By Ruwan Jayatunge
(February 25, Colombo, Sri Lanka Guardian) Psychological trauma affected the humankind since dawn of history. A countless number of people suffered from natural and man made disasters. For centuries, there were no methods to heal the suffering. People lived with their traumatic memories and believed that the time would heal them. Some could get away with their suffering when the time passed by, but others could not.
The famous Viennese doctor Sigmund Freud knew about the suffering carried by the emotionally disturbed patients. His Psychoanalytic therapy could be considered as one of the early researched based attempts to heal trauma. But Psychoanalysis had less popularity due to lengthy sessions and prolonged healing process. But his approach gave a wider understanding about anxiety.
Introduction of cognitive therapies gave a new hope. Beck and other pioneers in CBT helped a large number of people with emotional problems. Among all contemporary psychotherapies EMDR (Eye Movement Desensitization and Reprocessing ) became unique. What is exceptional about EMDR? It is easy to administer, gives quick positive results and no side effects. EMDR facilitates to ease traumatic experiences.
The hypothesis based on EMDR (Eye Movement Desensitization and Reprocessing ) is that the specific traumatic experiences from the past can cause negative impact on a person’s present emotions and behavior. EMDR helps to bring these traumatic memories to a positive resolution.
EMDR or Eye Movement Desensitization and Reprocessing was discovered by Francine Shapiro, Ph.D., clinical psychologist USA. Like many great theories (Eg Theory of Gravitation, Theory of Relativity) EMDR was discovered accidentally in 1987 by Shapiro while walking in a California park. While walking her eyes spontaneously moved rapidly from side to side and it helped her to erase an apparent distress that she experienced on that day. This finding ultimately led her to believe that rapid lateral eye movements’ help to release metabolize and reprocess traumatic memories.
Dr Shapiro tested this newly fond method on Vietnam veterans with Post Traumatic Stress Disorder. Even two decades after the War, these veterans still suffered from PTSD. After 60 – 90 -minute sessions there were significant reduction in PTSD symptoms and the patients did not experience nigh terror and distress any more. It was a great relief for them.
EMDR started to boom gradually. In 1989, Shapiro reported in the Journal of Traumatic Stress her new method EMDR which is effective in treating trauma. Following its efficacy, many therapists believed in EMDR.
Eye Movement Desensitization and Reprocessing is indicated in anxiety, panic, disturbing memories, post traumatic stress and many other emotional problems. Research indicate that EMDR is the most effective and rapid method for healing PTSD.
The control studies of EMDR reveal that this mode of therapy is more efficient. Fourteen controlled studies support the efficacy of EMDR, making it the most thoroughly researched method ever used in the treatment of trauma. Research shows that EMDR is rapid, safe and efficient.
Dr. Shapiro developed the adaptive information-processing model to help explain the success of EMDR. According to Dr. Shapiro’s assumption, humans have an information processing system in the brain. While memories of an ordinary event are processed completely and normally, memories of a traumatic event may be insufficiently processed and remain trapped in the processing system. The information processing system processes the multiple elements of our experiences and stores memories in an accessible and useful form. Memories are linked in networks that contain related thoughts, images, emotions, and sensations. Learning occurs when new associations are forged with material already stored in memory. When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interferes with information processing. Moreover, the initial emotions, perceptions, and physical feelings existing at the time of the trauma may also get trapped, and can be triggered by events in the present. The result can be a range of psychological problems.
Professor Robert Stickgold of Harvard says EMDR mimics REM sleep. Dreams are safety valves. We experience dreams in the REM sleep. Traumatic memories do not process sufficiently. Therefore these memories can cause continuous distress. EMDR which acts like induced REM sleep helps to process traumatic memories.
After exposing to a traumatic incident, people psychologically get stuck. Shapiro uses the example of rape to illustrate how people can get stuck in trauma. “A rape survivor may ‘know that rapists are responsible for their crimes, but this information does not connect with her feeling that she is to blame for the attack. The memory is then dysfunctionally stored without appropriate associative connections and with many elements still unprocessed. When the individual thinks about the trauma, or when the memory is triggered by similar situations, the person may feel like she is reliving it, or may experience strong emotions and physical sensations. The EMDR unlocks the negative memories and emotions stored in the nervous system, and it helps the brain to successfully process the experience.
EMDR is now an internationally recognized psychotherapeutic procedure. EMDR has been given the same status as CBT as an effective treatment for ameliorating symptoms of both acute and chronic PTSD (APA 2004). According to a taskforce of the Clinical Division of the American Psychological Association the only methods empirically supported for the treatment of any PTSD population were EMDR, Exposure Therapy, and Stress Inoculation Therapy (Chambless D.L.et al1998). In the practice guidelines of the International Society for Traumatic Stress Studies EMDR was listed as an efficacious treatment for PTSD.(FoaE.B Kene T.M & Friedman M.J 2000).
