Professor Daya Somasundaram / Dr Ruwan M Jayatunge

Prolonged armed conflict in Sri Lanka has created higher rates of mental ailments among the Army personal and members of the LTTE. A significant number of people have been diagnosed with complex forms of PTSD aka Malignant PTSD. These individuals with malignant forms of anxiety have a wider range of clinical symptomatology with severe psychosocial impairments. These people would fit into the diagnostic category of DESNOS (Disorders of extreme stress not otherwise specified) or Complex Post-Traumatic Stress Disorder (C-PTSD) / Malignant PTSD that was described by Dr. Judith Herman in 1992.  Complex PTSD has been recognised as a new diagnosis in the International Classification of Diseases 11th Revision (ICD-11).  

According to Herman (1992), Complex post-traumatic stress disorder (C-PTSD) is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma in the context of either captivity or entrapment that results in the lack or loss of control, helplessness, and deformations of identity and sense of self. C-PTSD is distinct from but similar to, PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder. (DESNOS), characterised by alterations in regulating affective arousal with difficulty in modulating anger, self-destructive and suicidal behaviour and impulsive and risk-taking behaviour.

They have chronic characterological changes with alterations in self-perception: chronic guilt and shame; feelings of self-blame or ineffectiveness and of being permanently damaged; a tendency to victimize others and alterations in systems of meaning such as despair and hopelessness or loss of previously sustaining beliefs (Jong, 1997).

Sri Lanka’s Armed Conflict and Its Impact on the Victims

A three-decade-long armed conflict in Sri Lanka has created higher rates of psychological problems among the victims.  They were at high risk of developing war-related psychopathology. The armed conflict between government forces and the Liberation Tigers of Tamil Eelam has resulted PTSD and DESNOS (C- PTSD). DESNOS has caused considerable impairments in psycho-social functioning among the affected individuals. These people often experience multiple mental health problems. Most of the victims have not received adequate treatment and some cases are still undiagnosed. Lack of availability of mental health services is one of the barriers to treat war victims and ameliorating their distress. 

C- PTSD Among the Sri Lankan Combat Veterans

A significant number of Sri Lankan soldiers suffered severe war trauma during the Eelam War that lasted from 1983 to 2009. It changed the psychological makeup of soldiers. A large number of combatants underwent traumatic battle events outside the range of usual human experience. These experiences include constantly living in a hostile battle-ravaged environment, seeing fellow soldiers being killed or wounded and sight of unburied decomposing bodies, handling human remains, hearing screams for help from the wounded, and helplessly watching the wounded die without the possibility of being rescued etc. The affected combatants with war trauma experience problems in their living, working, learning, and social environments. War trauma has drastically impacted their mental health and long-term functioning. Some of the Sri Lankan combatants with full blown PTSD showed a wider range of clinical symptomatology with sever psychosocial impairments and these veterans would fit in to the diagnostic category of DESNOS (Disorders of extreme stress not otherwise specified) or Complex Post Traumatic Stress Disorder (C-PTSD).

C- PTSD Among the ex LTTE Carders

The Liberation Tigers of Tamil Eelam (LTTE) – a Tamil militant organization and they attacked the Sri Lankan armed forces with modern weapons. The LTTE used numerous unconventional methods to fight the Sri Lankan Forces using child soldiers and suicide bombers. Many surviving members of the former LTTE either now live in Sri Lanka or live abroad. Most of these ex-militants joined the movement as children and throughout the war, they underwent the harsh realities of war trauma. A significant numbers of ex LTTE members suffer from malignant PTSD. These victims live with rage, guilt, alienation and suicidal ideation. They lack social skills and unable to form families due to a lack of parental skills and intimacy. Some affected by addiction problems.

Case Studies

1)    Rifleman Sn34 became psychologically wounded after facing traumatic battle events in Operation Yale Devi which was launched in 1993 to destroy the LTTE Sea Tiger strongholds at Kilali.  The enemy launched a surprise attack on the advancing column resulting in the deaths of hundreds of soldiers. The LTTE attacked them with mortars and Rocket Propelled Grenades. Rifleman Sn34 saw the deaths of a number of his fellow soldiers. The enemy captured some of the wounded men.  After this dreaded battle, Rifleman Sn34 had a pessimistic outlook on the future. He had ruminations about the battle events. He relived these experiences. Startle reactions troubled him significantly. He had no way of receiving treatment or no way of explaining to anyone his psychological anguish. For a long period, he lived with his posttraumatic symptoms. Over the years he felt that he was unable to trust people or the system. He became extremely vigilant during the presence of unknown people. He stopped associating with people and became socially isolated. He was demotivated to initiate new events and felt lethargic and withdrawn. He became an extremely fearful person. Prior to the traumatic event, he was decorated for bravery but after the battle trauma, the sound of a firecracker could make him excessively frightened

