better expect not too many to be immune. According to a 1944 Inspector Generalls report: “If screening is to weed out all those likely to develop a psychiatric disorder, all should be weeded out.,,

Therefore, the belief that war neurosis could only grow in the fertile ground of a defective character had outlived its usefulness. Psychiatrists now began to look into the “intrinsic qualities of the combat situation” for the reasons for the breakdown and the blame was beginning to shift from the shoulders of the fighting men to the conditions of battle themselves. Basically, war itself held the capacity to exhaust anyone.

What changed during the Korean War was the way the men were treated. Terminology had now progressed from “war neurosis” to “combat exhaustion”. But soldiers were no longer so readily discharged from service when they showed signs of mental disorders attributable to combat. Rather, doctors began treating men immediately and close to the front. A very good rate of return to duty was achieved.

Vietnam, however, was a vast surprise for everyone. Military psychiatrists were prepared for the same situations as seen in past wars, but these did not develop. Battlefield breakdown in Vietnam was “at an all-time low: 12 per one thousand”.

Were the men fighting in Vietnam staunchier than their predecessors? If so, why then were Vietnam Veterans so severely criticized? How could they have been statistically so much better able to endure combat than their predecessors and yet have been at some points nearly universally considered inferior and the reason the war was lost?

The answer is that the basic package was really the same; it was the wrapping that differed….

Most of our problems surfaced after our return from combat. We succumbed as did our older brothers, but we did so alone and thus did not lend ourselves as much to being battle statistics. Furthermore, the differences in our respective homecomings contributed to the apparent disparity.

By virtue of their coming home together and on long journeys that allowed for mutual sharing of the war experience, older veterans were able to lay to rest much of their horror. We were forced thereby to carry ours with us into life after our war. Additionally, the initial recovery of WW II veterans was greatly aided by their country’s reception: very warm and appreciative. The negative homecoming we received — the rebuke, disdain, criticism, blame, and forced silence and isolation — not only helped retard recovery but actually very severely added to the stress we had to overcome.

Another characteristic difference between Vietnam and other wars was the personal involvement and ability to understand and relate to the public.

Our countrymen were bludgeoned daily with the horror of our war, which received mostly negative and biased press. Our war’s purpose was not clear-cut and our people at home were not encouraged to feel a part of it. And despite the vast coverage graphically displayed to them, the American people were really not made privy to the actual experience of their soldiers on the battlefield.

During the second World War, conversely, it had been unthinkable to present the fighting men’s efforts in anything but a positive light and the nation received primarily reports which cultivated a sense of unity, purpose, conviction and optimism. Our soldiers were aware of the nation’s constant sacrifices and the people were made aware of the soldier’s sacrifices — and each shared the other’s respect as well as experiences.

Ultimately, then, our nation and its servicemen suffered together during World War II, bled together and healed together. Vietnam? –The factors created an environment socially that demanded veterans recover on their own and with fewer of the tools required for such recovery.

Hence PTSD.

Post-Traumatic Stress is a consequence of extreme or severe trauma. The reactions to it do not often appear until after the fact. The victim may have come through the traumatic situation apparently relatively intact only to ultimately exhibit the symptoms that characterized the PTSD condition.

PTSD is diagnosed according to two categories. These, according to Dr. Erwin R. Parson, are:

ACUTE PTSD — The onset of symptoms occurs within six months of the trauma and the symptoms last for less than six months.

CHRONIC or (a) The onset is at least six months DELAYED PTSD — after the trauma (DEIAYED).

(b) Duration of the symptoms is more than six months (CHRONIC).

Chronic/Delayed PTSD would, thus, be the condition of those of us now exhibiting the symptoms. Following are the generally accepted symptoms of PTSD:

Depression Isolation Rage Intrusive thoughts Alienation Survivor guilt Sleep disturbances and nightmares Anxiety reactions

Depression may include feelings of worthlessness, feelings of helplessness, suicidal thoughts, etc. Isolation is the inability to get close to others (veterans of combat often have very few friends and tend to feel they cannot relate to most people and vice versa). Others often see such a veteran as “cold” due to the symptom of Alienation in which the veteran does feel “emotionally dead”. Anxiety Reactions include the tendency to overreact to certain stimuli — being acutely startled by loud noises or feeling extreme discomfort in the open or when people are behind the veteran (there is a tendency to identify the stimulus with combat and/or to react to it as one would have to combat). Rage is an uncontrolable urge to lash out at people, often suddenly and without apparent reason, with the veteran being himself frightened by the rage response. Survivor Guilt causes the veteran to recount the death of comrades with a sense of guilt over not having been able to do anything about it; the “why wasn’t it me” attitude can drive some to self-destructive behavior. Sleep Disturbances & Nightmares — the sufferer has much difficulty in falling asleep and maintaining sleep; there is a tendency even to avoid and postpone sleep or the use of drugs or alcohol where the veteran feels he needs sleep; and the nightmares are often of a recurring nature with the same scenery, events and situations.

The above symptoms may also be indicative of other conditions and that a veteran may be suffering from one or two of the above is by no moans to be taken as a sign that he does indeed suffer from PTSD. Only a competent, professionally-made determination should be sought; and it should be noted that not all veterans suffering PTSD exhibit all of the given symptoms.

But who does suffer from PTSD and how is the determination made?

Determination of PTSD cases is something that should be done only by the professionally qualified who also have specialized experience with and knowledge of PTSD in combat veterans. Any veteran presenting himself for such a determination should fully be aware of the fact that the process must necessarily be lengthy and involved.

One reason is this: PTSD as an ailment of combat veterans qualifies the sufferer for compensation from the government. There are, unfortunately, some who may not really need treatment and who merely want to exploit the system for personal gain. Dr. Jim Goodwin states this: “When a veteran appears in an interview wanting something from us (the VA) other than treatment, there is a manipulative flavor to the interview. I am then immediately alerted that issues other than PostTraumatic Stress may be involved.”

Some time must be spent by the psychologist in ascertaining the honesty of a prospective sufferer not to save the government money. The main reason is a seriously practical one: The number of qualified doctors available to veterans is limited and dishonest and undeserving veterans who are permitted to undergo counseling and treatment detract from the total available help for those having serious problems.

Even more critical is that the initial interviews and exams must attempt to distinguish possible PTSD-sufferers from those afflicted with other mental ailments whose symptoms often may be confused with those of PTSD.

Schizophrenia is not uncommon and the disorder is one often confused at first with PTSD. For example, decreased productivity, certain types of amnesia, and hallucinations are common to both disorders. On the other hand, many aspects of each disorder are completely different, some even opposite. Medication indicated for schizophrenia will do no good for the PTSD-sufferer and vice versa. Schizophrenics respond well to the phenothiazines, which have no effect on PTSD patients. Conversely, tricyclic antidepressants work well in PTSD cases, but have no effect at all on schizophrenics.

Veterans who finally present themselves for evaluation and treatment often become impatient with the evaluation process. They see no need for the psychologist or psychiatrist to “waste time” with tests and questions that do not readily seem pertinent to their service experiences. The veteran usually is convinced from the start that he suffers from his combat experiences and wants only to discuss war-related matters, all else in his opinion being irrelevant. What has the doctor’s question concerning his grade school years got to do with the time he had to crawl into a VC tunnel in Vietnam? Why should he submit to hundreds of questions on the Minnesota Multiphastic Personality Inventory — which seem to be designed more to determine if he’s lying than to determine if there’s anything abnormal about him — when he knows that the only thing wrong with his personality is whatever was changed by war experiences?

This attitude of some of-us is quite understandable. Many or most of us do not seek help until we’ve essentially reached the end of our rope — either just unable to endure it alone anymore or are in some sort of serious trouble. So, there is a deep sense of urgency and we are in no frame of mind to sit back and let someone drag us down those “dead-end roads”. Moreover, many veterans have developed a tendency to distrust authority and, should we be seeking aid at the VA, some of us might even assume that the doctor is looking for ways to deny that we have any war-related problem.

We simply have to understand that no competent psychologist can make snap decisions or diagnoses if the intention is to provide proper help. Misdiagnosis of mental/emotional disorders can be just as dangerous and detrimental as misdiagnosis of physical ailments. It isn’t merely a question of whether the wrong medication will help or do no good at all; the wrong medication in some cases can do severe harm. Medication aside, the course of treatment for various mental disorders is to be considered. The incorrect approach here may also do damage, not just be ineffectual.

Complicating the situation for the doctor and the patient is the fact that a veteran may not be suffering from only a single condition. PTSD does not necessarily push aside other possible problems by its presence. one patient may suffer PTSD and have a tendency to drink too heavily because of it — without being an alcoholic. Yet, another veteran may suffer from both conditions. Still a third may be purely alcoholic and characteristically blaming his troubles on a condition he does not actually possess, in this instance PTSD.

The course of treatment for PTSD is not identical to that preferable for alcoholism. In fact, treatment of the veteran’s PTSD may have little or no effect on his alcoholic tendencies — but if the veteran should join Alcoholics Anonymous and truly embrace its Twelve Steps program for recovery, the new way of life and advantages available to one dedicatedly working this program may actually alleviate the PTSD symptoms considerably.

But let’s consider medication within the same scenario-: A PTSD sufferer may indeed benefit from the use of prescribed antidepressants or, for the anxiety-ridden, tranquilizers. Suppose that the PTSD sufferer is also alcoholic. Alcoholism is a disease involving an addictive personality. Therefore, it may be dangerously inappropriate to treat one drug addition as if it were some sort of “Valium deficiency” — prescription of tranquilizers may only serve to feed the inherent need for drugs.

During the evaluation stage, the patient will also be classified according to veteran status: non-veteran, V.E.V (Vietnam Era Veteran — one who served during the conflict period, but not in Vietnam), or V.V. (Vietnam Veteran). The likelihood of the patient’s suffering from PTSD is obviously greater if he did serve in the war zone. It is still greater if he did actually see combat.

As Dr. Goodwin states: “One proven indicator of the intensity of the disruptive symptoms is the extent to which the veteran was exposed to actual combat.” Thus VV’s,are further classified as “noncombat” and “combat” veterans… and as we’ll see, combat veterans are still further assessed as low- and high-combat veterans.

Combat — and the degree to which it was experienced — is a major factor in the diagnosis of PTSD. Dr. Woodwin says, “In developing a diagnosis of PTSD, chronic and/or delayed, it is particularly important to be empathetic to the horrors of the combat situation. Many veterans have struggled endlessly to suppress these feelings, in part because of the refusal of society to even acknowledge their existence.”

Many of us who saw heavy and prolonged combat never had the opportunity to rid ourselves of the concomitant and associated emotions as did veterans of the other wars. It is generally acknowledged now that the Vietnam Veterans endured the same and similar hardships that other veterans did. Why we fell prey to resultant disturbances to a greater degree is at least in part due to major differences in the homecoming experiences.

The Vietnam Veteran came home to a vastly different climate. He went from battlefield to Main Street in less than 48 hours and did not receive the distinct and recognized advantage of long weeks aboard troopships with the chance to share experiences with others who had endured the same things. Further to his detriment, he found himself rejected and severely criticized — even blamed for what people saw as wrong with his war. Veterans benefits were often much less and more difficult to obtain. Society was in turmoil and many veterans found themselves the object of ridicule by fellow citizens in their own age group. And so on.

Dr. Goodwin maintains this: “When the (Vietnam) veteran finally returned home, his fantasy about his DEROS date was replaced by a rather harsh reality. As previously stated, WW II veterans took weeks, sometimes months, to return home with their buddies. Vietnam vets returned home alone. Many made the transition in less than 36 hours. Most made it in under a week. The civilian population of the WW II Era had been treated to movies about the struggles of readjustment for veterans (i.e., THE MAN IN THE GREY FLANNEL SUIT, … PPIDE OF THE MARINES, etc.) to prepare them to help the veteran. The civilian population of the Vietnam Era was treated to the horrors of the war on the six o’clock news. They were tired and numb to the whole experience … some were even fighting mad … WW II veterans came home to victory parades. Vietnam Veterans witnessed protests. For WW II veterans resort hotels were taken over and made into redistribution centers to which the veterans could bring their wives and devote two weeks to the initial homecoming. For Vietnam Veterans there were screaming antiwar crowds and locked military bases where they processed back into civilian life in two or three days.

In STRESSES OF WAR: THE EXAMPLE OF VIETNAM by Arthur Blank, MD (1981, THE FREE PRESS, MacMillian Pub. Co.), there is this assessment of wars and how Vietnam compared:

I. Stresses Typical for All Wars:

A. Miserable living conditions B. Fatigue C. Sensory assault D. The fighting itself E. Wounds F. Special stresses of the combat situation:

1. Capture and torture 2. Isolation 3. Acute survivorship (only narrowly escaping death when others were killed) 4. Authoritarian organization 5. Command incompetence 6. The observers (fighting while others merely watched)

II. Unusual Stresses Peculiar to the Vietnam War:

A. Guerilla warfare B. Lack of clear objectives C. Limitations on offensive actions D. Terrorism (“All of Vietnam was a combat zone; what varied was only degree.” E. Climate and topography F. Miscellaneous bizarre physical dangers G. Tropical diseases H. Immersion in an extraordinarily poor Third World society I. Chaos and confusion

III. Psychological Stresses Secondary to the General Political Character of the War:

A. Experience of absurd waste B. Government deceit and misjudgment C. Massive national conflict D. Defeat

From the above it is evident that stresses were much greater for those who actually participated in the fighting. Those who treat PTSD cases are well aware of this, but many veterans assume a need to explain more than they need to. That may have been necessary or a good idea several years ago but much has been gained by the professional since — via the enlightenment provided by the many veterans who have been so far treated.