Sri Lankan Soldiers treated with EMDR
The Democratic Socialist Republic of Sri Lanka is an island in the Indian Ocean about 28 kilometers (18 mi.) off the southeastern coast of India with a population of about 19 million. Sri Lanka is shattered by an internal conflict, which claimed 70,000 lives over 30 years. Many Psychiatrists claim that this conflict has a direct impact on mental health indicators. In the aftermath of the ethnic conflict, many people in the military, paramilitary and civil society have undergone severe stressful events beyond usual human experience.
Following the 30-year conflict in Sri Lanka, combat veterans have undergone numerous battle related stresses. Unlike the servicemen of WW1, WW2 or the Vietnam War, Sri Lankan combatants were exposed to combat trauma for long years. Some have served 10-15 years in the operational areas with brief intervals. Until recent times the military had no systematic mode of treatment or methods to deal with combat trauma. The attention was mainly focused on physical injuries and consequently psychological issues were neglected. This has invariably resulted in accumulation of psychological casualties both during the war and the post combat era.
In one of our uncontrolled studies, we treated 18 Sri Lankan Soldiers suffered from PTSD with EMDR. Their therapeutic outcome was exceptional. This study was started in June 2005 and 18 combatants with PTSD were selected. Prior to the study their consent has been obtained and they were explained about the EMDR procedure. All the combatants have undergone various combat related traumatic events and had PTSD symptoms. Some were treated with SSRI, Exposure Therapy, Client Centered methods and Rational Emotive therapy. Many had undergone traditional healing methods. Dr Nancy Errebo of the EMDR HAP who introduced EMDR to Sri Lanka observed some of the therapeutic sessions.
Despite the various modes of treatment, more than 99% of them still experienced nightmares, intrusions of combat related events, numbing, anhedonia, startling reactions, and some had suicidal ideas. All of the combatants underwent 5-8 sessions of EMDR. Most of them showed spectacular results with EMDR. After EMDR sessions they were subjected to follow up which continued for 6 months.
Lance Corporal S (44Y) was one of the soldiers who was in our study. He has served in the operational areas for five years. In 2000 March, he met with a land mine explosion in Mannar (Northern Part of Sri Lanka). Although he survived the blast with minor physical injuries, he witnessed the death of other soldiers who traveled with him. Many of them were his friends who have served with him for a number of years. Lance Corporal S was shattered by this incident and went in to anxiety and depression mixed reaction. Gradually he experienced survival guilt, night terror, exaggerated startling reactions, numbing of general responsiveness and marked avoidance. In 2002, he was diagnosed with PTSD. He was on SSRI and relaxation therapies. His PTSD symptoms were under control until the Tsunami devastation in 2004 December. He was exposed to Tsunami events and had a relapse of PTSD symptoms.
Lance Corporal S willingly and positively responded to EMDR. During the first sessions, he developed psycho-physiological reactions and eye movements were switched to hand taps. But in the subsequent sessions he faced eye movements without a difficulty. With EMDR his nightmares became minimal and later disappeared so as his intrusions. His negative feelings changed in to more positive.
Lance Corporal K was another solder who underwent EMDR. He joined the Army in 1989 and served in the operational areas for many years. When the LTTE attacked the Kiran Camp his unit went on a rescuer mission. There he saw a large numbers of dead bodies mutilated and decomposed. When the enemy attacked them with heavy weapons, he became distressed and manifested stress reactions. After the rescue mission, they came home. But the events at the Kiran Camp started troubling him. He could not sleep, for the slightest sound; he would give a startled reaction. He had flashbacks with fear feelings. Finally, he was referred to the Military Hospital Colombo and was diagnosed as having PTSD.
Lance Corporal K faced EMDR with a mild hesitation. He was used to talk therapy. However, gradually he was able to adapt to EMDR. His image was a thunder and the negative cognition was “I whish I was dead” and the SUD was 9. ( Subjective Units of Disturbance Scale SUDS; adapted from Wolpe as described in Shapiro, 1989a This measure is taken at several intervals during the treatment of each upsetting memory, as treatment is generally continued until the SUDS reaches 0. Non-reactivity to the traumatic memory is considered an indicator of recovery (Horowitz 1986).
That night he was able to sleep without any night terror and then he was more positive about EMDR. Subsequent sessions marked a significant success in him. When Lance Corporal K came for a follow up on the 28th of November 2005, except startling reactions most of the PTSD symptoms had been reduced.
