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Module 6: Psychological Evidence of Torture and Ill-Treatment
Symptoms of PTSD may appear in children. The symptoms can be similar to those observed in adults but the clinician must rely more heavily on observations of the child’s behaviour than on verbal expression. For example, the child may demonstrate symptoms of re-experiencing as manifested by monotonous, repetitive play representing aspects of the traumatic event, visual memories of the events in and out of play, repeated questions or declarations about the traumatic event and nightmares. The child may develop bedwetting, loss of control of bowel movements, social withdrawal, restricted affect, attitude changes toward self and others and feelings that there is no future. S/he may experience hyperarousal and have night terrors, problems going to bed, sleep disturbance, heightened startle response, irritability and significant disturbances in attention and concentration. Fears and aggressive behaviour that were non-existent before the traumatic event may appear, such as aggressiveness toward peers, adults or animals, fear of the dark, fear of going to the toilet alone and phobias. The child may demonstrate sexual behaviour that is inappropriate for his/her age and may experience somatic reactions. Anxiety symptoms may appear, such as exaggerated fear of strangers, separation anxiety, panic, agitation, temper tantrums and uncontrolled crying. The child also may develop eating problems.
Symptoms of PTSD may appear in children. The symptoms can be similar to those observed in adults but the clinician must rely more heavily on observations of the child’s behaviour than on verbal expression. For example, the child may demonstrate … Continue reading
The family plays an important dynamic role in persisting symptomatology among children. In order to preserve cohesion in the family, dysfunctional behaviours and delegation of roles may occur. Family members, often children, can be assigned the role of patient and develop severe disorders. A child may be overly protected or important facts about the trauma may be hidden. Alternatively, the child can be “parentified” and expected to care for the parents.
When the child is not the direct victim of torture but only affected indirectly, adults often tend to underestimate the impact on the child’s psyche and development. When loved ones around a child have been persecuted, raped and tortured or the child has witnessed severe trauma or torture, s/he may develop dysfunctional beliefs, such as that he/she is responsible for the bad events or that s/he has to bear the parent’s burdens. These types of beliefs can lead to long-term problems with loyalty conflicts, guilt, personal development and maturing into an independent adult.
The family plays an important dynamic role in persisting symptomatology among children. In order to preserve cohesion in the family, dysfunctional behaviours and delegation of roles may occur. Family members, often children, can be assigned the role of patient and … Continue reading
Selections from the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10 Version:2007).
(Complete, updated ICD-10 Version:2010 available at http://www.who.int/classifications/apps/icd/icd10online .)
Mood [affective] disorders (F30-F39)
F32 Depressive Episode
In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and self-confidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called “somatic” symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe.
Includes: single episodes of:
- depressive reaction
- psychogenic depression
- reactive depression
Excludes: adjustment disorder (F43.2 )
F32.0 Mild depressive episode
Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities.
F32.1 Moderate depressive episode
Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.
F32.2 Severe depressive episode without psychotic symptoms
An episode of depression in which several of the above symptoms are marked and distressing, typically with loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of “somatic” symptoms are usually present.
Agitated depression / Major depression / Vital depression: single episode without psychotic symptoms
F32.3 Severe depressive episode with psychotic symptoms
An episode of depression as described in F32.2, but with the presence of hallucinations, delusions, psychomotor retardation, or stupor so severe that ordinary social activities are impossible; there may be danger to life from suicide, dehydration, or starvation. The hallucinations and delusions may or may not be mood-congruent.
Single episodes of:
- major depression with psychotic symptoms
- psychogenic depressive psychosis
- psychotic depression
- reactive depressive psychosis
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
Under “Mood [affective] disorders (F30-F39)” see also:
- F30 Manic episode
- F31 Bipolar affective disorder
- F33 Recurrent depressive disorder
- F34 Persistent mood [affective] disorders
- F38 Other mood [affective] disorders
Neurotic, stress-related and somatoform disorders (F40-F48)
F43 Reaction to Severe Stress and Adjustment Disorders
This category differs from others in that it includes disorders identifiable on the basis of not only symptoms and course but also the existence of one or other of two causative influences: an exceptionally stressful life event producing an acute stress reaction, or a significant life change leading to continued unpleasant circumstances that result in an adjustment disorder. Although less severe psychosocial stress (“life events”) may precipitate the onset or contribute to the presentation of a very wide range of disorders classified elsewhere in this chapter, its etiological importance is not always clear and in each case will be found to depend on individual, often idiosyncratic, vulnerability, i.e. the life events are neither necessary nor sufficient to explain the occurrence and form of the disorder. In contrast, the disorders brought together here are thought to arise always as a direct consequence of acute severe stress or continued trauma. The stressful events or the continuing unpleasant circumstances are the primary and overriding causal factor and the disorder would not have occurred without their impact. The disorders in this section can thus be regarded as maladaptive responses to severe or continued stress, in that they interfere with successful coping mechanisms and therefore lead to problems of social functioning.