In the beginning of evaluation and treatment, this might be important for the veteran of heavy combat, since he is the least likely to want to recall bad experiences. It does take time for proper rapport with the psychologist to develop. As Joel Osler Brende, MD states in COMBINED GROUP THERAPY FOR VIETNAM VETERANS, “Even though every combat soldier has been traumatized and harbors the residual effects of that trauma within him, he will be unable to disclose his pain until the right circumstances allow,’and then only gradually.”

Therefore, a determination of the degree of combat a patient has seen not only makes the psychologist aware of the degree of probability that this patient may suffer PTSD but helps him design his approach to dealing with that veteran. Some doctors may choose to employ what is known as The 13-Point Combat Scale.

The scale is a set of ten questions designed to determine how extensive the veteran’s combat experience were. The test/scale was prepared by Drs. Mark Gallop, Robert Laufer, and Thomas Yeager. Although the test is called The 13-Point Combat Scale, a total score of 14 is actually possible. It is, however, highly unlikely that a given veteran would score 14, unless he happened to have been in combat with both the artillery and another combat arm, primarily the infantry. (When the scale was being tested, no veteran scored more than 13 points.)

The test, shown below, simply requires a YES or NO answer to each question. Each question has been assigned a certain numerical weight.

THE 13-POINT COMBAT SCALE

COMBAT EXPERIENCE WEIGHT

1. Served in an artillery unit which fired on the enemy 1 2. Flew over Vietnam in an aircraft 1 3. Was stationed at a forward observation post 1 4. Received incoming fire 1 5. Encountered mines and boobytraps 1 6. Received sniper or sapper fire 1 7. Unit patrol was ambushed 2 8. Engaged VC in a firefight and/or engaged NVA in a firefight 2 9. Saw Americans killed and/or saw Vietnamese killed 2 10. Was wounded 2

MAXIMUM SCORE 14

An answer of NO to all questions results in a “noncombat” classification of the veteran. A score of 1 through 6 is rated as “low combat” while one of 7 through 14 is regarded as “high combat”. A linear, graphic scale may be drawn to visualize where one places according to his combat-experience rating:

—high combat—–

7 8 9 10 11 12 13

0– /– /– /– /– /– /– /– /– /– /– /– /– /– 14

1 2 3 4 5 6

—low combat ——

(The 13-Point Combat Scale is taken from LEGACIES OF VIETNAM: COMPARATIVE ADJUSTMENT OF VETERANS AND THEIR PEERS. This study was done for the Veterans Administration by the Center for Policy Research, Inc. of New York and is copyrighted 1981. The text consists of five volumes with two appendices.)

A high score on the scale does not always indicate that a given veteran will suffer PTSD, nor does a low score rule out that possibility. In general, the more combat, the greater the probability of PTSD and the higher one places may predict a greater severity of the disorders.

There are, in fact, some indications that veterans scoring in the “low combat” grouping may be better adjusted than not only high-combat veterans but also noncombat veterans. In LEGACIES a study of arrests shows that, of men of the same age group, 24% of high-combat veterans and 17% of Vietnam Era Veterans were arrested after service, while only 10% of those in the low-combat group were arrested. As a matter of fact, 14% of nonveteran men of the same age had been arrested — still more than the low-combat veterans.

Some studies reflect another phenomenon: some veterans who served in Vietnam, but saw no combat, apparently returned with more guilt feelings than they who had seen combat because they felt they “didn’t do their part”.

Possibly more surprising is the report that some former war protesters today experience guilt-feelings over not having served. Some admit to admiration for those who served in Vietnam. An example is given by Myra MacPherson in her excellent book, LONG TIME PASSING: VIETNAM AND THE HAUNTED GENERATION (Doubleday, 1984).

She reports that one protestor evaded induction by the inhalation of canvas dust “to revive a childhood case of bronchial asthma.” Years later he is haunted by ambivalence: ” … as I survey my friends and acquaintances who have served, I notice something disturbing that makes me want to rethink the issue. To put it bluntly, they have something we haven’t got. It is, to be sure, something vague, but nonetheless real, and can be embraced under several headings: realism, discipline, masculinity (kind of a dirty word these days), resilience, tenacity, resourcefulness … I’m not at all sure they didn’t turn out to be better men — in the best sense of the word.”

Post-Traumatic Stress Disorders, like most other illness, are not only to be found in veterans of this or that station in life. PTSD is no respecter of education, intelligence, race, creed, socioeconomic level or whatever. Tom Williams, Psy. D. by his experience can represent those veterans who went to war with better-than-average intellect and the attainment of or potential for advanced education, for example. From his case history: he ‘ attended the US Naval Academy and served as a Marine Officer for eleven years, which includes two tours of duty in Vietnam. He has been married and divorced and has remarried. He obtained his master degree, worked in mental health for five years and then obtained his doctorate.

One experience with PTSD symptoms that Dr. Williams had was reported in POST-TRAUMATIC STRESS DISORDERS OF THE VIETNAM VETERAN:

” … (in the winter) of 1979, I was overcome by a wave of poor judgment and saw the movie, THE DEER HUNTER. It was hard to watch the movie, but I white-knuckled it through. The sound of helicopters and the realistic battle scenes were disturbing, but not as disturbing as the metaphor of Russian roulette used to symbolize the constant stresses of combat in Vietnam. I was reminded of the guerilla nature of the war, especially of the continued and heavy use of booby traps by the enemy. The movie brought up more memories and overwhelming emotions than I could handle. At the end of the movie, I was unable to talk. As I walked out, I hoped that someone would jostle me or some kid usher would tell me to go out a different exit than I intended so I could express my rage at him.

“When my wife and I arrived at the car, I got in the passenger side, knowing full well I couldn’t drive, and cried deeply and uncontrollably. All I could say was ‘those poor fucking kids’ over and over again between my sobs. My wife made an excellent therapeutic inter-vention by taking me to a loud bar and buying me a taco and a beer. We talked. It helped, but I remained confused about being so completely overwhelmed by such a multitude of emotions.”

The date of the quotation tells us that Dr. Williams’ reaction to war stresses is delayed. His reaction was, typically, brought on by war related stimuli: the sound of helicopters, realism in battle scenes (and sounds), and even the symbolism of the guerrilla warfare. He experienced rage. His emotions became unmanageable. There is probably survivor guilt evidenced by his feelings about the children. He also experienced the common temporary loss of the ability to function (couldn’t drive).

Dr. Williams could not be classified as an average person, yet he does share the common experience of PTSD symptoms as described. But the doctor who evaluates the prospective sufferer of PTSD will also concern himself with differences as well as similarities his patient exhibits with relation to other veterans.

Again, a big difference among us is whether or not a veteran has seen combat and this difference has certain implications. From page 43 of LEGACIES: “Our findings demonstrate that Viet Vets exposed to combat generally feel the war had a negative psychological effect. Of the majority who feel the war had a positive effect on their lives (a mating effect, for example), many still emphasize traumatic wartime experiences. Most important, we find that combat vets continue to have significantly more psychological and behavioral difficulties than Vietnam Era Vets, Vietnam Vets not exposed to combat, or nonveterans.”

The same source also states that “only one-quarter of Vietnam Vets believe the war had little,or no effect on them. Vietnam Veterans not involved in combat are much more likely to make this assessment.”

How one recalls military life is also dependent, in general, on the category to which the veteran belongs. From page 30, vol. 1 of LEGACIES: I’VEVs recall service primarily in terms of pleasant experience (78.8%), while 70% of Vietnam Veterans recall the negative primarily, especially combat, and the greater the involvement in combat, the more likely memories of battle would be cited.”

No veteran is a perfect “classic” PTSD case. Whether one will suffer PTSD experiences and to what degree is dependent on many factors –basic personality and life experiences must be taken into account as well as combat service and its intensity. Because of factors other than combat, then, it is possible for the veteran of extreme combat to survive the war and the aftermath with even fewer adjustment difficulties than will some veterans who saw much less action. The reverse is also true. Family histories do enter the picture.

LEGACIES reports (p. 47, vol. 1): “Men from the most stable families are likely to develop stress reactions in response to heavy combat. Men from average families are more likely to develop stress reactions after exposure to even low amounts of combat. Men from the least stable families may develop stress reactions simply in response to daily life stressors, exposure to combat does not greatly affect their level of stress reaction.”

Further (p. 48, vol. 4 of LEGACIES): “We have found consistently that men who were sent to Vietnam, but were not involved in combat at all, score lower on the Stress Scales than any other men in our sample. This holds true regardless of race, most levels of family stability, and parental class. We reason that such men found clerical and bureau-cratic positions well removed from the possibility of being subjected to hostile fire. In their terms — though perhaps not in the terms of the military — they were a ‘success’. Further, when they compared their distress to that of other men they knew in Vietnam, they had to judge themselves as being much better off. Similar findings with respect to ‘relative deprivation’ were reported in the classic study of World War II troops in THE AMERICAN SOLDIER (Stouffer et al, 1949).”

There is this with regard to race: Myra MacPherson reports, “By the mid-sixties the racial and class inequities of the Vietnam war were scandalous. Gen. S. L. A. Marshall… commented, ‘In the average rifle company the strength was 50% composed of Negroes, Southwestern Mexicans, Puerto Ricans, Guamanians, Nisei and so on. But a real. cross-section of American youth? Almost never.”‘

MacPherson goes on to say, “In 1965 blacks accounted for 24% of.all Army combat deaths. As black leaders publicized the plight of blacks in Vietnam, the Department of Defense reduced the minorities’ share of the fighting — to 16% in 1966 and 13% in 1968.11

Some psychologists have established that blacks who experienced a degree of combat equal to that of whites tend to suffer fewer PTSD-type problems or possess them to a lesser degree. The explanation offered is that blacks who came from more deprived areas and lives were most accustomed to handling trauma. Yet this seems incompatible with the findings which deal with family stability.

Another finding that seems to run contrary to the common sense expectation is the prevalence and severity of PTSD in the severely wounded and disabled of the Vietnam War. These men tend, as a group, to suffer less from PTSD.

This is the finding offered by Dr. Goodwin: “It is important to note an interesting trend… it has only been on rare occasions that we have interviewed significantly disabled veterans, suffering the loss of a limb or another wound that required months or even years of hospitalization. … We have concluded that significant numbers of severely disabled veterans received much more comprehensive care after their combat experiences. In particular, this included close emotional support from other veterans on the hospital wards regarding their own combat emotional experiences. This, in turn, helped the seriously disabled veterans find some final solution to their feelings about Vietnam. It also included a more empathetic understanding of the physically wounded veteran by the VA, which had learned about wounds and their concomitant psychological problems in WW II. Subsequent support and training to help these veterans to readjust,to their losses was also provided. The veteran who was not seriously physically wounded had no such resources, hence the apparently smaller incidence of post-traumatic stress, chronic and/or delayed, in severely disabled veterans of Vietnam.”

This last finding does seem to encapsulate the conditions that made PTSD so rampant among our returning combat veterans of Vietnam. Very simply put, the lack of caring coupled with the inability of the veterans to rid themselves of their emotions at an early date provided very fertile soil for the growth of severe problems.

With this understanding comes a solution. Proper treatment in light of the causes. Such assistance is available in several forms. But it is up to each veteran to recognize his situation and acutely seek help, whatever program he may eventually choose.

(VVNW, Inc.)

For Some War Veterans The War Never Ends - PTSD

Post Traumatic Stress Disorder is a mental disorder. I was first diagnosed with PTSD in 1994, but it wasn’t until a psychotic episode in 1999 that I finally had to admit…admit that I had a mental disorder.

The traumas that cause PTSD are as unique as the individuals suffering from the disorder. A friend of mine just recently survived a terrible auto accident. She currently complains about living in a fog, that nothing makes much sense to her right now, and that she has trouble concentrating. These are all symptoms of Post Traumatic Stress Disorder.

Any fearful trauma can produce symptoms of PTSD. I remember being in a tornado a few years back, and for the longest time, any wind, and I mean any wind, would send tremors through my body.

PTSD can be either acute or chronic; the acute phase occurring directly after the trauma, while the chronic phase can come along much later. In the acute phase, PTSD is said to be treatable and curable. In its chronic phase, it is only treatable. One must learn to live with it and to cope with it.

This paper is designed to demystify this newly named disease (it’s been around for centuries, but named and recognized by the American Psychiatric Association in 1978 as an official mental disorder, allowing patients to receive the treatment they needed), to list some of its symptoms, and to help you to help someone else, should you suspect they have a problem. This last part, helping someone, is not meant to be construed that you can help cure them, but rather you can direct them to caregivers who can help them. A person with a mental disorder is usually the last to know. Greater than one third of Vietnam Veterans suffering from PTSD were diagnosed after being released from jail.

Some of you will see yourself within these paragraphs. Enjoy the liberation.

This paper is also very personal. Some of what I’ve learned about this disorder pertains to all PTSD sufferers, but most of what I’ve learned pertains to the trauma of war. I am a Vietnam Veteran. I flew Cobra Gunships in Vietnam. After a recent episode in which I had been turned into a babbling, stuttering idiot and locked up at the local Veterans Hospital, I spoke with my sister-in-law. She told me that I was the only returning Nam Vet she knew who laughed at it all; who made jokes of it. When I look back, it seems that that was how I dealt with it, how I’d stuffed it.

