Escalating Incidence of Post Traumatic Stress Disorders (PTSD) and Suicides Among Soldiers and Civilians Who were Exposed to Civil War in Sri Lanka
Posted on October 3rd, 2012

Article  No 13

Abstract:  Post-traumatic stress disorders is characterized by serious behavioural and psychological abnormality that occurs following exposure to one or more acute stressful life events, including soldiers and civilians exposed to war situations, and also in several other non-combat circumstances.  The latter includes, victims of sexual abuse or rape, mugging, violent robberies and home invasions, natural or man-made disasters, school bulling, and work place harassments and retaliations.  It is essential to promptly diagnose these victims and provide them with effective therapeutic programs, enabling them to get back to normality and productive lives.

This piece of writing was in response to the brief newspaper article in The Island (see below) on 24th September, 2012, by Shanika Sriyananda to elucidate this issue, and to provide broader information on this subject that would hopefully help prioritising, and initiating the process of planning and implementing a comprehensive therapeutic program for the PTSD victims of the civil war that ended three years ago in Sri Lanka:

“Nearly 400 soldiers committed suicide in peacetime”

http://www.island.lk/index.php?page_cat=article-details&page=article-details&code_title=62302

The content of the article by Ms. Sriyananda from the http://www.island.lk:  “A majority of soldiers who committed suicide were suffering from Adjustment Disorder (AD). Only five of them were those under treatment for Post-traumatic Stress Disorder (PTSD), military Spokesman Brig. Ruwan Wanigasooriya said.  “Many of them committed suicide because they were unable to cope up with their problems,” he said, adding that nearly 400 army personnel had, during the past three years, due to various reasons, including various illnesses, committed suicide.  Brig. Wanigasooriya, citing the recent incident where a Major of the 8th Gajaba Regiment, who allegedly blew himself up with a grenade over a broken love affair, said most of the soldiers, who were suffering from adjustment disorder, had committed suicide.  But, he said, the Sri Lanka Army had taken several effective measures to identify and treat soldiers suffering from AD and PTSD.

According to the Defence Military Spokesman, the SLA conducts monthly awareness programmes and mobile psycho-therapeutic clinics with the help of a team of qualified consultant psychiatrists and counsellors.  Consultant Psychiatrist Dr. Roshan Moneragala is now conducting awareness programmes and mobile clinics for the junior and senior officers attached to the Killinochchi Security Forces Head quarters.  Brig. Wanigasooriya said the officers would be educated on how to detect PTSD, what measures should be taken if a person was detected with the symptoms, how to treat them and also the measures needed to be taken to prevent causes leading to PTSD”. 

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Post-traumatic stress disorders (PTSD) is a syndrome with well-identified serious behavioural and psychological abnormality that occurs following exposure to one or more acute stressful event.  Commonly, it is known to occur among the soldiers who returning from battle fields, but it is also occurring in several other non-combat circumstances (http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/what-is-post-traumatic-stress-disorder-or-ptsd.shtml ).  These include the civilian victims of the wars, victims of sexual abuse or rape, mugging, violent robberies and home invasions, natural or man-made disasters, school bulling, and work place harassments and retaliations.

It is not uncommon that PTSD patients are miss diagnosed, and at time inappropriately labelled as a vague elements such as ‘adjustment disorders.’  Unfortunately, these miss-labelling not only can harm these PTSD victims, but also their families.  Whereas, prompt identification of them and offering appropriate, well-organized treatment and therapeutic plans would enable them to alleviate their PTSD symptoms and facilitate them to return to normal productive lives.

PTSD, depressions and psychological disorders are relatively neglected entities in Sri Lanka and thus, have a shortage of trained health professional with expertise in handling these conditions.  The associated conditions that may lead to self harm include severe mood disorders, bipolar disorder, depression with suicidal ideation, burst of aggressive tendencies, severe uncontrollable anxiety status, panic and personality disorders, and PTSD.  Good news is that most of these disorders are controllable or curable with persistent therapy, follow-ups, and community, religious and family support.