F43.0 Acute Stress Reaction
A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions. The symptoms show a typically mixed and changing picture and include an initial state of “daze” with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor – F44.2), or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). Partial or complete amnesia (F44.0) for the episode may be present. If the symptoms persist, a change in diagnosis should be considered.
- crisis reaction
- reaction to stress
- Combat fatigue
- Crisis state
- Psychic shock
F43.1 Post-Traumatic Stress Disorder
Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories (“flashbacks”), dreams or nightmares, occurring against the persisting background of a sense of “numbness” and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0)
- Traumatic neurosis
F43.2 Adjustment Disorders
States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event. The stressor may have affected the integrity of an individual’s social network (bereavement, separation experiences) or the wider system of social supports and values (migration, refugee status), or represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement). Individual predisposition or vulnerability plays an important role in the risk of occurrence and the shaping of the manifestations of adjustment disorders, but it is nevertheless assumed that the condition would not have arisen without the stressor. The manifestations vary and include depressed mood, anxiety or worry (or mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine. Conduct disorders may be an associated feature, particularly in adolescents. The predominant feature may be a brief or prolonged depressive reaction, or a disturbance of other emotions and conduct.
- Culture shock
- Grief reaction
- Hospitalism in children
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified
F44 Dissociative [Conversion] Disorders
The common themes that are shared by dissociative or conversion disorders are a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. All types of dissociative disorders tend to remit after a few weeks or months, particularly if their onset is associated with a traumatic life event. More chronic disorders, particularly paralyses and anaesthesias, may develop if the onset is associated with insoluble problems or interpersonal difficulties. These disorders have previously been classified as various types of “conversion hysteria”. They are presumed to be psychogenic in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. The symptoms often represent the patient’s concept of how a physical illness would be manifest. Medical examination and investigation do not reveal the presence of any known physical or neurological disorder. In addition, there is evidence that the loss of function is an expression of emotional conflicts or needs. The symptoms may develop in close relationship to psychological stress, and often appear suddenly. Only disorders of physical functions normally under voluntary control and loss of sensations are included here. Disorders involving pain and other complex physical sensations mediated by the autonomic nervous system are classified under somatization disorder (F45.0). The possibility of the later appearance of serious physical or psychiatric disorders should always be kept in mind.
- hysterical psychosis
F44.0 Dissociative Amnesia
The main feature is loss of memory, usually of important recent events, that is not due to organic mental disorder, and is too great to be explained by ordinary forgetfulness or fatigue. The amnesia is usually centred on traumatic events, such as accidents or unexpected bereavements, and is usually partial and selective. Complete and generalized amnesia is rare, and is usually part of a fugue (F44.1). If this is the case, the disorder should be classified as such. The diagnosis should not be made in the presence of organic brain disorders, intoxication, or excessive fatigue.
Under dissociative [conversion] disorder see also:
- F44.1 Dissociative fugue
- F44.2 Dissociative stupor
- F44.3 Trance and possession disorders
- F44.4 Dissociative motor disorders
- F44.5 Dissociative convulsions
- F44.6 Dissociative anaesthesia and sensory loss
- F44.7 Mixed dissociative [conversion] disorders
- F44.8 Other dissociative [conversion] disorders
F45 Somatoform Disorders
The main feature is repeated presentation of physical symptoms together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis. If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient.
F45.0 Somatization Disorder
The main features are multiple, recurrent and frequently changing physical symptoms of at least two years’ duration. Most patients have a long and complicated history of contact with both primary and specialist medical care services, during which many negative investigations or fruitless exploratory operations may have been carried out. Symptoms may be referred to any part or system of the body. The course of the disorder is chronic and fluctuating, and is often associated with disruption of social, interpersonal, and family behaviour. Short-lived (less than two years) and less striking symptom patterns should be classified under undifferentiated somatoform disorder (F45.1).
- Briquet’s disorder
- Multiple psychosomatic disorder
- Excludes: malingering [conscious simulation] (Z76.5 )
F45.4 Persistent Somatoform Pain Disorder
The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences. The result is usually a marked increase in support and attention, either personal or medical. Pain presumed to be of psychogenic origin occurring during the course of depressive disorders or schizophrenia should not be included here.