My family doesn’t know this, but on my first Thanksgiving in civilian life I attempted suicide. I had attended a party with some friends from high school. It hit me that evening that they were all still in high school while I was a few generations older. On my way home, I had my first anniversary reaction (I will explain these later); while listening to the heavy marketing for Christmas on the radio, I couldn’t shake the thought of all those kids who were going to get “daddy in a box” for Christmas this year, and all those kids who got “daddy in a box” on previous Christmases, and I unlatched my seatbelt, sped up to 60 miles an hour on a city street and aimed for a tree. The curb bounced me back onto the road, I spun around a g’zillion times in the thick new snow, jumped the curb, and hit a tree nearly one block away from my original target. I totaled my car and bumped my head. After that, figuring that I had survived that for some unknown reason, I went on with my life and “stuffed” it. Some twenty years later though, it slapped me upside the head, and now it’s here to stay. However, and this is a very important point, I have PTSD; PTSD does not have me.

So before we take a look at the symptoms, the results of this disorder, you might first like to view a few facts about war related PTSD that I’ve gleaned from the past five years (of therapy).

What is learned in combat is never, ever forgotten.

PTSD was once called Shell Shock, something soldiers got from battle, or from “being shelled.” It wasn’t until the eighties, when the name changed to Post Traumatic Stress Disorder, that others who had not been in battle, but had been the victims of car accidents, domestic abuse, rape, incest, or other traumas that these people finally got the help they needed and the disorder was clearly defined and studied. What is learned in trauma is never forgotten.

Per capita, more Vietnam Veterans suffer from chronic PTSD than from any other war. There are lots of theories as to why this is, including the simple fact that we fought an unpopular war and were never given the welcome home other soldiers received, at least not until recently. It was the first war America had lost, and many Vietnam era veterans received initial scorn from veterans of previous wars. However, there were fewer cases of acute PTSD in Vietnam, attributed to the fact that every soldier knew the day he was coming home, thus the countdown (“Short” meant the soldier had a short time left in country) to the day he’d return, and the subsequent “stuffing” of their trauma while counting down. Following a battle in WWII, 17% were afflicted with acute PTSD, while in Vietnam only one percent were afflicted, debilitated.

In WW2, soldiers fought a battle, on the average, twice a year. In Korea, our soldiers fought a battle, on the average, between two and three times a year. In Vietnam, our soldiers fought a battle every three weeks.

People with PTSD are famous for self-medicating (drugs, alcohol), however, ex-soldiers have an additional addiction that often lands them in trouble, or jail: an addiction to adrenaline. We love danger, even when trying to avoid it. Deep down inside, we love adrenaline. I remember an ex kissing me goodbye (the old last kiss) and sending me out into weather I wouldn’t send an enemy into: deep snow, I lived in the country, no chance of finding a plowed thruway. The average person would have gone to a motel, but not I; to me the entire ride home was the most exhilarating ride I’d taken in years (I had no cell phone, there was no other traffic on the roads, I didn’t even have a thick jacket, the storm had hit unexpectedly). I was so high from the adrenaline (knowing that every turn could be my last) that it took me 6 hours to come down after the ride home.

It has recently been learned that prolonged stress actually changes a person’s brain chemistry. PTSD is a physical disease. There is no escaping it. Even if most of the symptoms are suppressed, a person with PTSD will make all his/her decisions through the veil of this disorder, simply because one’s brain chemistry determines one’s thought patterns.

The Time Bomb

Inside every person with PTSD is a time bomb. It is merely a matter of time before symptoms begin to show up. One might exhibit all manner of symptoms in nearly everything s/he does, and still live what appears to be a normal life. However, it doesn’t take much to bring out full-blown symptoms of a full-blown case of PTSD.

Retirement: the kiss of death. Many World War II soldiers lived nearly normal lives, up until they retired. Within weeks of retiring, many WWII vets suddenly started showing up at the VA hospitals exhibiting symptoms of PTSD. Keeping busy (like writing this paper) keeps the symptoms down. Free time (and worry) exacerbates PTSD symptoms.

Additional Stress: Stress kills; we know this. Additional stress in the life of a PTSD sufferer will bring out their PTSD symptoms. Even good stress can increase one’s symptoms; good stress such as a birth, or a new love, or a promotion at work. Anything that wobbles the apple cart—little changes, big changes, good changes, bad changes—will promote PTSD symptoms. Then there are the huge stressors; the larger the stressor, the more virulent the PTSD symptoms.

Reminders: anything that reminds the PTSD sufferer of the original trauma will pique symptoms. This includes odors, sounds, and sites. Additionally, the anniversary of a trauma will cause a rise in PTSD symptoms. Many soldiers dread holidays, for during their service, some of the days they remember most vividly were the holidays (sometimes, it was only on a holiday when a soldier knew what day it was). If a woman was assaulted near an elevator, elevators will trigger her symptoms. If she remembers the date of her assault, as the anniversary approaches, symptoms increase.

Now, let’s take a look at the actual symptoms and results of PTSD.

Anger

I know of no more disagreeable situation than to be left feeling generally angry without anybody in particular to be angry at.
Frank Moore Colby

Persons with PTSD hold in a lot of anger. It is a free-floating anger with no real target and very subtle causes. It simmers below the surface and can jump out at inappropriate times, aimed at the wrong person for the wrong reasons (displaced anger).

Following a rape, the rape victim is filled with rage. The specific targets of this rage are quite obvious: the rapist, the system that puts the victim on trial, the doctors for their insensitivity, and the list can go on depending on the ordeal the rape victim endures. However, years later, this anger can still exist, simmering just below the surface. And though many argue that the cues to the anger have changed, that the original incident has softened in the mind of the sufferer, that this, that that—it’s all “neither here nor there” because there is no logic, no reasoning in a mental disorder: with chronic PTSD, everyone and everything is the cause, and the nearest person or object can be the target.

Flashbacks/Hallucinations

A hallucination is a fact, not an error; what is erroneous is a judgment based upon it.
Bertrand Russell

Common to all PTSD sufferers are flashbacks. The longer the trauma lasted or the more powerful the trauma, the more intense the flashbacks. Hollywood flashbacks and real-life flashbacks are very different from each other. Whatever you see coming from Hollywood, is just that, a creation of Hollywood. In real life, it’s hard for someone suffering PTSD to explain their flashbacks, and since they do not conform to what is viewed in the movies, they are not easily identified as flashbacks. Personally, I oftentimes have auditory flashbacks: I hear the jet engine whistle. When I see helicopters, I smell the JP4, the fuel.

Hallucinations and flashbacks are related, though one can have hallucinations that go beyond flashbacks. When Christmas comes around, my anniversary, I begin to see muzzle flashes off to the right in the periphery. Additionally, I’ve heard screaming “Receiving fire! Receiving fire!”

After a while, one gets used to these flashbacks and hallucinations. Doctors put us on anti-psychotic drugs to eliminate them, however, the side effects of the drugs are horrible, and the actual hallucinations, after a time, really amount to nothing; in fact, we get used to them. At a class on Grief and Loss, I was once told that I might have to deal with loss one day when the hallucinations went away. It seems ludicrous, but we get used to them, and miss them when they are gone.

Fear

There is no terror in a bang, only in the anticipation of it.
Alfred Hitchcock

For a long period of time after I had lived through a tornado that ran its course directly over my head, the slightest wind sent shivers through my blood stream. A rape victim suddenly has half the population to fear as every man becomes a potential rapist.

However, years after the trauma, the fear still exists, and like the anger, it has no specific cause. Fear of fear of fear of….

Having studied the martial arts and feeling sufficiently skilled to defend myself in any situation, I have conquered a specific fear. I fear no man. Once a fear is conquered, it never returns. However, a PTSD sufferer lives in constant fear and oftentimes this fear is diagnosed as paranoia; it is a general fear that never goes away and sits insidiously beneath the surface.

It can be argued that fear is the basis of one’s anger; that it is the basis of all other symptoms. Perhaps, but most important is knowing that every decision, every action of a person suffering from PTSD has some fear in its motivation, in its execution.

Dread

It is a time when one’s spirit is subdued and sad, one knows not why; when the past seems a storm-swept desolation, life a vanity and a burden, and the future but a way to death.
Mark Twain

Once during a group session, one fellow said, “I have the feeling that I’m going to die in six months.” Eyes throughout the room widened; you could even hear the hard swallows. I spoke up: “My God, I’ve felt that way for years!”

Because soldiers know death intimately, we are consumed with death. A friend or a lover calls and says s/he’ll be over in fifteen minutes; when s/he is five minutes late, the PTSD sufferer is convinced s/he is dead on the highway.

There is a French phrase: Partir c’est mourir un peu. To part is to die a little. Whenever I went away, I assumed I would never see my loved ones again. This wasn’t a conscious, active thought, just something packed away nicely down under the surface. I’m going to die, they’re going to die, we’re all going to die; we will never see each other again.

Every little pain is cancer. Heartburn is a heart attack. A skin rash is skin cancer. A sore throat is actually throat cancer, a burgeoning tumor about to cut off my air supply and viscously choke me to death. I will not make it six months. I’m going to die.

Having thoughts like these can cause some very dangerous behaviors. I am reminded of a sixties TV program called “Run For Your Life” starring Ben Gazara. He’s told by his doctor he has two years to live and so he vows to live every remaining moment of life to its fullest, risking everything; afraid of nothing: he races cars, climbs mountains, etc. Well, imagine, just imagine all the Vietnam Veterans out there with adrenaline addictions who believe they have six months left to live: check out your jails and prisons; that’s where they’ve landed. This is a very deadly combination, producing some very dangerous behaviors.

Hyper-Vigilance

My apprehensions come in crowds;
I dread the rustling of the grass;
The very shadows of the clouds
Have power to shake me as they pass:
I question things and do not find
One that will answer to my mind;
And all the world appears unkind.
William Wordsworth

It is very hard to get some of my friends to go out in public with me. Veterans suffering from PTSD feel unsafe in crowds, especially Vietnam Veterans, since the enemy was all around. During the day they cut your hair; at night they cut your throat. At any moment, at any place, someone could walk up to you and drop a hot grenade in your lap. Those soldiers who’ve had to secure an area and watch for “Charlie” will never, ever stop watching for Charlie.

My situation is different from those who were in the infantry. I too am hyper-vigilant and somewhat paranoid (always checking out the window for intruders), but I’m not as security conscious. In my job as a gunship pilot, if I found something I didn’t like, I killed it. Infantry people sometimes never saw the enemy; never saw the muzzle flashes of the bullets whizzing over their heads. Their fears were ubiquitous and overwhelming at times, as all they saw where the bodies of their buddies being ripped apart.

If you walk up behind an ex-infantry person and tap him on the shoulder, you’ll see him leave the ground. Most of my friends sit near a wall or right up against it. They sit near exits. They are constantly on guard; their “startle reflex” is heightened. Danger lurks everywhere.

Anxiety

In a world we find terrifying, we ratify that which doesn’t threaten us.
David Mamet

Add up the fear, dread, and uncertainty, mix in a few flashbacks and hallucinations, and you have yourself the groundwork for some full-blown anxiety attacks. However, on the positive side, one’s anxiety level can be a determination of what else is happening inside of the person suffering from PTSD.

We learn in Symptom Management classes our own individual symptoms, which ones to watch, and what to do if they increase. One chief symptom (common to everyone) is our overall anxiety level, for this can be a barometer of our PTSD in general. When anxiety attacks are frequent, all our PTSD symptoms are on the rise. Thus, being aware of one’s anxiety level is one good way to keep one’s PTSD in check, or know when to check into a hospital for help.

Intimacy Issues

It is impossible to go through life without trust: that is to be imprisoned in the worst cell of all, oneself.
Graham Greene

Again I must repeat: What is learned in combat, is never, never forgotten. Who can a soldier ever trust as much as he trusted his buddy with him in that foxhole? Or that pilot, who knows that the enemy is dangerously close, yet his deadly fire is accurate, on target, and no friendlies need worry?

And who can I ever trust as much as I trusted my wingman, or my co-pilot?

In real life, if someone says they’ll be over in fifteen minutes, who cares if they’re a half-hour late? In combat, seconds count. No pilot is fifteen minutes late on target. No artillery is fifteen minutes late on target. And if a buddy doesn’t show up in fifteen minutes, you go after him.

Lacking trust places barriers between us and our partners, and there is still another barrier: we learned that we lose those we get close to.

There are two immutable rules to war:

People die.
You can’t change rule # 1.
So when we get home, we have trouble getting close again, because eventually the people we get close to will die.

Your wife will die; your kids will die; everyone eventually dies. Normal people accept this intellectually, but can never feel it as personally or as immediately as a combat veteran does.

It is very difficult for combat veterans to be intimate again, very much like a victim of rape. Fearing intimacy and needing intimacy can lead to superficial relationships, one night stands, multiple partners, and extra-marital affairs.

It’s all very complicated, very ingrained, and very hurtful to someone who does not understand, someone who wants to throttle the PTSD patient and scream at them: “Hey! Get over it!”

We all wish it were that easy, believe me.

Drug and Alcohol Abuse

Addictions do come in handy sometimes: at least you have to get out of bed for them.
Martin Amis

It seems much easier to deal with a problem when you’re stoned out your mind. At least it seems so. In reality, one’s PTSD symptoms are aggravated using drugs and alcohol. Your best psychologists cannot deal with or work with someone who’s been drunk or stoned for a month; the patient is unresponsive and unmotivated. Chemical Dependency classes are in order before any sort of talk therapy will do any good.