2)    Private SXXT31 served in the operational area for 9 years and firsthand experienced combat trauma. He witnessed how his unit members got killed following enemy fire, mortar blasts, artillery attacks etc. and became severally overwhelmed while handling human remains. After experiencing these events over a long period, he suffered severe transient headaches and loss of memory. By 2002 he was diagnosed with full-blown symptoms of PTSD. He was frequently troubled by nightmares and flashbacks. When he experienced flashbacks, he used to re live the traumatic event and often became disconnected from reality. Once Private SXXT31 went into a dissociate flashback and he had squeezed the neck of his five-year old daughter. When the little girl was suffocating, his wife accidentally noticed the dreadful event, alerted the neighbors and saved the little girl from Private SXXT31’s strong grip. The girl was immediately hospitalized and later recovered. Private SXXT31 became extremely distressed and felt guilty after realizing that he tried to strangle his own daughter. He had no memory of the incident and did not realize how he grabbed the daughter’s neck.

3)    Bombardier AXTX36’s self-perception changed drastically with the onset of symptoms. He lost his self-esteem and viewed himself as a sinner and a perpetrator who deserved to be punished by the Karmic forces. I am a villain he openly said and he wished all the blasphemes to fall upon him. He frequently said that he is not a human anymore and the human part of him had gone a long time ago. He urged other people to call him derogatory names. He started to reveal his past interrogative work even to unknown people on the street and never expected a word of sympathy from them. When people sympathized with him he became extremely annoyed and sometimes tried to assault them.  Bombardier AXTX36 became aggressive and emotionally numbed. He lost the ability to trust anyone.  Sometimes he blamed his senior officers, his parents, and sometimes, even himself, for his anguish and suffering.  He had no hopes for the future and several times planned to commit suicide.

4)       A 23-year-old male presented at the psychiatric clinic at the Teaching Hospital Jaffna, with complaints of insomnia, numbness of the head, and flashbacks of dead friends. He had joined the militant group at the age of 14 and underwent extensive training. As he lost his friends one by one on missions, he became more withdrawn and preoccupied with thoughts of his dead friends. He also led a very tense life during active duty. He developed a hatred for people whom he was led to believe were traitors and who passed information to his enemies. He caught 3 people whom he considered informants and tortured them by slowly cutting them to pieces while they screamed. He then threw these pieces onto the nearby road. After this, he began to be obsessed with the sight of blood and hearing his victims screaming in pain. He also had nightmares of dead comrades being blown to bits. His insomnia worsened, and he began to take Diazepam. He became addicted and started taking up to 40 mg at a time. He introduced this to the other boys. He also had a severe headache accompanied by numbness of the head. His drug abuse habit was detected by his superiors, who put him on punishment, where he was physically beaten and kept in detention. He is obsessed with the urge to torture and to see blood. When he was asked to draw a picture, he chose a dark red crayon and drew blood drops, a hanging man, a knife stained with blood, a grave and ghosts.

Treatment Measures

The main treatments for DESNOS (C- PTSD) are psychotherapy and medication. Trauma-focused cognitive behavioral therapy, Eye movement desensitization and reprocessing (EMDR) and Dialectical behavior therapy (DBT) are highly recommended as psychological therapies. Studies recommend multicomponent therapies starting with a focus on safety, psychoeducation, and patient-provider collaboration, and treatment components that include self-regulatory strategies and trauma-focused interventions (Maercker et.al.,2022).  These interventions are alleviating the patient’s distress in several psychological and physical domains.

Psychological interventions improve C- PTSD symptoms. It is essential to provide more efficient and comprehensive therapies to the individuals with war trauma, and the psychiatric and rehabilitation services should work in collaboration to achieve success. The victims with war trauma need psychosocial rehabilitation to recover. Warren (2002) is of the view that addressing the broader emotional, social and economic needs of survivors is a critical aspect of the rehabilitation process.

 The Health Ministry should provide sufficient training to the doctors to identify war trauma symptoms and do referrals effectively. Psychosocial Rehabilitation should be incorporated to help traumatized combat veterans to achieve recovery.   Psychosocial Rehabilitation practices help war veterans re-establish normal roles in the community, independence, and reintegration into community life. These interventions help to manage behaviors, perceptions, and reactions and give the opportunity to the victims to live a full and meaningful life.