Corporal W (37Y) has served 15 years in the operational areas. In 1992, he was exposed to a blast at Welioya. Although the blast did not harm him physically his psyche was horrified. At another incident at the Comma Point Mulathive he was ordered to bury dead soldiers. They were half swollen and putrefied. Some of the dead soldiers were known to him. Since it was an order he fulfilled the duty but with repulsion. Following these events he felt despair. Gradually his nights became disturbed; he was depressed and had no aim in life. He stopped associating with people and became more withdrawn. His mind was full of past combat events and sometimes he had a sense of re-experiencing these events. While experiencing PTSD symptoms Corporal W became extremely hostile. Once he physically punished his teen aged daughter and she was hospitalized. He even had several suicide attempts.
Corporal W was treated with EMDR. His image was an unarmed man surrounded by the enemy and SUD was 8. He underwent six sessions of EMDR as an inpatient. In each session he showed a dramatic improvement. Finally he was free of most of the PTSD symptoms.
Capt K was a brave officer who had participated in a number of military operations. In 1992 he went on a rescue mission and directly engaged with the enemy. There in front of his eyes he lost 23 of his men whom he treated as his own children. He trained them and looked after them and went to the battle ground with them. But they were perished leaving a deep despair in his heart. Capt K could not forget these terrible events for many years. In order to avoid intrusions and night disturbances he started indulging in alcohol. He became numbed and withdrawn. Capt K volunteered for EMDR and underwent the full therapeutic protocol. With the reprocessing therapy, his disturbed feelings and intrusive memories became minimal. After many years, he was able to sleep without horrible nightmares.
EMDR and Cultural Variations in Combat Trauma
Combat trauma is a very complex multi-dimensional phenomenon. It disrupts the soldier’s military performance as well as his psychosocial functioning. Prolonged exposure to combat trauma can cause various anxiety related conditions. Soon after a traumatic combat action soldiers should be provided with psychological first aid and counsel them in an ethically and culturally appropriate manner.
Many Sri Lankan combatants believe in reincarnation and the effects of Karma. Often these concepts help them to come to terms with their trauma. If a disabled soldier asks, “why I became a disabled? Alternatively, if he develops “why me” concept or “why on earth this disaster fell on me”, it can lead to unresolved mental conflicts. Those who have these perceptions inside them can easily go in to depression and posttraumatic symptoms.
Following case example gives a better understanding of trauma and rationalization. Major J lost his leg as a result of an antipersonnel mine. He was distressed for a short period. Now he has almost come to terms with his physical disability and the mental trauma. “I have to pay for my Karma” says Major J who was an infantry officer. He believes he had committed sins in this life as well as in his past life. He does not curse his present life and his misery. He is now doing a computer course and positively faces the future.
Sri Lankan combatants have more somatic ailments when they manifest anxiety. The somatic component is highly expressed than the emotional picture. Therefore, the clinical picture is often misleading. Many patients with depressive disorder get treatment for migraine or joint pains before coming for psychological help. Once a patient with post combat depression was treated for migraine for seven months and he was recommended to use spectacles in order to soothe his intermittent headaches. The elements of depression were elicited in the psychological assessment and treated accordingly. When he was treated with SSRI and EMDR within six weeks his headache subsided.
During the WW1 Conversion, reactions were in abundance. But in Europe and in North America conversion reactions became minimal with the WW2, Vietnam War and the Iraq War. Nevertheless, the Eelam war in Sri Lanka has generated a large number of conversion reactions. There are many reasons for this. In the Sri Lankan conflict, soldiers had no psychological debriefing or similar trauma management soon after the traumatic combat events. There were little psycho-education of combat reactions for the soldiers. Military doctors had little knowledge about the psychological reactions after heavy combat. In addition, the soldiers were reluctant to show their emotions which was considered as an act of cowardice. Therefore, many combat reactions were expressed through disociative channels.
The dissociative symptoms that they have experienced following combat trauma, in most occasions were interpreted as the disturbances created by the bad spirits. Psychogenic paralysis was considered as an act of black magic and possession states were regarded as mediation with the gods and goddesses.
Sri Lankan soldiers with somatoform disorders gave optimistic results when they were treated with EMDR. Many patients had pathetic hospital stories apart from their combat trauma. These patients had vivid somatic complaints that did not compatible with the medical book. Most of the investigations were normal and the Military Doctors suspected them as malingerers. Some were accused of faking their illnesses.
This is the story of Lance Corporal W. ……..