One unique facet to the war in Vietnam was the number of addicts and alcoholics who returned to the states only to have to deal with this problem. Most soldiers pick up an adrenaline addiction that can cause some very dangerous behaviors, however, a drug or alcohol problem is another slow and painful death, whose process exacerbates and stimulates all other PTSD symptoms. Alcohol, drugs, and adrenaline are the deadliest of combinations. Graveyards, jails, and prisons are full of Vietnam Veterans who’ve suffered these addictions.

Avoidance/Immersion

Of all the…alternatives, running away is best.
Chinese Proverb.

Diagnosing PTSD means determining the patient’s attitude toward the original trauma. A soldier with PTSD will do one of the following: he will either avoid everything that has anything to do with the military, the war, etc, or else he will immerse himself in those very same things.

I have an acquaintance who comes home every night and plays the video Platoon. Myself, after one visit to a VFW club and a less than warm reception, I never went to anything remotely associated with the military or the war until my diagnosis 5 years ago. However, it was certainly always on my mind, for someone once pointed out to me, not long before I was diagnosed, that I had issues with Vietnam because within five minutes of meeting me, people knew I was a Vietnam Veteran.

Of both behaviors, immersion is the least healthy. It can aggravate symptoms, cause flashbacks, and send one right back to the war (in their heads). Those who avoid those things reminding them of their experience are much healthier, even though this is a symptom of their PTSD; it is a healthy symptom.

Sleep Disorders

Sleep is a reward for some, a punishment for others.
Isidore Ducasse

Psychologists working with wives and partners of combat veterans usually caution them about their method of waking the veteran. From across the room, is usually the best way. We don’t want to startle a sleeping combat veteran, especially since most veterans return to combat in their sleep.

Many combat veterans need to sleep in separate beds, sometimes in separate rooms. They fear they will hurt their loved ones during a terrible dream. Personally, I’ve been lucky here. Having been a pilot, I never slept in the bush, was always on a base with good security, and only once when I wasn’t, I was lucky enough to come down with a migraine headache and the corpsman administered a hypo that knocked me clear of reality (on a night we were expecting to be overrun). Personally, I sleep better with a partner in bed with me, or at least someone in the house making noise.

Infantry soldiers are acutely aware of security. Many combat veterans have trouble falling asleep or staying asleep when they do fall asleep. There are many sleep aids prescribed for these disorders, and since every drug affects every person differently, it is best not to self prescribe or use someone else’s medication.

Even when a PTSD sufferer gets to sleep, normal sleep is no guarantee; they suffer night terrors, nightmares, and night sweats. I have gone two weeks sleepless, only to grab a couple of hours when the housekeeper arrived and banged pots around in the kitchen. I guess I felt that someone was there to watch over me and I could at least grab a couple of hours.

Any possible night time disorder you can think of has occurred to a patient with PTSD. Though I was never an infantry soldier, escape and evasion was always in the back of my mind as a pilot, and twice in recent years have I awoke, naked, and crawling in the snow. I’ve been forced to lock my doors and take other measures to keep myself from freezing to death on a nighttime excursion.

Guilt

Guilt always hurries towards its complement, punishment; only there does its satisfaction lie.
Lawrence Durrell

During war, we do things we are not proud of. Some soldiers have done things they can never mention, even to their therapists, because they seem so horrible. Guilt is an interesting emotion, for it even shows up in rape and incest victims, as if they were somehow the cause of their abuse. This fits into the frame of the above quotation; for many victims of abuse feel as if the abuse was their punishment for doing something (some unnamed thing) wrong.

The question is this: Can a person kill someone and walk away guilt free? Sure, we can rationalize our actions: we were only doing our duties (doesn’t seem to work for war criminals); we were actually saving American lives; it was him or me; etc. etc. etc.

What if we enjoyed killing, much like the quarterback enjoys the game, that feeling of success when he puts that pigskin on the numbers? As soldiers, we were highly trained killing machines. We performed like well oiled machines, proud of our expertise, proud of our skills. The war demanded results and we each kept track of how many confirmed kills we could rack up. Can a person kill 50 enemy, come home, sit at a desk, and go on working as if nothing ever happened? (For an essay on this subject, read “It’s Only a Game.”)

In the movie “The Meaning of Life” by the Monty Python group, one soldier, lying across the barrel of a cannon, slightly wounded, but having just killed 15 Zulus states: “Back home they’d hang me, but here they gimme a fuckin’ medal!”

Another form of guilt, one which I denied for the past 5 years, that is until some 30 year old repressed memories came back is Survivor’s Guilt (Survivor Guilt). “Why did I, with no wife, no kids, make it out alive when my friends who had wives and kids didn’t?”

Or what about those who, out of 30 or 60 men, were the only ones standing after the battle? Why were they singled out to survive?

When something lousy happens to a combat veteran, a car accident, a job demotion, a failed marriage, it all fits into the big picture; the veteran feels he deserves such lousy luck, such lousy outcomes, because he feels guilty.

Memory Loss/Cognitive Dysfunction

The effectiveness of our memory banks is determined not by the total number of facts we take in, but the number we wish to reject.
Jon Wynne-Tyson

Memory loss, the inability to “think straight,” the feeling that one is lost in a fog: these are the most salient features of PTSD, the most common complaints. Right after the trauma, the fog rolls in and it is at this time that the patient must seek immediate help, because it can only get worse.

In group, one common thread, one common expression is: “Did it really happen, or did I dream it.” The war is far away now. What we all did there is far away. Did it really happen? Pieces, huge chunks are missing. There isn’t a one in my group who doesn’t complain of CRS (Can’t Remember Stuff) on a regular basis.

Additionally, should one of us lose it, go off and have a psychotic episode, memory loss is a given and subsequent cognitive losses can also occur.

This was brought home recently to your author, who, after having a particularly bad anniversary reaction, wound up in the VA hospital, a babbling, stuttering idiot. While there, I’d forgotten I’d had a fiancée, the woman who a month earlier, I had intended on marrying. I’d forgotten nearly everything associated with her. I’d forgotten my own phone number, and when prompted for my Military Signature, I had to ask, “What’s that?” I was told that it was my signature with a middle initial (yes, I remembered when told). I began writing my signature, and stopped. I looked up, shaking, “What’s my middle name?” I pulled out my wallet and looked at my driver’s license; the nurse asked, “Well, what’s your middle name?” to which I responded, “Apparently, it’s Bruce.”

A few days later, in the computer lab, I found an IQ test. I took it, answered all the questions to the best of my ability, summed her up, and whammo, a kick to the groin: my temperature was a half a point higher.

In a recent test, my IQ has risen somewhat. I expect to get most of it back, most of my cognitive ability back, but there will always be some loss, I am told.

Though memory loss and cognitive dysfunction are common to sufferers of PTSD, how it affects us, when it affects us, and to what degree it affects us varies from person to person. I brought up in group once that I’d sat down to pay my phone bill at 9:00 o’clock in the morning. At 5:00 o’clock in the afternoon I’d stuffed it in the mailbox. The entire day was spent trying to pay the bill because I had gotten off on a tangent. I had MCI (5 Cent Sundays) as my long distance carrier. I’d made one call to Virginia, under a minute, and the total bill was $5.96. I spent the day contacting long distance carriers, talking to friends about long distance carriers, and at one point, totally exhausted, I had to take a nap. After relating this story to the group, the psychologist who ran the group stated that this is a common theme in PTSD. We often spend more time on the periphery of a problem than on the problem itself. This is one reason many of us are unemployable.

Memory loss is sometimes a good thing, especially when the memories are painful. However, they don’t always last forever. Repressed memories can eventually come back, though they don’t hurt as much as we’d expect and oftentimes help us clarify our experience. It has been said that God never gives us more than we can handle. This is a good thing, I am sure.

Sometimes it is hard to understand why this memory or that memory is lost. Especially when the incident is not significantly harmful and sometimes it is absolutely benign. I recently met with a woman I’d dated during my first large anniversary reaction, the one preceding a trip to the VA and a subsequent diagnosis of PTSD. We had lunch together. I had to tell her that I did not remember her at all. She told me how we’d spent the New Years; watching a movie (that I to this day want to see), and playing the guitar. I just do not recall a single second of our time together and perhaps never will.

Because we tend to “stuff” our feelings about something, a common masculine trait (though women under stress will do the same), we also, eventually, forget what it is we stuffed and why we stuffed it. There are techniques used by psychologists to pull these memories back to consciousness, however, this isn’t always as productive as it would seem. Some things are just better left forgotten, or left to return in their own time. But as my ex-fiancée’s coffee mug states: Of all the things I’ve lost, I miss my mind the most.

Intrusive Thoughts

Once upon a midnight dreary, while I pondered, weak and weary,
Over many a quaint and curious volume of forgotten lore,
While I nodded, nearly napping, suddenly there came a tapping,
As of some one gently rapping, rapping at my chamber door.
“‘Tis some visitor,” I muttered, “tapping at my chamber door-
Only this, and nothing more.”
Edgar Allen Poe

This symptom of PTSD really belongs above under Cognitive Dysfunction, for intrusive thoughts are an underlying cause of cognitive dysfunction: How can a person maintain a line of thought when constantly being bombarded with unwanted, intrusive thoughts?

The frequency and intensity of intrusive thoughts can be a barometer of a PTSD sufferer’s overall mental health, and the patient (and those around him) should be aware of any changes as this might call for a trip to the doctor. The frequency of intrusive thoughts can increase during anniversary periods, after watching a movie that brings back memories, after a flashback, or after anything that revives unwanted memories in the patient’s mind.

Interestingly enough, the content of the intrusive thought need not be from the original trauma, though most of the time it is. Like the ex-smoker who takes up chewing gum and is suddenly a gum addict, a patient with PTSD can substitute, at a subconscious level, a whole slew of ideas, imaginings, or obsessions aimed at keeping away those original traumatic thoughts. This has caused the PTSD patient to oftentimes get an early diagnosis of Obsessive/Compulsive Disorder or OCD; the substituted thoughts have completely taken over; masking the original thoughts and tricking even the patient into thinking they are no longer the problem, but that these new intrusive thoughts are. If these new obsessions are delusional, the patient is teetering.

Patients with solid families and healthy therapeutic techniques picked up from classes such as Symptom Management, when hit with these thoughts can usually pull themselves out (with a little help), by merely changing what they were doing when the thoughts came on. A wife can suggest a walk, or a trip to the Mall or, a night out together. The patient might suggest a trip to the park with the kids to play in the sun, or slide down some slopes in winter time. The secret here is to find something else to focus on, something else to do. Keeping busy is very healthy.

Depression

My depression is the most faithful mistress I have known—no wonder, then, that I return the love.
Søren Kierkegaard

Given all of the above, is it any wonder that most people suffering from PTSD also suffer from depression?

Luckily, depression is very treatable, and can be controlled with drug therapy, talk therapy, and a loving, safe environment.

Summary

Chronic Post Traumatic Stress Disorder is treatable but not curable (though this is debatable). One learns to cope with it, learns what stimulates and exacerbates the symptoms, and learns what to do when the symptoms get out of check, hopefully before they get out of check.

There are many ways of learning to cope with PTSD whether you suffer from it or your partner/spouse suffers from it. As a spouse or partner of a PTSD patient, learning love and patience is the first step to helping your partner: you didn’t cause it nor can you cure it, but you can support your partner and lead your partner on the right path to healing.

Partners should attend everything associated with PTSD they can. There are not as many classes available to the partners of patients as there are for the patients themselves, but if you look around you will find them.

For the patient, taking classes in Symptom Management, Anger Management, and attending rap groups is a way of keeping one’s symptoms at bay. Knowing when to reach out for help, is a second strategy; one to fall back on when the others don’t work.

Practicing Bio-Feedback, relaxation, Tai Chi, meditation have an enormous healing power for the PTSD sufferer. I’ve often told people that if it wasn’t for Tai Chi and meditation, I’d have off’d myself long long ago.

EMDR is showing some promise; studies are currently being conducted at the VA hospitals and as soon as the findings are released, we will post them here along with an article explaining/discussing EMDR.

Many new treatments are being studied as I write this. But the simplest and most straight forward means of dealing with PTSD is to be aware of one’s own mental condition, have a place to go, and have a friend to call when everything seems to go wrong.

Normal people get warm, then angry, then angrier, and progress to a state of rage if the stimulus to the anger is not abated. A PTSD sufferer can go from A to Z immediately, especially if s/he’s an ex-soldier. Soldiers are taught to react. They are not taught to think, deliberate, or discuss. They are taught to react, because during war, the distance between life and death is measured in milliseconds and centimeters. When anger strikes, it quickly turns to rage.

Anger Management classes are usually prescribed for PTSD patients, however, the patient might still never arrive at the cause of this anger, as the original cause has faded, leaving only the anger. Learning to deal with this anger is much more productive at this juncture than trying to discover its cause or causes. In a good Anger Management class, the PTSD sufferer can learn that one cannot control one’s initial feeling about something aggravating, however, s/he can control her/his reaction.

Being the target, displaced or not, of this anger is one of the major causes of “secondary PTSD,” the disorder suffered by those close to the PTSD sufferer. Oftentimes families walk on eggshells to avoid doing anything to upset the PTSD sufferer. Children, wives, and lovers tend to withdraw and avoid any and all possible confrontation. Ironically, simply talking about it; sitting down to have a family discussion and bringing their issues to light often relieves the tension PTSD has caused. Partners of PTSD patients must keep alert and note when the anger outbursts increase in intensity and the intervals between them shorten. This is a sure sign that there is something else occurring within the patient and a trip to the therapist is needed.

