Dr Sarath Panduwawala / Dr Ruwan M Jayatunge 

The Sri Lanka Army engaged in prolonged military conflict against the armed separatists of the Northern Sri Lanka. The conflict started in 1981 with the killing of two members of the Sri Lanka Army by the rebels. In the early stages the conflict emerged as guerrilla attacks and later evolved into a proxy war. The armed conflict which continued until 2009 came to be known as the Eelam War. Following the armed conflict nearly 26 ,000  soldiers died and a large numbers became physically and psychologically disabled.

When the militants intensified their attacks on military and civil targets, the Sri Lanka Army deployed its entire bayonet strength for more than 25 years. During the critical period of the Eelam War the Sri Lankan military launched nearly 20 major military operations against the rebels starting from 1987 to 2009. Over 100, 000 members of the Sri Lanka Army had been directly or indirectly exposed to combat events during the Eelam War.  They were exposed to hostile battle conditions and many soldiers underwent traumatic combat events outside the range of usual human experience.

In 2009 May the Sri Lankan government declared that the country had won the war against the armed militants. Although the armed forces were able to gain a decisive victory it came with a huge social cost. The Eelam war affected the psychosocial health of the combatants and civilians. Significant numbers are still impacted by combat trauma.

The current PTSD study among the Sri Lankan combatants (done by Dr Neil Fernando and Dr Ruwan M Jayatunge) shows a low PTSD prevalence rate (6.7%) compared to Vietnam, Iraq and Afghanistan veterans. There could be several factors including cultural and religiousfactors which acted as buffers and protected the combatants from the development of PTSD. However this sample was not randomly selected and it was a presented sample that was refereed for treatment and psychological evaluations. Therefore this study may not reflect the actual picture of combat trauma in the Sri Lanka Army. The actual PTSD numbers may be high. According to rough assumptions PTSD rate among the soldiers of the Sri Lanka Army could be 12 % – 16 %.

In this study six soldiers were found with partial PTSD. Within the literature on PTSD, individuals who fail to satisfy diagnostic criteria yet report notable symptomatology have been termed as experiencing partial PTSD ( Kulka, Schlenger, & Fairbank, 1990; Gudmundsdottir &  Beck , 2004). According to Stein and colleagues (1997) patients with partial PTSD lack one or two of the three required avoidance or numbing symptoms, and/or one of two required hyperarousal symptoms. Breslau, Lucia and Davis (2004) state that PTSD identifies the most severe trauma victims, who are markedly distinguishable from victims with subthreshold PTSD. However Dickstein et al (2013) highlight thatsubthreshold posttraumatic stress disorder symptomatology is associated with increased risk for psychological and functional impairment, including increased risk for suicidal ideation. Six of the Sri Lankan soldiers with partial PTSD had significant functional impairments such as marital and parenting problems and impairments in quality of life and functioning.

The war affected Sri Lankan soldiers face a number of psychosocial problems. Pearrow and Cosgrove (2009) indicated that veterans’ exposure to heightened levels of stress resulting from combat and associated threatening and catastrophic events can markedly disrupt their functioning, not only while on the front lines but also upon their reentry into civilian life. With regard to Sri Lankan soldiers with PTSD the investigators found the same outcome. The Sri Lankan combatants with PTSD were found to be affected by numerous work related and other psycho social dysfunctions. Domestic violence, Alcohol and substance abuse, attempted suicides and self harms, disciplinary infractions were found among them.  Combat trauma symptoms impacted their marital, vocational, and social function.

The individuals with PTSD frequently suffer from other comorbid psychiatric disorders, such as depression, other anxiety disorders, and alcohol or substance abuse/dependence (Friedman et al., 1994). Comorbid disorders have an adverse impact on the prognosis and treatment of individuals with PTSD (Abram et al., 2013).  Data from epidemiologic surveys indicate that the vast majority of individuals with PTSD meet criteria for at least one other psychiatric disorder, and a substantial percentage have 3 or more other psychiatric diagnoses (Brady, 2000). Sri Lankan combatants with PTSD were found have other comorbid psychiatric disorders such as Depression, Substance Abuse Disorder and sometimes Psychosis.  

The main treatments for PTSD are psychotherapy and medication. Recent guidelines suggest that psychotherapy should be initiated as a first-line treatment for PTSD ((National Collaborating Centre for Mental Health, 2005). The most commonly used medications have been antidepressants, and specifically SSRIs (Davidson, 2000; Davidson & Connor, 1999; Cukor et al., 2009). Spinazzola, Blaustein and van der Kolk (2005) identify prolonged exposure (PE), cognitive processing therapy, cognitive restructuring, and eye-movement desensitization and reprocessing (EMDR) as some of the leading interventions for PTSD.

In Sri Lanka the combatants with PTSD are treated with drug therapy (anti depressants, mood stabilizers, anti psychotics, pain killers etc.) psychotherapy (CBT, EMDR, Rogerian therapy) and traditional healing methods. Drug therapy helps to minimize acute PTSD symptoms and normalize sleep. Rogerian Person Centred Therapy allows the combatants to release their bottled up negative emotions.  Cognitive Behavior Therapy has helped the combatants to improve their social functioning. In 2005 eighteen Sri Lankan combatants were treated with EMDR and twelve of them showed significant clinical improvement after 5-6 sessions of EMDR.

Among the traditional therapies Thovilaya has been identified as a conventional healing method. It is a form of psychodrama geared to heal the patient as well as his environment. Spiritual therapy also plays a vital role in treating soldiers with combat trauma. Spiritual therapy especially Buddhist psychotherapy helps the war victims to find meaning and achieve post traumatic growth.

In Sri Lanka a large number of ex combatants transited to civil society without any prier screening process. Many of them have readjustment problems. Psychosocial rehabilitation of the war veterans have been recognized as a crucial component in Sri Lanka. A range of social, educational, occupational, behavioral and cognitive interventions would be needed to address the needs of the combatants who were affected by the war.