Lance Corporal W handled human remains for many months. He always felt uneasy when he put dead soldiers to body bags. In addition, he had to do mine clearing operations in the North. Several occasions he witnessed, his team members either losing their legs or receiving fatal injuries due to mine explosions. After serving a number of years, Lance Corporal W experienced transient headaches, chest discomfort, heart pounding, fatigability, decreased libido and joint pains. He was referred to the hospital. His complaints had no medical compatibility and the laboratory tests, ECG and other reports were in normal range. Above all, he never had any physical injury in the battle. Therefore, he was discharged as a malingerer.
After some months, his condition aggravated and he had associated symptoms of depression and anxiety and referred to for a psychological valuation. After a detailed assessment, Lance Corporal W was diagnosed as having Somatoform Disorder. With his consent, he was treated with EMDR. His somatic ailments became minimal after five sessions.
Many decades ago, mental health clinicians believed PTSD is a culturally based phenomenon. They thought PTSD is an illness in the Western world or rather an Americal illness. The first patients of PTSD were recorded in the Western world in Samuel Pepy’s diary in 1666. He describes the night terror and intrusions experienced by people soon after the great fire of London. Unfortunately, nobody knows that the King Seethawaka Rajasinghe who fought against the Portuguese in 1532 suffered from full-blown symptoms of PTSD. The ancient historians described his symptomatalogy in vivid terms. Also in the Jathaka stories, which was written thousand years ago describes a PTSD patient. In the Jathaka story book there is a story of a monk who had PTSD like symptoms. He was called Marana-Bheruka Bikku or the monk with mortal fear and startling reactions. These clues show us that PTSD is not something new or which came from the West. PTSD is universal and each culture has different interpretation for this anxiety related disorder.
EMDR has been practicing in worldwide. Today the psychotherapists in America, Europe, Africa and Asia treat numerous patients with depression and anxiety with EMDR and they achieve constructive results. This shows that without cultural barriers we can successfully treat combat and other type of trauma by EMDR. This is a major victory achieved by the humankind. Dr Steven Silver and Dr Susan Rogers in their outstanding book “Light in the heart of darkness” mention that EMDR has similar therapeutic effects world wide and EMDR model varies from place to place. This is a valid expression.
Combat trauma has many faces. In different societies, it can give variety of features. However, one thing is common in combat trauma. That is the human suffering. Human suffering is universal. It has no cultural variations. Psychological Trauma has no demographical barriers. The researched data and controlled studies, which have done in different parts of the world reveal that EMDR, can be applicable to any society to heal trauma. It has no cultural or social limitations. EMDR is unique. It is effective as a mode of psychotherapy and the trauma survivors are arable to regain the control and lead to productive lives.
EMDR and Dissociative Disorders Following Traumatic Combat Exposure
Combat soldiers who were exposed to distressing battle events can go in to dissociative reactions. Dissociation can be interpreted as a protective or defensive reaction in extreme stress. Repression of war experience may be a temporary reaction. Among the dissociative features psychogenic seizures, psychogenic tremors, aphonias and fugue states are frequent. Some of these reactions evident soon after the traumatic battle events and some manifest as delayed reactions. The combat stresses led soldiers go in to an unprecedented numbers suffering from dissociative disorders.
The Nature of Dissociative Disorders in Combat
The dissociative disorders are usually associated with trauma in the recent or distant past, or with an intense internal conflict that forces the mind to separate incompatible or unacceptable knowledge, information, or feelings. Dissociative disorders appear to be ways of avoiding psychological stress while denying personal responsibility for doing so. In this context combat related stress can generate a numerous traumatic experiences and this overwhelming stress can lead to dissociation. In addition combat experience in many occasions can cause unresolved mental conflicts among the soldiers.
Somatoform dissociation is a lack of the normal integration of sensorimotor components of experience such as hearing, seeing, feeling, speaking, moving, etc. It is a major consequence of psychological trauma. Trauma-related structural dissociation, including somatoform symptoms model was developed by British army psychiatrist/psychologist Charles Samuel Myers. He had investigated soldiers suffering from vivid, painful sensorimotor memories of the trauma, i.e., hypermnesia, partial or complete amnesia of the trauma, detachment, and numbing. Myers and other WWI psychiatrists also noted various dissociative symptoms more directly manifested in the body, such as lack of awareness or control of movements and sensations.
Dissociative amnesiais classified by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, as one of the dissociative disorders, which are mental disorders in which the normally well-integrated functions of memory, identity, perception, or consciousness are separated (dissociated). Patients with dissociative amnesia usually report a gap or series of gaps in their recollection of their life history. The gaps are usually related to episodes or abuse or equally severe trauma. In dissociative amnesia, the continuity of the soldier’s memory is disrupted. They have recurrent episodes in which they forget important personal information or events, usually connected with trauma or severe stress.