PTSD Sri Lankan Experience by Dr Ruwan M Jayatunge

Just as the body goes into shock after a physical trauma, so does the human psyche go into shock after the impact of a major loss. -Anne Grant

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 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.

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 2^nd 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 2^nd 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 26^th 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%.

30 year War in Sri Lanka

Sri Lankan conflict was one of the longest armed conflicts of the 20^th 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.

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%).

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

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.

Please send your comments to - ruwanmjayatunge@gmail.com

(Dr Ruwan M Jayatunge studied at Nalanda College Colombo and Graduated from the Vinnitsa National University Ukraine and received his basic psychology education at the Barnsly College United Kingdom. He was trained in EMDR Psychotherapy at the Coatesville VA Philadelphia USA.
He worked in the Ministry of Health Sri Lanka as the Focal Point in Mental Health in Puttalam District. At present, he is furthering his education in Canada.)

The History of PTSD by Dr Ruwan M Jayatunge M.D.

“The symptomatic picture presented by traumatic neurosis approaches that of hysteria in the wealth of its similar motor symptoms, but surpasses it as a rule in its strongly marked signs of subjective ailment . . . , as well as in the evidence it gives of a far more general enfeeblement and disturbance of the mental capacities” – Freud

PTSD is a relatively newly defined disorder with an old history and historical medical literature reveal clinical symptoms similar to post traumatic stress disorder dating back to the Egyptian civilization. In 1900 BC, an Egyptian physician eloquently described hysterical reactions of a patient after traumatic experience. These reports became one of the first medical textbooks ever when published in 1990 B.C. (Figley, C.R., 1993).

PTSD Described in the Holy Bible

The Book of Job in the Holy Bible is a heartbreaking story of human trauma. Job was subjected to extreme suffering, los of material possessions and psychological anguish. Job’s s story describes the nature of emotional suffering.

This Biblical story has a great importance in human response to trauma. Carl Jung in his 1952 book Answer to Job analyzed the psychological components associated with the book of Job. Jung was on the view that Job’s story as a landmark development in the “divine drama.

As Dan Mathewson postulates Job, deals with the trauma of suffering, attempts to come to terms with a collapsed moral and theological world, and eventually re-connects the broken pieces of his world into a new moral universe. (Dan Mathewson – Death and Survival in the Book of Job Desymbolization and Traumatic Experience).

Job was deeply shattered by the trauma fell upon him. He desolately expresses self-pity and troubled by the intrusions. He feels hopeless and his mental agony is similar to one who suffers from PTSD. Probably the biblical character Job meets the criteria for PTSD.

In their research article The Book of Job: Implications for construct validity of posttraumatic stress disorder diagnostic criteria Clifford Haughn Quincy (College, Massachusetts, USA ) and John C. Gonsiorek ( Department of Psychology, Argosy University/Twin Cities, Minnesota, USA ) argue that there is a high ratings of congruence between descriptions of Job’s reactions and symptoms of PTSD described in DSM-IV-TR.

The book of Job is a great acknowledgment of human trauma and resilience. The main essence of the book of Job is in spite of trauma, pain and disappointments in life, there are reasons to celebrate the human existence.

War Trauma described in the Mahabharata

Mahabharata, an epic tale in Indian mythology originally written by Sage Ved Vyas in Sanskrut. Mahabharata illustrates the Great War of Mahabharat between the Pandavas and the Kauravas happened in 3139 BC. Although many believed, that Mahabharata was a fable the archeological discovery of the ancient city of Dwaraka, situated on the extreme West Coast of Indian territory by Dr. S.B. Rao, Emeritus Scientist of the National Institute of Oceanography provided credence to the legend of Krishna and the Mahabharata war. The great epic Mahabharata describes vivid combat stress reactions exhibited by the ancient worriers.

The horrendous combat events described in Mahabharata (translated by Dr P.V Vartak)

On the 14th day of the Mahabharat War, i.e., on 30th October a similar phenomenon took place. Due to the October heat enhanced with the heat of the fire-weapons liberally used in the War, the ground became so hot that the layers of air near it were rarefied while the layers at the top were denser. Therefore the sun above the horizon ws reflected producing its image beneath. The Sun’s disc which was flattened into an ellipse by a general refraction was also joined to the brilliant streak of reflected image. The last tip of the Sun disppeared not below the true horizon, but some distance above it at the false hor- izon. Looking at it, Jayadratha came out and was killed. By that time, the same appeared on the true horizon. Naturally there was no refrac- tion because the light rays came parallel to the ground. This revisu- alized the Sun at the true horizon. Then the sun actually set, but the refraction projected the image above the horizon. The sun was thus visible for a short time, which then set again.

Combat Related PTSD Poetically Described by Homer

The Greek epic poet Homer was an artistically gifted oral poet who had the capacity to inspire human nature in dramatic terms. Homer’s great epic Iliad, which was composed may be in 730 BC narrates a series of harrowing experiences of battle stresses that were experienced by the ancient Hellenic combatants. In depicting the world of the warriors in the Iliad, Homer pays special attention to the objects of war and human relations in extreme situations.

Iliad offers a glimpse of battle stress and human capacity to resist such trauma. Despite the beautiful objects and environments for their aesthetic value, Iliad expresses the ironies of war. Homer recounts the horrors of war using various expressions such as smell of blood and sweat of slaughter and earth soaked in blood etc. Hence, Homer articulates that there is no glory in the slaughter.

Iliad may be the most complete single metaphor for the deadly perils of warfare. Homer tells how the warriors in motion on the battlefield and their obsession of terror that creates a destructive enterprise of war. Homer analytically describes the rage of Achilles the warrior thus.

Sing me, goddess, of the anger
of Achilles, son of Peleus,
bane that brought to the Achaeans
countless woes, and hurled to Hades
countless mighty hero spirits,
left to dogs and birds their carrion,
and the will of Zeus accomplished.
Sing from when they first made quarrel,
Agamemnon, king of peoples,
and the noble-born Achilles. – (Translation by John Porter)

Achilles was utterly overwhelmed with grief when he heard the death of his friend Patroklos. Patroklos went to the battlefield wearing Achilles’s armor to fight the Trojan prince Hector. Patroklos was killed in the fight. His body was mutilated and put to vultures to eat. Iliad describes Achilles’s survival guilt as an outcry.

I would die here and now, in that I could not save my comrade. He has fallen far from home, and in his hour of need, my hand was not there to help him. What is there for me? Return to my own land I shall not, and I have brought no saving neither to Patroklos nor to my other comrades of whom so many have been slain by mighty Hektor; I stay here by my ships a bootless burden upon the earth. Iliad 18.97

Battle scenes and human suffering occupy much of the Iliad. When exposed to combat atmosphere soldiers have feelings that become more intense and unpredictable. They may include responses that are re-awakened or amplified. Homer proficiently articulates such responses. In Iliad, some combatants go in to extreme confusion and experience the feelings of insecurity. Their reactions are similar to modern-day combat related PTSD.

The Iliad epitomizes another tragedy of war. The agony of war widows which roofed with physical and mental trauma. The page of Iliad echoes the woe and afflict of the Trojan women. Homer expounds their snivel and helplessness comprehensively. Trojan women have become the ultimate symbol of a man made disaster.

Homer’s Iliad is a universal affirmation of combat trauma and poetically recites how human psyche reacts to extreme situations. Based on its artistic qualities and deep analysis of human relations in a time of war, Iliad represents a great epic and a human melodrama.

PTSD in Buddhist Jathaka Stories

According to archaeological and literary evidence the Jataka stories were compiled in the period, the 3rd Century B.C. to the 5th Century A.D. The Khuddaka Nikaya contains 550 stories the Buddha told of his previous lifetimes as an aspiring Bodhisatta. According to Professor Rhys Davids Jataka stories are one of the oldest fables. The Jataka stories deeply analyse the human mind. It contains a profound psychological content. The renowned Sri Lankan writer Martin Wickramasinghe once said Psychoanalysis was not initiated by Freud but by the Jataka storyteller.

In the Jataka stories there are numerous characters who have displayed hysteria type of reactions. For instance in the Maranabheruka Jathaka one monk shows anxiety based reactions that is similar to modern day PTSD. This monk displays extreme fear, hyper-arousal, avoidance, frightful mental pictures (flashbacks?) and emotional anesthesia.

Shakespearian Work and PTSD

The eminent English poet and playwright William Shakespeare created many characters that appear to be afflicted by psychological and psychiatric disorders. Shakespeare had an exclusive ability to grasp the dynamics of the human mind and fathom the dysfunctions of the human psyche. Indeed Shakespeare was very comprehensible in his descriptions of various psychological and psychiatric symptoms. Shakespeare’s influence on psychopathology was immeasurable. Many of Shakespeare’s lead characters seem to be having mental disorders and even psychoses.

Shakespeare’s play of Macbeth probably written sometime between 1603 and 1607 reveals a misfortune filled with guilt, emotional overwhelming, nightmares, hallucinations, disturbing reminiscences. Macbeth was a Scottish Army General who wanted to rise to nobility and to become the king of Scotland. To fulfill his ambition he was pushed to kill the king Duncan by his ambitious wife. Macbeth murders his king Duncan while Duncan is a guest at their castle. After the murder, Macbeth and his wife become emotionally unstable. Lady Macbeth she sleepwalks (a form of dissociation that is evident in trauma) She continuously washes and wrings her hands in an attempt to make it clean (OCD type of behavior that could be co morbid with PTSD). Her nights were full of disturbances and she becomes hypervigilant. Following distressing mental condition, Lady Macbeth commits suicide.

Samuel Pepys’s Diary describes PTSD reactions after the Great Fire

Samuel Pepys a Member of the Parliament kept a detailed private diary described the aftermath of the Great Fire of London, which occurred in 1666. Samuel Pepys vividly wrote about the emotional reactions of the survivors who manifested nightmares and intrusive thoughts about the calamity.

Pepys Diary Entry, September 2 1666

Some of our maids sitting up late last night to get things ready against our feast today, Jane called up about three in the morning, to tell us of a great fire they saw in the City. So I rose, and slipped on my night-gown and went to her window, and thought it to be on the back side of Mark Lane at the farthest; but, being unused to such fires as followed, I thought it far enough off, and so went to bed again, and to sleep. . . . By and by Jane comes and tells me that she hears that above 300 houses have been burned down tonight by the fire we saw, and that it is now burning down all Fish Street, by London Bridge. So I made myself ready presently, and walked to the Tower; and there got up upon one of the high places, . . .and there I did see the houses at the end of the bridge all on fire, and an infinite great fire on this and the other side . . . of the bridge. . . .

So down [I went], with my heart full of trouble, to the Lieutenant of the Tower, who tells me that it began this morning in the King’s baker’s house in Pudding Lane, and that it hath burned St. Magnus’s Church and most part of Fish Street already. So I rode down to the waterside, . . . and there saw a lamentable fire. . . . Everybody endeavouring to remove their goods, and flinging into the river or bringing them into lighters that lay off; poor people staying in their houses as long as till the very fire touched them, and then running into boats, or clambering from one pair of stairs by the waterside to another. And among other things, the poor pigeons, I perceive, were loth to leave their houses, but hovered about the windows and balconies, till they some of them burned their wings and fell down.

Having stayed, and in an hour’s time seen the fire rage every way, and nobody to my sight endeavouring to quench it, . . . I [went next] to Whitehall (with a gentleman with me, who desired to go off from the Tower to see the fire in my boat); and there up to the King’s closet in the Chapel, where people came about me, and I did give them an account [that]dismayed them all, and the word was carried into the King. so I was called for, and did tell the King and Duke of York what I saw; and that unless His Majesty did command houses to be pulled down, nothing could stop the fire. They seemed much troubled, and the King commanded me to go to my Lord Mayor from him, and command him to spare no houses. . . .

Although Samuel Pepys survived the Great Fire of London without any physical damage, his emotions were inundated. He wrote about his fires, sleep disturbances, fear feelings, intrusive memories and that haunted him for a long time.

PTSD victims of Russo Turkish War

During 1676 to 1681 series of military conflicts occurred between Russian and Ottoman Empires. Professor V.I Buganov – a renowned Soviet Historian described unusual events that occurred during the war between the Turkish troops and the forces of the Peter the Great. According to Baranov’s historical recollections, some soldiers lost their voices (became aphonic as a result of hysteria type dissociative reaction). Some manifested fear feelings and became insane (stress related behavior following Acute Stress Disorder?).

Railway Hysteria

In 1800, a condition called Railway Hysteria / Railway Spine that bore a remarkable resemblance to modern day PTSD. The sufferers of Railway Hysteria / Railway Spine showed anxiety and somatoform symptoms after facing catastrophic railway accidents. Railway spine was a nineteenth-century diagnosis for the post-traumatic symptoms. A large numbers of casualties reported on Britain’s Victorian railways between the 1840s and the 1860s. The Medical experts regarded ‘Railway as a condition produced by a jolted and shaken spinal cord to one of traumatically-induced mental and nervous collapse fraught with implications of hysteria, neurasthenia and degeneration.

Neurasthenia

In 1869, the neurologist George Beard called a group of symptoms neurasthenia that was appeared in Beard’s Neurasthenia As a Cause of Inebriety (1879) characterized by chronic fatigue and weakness, loss of memory, and generalized aches and pains, formerly thought to result from exhaustion of the nervous system.