In the post-war period in Sri Lanka, due to the above mentioned, diagnosis of PTSD is made too infrequently among the affected soldiers and civilians.  In fact, no one even talks about those civilians who were brutalized by terrorists.  Consequently, the attention, resources allocation, and the research conducted with PTSD are diverted from the real issues affecting in patients with PTSD, to much milder forms of behavioural issues such as, ‘adjustment disorders’.  PTSD is defined as a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma.  Contrary to the popular believes, PTSD can occur outside the war grounds.  Taken together, the latter groups of PTSD exceed several-fold more than the number of post-war PTSD victims.

A schema of human psychological responses to stressful life events may leads to pathological stress response syndromes that can be sustain for long periods.  These syndromes encompass both acute PTSD and delayed manifestations of PTSD.  Event may involve or extend from a threat of death to oneself or to someone else, or to one’s own or someone else’s physical, sexual, or psychological integrity, that overwhelm his or her ability to cope (American Psychiatric Association).  Since the ability of people to handle acute stress experiences markedly varies between individuals, the development of PTSD can also varies whether they have exposed to full-blown stressful incidences or less than overwhelming stressors.   Moreover, some may be inherently vulnerable to develop PTSD even with a less degree of exposure, while others may be resistant.

The most common symptoms of PTSD include recurring unpleasant memories or frequent nightmares of the event(s), flashbacks, inability to initiate sleep, sleeplessness, and loss of interest in common activities and the activities they were used to enjoy previously, or feeling numb or insensitive, unexplained anger and or irritability. However, if unrecognized and/or untreated, these can lead to more sinister behavioural issues including harming self or others, or suicides.  Formal diagnostic criteria of PTSD require that the symptoms last more than one month and cause significant impairment in social, occupational, or other key areas of human functioning or interactions.  Diagnostic criteria for PTSD include re-experiencing the original trauma(s) through flashback of memories and nightmares, avoidance of stimuli associated with the “trauma”, and increased behavioural disorders since the incident.

It is a myth that PTSD only affects the victim’s mental status.  On the contrary, these chronic psychological stresses affect many bodily system, in particular the neuro-endocrine system and the metabolism.  Major traumatic events could impair one’s endocrine systems, causing over-reactive adrenaline responses with paradoxical suppression of the corticosteroid responses.  This leads to sustained pathological abnormality of these stress hormones; i.e., elevation of adrenaline and inappropriately low levels of corticosteroid.  This inverse ratio would leads to a deep neurological disruptive pattern in the brain, not only functionally, but also structurally.

These abnormalities and patterns of changes can continue for month to years after the event that triggered the anxiety or trauma.  Consequently, these abnormal neuro-hormonal memories and responses lead an individual to become hyper-responsive to certain fearful situations in the future, even they are not related to the original event or otherwise trivial.  Following post traumatic experience, the sustained elevation of stress hormones, particularly the catecholamine blunts the activity and responses of key anatomical portions of the human brain, the hypothalamus, which control most of human behaviours and responses to stimuli.

When exposed to an acute stress situation, which is classically describe as “fight-or-flight” response, blood levels of both catecholamine and glucocorticoids are elevated; as a survival mechanism to fight or escape from the acute situation.  Even though the classic response to acute stress or an adverse encounter is to secrete higher amounts of the hormone, corticosteroid from the adrenal glands, in chronic situations as with PTSD, it tend to secrete less glucocorticoids, but continued to have sustained elevation of catecholamines.  This then leads to a pathological, abnormally high norepinephrine to cortisol ratio, in comparison to control human subjects.  This situation is further exaggerated in the hypothalamic brain nuclei.  This is reflected as sustained abnormalities of responses from the hypothalamic-pituitary-adrenal axis (HPA), and thus, manifest as abnormal response and mal-adaptation to the chronic stress situation.