Private D witnessed the death of four soldiers following an incoming mortar. Although Private D was physically unharmed he was frightened and felt powerless. He went in to heightened stress reaction and later evacuated. Even after several years Private D could not remember how he was evacuated from his bunker and he has memory lapses about the incident which occurred in the battle field.
Fugue States in the Battle Field
Fugue states can be resulted from dissociative disorders as well as depressive disorders. Dissociative fugue states are not uncommon in combat situations.
Corporal A has served 17 years in the operational areas. On one occasion he went in to dissociative fugue and walked in to the enemy linens. When he was found by a friendly group of soldiers Corporal A had thrown his weapon and was wondering about in hostile territory. He did not have any idea of what he was doing near the enemy lines. Later this soldier was diagnosed with dissociative disorder.
Psychogenic seizures are caused by subconscious mental activity, not abnormal electrical activity in the brain. Psychogenic seizures are not classified as epilepsy and it can arise from various psychological factors, may be prompted by stress, and may occur in response to suggestion. It has also been found that such disorders may be self-induced. They may be used to get attention, to be excused from work or merely to escape an intolerable combat situation.
Psychogenic attacks differ from epileptic seizures in those out-of-phase movements of the upper and lower extremities, pelvic thrusting, and side-to-side head movements are evident. However, psychogenic seizures vary from one occurrence to another and are not readily stereotyped. Indicators like pupillary dilation, depressed corneal reflexes, the presence of Babinski responses, autonomic cardio-respiratory changes, tongue biting and urinary/fecal incontinence are more probable with epilepsy and are not usually manifested in psychogenic seizures.
Corporal C was exposed to traumatic combat situations. A number of times he witnessed killings and faced enemy artillery attacks. Several times his platoon was surrounded by the enemy and every occasion he felt desolated. Corporal C was lucky enough to survive without any physical injuries. In 2004 he manifested convulsions and investigated at the National hospital. His post ictal EEG report and brain scan did not confirm any pathological condition. The eye witnessed account revealed that Corporal C is experiencing psychogenic epilepsy. He was diagnosed with Dissociative Disorder.
Psychogenic voice disorders are distinguished from other vocal dysfunction by the fact that, though the symptoms or secondary characteristics are physical or 'organic', the origins of the problem are psychological rather than physical. It is not always easy to distinguish from listening and quick observation alone whether the cause of the problem is psychological or organic. It is usually important to have a full medical and laryngeal investigation to rule out physical causes first (such as viral infection, allergy, neurological disease, cancer). Examples of psychogenic causes of vocal problems are chronic anxiety states, stress, depression, intrapersonal and interpersonal problems (often dating back to unresolved emotional and psychological issues from childhood), and trauma.
Bombardier T experienced horrendous combat events during 1997-1998. On one occasion he and his team went on an ambush. Unexpectedly the enemy attacked them and Bombardier T witnessed the death of his friends. The enemy shot them and chopped their heads with swards. He was hiding in the woods and observed the terrible events. He was the only member who survived that day. In 1993 he complained of the numbness of the right hand and difficulty in speech. Bombardier T was seen by the Consultant ENT surgeon and found no ENT pathology. He regained his voice after hypnotherapy.
Tremor is defined as a rhythmic, involuntary, oscillating movement of a body part occurring in isolation. Psychogenic tremor may involve any part of the body, but it most commonly affects the extremities. Usually, tremor onset is sudden and begins with an unusual combination of postural, action, and resting tremors. Psychogenic tremor decreases with distraction and is associated with multiple other psychosomatic complaints.
Lance Corporal S was investigated for tremors and weakness of the right hand which had no apparent medical basis. After neuro-physiological investigations it was revealed that Lance Corporal S was suffering from psychogenic tremors. Combat stress may have a link with his psychogenic tremors. Several years ago he had undergone a numerous combat related stress events. At one incident (1991) they were trapped inside the Elephant Pass camp for nearly one month. He was distressed and uncertain about the rescue. Finally they were freed by the friendly forces. The psychogenic tremors in the right hand indicate unconscious avoidance of the battle field.
Delayed Dissociative Reactions
Combat stress has a residual effect on some veterans. The delayed retrieval of traumatic events have been written about for nearly 100 years in clinical literature military veterans who survived combat. Some of the dissociative reactions can manifest 5-10 years after the original trauma or may be after a long period. According to Dr. Michael Robertson of the Mayo Wesley Clink, aging veterans of WW2 have manifested combat stress reactions after 50 years. Therefore treatment of combat stress cannot be limited to the battle era.