Soldier’s Heart

In 1876 US Civil War Physician Dr Mandez Da Costa introduced the term Soldier’s Heart which illustrated the physical and emotional symptoms displayed by the Civil War veterans. These symptoms included startle responses, hyper vigilance, dyspnea, palpitation, chest pain, fatigue, faintness and heart arrhythmias. Soldiers Heart or Da Costa’s syndrome is considered the manifestation of an anxiety disorder and treatment is primarily behavioral, involving modifications to lifestyle and daily exertion.

Pierre Janet on Trauma

In 1889, Pierre Janet published L”Automatisme Psychologique, his first work to deal with how the mind processes traumatic experiences. Pierre Janet coined the word ‘dissociation and explained the effects of dissociation of the traumatic memories and their return as fragmentary reliving experiences

Effort Syndrome

Effort Syndrome was introduced in 1900. This condition was characterized by chest pain; dizziness; fatigue; palpitations; cold, moist hands; and sighing respiration. The condition is often associated with soldiers in combat but occurs also in other individuals. The pain often mimics angina pectoris but is more closely connected to anxiety states and occurs after rather than during exercise.

Chronic Fatigue Syndrome (introduced in 1900)

Chronic fatigue syndrome (CFS) is a complicated disorder characterized by extreme fatigue that may worsen with physical or mental activity, but doesn’t improve with rest. Although there are many theories about what causes this condition — ranging from viral infections to psychological stress

Jean-Martin Charcot

In 1901 the Parisian clinical neurologist Jean-Martin Charcot better known as “the founder of modern neurology” described traumatic memories as parasites of the mind. He formulated a comprehensive, neurogenic model of ‘the great neurosis’. For Charcot, hysteria was strictly a dysfunction of the central nervous system. In Charcot’s view, traumatic hysteria and male hysteria were identical. Charcot acknowledged the relevance of psychological traumas, dissociated from the patient’s consciousness, in determining the nature of its symptoms. Jean-Martin Charcot’s views immensely affected Sigmund Freud’s early theory of hysteria and the notion of psychical trauma.

Sigmund Freud and Traumatic Neurosis

Sigmund Freud used the term Traumatic Neurosis that resembles the present day PTSD. The term traumatic neurosis designates a psycho-pathological state characterized by various disturbances arising soon or long after an intense emotional shock. Freud specifically wrote about effects of traumatic memories and traumatic shock.

In Freud’s words, “The symptomatic picture presented by traumatic neurosis approaches that of hysteria in the wealth of its similar motor symptoms, but surpasses it as a rule in its strongly marked signs of subjective ailment . . . , as well as in the evidence it gives of a far more general enfeeblement and disturbance of the mental capacities” (1920g, p. 12).

Freud’s understanding of trauma was well represented in his works mainly in Mourning & Melancholia (1917), Beyond the Pleasure Principle (1920), and Symptoms, Inhibitions & Anxiety (1926). Freud assumed that the negative emotional energy associated with traumatic memories unconsciously converted into the somatic manifestations of hysteria. Freud’s lectures in 1917–1918 eloquently described the broad clinical picture of PTSD.

In one of his famous lectures- Fixation upon trauma / the unconscious which was conducted in America Freud states thus…..

The closest analogy to this behavior in our nervous patients is provided by the forms of illness recently made so common by the war – the so-called traumatic neurosis. Of courses, similar cases have occurred before the war, after railway accidents and other terrifying experiences involving danger to life. The traumatic neurosis are not fundamentally the same as those which occur spontaneously…..

….. The traumatic neurosis demonstrates very clearly that a fixation to the moment of the traumatic occurrence lies at their root. These patients regularly produce the traumatic situation in their dreams, in case showing attacks of a hysterical type in which analysis is possible; it appears that the attack constitutes a complete reproduction of this situation. It is as though these persons had not yet been able to deal adequately with the situation, as if this task were still actually before them unaccomplished.

In 1910 Freud stated that hysterical patients suffer from intrusive reminiscences. There are many suggestive evidence to prove that Sigmund Freud knew the spacious clinical picture of PTSD.

Shell shock

By 1918, British Military Doctors identified a group of symptoms included tiredness, irritability, giddiness, lack of concentration and headaches among the soldiers who fought in the World War one. A British Pathologist Col Fredrick Mott coined the term Shell Shock and he considered shell shock as an organic condition produced by miniature hemorrhages of the brain. Between 1914 and 1918, the British Army identified 80,000 men as suffering from shell shock. Shell shock was generally seen as a sign of emotional weakness or cowardice.

Wilfred Owen was a Captain of the British Army and witnessed the atrocities of WW 1 first hand. He wrote his famous anti-war poem “Dulce et Decorum Est” while receiving treatment for shell shock in Craiglockart.

Bent double, like old beggars under sacks,
Knock-kneed, coughing like hags, we cursed through sludge,
Till on the haunting flares we turned our backs
And towards our distant rest began to trudge.
Men marched asleep. Many had lost their boots
But limped on, blood-shod. All went lame; all blind;
Drunk with fatigue; deaf even to the hoots
Of tired, outstripped Five-Nines that dropped behind.

Gas! Gas! Quick, boys! – An ecstasy of fumbling,
Fitting the clumsy helmets just in time;
But someone still was yelling out and stumbling,
And flound’ring like a man in fire or lime . . .
Dim, through the misty panes and thick green light,
As under a green sea, I saw him drowning.
In all my dreams, before my helpless sight,
He plunges at me, guttering, choking, drowning.

Combat Fatigue

The World War 2 was the global military conflict, which began in 1939, and 110 million persons were mobilized for military services. In 1939, the term Combat Fatigue was introduced to describe the combat trauma reactions that occurred during the WW2. Combat Fatigue was characterized by hypersensitivity to stimuli such as noises, movements, and light accompanied by overactive responses that include involuntary defensive jerking or jumping, easy irritability progressing even to acts of violence, and sleep disturbances including battle dreams, nightmares, and inability to fall asleep.

Following a battle in WWII, 17% were afflicted with acute PTSD. A longitudinal study of Harvard University alumni found 56% of World War II veterans who experienced heavy combat were chronically ill or dead by age 65 (Lee, Vaillant, Torrey & Elder, 1995).

1952 DSM 1 – Neurotic Reaction (Stress Response Syndrome)

The Diagnostic and Statistical Manual of Mental Disorders (DSM 1) was published in 1952 by the American Psychiatric Association and provided new diagnostic criteria for Neurotic Reaction (Stress Response Syndrome).

1968 DSM 2 Transient Situational Disturbance

Transient Situational Disturbance defined as a form of maladaptive reactions to identifiable psychosocial stressors occurring within a short time after onset of the stressor. They are manifested by either impairment in social or occupational functioning or by symptoms (depression, anxiety, etc.) that are in excess of a normal and expected reaction to the stressor.

1980 DSM 3 PTSD

In 1980, the American Psychiatric Association added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme. In its initial DSM-III formulation, a traumatic event was conceptualized as a catastrophic stressor that was outside the range of usual human experience.

In 1993 WHO recognizes PTSD as a Separate Diagnostic Entity

The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO).ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States. The ICD is the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use.

1994 DSM 4

The Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition (American Psychiatric Association, 1994) defines PTSD as a constellation of symptoms and behaviors that includes three core clusters. Re-experience the trauma in the form of intrusive thoughts, dreams and images, avoidance of thoughts or reminders of the trauma, together with emotional numbing and withdrawal and signs of increased central and autonomic arousal.

PTSD – Sri Lankan experience By Dr Ruwan M Jayatunge

Post-traumatic stress disorder – Over View

Natural and man-made disasters

experienced by Sri Lankans

1971 insurrection

1983 communal riots

The insurgency in 1988/89

Tsunami disaster 2004

30-year-war in Sri Lanka

SHELL SHOCK TO PALALY SYNDROME : SOME REFLECTIONS - By Gamini Gunwardane Rtd. Snr. DIG

I am indebted to Dr. Ruwan Jayatunge for his two part article in ‘The Island’ of 2nd and 4th Jan. with the above heading i.e. on PTSD – Post Traumatic Stress Disorder. It helped me to understand the behaviour of some of my men in Jaffna in 1984/85 which baffled

me all this time, without being able to find an explanation as to the cause of such behaviour.

Before I state the behavioral problems that baffled me, I must give a brief background description of the circumstances in which these incidents occurred. I assumed duties as Co-ordinating Superintendent to the then Jaffna Co-ordinating Officer (Late) Brig. Nalin Seneviratne, (later Lt. Gen & Army Commander), on 1 st Aug. 1984. That was in fact the day that the Terrorists formally declared ‘war’ on the SL Government. Of course, I had arrived in Jaffna a few days earlier to familiarize myself with the setup. I took up residence in the Jaffna Fort where the Jaffna Police H.Q. was.

The Terrorists did not expect their ‘war’ to last very long. They expected the government forces to cave in, in a short time. Their strategy was simple. They mined all the approaches to the Police stations and Camps. They mounted units to monitor movements

of troops and police squads from the Camps and Police stations, to give early warnings of the approaching army, police units. They also setup units to attack air craft that brought food and provisions to the Camps. Before long, they blasted the railway and the train

service at Murugandy. That was the end of rail transport of people and fuel. Their plan was to besiege the security establishments and slowly starve us into submission over time, without food, water and other provisions including arms & ammunition.

A few days after 1st Aug. ASP Siri Jayasundera who was on a patrol with an Army unit on the VVT – Pt. Pedro road was killed in a crude claymore charge (probably their first one and first senior police officers to die). Two days later, P.H.M.A. Herath SSP

Vavuniya who spoke to me on the phone around 10 a.m. was blasted seated on his office chair at about 4 p.m. His pieces had to be collected from the roof top of the office. Chunnakam Police station was attacked in the night shortly afterwards.

On 1st September, the Ist STF unit got caught in a landmine on their way to Point Pedro police station from Jaffna, where 4 police constables died. On 26th Nov. Chavakachcheri Police station which was attacked for the 3rd time, was blasted at 1.15 p.m. by a lorry packed with explosives that drove through the front gate, killing all men there except S.I. Subramaniam. The I.G. Mr. Rudra Rajasingham wanted me to close down immediately all the police stations in the Peninsula which were vulnerable. He told me that he would 2 hold me personally responsible if any more police stations were attacked. The tension and panic was so much! So, all police stations other than Point Pedro which was backed by the Army and VVT Police station remained open, other than the Jaffna HQ Police Station. However, many Tamil Police officers who traveled from home to work were killed intermittently.

Somewhere in September or October, all Sinhalese people in the Dollar and Kent farms in Vavuniya jungles were slaughtered in the night, with knives and swords. Kotakedeniya SSP at VVN, was asked by Police H.Q. to undertake the daunting task of leading a combined Army Police team to visit the scene, investigate and retrieve the bodies and any survivors. We followed with awe, on the Police Radio Net, Mr. K’s journey on his dangerous mission, through the heart of the jungle. We did not know at what point his

convoy would run into an ambush. He reported on the radio, the gruesome scenes he witnessed. There were no survivors. No witnesses. He was asked to bury the dead bodies.

Police had no military training or combat equipment. Men who were engaged in peaceful police work in the South were transferred against their wishes for a six month tour of duty to the North and the East, to defend the police stations there. All were scared stiff

and did not know what moment one would be killed. In these circumstances I realized that role of the police was to “just hang on, without capitulation”. “Just survive at any cost!” And hold your men. The situation was that desperate. So, we hurriedly organized

crash training courses of mental toughening and defensive fighting etc.

Going over these memories may be a good exercise now, to remind these conditions to those who are already trying to trivialize the subsequent victories, for various reasons. When Chunnakam Police station was attacked by the terrorists one night in the second

week of August, I visited that station at about 1 a.m. with a combined Army-Police convoy. We found that the Police officers and men led by SI Sudeshanathan and another SI whose name I cannot recall now had done extremely well to repulse the attack. They

were quite confident in holding the station. But when I visited this station two days later, I found that this other SI behaving in a queer fashion, bordering on unruly behaviour. The others were embarrassed. He was demanding an immediate recognition of their good performance and supply of sophisticated weapons etc. Not being aware of Post Traumatic Stress Disorder (PTSD) at that time, I thought the SI was behaving in a reprehensible manner in this crisis situation when he should set an example to his men building on his gallant performance. I was also suspecting whether he was now getting the jitters reflecting over his new experience.

After 25 years, thanks to the Dr. Jayatunge’s article I realize that this SI must have been suffering from PTSD. He was probably, “psychologically wounded” in Dr. Jayatunge’s words. “PTSD denotes an intense prolonged and sometimes delayed reaction to an

extremely stressful event.” This must have been such a case. There was a similar situation at VVT a few weeks later. The terrorists mounted an attack on the police station one night. Police did well to repulse the attack with out suffering any 3 casualties. When I visited this station the next morning, many men were quite agitated despite faring well at battle. They were very upset that the attackers abused them in filth and in disparaging language. They said it was very demoralizing. For the first time they had tasted what they were giving the public! Here too, the agitated police officers demanded more sophisticated weapons and ammo other equipment and additional strength overnight, and wanted to be relieved, which was out of the question at that time. Now I know that they too may have been suffering from PTSD Syndrome.

In the landmine blasting of the STF party on 1st Sept. on their way to Point Pedro referred to earlier, the heavy truck in which the troop traveled was thrown higher than the electricity post near by, by the blast. When they came down, 4 constables were dead.