The stress responses occurs when the neuro-hormonal feedback system is not functioning well or missing; for instance, an imbalance in homeostasis or an impending severe threat to homeostasis or life.  These sophisticated brain chemical signalling pathways and neuro-hormonal activities have been evolved and optimized with duplicated functions over thousands of years to keep humans healthy, both physically and mentally.  A delicate balance of these neuro-hormonal and chemical moduli is essential to have a balance in our minds and stability in the mental health.  Stress-related imbalances and the over activation of norepinephrine and its receptor system with down-regulation of glucocorticoid receptors in the prefrontal cortex and hypothalamus lead to unpleasant flashback memories and nightmares that are frequently experienced by those suffer from severe chronic stresses situations.

In patients with PTSD, the functions are distorted in three key anatomical areas of the human brain, which includes the prefrontal-cortex, hippocampus and amygdala.  Interestingly, these are three brain areas that can be positively modify structurally and functionally, using Buddhist meditation practices (Buddhist Meditation Practices for Happiness; ISBN-978-955-458400-6 ).  It is interesting that the research conducted on the PTSD victims of the Vietnam War has postulated that the initial acute “ƒ”¹…”damage’ to the prefrontal-cortex could be in fact protective against later development of PTSD.  Thus, at the immediate period following an acute exposure to a major stressful situation, shutting off the prefrontal cortex could be designed as an evolutionary survival mechanism.  However, with sustained stress, perhaps this beneficial switching-off of the prefrontal cortex would become semi-permanent, thus leading to the development of flashbacks and PTSD.  i.e., the survival-related physiological process is switched into a pathological process leading to the development of PTSD.

Structural brain imaging studies of the groups of soldiers with PTSD reported a 20% reduction in the hippocampal volumes compared with veterans who suffered no such symptoms, but other studies using different groups failed to confirm these.  More importantly, studies of meditating Tibetan monks have repeatedly demonstrated positive structural changes that are associated with mediation.  Since these are exact areas that are negatively affected in patients with PTSD, the regular mediation practices should be an effective and a complementary mean to reverse the negative structural and functional hypothalamic-brain changes that consistently observed in patients with PTSD.  Thus, Buddhist and other meditation practices not only would have a major role in helping, but also offer a highly cost-effective way of structural and functional restoration of brains in those who are affected with stress-disorders including PTSD due to any cause.

Neuro-imaging studies using functional-MRI in humans have revealed both morphological and functional aspects of PTSD.  For example, the brain area, amygdala in humans has been shown to be strongly involved in the formation of emotional memories, especially the fear-related memories.  However, during the high stress periods functions of both amygdala and the hippocampus, which are associated with the ability to place and identify memories in the correct framework of space and time, and the ability to recall the memory, is dampened.  One could argue that this is yet another survival mechanism for allowing humans to make very rapid decisions, rather than permit the brain to rationalize the event prior to responding.  However, in the long run, when this suppression continues, it distort the memory and cause the deleterious flashbacks that often spate the PTSD patients.

Treatment for PTSD includes frequent professional counselling to understand thoughts of these victims and to discover ways to help them to cope with their stress-feelings.  Commonly used medications to treat PTSD includes, generic beta-blocker propranalol, and a series of selective serotonin reuptake inhibitors to help less anxious, stressed, and feel less worried.  Nevertheless, the valuable adjunct of engaging them in meditation and relaxation methods, and establishing community, religious and family support should not be overlooked.

Some benefits have also been reported with cognitive-behavioural therapy.  Whereas, methods such as critical-incident stress management may in fact produce iatrogenic or perhaps worse outcomes.  Multiple studies, involving a number of different post-event psychological interventions structured to prevent or treat PTSD not surprisingly suggested that simultaneous multiple interventions may result in worse outcome than no intervention.  Thus, selecting the appropriate individualized therapy is critical in helping those who are affected.  Some studies have reported that interpersonal psychotherapy provides a better remission from symptoms and responses of PTSD than using prolonged-exposure therapy or relaxation therapies.  As with engaging these patients in regular meditation practices, it is very important to incorporate other simple and cost-effective approaches involving re-establishing and strengthening social support and networks, faith and religious activities and community support.

