Post Combat Reactions among the Sri Lankan Soldiers
Posted on August 7th, 2011

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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