Several were injured. (To my recollection, this was the 1st successful landmine blast by the terrorists.) The survivors fought a pitched battle and drove away the terrorists who ambushed them. The SI who led the unit in this gallant fight, had the presence of mind to recover his Service pistol and the bag containing the salaries of the men from among the debris in the sand. This SI lasted through the subsequent thorough interrogations done to reconstruct the incident, but a few days later he began to become unruly in his conduct.

As his behaviour later deteriorated further, I learnt that subsequently he was sent out of the STF and was on long medical leave. While on leave too, he clashed with a doctor on the streets of Kandy. A few years later he was killed in his home by the JVP in the ‘88/89 Insurgency. All this time, I had a dim view of this person, as I was ignorant of PTSD at that time. Perhaps, he never recovered from his psychological injury, though up till then considered to be a tough STF man. If this was known to us at that time, we could have helped him to rehabilitate himself psychologically. Hence this must be a clear case of what Dr. Jayatunge describes as “mismanagement of combat trauma.”

In hindsight, probably the American soldier who went berserk in Mylai, Vietnam killing so many villagers too may have suffered form PTSD. Similarly, the soldiers all over the world who engage themselves in indescribable acts of cruelty too may be suffering from some psychological condition which we conventionally condemn and dismiss as just ‘sadism’.

Dr. Jayatunge has dealt with the case of Rajasinghe I of Seethawake in the 16th Century.

Very probably, the king suffered from the ‘burn out’ of his exploits. Otherwise, one could not account for some of his conduct especially in the latter stages of his life. I started to think on the same lines, of his contemporary warrior, Veediye Bandara, the most daring and ruthless fighter under all three kings of Kotte, Seethawaka and Kandy, who was said to have been feared by the Portuguese. He is reported to have killed his wife, the Kotte king’s daughter, by drowning her in the Diyawanna. He fell out with all three kings at different times and fought the Portuguese on his own with his own army, from Kotte to Dondra. He then fled to Jaffna with the hope of getting the assistance of the regional ruler of Jaffna. At some point when in the company of the Ruler’s soldiers he suddenly felt suspicious that someone was trying to kill him. He stood in front of banyan tree drew his sword and challenged the people who were negotiating with him. With his fighting skills and undaunted bravery, he fought alone with the whole group killing many of the when finally; a desperate soldier climbed the banyan tree from behind, jumped on his neck 4killing him. It would appear that most of the things that he did despite his bravery and daring were irrational. It could only be explained with PSTD.

Then again, something that was always worrying me was the case of our last King, Sri Wickrama Rajasinghe who turned out to be a tyrant and lost his kingdom to the British marking the end of our independence. I was trying to figure out as to how this king became a tyrant. He was supposed to have been a tall and handsome man who loved beauty, music and enjoyed his liquor which his confidantes and the British later exploited.

What beat me was how a man who could entertained in his thought, the concept of the beauty of the city of Kandy that we see it today, could have turned out to be such a tyrant cruel enough to order the gruesome killing of the Ehalepola Kumarihamy and her children and how he could witness from the Patthirippuwa, the barbaric act being carried out. The story is that, one day he summoned his Architect, Devendra Moolachari and told him that he wanted a city designed like Alakamanda where he would feel as if he was Kubera, the Yama, the king of splendour. The Moolachari after some time brought before him a design model made out pieces banana trunk which showed the Kings palace, the proposed Dalada maligawa, Pattirippuwa (octagon), the lake surrounded with the Walakulu bemma (the wall representing the clouds), the plan to convert the paddy field in front to a lake which he called Kiri muhuda. The Moolachari converted the dream of the king thus, into reality on the ground. And this is the most beautiful part of the city of Kandy that the whole world admires today. One could discern in the contemporary book of verse, Ehelepola Hatana the effort the king made to make this design a reality by driving his officials and subjects hard. He had even wanted to make the streets beautiful.

But there was much resistance from the people because the king was unpopular. The book itself is a reflection of the resentment toward the king. He had even wanted to build a new palace for himself on the Palace Square, but two royal astrologers whom he

consulted independently, advised against it. Now the question is, how a man who was obsessed with such a high aesthetic sense could turn out to be a senseless tyrant within a short time?

His Ministers, down from his chief Adigar, Pilimathalawwe were conspiring against him, to oust him. There were the chieftains who carried tales to him against each other, driven by mutual jealousy, each aspiring to usurp the throne. He became suspicious of all of

them and trusted only his Nayakkar relatives which compounded the hatred of the Kandyan aristocracy towards him. This led to his killing some of his best generals like Lewke Methindu on mere suspicion of their loyalty. This made the situation even worse, driving his next Chief Adigar, Ehalepola, to the British. On the other hand, there were the British who were engineering conspiracy after conspiracy against him, waiting for the right opportunity to pounce on him to grab his Kingdom. He lived in constant fear, tormented by suspicion of everyone around him. A truly unenviable position for any one to be in. He had become addicted to liquor, probably as an escape route. In describing Seethawaka Rajasinghe’s plight, Dr. Jayatunge writes: “…showed outbursts of anger, irritability, deep mistrust, alienation, emotional numbing and various other PTSD related symptoms.” He also mentions: “Emotional anesthesia or emotional numbing is a distinctive feature of PTSD.” Elsewhere he says” It (PTSD) can change he mark up of a person making him more dysfunctional.” I think these descriptions fit the behaviour of 5Sri Wickrama Rajasinghe and offer a plausible explanation to the major contradictions in his character.

My thoughts meandered towards the operation of Karma theory in such circumstances. For, according to Buddhist analysis of Karma, presence of Chetana, intention, is the key factor for moral responsibility. If for instance, the Mylai soldier was affected by PTSD he was probably not in his senses to realize the implications of his action. Though he acted with volition in a limited sense, he probably did not intend to do what he did, if was of sane mind. He was probably in a kind of diseased mind. Hence, there could not be any moral responsibility for his action. Then, does it become an Ahosi Kamma? Perhaps, this might need a larger discussion by more knowledgeable people. Dr. Jayatunge says: “Rehabitation programmes include education, vocational training, income generating projects, loans, housing that is tailored to the needs of the survivors and post disaster situation.” While not challenging these remedial measures, a commonsense approach tell me engaging such victims in art, music, dancing, writing down their experiences, describing the incidents and living in areas of scenic beauty may also be helpful cathartic exercises in helping to relieve their trauma. My wife had some degree of success with the seriously injured and traumatized police officers kept at the Police Hospital, by adopting such methods, during those gloomy days.

Sri Lanka war-displaced have high occurrence of mental health conditions, study reports

According to a study conducted by a medical research team Sri Lankans displaced by the war have a higher occurrence of war-related mental health conditions including depression, anxiety and post-traumatic stress disorder (PTSD).

The study, published in the prestigious medical journal of American Medical Association (JAMA) on its today’s theme issue, was conducted by a research team led by Farah Husain, D.M.D., M.P.H., of the Centers for Disease Control and Prevention in Atlanta, USA.

The team has carried out a health survey between July and September 2009 among 1,517 households in Jaffna District including two internally displaced person (IDP) camps to estimate the prevalence of the most common war-related mental health conditions, symptoms of posttraumatic stress disorder (PTSD), anxiety, and depression, and to assess the association between displacement status and these conditions in postwar Jaffna District, Sri Lanka.

The study received a high response of 92 percent from 1,448 subjects of which 1,409 were eligible. Among the respondents 2% were currently displaced, 29.5 % were recently resettled, and 68.5 % were long-term residents.

The researchers discovered that compared with long-term residents, currently displaced participants were more likely to report symptoms of PTSD and depression while recently resettled residents were more likely to report symptoms of PTSD. However, displacement was no longer associated with mental health symptoms after controlling for trauma exposure. The overall occurrence of PTSD was 7.0%, with 32.6% suffering from anxiety and 22.2% experiencing depression symptoms.

The study concluded that among residents of Jaffna District, prevalence of symptoms of war-related mental health conditions was substantial and significantly associated with displacement status and underlying trauma exposure.

The researchers wrote that although the association between displacement status and symptoms of PTSD, depression, and anxiety was no longer significant after adjusting for trauma exposure in this study, the act of being displaced and the daily stressors associated with it may be considered traumatic in themselves and may be an indicator or proxy for recent trauma as well.

The team suggested that interventions in Sri Lanka should target the most vulnerable populations, mainly those living in displacement camps and include support from family, friends, religious leaders, and traditional counselors.

Post Combat Reactions among the Sri Lankan Soldiers by Dr. Ruwan M Jayatunge M.D.

I exhort you also to take part in the great combat, which is the combat of life, and greater than every other earthly conflict. Plato

Combat experiences are often traumatic. After exposing to combat related events many soldiers undergo dramatic behavioral and personality changes. Following the 30 year war in Sri Lanka many soldiers have experienced Post combat reactions that changed their psychological makeup significantly. Some of these post combat reactions were easy to detect and some were hidden for long years. The veterans can experience a vast range of post combat reactions that cannot be identified easily and some of these reactions have no concordance with clinical symptomatology. There are common post combat reactions that can be elicited among the soldiers who were exposed to the traumatic battle events. These combat reactions can be classified in to several groups.

1) Post Combat Reaction -Depressive Type

2) Post Combat Reaction -Dissociative Type

3) Post Combat Reaction -Somatic Type

4) Post Combat Reaction -Psychotic Type

5) Post Combat Reaction- Undifferentiated Type

Post Combat Reaction Depressive Type

Depression is an affective disorder leading to persistent feelings of worthlessness, hopelessness, guilt, agitation and indecisiveness. Depression can dramatically impair a soldier’s ability to function in the combat zone. Combatants with depression often have feelings of despair, hopelessness, and worthlessness as well as thoughts of committing suicide. Depressive factors in combat were evident to Dr. Mendez Da Costa of the American Civil War to Dr. Fredric Mott who coined the shell shock term during WW1.

Combat can challenge a person’s moral judgment. Killing is not that much easy for many soldiers. To put a bullet through another man’s heart or head can cause psychological repercussions in later years. Overall view of the battle field might look depressive to most of the combatants. Scattered dead bodies, damaged houses and vehicles, destroyed vegetation always give a gloomy look.

A large number of Sri Lankan combatants manifested depressive reactions after the combat situations in the North. Some were shattered by the death of their buddies and blamed themselves for not rescuing their friends. Some experienced severe depression after becoming physically disabled by the war. Ironically a considerable portion of soldiers became depressed after killing the enemy in the battle field.

Lance Corporal SU (32Y) was diagnosed as having depression in May 2000. His depressive symptoms started in 1992 after witnessing a land mine explosion. Even though he managed to escape without any physical harm he saw how his friend died in the blast. His depressive features appeared as survival guilt, self-blame, hopelessness, grief and bereavement.

Private T had served seven years in the operational areas. On one occasion his best friend died of a sniper attack. After the conformation of death private T was ordered to bury the body. When he wrapped the friend’s dead body he could feel the body warmth. This warmth may had been caused by the hot Northern climate. But Private T was shattered. After some years he had an irrational feeling that he buried the man alive. He manifested guilty feelings, anhedonia, insomnia, cognitive impairments, reduced life interests and was later diagnosed with Depressive Disorder.

CplNx felt despair after killing two members of the LTTE who came to attack his camp in Jaffna. After the incident he felt sorry for the lives that he had eliminated. The depressive feelings hounded him for many years. He became more religious and expected to get a transfer to a non-combat area.

De Fazio, Rustin and Diamond (1975) and Helzer Robins and David(1976) all found a higher rate of mild to severe depression and anxiety in Vietnam veterans from five years after discharge. Davis (1976) found a higher incidence of depression in veterans who had been in combat and had lost a friend.

Post Combat Reaction -Dissociative Type

Dissociation is a mental process, which produces a lack of connection in a person’s thoughts, memories, feelings, actions or sense of identity. Dissociation can be interpreted as a protective or defensive reaction in extreme stress. Soldiers may use their natural ability to dissociate to avoid conscious awareness of a traumatic experience while the trauma is occurring and for an indefinite time following it.

Disturbances of physical function are a characteristic feature during combat and even after combat period. Disruption of motor sensory and speech functions can be noticed. The affected soldiers have manifested following symptoms.

1) Weakness or paralysis of hands, limbs or body

2) Gross tremors

3) Pseudo Convulsive seizures

4) Hysterical blindness

5) Hysterical deafness

6) Psychogenic aphonia

7) Loss of sensation

8) Abnormal sensation(parasthesia)

Lance Corporal A has served 17 years in the military predominantly in the combat zone. During the height of the Northern conflict he went in to dissociative fugue and walked to the enemy line abandoning his post. Later he was saved by a friendly group of soldiers. Lance corporal A was referred to the Psychological Unit of the MilitaryHospitalColombo with psychogenic aphonia and diagnosed as having dissociative disorder.

During the WW1 trigger finger palsy was seen in abundance in the war trenchers in France and Germany. Although trigger finger palsy is rare among the Persian Gulf veterans we have observed several trigger finger palsy among the Sri Lankan combatants.

Post Combat Reaction Somatic Type

Long term impact of combat on physical illness is an evident factor since the American Civil War. Stress can have a direct effect on physical symptoms. Acute and chronic combat reactions frequently manifest as somatic symptoms including fatigue, palpitation, headaches, joint pains, tremors, impotence and numbness. According to Freud anxiety can be presented in somatic channels.