It is never too late to provide or receive professional treatment and appropriate support for patients with PTSD.  Hospital and community-based treatment programs should include facilitating connecting with and learn to trusting others, learn to forgive others, exercise and relaxation to reduce physical tension, and volunteering in local community projects that also can facilitate them reconnecting with the community.  With the availability of extensive medical facilities in the west, even in America, less than half of those who are significantly affected get treated for PTSD (http://bbrfoundation.org/ptsd).  It is time that not only the Ministry of Defence and its network of health professionals, but also the department of health work together and pay more attention to these post-war victims, both civilians and soldiers, who are now scattered throughout the country, and should not be restricted to military facilities.  However, to obtain the maximum benefits to those who are affected and to their families with least costs, these efforts must be well coordinated.

The main psychotherapeutic approach is to treat PTSD patients is the cognitive behavioural programs, but several other approaches have also been tried.  The aims of the cognitive behavioural therapy (CBT) is to change the way a trauma victim feels and acts by changing the patterns of thinking, memories, and the behaviour that responsible for emerging negative emotions and flashbacks.  CBT therapy is geared for patients to identify and learn their thoughts which make them generate fear or feel afraid, and substitute these negative thoughts with positive or less upsetting thoughts.  CBT has been proven to be an effective treatment for some patients with PTSD and is currently considered the standard of care for PTSD by some psychiatric societies and the United States Department of Defence (http://www.defense.gov/news/newsarticle.aspx?id=117339 ).  The goal of CBT is to understand how certain thoughts about events cause PTSD-related stress, and identify effective ways to overcome these.

Situation among the brave Sri Lankan soldiers in the post-war period from May 2008 and even several years prior to that is no different than any other soldiers in post-war situations, including Vietnam, Iraq, and Afghanistan; i.e., soldiers returning from the battle fields.  The vast majority of them are subjected to and suffer from varying degrees of PTS disorders, in addition to the subsequent inevitable adjustment disorders.  As with the soldiers who suffer from the PTSD in the West, Sri Lankan soldiers with PTSD also deserves the best possible treatment options.  Because of the sustained chronic stresses due to the changes in brain chemical patterns and foot prints that acquired and manifest as a consequence to their war-related experiences, the occurrence of various levels of adjustment disorders is inevitable among these groups.  Thus adjustment disorders are a part of the post-traumatic disorders and are inseparable.  Therefore, treating them “separately” will only have a little impact neither in decreasing suicidal rates nor on individual person or affected families.

Summary:

It is necessary to have an educational campaign to over the stigma attached to the terminology of PTSD, as this seems to be yet another barrier in diagnosis as well as accepting treatment by these victims.  Labelling soldiers with PTSD as an “adjustive disorder” is a misnomer and will not help these victims of stress, and in fact can be considered as an injustice to those who are affected.  This trend should not be continued as it will provide little help to these patients and families.  Unless actively intervene with validated therapies and providing a wider-based support to the victims and their families properly, the high incidence of suicide and the significant behavioural issues will continue, which would lead to loss of more lives and more family disruptions.  During the past three-decades of civil war in Sri Lanka, our soldiers have sacrificed their lives and their families for the benefit of the nation and the country and preserve its sovereignty; they indeed deserve the best treatments.

It is essential to improve the recognition, identification, and the awareness of PTSD.  The key is to identify the vulnerable people and get them into effective individual and group therapy.  In addition to families, professionals within the three armed-services should facilitate identifying those who are at risk, and directed them to appropriate local centre or professionals to take care of them.  Meanwhile, intensive coordinated therapeutic program together with community, religious, and family support should be undertaken and offered to the victims as a vital part of curing them, and keeping affected people in remission and preventing suicides.