L/Cpl S has served 9 years in the operational areas without any physical injuries. He witnessed a number of traumatic battle events. At Welioya he saw a claymore mine explosion and death of 4 soldiers. In 1997 he had a narrow escape when the enemy fired a RPG to his bunker. By 2003 L/Cpl S was presented with a long lasting backache, headache, chest discomfort, tremors which had no apparent medical basis. He was later diagnosed with Somatoform Disorder.

Sgt TMX is a skilled NCO who participated in numerous military operations. All these years he had been lucky and never became a battle casualty. After serving 15 years in the armed forces Sgt TMX experienced sudden onset headaches, fatigability and generalized body pain. He was referred to a physician and found no any physical abnormality. His exercise ECG and other investigations were normal. His headache and physical pains did not respond to the pain killers.After a psychological evaluation Sgt TMX was diagnosed as having SomatoformDisorder. He positively responded for relaxation therapies and EMDR.

Post Combat Reaction -Psychotic Type

Combat stress can aggravate hidden psychotic factors. Many combatants have manifested psychotic reactions soon after the traumatic combat events. Temporary or transient mental disorders may develop even in previously stable personalities after exposure to battle stress.

Cpl W (38Y) was a competent soldier from the Special Forces. In 1990 he sustained a gunshot injury to the chest at the Jaffna Fort. After he became wounded his mental condition changed gradually. He had passivity feelings, thought broadcasting, flatness of affect, social withdrawal, auditory hallucinations and ideas of grandeur. He was referred to the Psychiatric Unit -Teaching Hospital Peradeniya and treated for Schizophrenia.

Private BHX participated in the Operation Liberation that commenced in 1987. After the military operation he was posted to Colombo. Gradually his psyche started to change. He could hear the voices of the enemy attackers, helicopter sounds. He had a feeling that some external force was controlling him and the enemy is extracting thoughts from his mind. He became delusional and paranoid. After a detailed psychiatric evaluation Private BHX was diagnosed with Schizophrenia. He positively responded to antipsychotic medication (especially for Risperidone)

Post Combat Reaction Undifferentiated Type

Some post combat reactions are vague and have dissimilar features. It could be a mixture of depression, somatic features, intermittent aggression, risk taking behavior and sometimes sexually deviant elements. Sexually deviant behaviors could be seen in (psychologically stable prior to the combat experience) combatants after exposing to traumatic combat events. During the Vietnam War such reactions were observed. These sexually based reactions can be sadistic or masochistic in nature. Although there is no extensive research on sexual deviant behaviors and combat experience we have observed and treated a small number of soldiers with Voyeurism, Exhibitionism, Zoophilia, and Hypoxyphilia. Most of the combatants who had sexual deviant behaviors were decent and psychologically stable characters prior to their traumatic combat experience. Many positively responded for CBT.

Pvt BDX served 7 years in combat areas and witnessed traumatic battle events. Gradually he realized that he was losing interest in his married life. He had a compulsive urge of Voyeurism- a deviant behavior which is characterized by intense sexually arousing fantasies, urges, or behaviors in which the individual observes an unsuspecting stranger who is naked, disrobing, or engaging in sexual activity. As a result of this compulsive urge he had to face disciplinary charges. Pvt BDX was referred to the Psychiatric Unit at the Military Hospital Colombo and treated with cognitive behavior therapy. After intensive behavior therapy program Pvt BDX was able tocontrol the voyeuristic impulses.

Risk taking behavior is closely connected with self-harm or suicidal intentions. Many skilled combatants sometimes take senseless risks in the battle field sometimes endangering their lives.

Lt GXT had participated in a number of battles and troubled by intrusions and combat related nightmares. He became more and more isolated and stated taking unnecessary risks in combat operations. In the later stages in combat he used to fire the enemy in stand up position. This habit brought him fatal repercussions. In late 1999 when his unit engaged the enemy Lt GXT risked his life once again. Regrettably this time his life was in real danger. He sustained a gunshot injury to the head and died instantly.

L/Cpl FWX served over 10 years in the operational areas. He sustained a gunshot injury to the left leg. After he became wounded he was posted to Panagoda camp in Colombo. He suffered from frequent headaches and had negative outlook on the future. Once he consumed a large amount of alcohol and slept on a 20 feet high parapet wall. He fell down from the wall and sustained a fractured femur.

Bessel Van der KolkProfessor of Psychiatry at the Boston University, and Director of the HRI Trauma Center elucidates that as a result of combat trauma some traumatized soldiers have a compulsive urge to expose to situations reminiscent of trauma. Ironically we have seen this factor among the Sri Lankan combatants as well. Many local 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.Compulsive expose often worsen their mental health. Repetition cause further suffering for the victim and for the people around them (Kolk, et al., 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 prematurely and joined with a local politician. During the 1999 infamous Wayamba PC election, Cpl FC8 engaged in many election related violence that was instigated by his political master.

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

Post Combat Syndrome (PCS)

As Shalton (1978) indicates there are several common responses showed by soldiers those who have PCS or the Post Combat Syndrome.

1) Guilty feelings and self-punishment

2) Feelings of being a scapegoat

3) Rage

4) Hyper-arousal

5) Loss of sensitivity and compassion

6) Alienation of their feelings

7) Substance abuse

8) Feelings of worthlessness

9) Self-harm

10) Mistrust and doubts of love towards others

11) Difficulty in concentrating

Residual psychological damage and lowering of tolerance to stress of any kind is an evident factor in PCS. Many have impaired sexual potency, low frustration tolerance and maladaptive psychological reactions.

Sergeant SU has been serving 17 years in the Military. He lost his leg as a result of an antipersonnel mine. After he became injured Sergeant SU started alienating his feelings. He has guilt and suspicion. He was hospitalized several times for deliberate self-harm. He is addicted to cannabis. Often he becomes aggressive and has violent impulses against indiscriminate targets.

Adjustment difficulties in Civil Life

Many ex-servicemen face post combat readjustment problems. They find it difficult to readjust to the civil life after serving a long time in the military. A number of psychological factors may contribute to the overall stress load experienced by the ex-servicemen. They are a vulnerable group both medically and psychologically.

Capt. KXLretired from the army after serving 20 years. During his military career he was exposed to heavy combat and sustained minor injuries. After the retirement he found it difficult to adjust himself in the civil setup. Capt. K felt a misfit in the civil society and was always uneasy. Although he did several jobs after the retirement he could not make up himself to work with civilians and working in the civilian environment. Frequently he became hostile and alienated himself form the colleagues. Eventually he gave up his civil job.

Delayed Combat Reactions

Combat stress has residual effect on some veterans. For some soldiers, conscious thoughts and feelings or memories about the over whelming traumatic circumstances may emerge at a later date. According to Dr. Michael Robertson of the Mayo Wesley clinic ex-servicemen can experience delayed reactions of combat stress. A large number of WW2 Veterans those who never had any anxiety related symptoms later complained of Delayed PTSD. Some reactions were manifested 40-50 years after the original trauma.

L/Cpl JXC served 8 years in the military. He participated in the Operation Safe Passage in 1995 and sustained minor injuries. But during this operation he witnessed horrendous battle events. In 1996 he became AWOL and worked as a laborer. By 2005 (after 10 years from the original traumatic event) he experienced nightmares, intrusions and became extremely hostile to his wife and children. To evade the disturbing feelings he started consuming alcohol in large quantities.

Treating Post Combat Reactions

Post combat reactions can cause significant discomfort to the combatant and his family and in the long run it could affect the society. Combat reactions can be identified soon after a traumatic combat operation or after a substantial time period. Many soldiers have behavioral as well as clinical features after facing heavy combat. Treatment should be started in the early stages otherwise post combat reactions can cause many complications. Cognitive behavior therapy is an effective form of therapy that can be used to treat post combat reactions. The goal of CBT is to guide the person’s thoughts in a more rational direction and help the person stop avoiding situations that once caused anxiety. It teaches people to react differently to the situations that trigger their anxiety symptoms. Therapy may include systematic desensitization or real life exposure to the fired situation.

Exposure Therapy is one form of cognitive behavior therapy unique to trauma. Treatment which uses careful repeated, detailed imaging of the trauma (exposure) in a safe controlled context, to help the survivor face and gain control of fear and distress that was overwhelming in the trauma. Intrusive thoughts, flashbacks, avoidances are best treated by exposure therapy.

Client Centered Therapy is effective in PCR- Depressive Type. By retelling the traumatic event to a calm, empathic, compassionate and nonjudgmental therapist the combatant achieves a greater sense of self-esteem, develops effective ways of thinking, coping and more successfully deals with the intense emotions that emerge during therapy. However in extreme trauma Client Centered Therapy was found to be not effective.

CISD or Critical Incident Stress Debriefing has been used to treat Sri Lankan combatants. Debriefings take place on the battlefield soon after the action. It helps the combatant to come to terms with his trauma and reduce the further progression of post combat reactions. Currently there is controversy regarding CISD. Some forms of debriefing may actually make people worse (Mayou& Ehlers, 2000)while other types of treatment have demonstrated good success in helping people to get through a trauma.

Rational Emotive Therapy is another effective form of treatment that can be used to treat soldiers with PCD. American Psychologist Albert Ellis comes to regard irrational beliefs and illogical thinking as the major cause of most emotional disturbances. In his view negative events do not by themselves cause depression or anxiety. Rather emotional disorders result when a person perceives the event in an irrational way. So despite the client’s irrational beliefs and long-lasting assumptions the rational emotive behavior therapists often use confrontation techniques.Most of the soldiers suffering from combat related stress have unresolved grief, survival guilt and irrational beliefs which lead to depression and anxiety. Rational Emotive Therapy can be used to break their illogical thinking pattern through friendly mediation.

Trauma focus therapy groups are typically smaller and more structured involving 5-10 soldiers. Group composition is controlled in some treatment settings with patients grouped according to the type of trauma they experienced. Traumatic memories are actively re-engaged and patients openly discuss traumatic experiences with a co- facilitator.

Anger and rage are widespread emotions in individuals experiencing combat trauma. Combat veterans experience more anger and hostility then their civilian counterparts. Treatment of anger component is a necessary ingredient in trauma recuperation work. In anger management combatants learn constructive ways to manage their anger.

Existential Therapy focuses on free will, responsibility for choices and search for meaning and purpose through suffering, love and work. Existential psychotherapy deals with basic issues of existence that may be present within a person. The Existential Therapy avoid restrictive models that categories or labels people. Instead they look for the universals that can be observed trans-culturally. Existential psychotherapy aims at enabling clients to find constructive ways of coming to terms with the challenges of everyday living.

EMDR(Eye Movement Desensitization and Reprocessing) is one of the most researched methods of psychotherapy used in the treatment of trauma. EMDR facilitates the accessing of the traumatic memory network, so that information processing is enhanced, with new associations forged between the traumatic memory and more adaptive memories or information. These new associations are thought to result in complete information processing, new learning, elimination of emotional distress and development of cognitive insights. EMDR has been given the same status as CBT as an effective treatment for ameliorating symptoms of both acute and chronic PTSD (American Psychiatric Association -2004). In treating Sri Lankan combatants EMDR has answered most of the practical questions. In addition remarkable success has been achieved by the affected combatants through EMDR.

Conclusion

Sri Lankan combatants fought a deadly war for over 3 decades and achieved a splendid victory over the LTTE – World’s most resourceful and dangerous terrorist organization. Sri Lankan soldier’s dedication, courage and contribution cannot be measured and it is inimitable. They risked their lives and physical / mental health for the country. Thereforethe soldier’s welfare, psychosocial health andthe betterment ought to be looked after with the utmost diligence.

After the prolonged war in Sri Lanka many combatants exhibit post combat reactions that need to be dealt with effectively. Several types of PCR have been identified. PCRDepressive type can cause clinical depression in combatants and if untreated it could lead to self-harm and suicide. PCR dissociative type often causes dissociative reactions such as psychogenic aphonia, psychogenic tremors, psychogenic seizers and various types of conversion reactions. PCR somatic type is a disabling condition and the solders have somatic complaints without any apparent medical basis. PCR psychotic type has triggered Schizophrenia, BPAD, and often Acute Transient Psychotic Reactions among the combatants. Soldiers with PCR undifferentiated type can have various reactions from aggression, compulsive addictions, risk taking behavior to sexual deviant behaviors. Post combat reactions could affect the combatants negatively and specific measures have to be taken to identify such reactions and to treat them. Among the effective modes of psychological therapies CBT, Client Centered Therapy and EMDR have shown more positive results. Military commanders, unit leaders and the military doctors should be aware of the post combat reactions and help the soldiers effectually.

References

1) Beck A.T: (1963) Thinking and Depression Idiosyncratic content and cognitive distortions. Arch Gen Psychiatry

2) Davidson J.R.T &Foa E.B (1991) Diagnostic issues in PTSD Considerations for DSM-4 Journal of Abnormal Psychology

3) Herman. J (1992)Trauma and Recovery. New York Basic Books

4) Jayatunge R.M- (2004) PTSD Sri Lankan Experience ANL Publishers

5) Shapiro, F (1995) Eye Movement Desensitization and Reprocessing: Basic Principles Protocols and Procedure. New York: The Guilford Press

6) Schnurr P.P (1991) PTSD and combat related psychiatric symptoms in older veterans.

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on April 19, 2009 at 7:42 am | Reply Violet

Thank you for a fascinating and informative work. I have recently connected with a high school acquaintance who is a Nam combat vet. I am seeing him in much of what you have written here. He was diagnosed by the VA as suffering “adrenaline addiction” and is fully disabled by PTSD. Your writing has given me some valuable insights into his situation and will help me in my correspondence with him. Thank you and best of luck in your future.
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