Solution lies not on handling the ‘adjustment or family issues’ alone, but directly addressing the root causes of the chronic stresses which must be individualized, and consequently improving the associated behavioural issues in the long run, in a sustainable manner.  With the current high suicidal rates among the PTSD victims, which is perhaps under-estimated, it is critical to carry out an urgent, broad but in-depth root-cause analysis to identify key contributory factors and warning signs.  Such suggestions were brought in by several of us in 2007/08 period, and there is no reason for waiting three-years to do such a focused and a useful study.  True findings from such a study should be publicized for the benefit of the society, and utilize to zoom into the “real” causes leading to PTSD and to eliminate or at least to alleviate chronic stresses and suicides among all vulnerable soldiers and officers in all three armed-forces and the police department in Sri Lanka.  These should also help to implement specific diagnostic and therapeutic guidelines, and a plan of action to assist all those who are affected.  Meanwhile, one should not neglect the civilian victims who have sustained PTSD secondary to violent terrorist activities.  They should also offer a similar diagnostic and treatment options to obtain effective therapies for them to get back to their productive lives.

Sunil J. Wimalawansa, MD, PhD, MBA, DSc.
Professor of Medicine, Endocrinology, Physiology, & Integrative Biology 

4 Responses to “Escalating Incidence of Post Traumatic Stress Disorders (PTSD) and Suicides Among Soldiers and Civilians Who were Exposed to Civil War in Sri Lanka”

  1. M.S.MUDALI Says:

    The state organs must help the people in this situations. My frends siblins in the army and have the same problems. I hope my superior, once Gota Rajapakashe will help them.

    I thank Mr Sunil for this issue.

  2. Vis8 Says:

    The root causes in this case could be the stresses induced under fight-or-die conditions, fighting face-to-face, knowing that the better one lives, and the other dies. It appears that there is a shortage in all forms of professionals, psychological and medical, that could diagnose and bring help to these Ranavirus. Unfortunately, most of the foreign-educated doctors (Psychiatrists) who could handle things on such a large scale, are living overseas.

    Mandating all soldiers to attend a Temple once a month, and listen to a sermon, would be good :)

  3. Fran Diaz Says:

    We thank Prof Wimalawansa for this article. Dr Ruwan Jayatunge too has, from time to time, written on the same subject. What can ordinary people do to help a person suffering from PTSD ? Not much, I think, except be kind and understanding toward such a person suffering from PTSD.

    Looking into alternate methods to help, teaching some Buddhist Meditation would be a self help way to aid anyone suffering from PTSD. There are homeopathic medicines that help too. Why don’t our Osu Salas sell h’pathy books and medicines ?

    Here is an article written by a doctor to explain the role of homeopathy in PTSD : http://hpathy.com/clinical-cases/homeopathic-treatment-of-ptsd/

  4. roshanmonaragala Says:

    First I must thank Prof Wimalawansa for a very stimulating account regarding the mental health issues of the Sri Lanka army. In fact, I further like to extend my gratitude for showing your patriotic enthusiasm of our victorious soldiers.

    Let me introduce my self. I am the consultant psychiatrist of the Sri Lanka army and have obtained overseas training in military psychiatry in the mental health department of the Israel Defence Force. Before I became the psychiatrist I was in the battle field working as a medical officer managing cases with battle injuries.

    I quite agree with the fact that there can be cases with PTSD. We have surveyed and extrapolated the prevalence of PTSD. Now we have taken measures to screen and treat cases with PTSD. There are practical problems as things do not work as it sound to be. We are going to expand the mental health services to the field , which of course is directed not only for secondary prevention (such as screening and treating cases with PTSD) but also primary prevention.

    I must categorically state here that most cases of suicide are not due to PTSD. In fact, according to the survey we did with the soldiers who attempted to commit suicide , 60 % or more were suffering from adjustment difficulties either due to the inability to cope with the military environment or new life events. Hence, we will be focusing on primary prevention by expanding mental health services to the field. We will be introducing resilience building programmes in the future to withstand these stressors and sustain motivation and cohesion . With this system of services we will be able to reduce not only suicides but also absenteeism and disciplinary issues. So ,, when we discuss about military mental health there are things beyond PTSD.

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