- Somatoform pain disorder
- Excludes: backache NOS (M54.9 )
Under F45 Somatoform disorders, See also:
- F45.1 Undifferentiated somatoform disorder
- F45.2 Hypochondriacal disorder
- F45.3 Somatoform autonomic dysfunction
- F45.8 Other somatoform disorders
Under “Neurotic, stress-related and somatoform disorders (F40-F48)” see also:
- F40 Phobic anxiety disorders
- F41 Other anxiety disorders
- F41.0 Panic disorder (episodic paroxysmal anxiety)
- F41.1 Generalized anxiety disorder
- F41.2 Mixed anxiety and depressive disorder
- F41.3 Other mixed anxiety disorders
- F41.8 Other specified anxiety disorders
- F41.9 Anxiety disorder, unspecified
- F42 Obsessive-compulsive disorder
Disorders of adult personality and behaviour (F60-F69)
F62 Enduring Personality Changes, not Attributable to Brain Damage and Disease
Disorders of adult personality and behaviour that have developed in persons with no previous personality disorder following exposure to catastrophic or excessive prolonged stress, or following a severe psychiatric illness. These diagnoses should be made only when there is evidence of a definite and enduring change in a person’s pattern of perceiving, relating to, or thinking about the environment and himself or herself. The personality change should be significant and be associated with inflexible and maladaptive behaviour not present before the pathogenic experience. The change should not be a direct manifestation of another mental disorder or a residual symptom of any antecedent mental disorder.
Excludes: personality and behavioural disorder due to brain disease, damage and dysfunction (F07.- )
F62.0 Enduring Personality Change After Catastrophic Experience
Enduring personality change, present for at least two years, following exposure to catastrophic stress. The stress must be so extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality. The disorder is characterized by a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of “being on edge” as if constantly threatened, and estrangement. Post-traumatic stress disorder (F43.1) may precede this type of personality change.
Personality change after:
- concentration camp experiences
- captivity with an imminent possibility of being killed
- exposure to life-threatening situations such as being a victim of terrorism
- Excludes: post-traumatic stress disorder (F43.1)
Behavioural syndromes associated with physiological disturbances and physical factors (F50-F59)
F52 Sexual dysfunction, not caused by organic disorder or disease
Sexual dysfunction covers the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish. Sexual response is a psychosomatic process and both psychological and somatic processes are usually involved in the causation of sexual dysfunction.
Under “F52-Sexual dysfunction, not caused by organic disorder or disease” see:
- F52.0 Lack of loss of sexual desire
- F52.1 Sexual aversion and lack of sexual enjoyment
- F52.2 Failure of genital response
- F52.3 Organic dysfunction
- F52.4 Premature ejaculation
- F52.5 Nonorganic vaginismus
- F52.6 Nonorganic dyspareunia
Under “Behavioural syndromes associated with physiological disturbances and physical factors (F50-59)”, see also:
- F50 Eating disorders
- F51 Non organic sleep disorders
Organic, including symptomatic, mental disorders (F00-F09)
F07 Personality and behavioural disorders due to brain disease, damage and dysfunction
Alteration of personality and behaviour can be a residual or concomitant disorder of brain disease, damage or dysfunction.
F07.2 Postconcussional Syndrome
A syndrome that occurs following head trauma (usually sufficiently severe to result in loss of consciousness) and includes a number of disparate symptoms such as headache, dizziness, fatigue, irritability, difficulty in concentration and performing mental tasks, impairment of memory, insomnia, and reduced tolerance to stress, emotional excitement, or alcohol.
Postcontusional syndrome (encephalopathy)
Post-traumatic brain syndrome, nonpsychotic
Schizophrenia, schizotypal and delusional disorders (F20-F29)
F23 Acute and Transient Psychotic Disorders
A heterogeneous group of disorders characterized by the acute onset of psychotic symptoms such as delusions, hallucinations, and perceptual disturbances, and by the severe disruption of ordinary behaviour. Acute onset is defined as a crescendo development of a clearly abnormal clinical picture in about two weeks or less. For these disorders there is no evidence of organic causation. Perplexity and puzzlement are often present but disorientation for time, place and person is not persistent or severe enough to justify a diagnosis of organically caused delirium (F05.-). Complete recovery usually occurs within a few months, often within a few weeks or even days. If the disorder persists, a change in classification will be necessary. The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.
Under “F 23 Acute and Transient Psychotic Disorders” see:
- F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
- F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia
- F 23.2 Acute schizophrenia-like psychotic disorder
- F 23.3 Other acute predominantly delusional psychotic disorders
- F 23.8 Other acute and transient psychotic disorders
- F 23.9 Acute and transient psychotic disorder, unspecified
Brief reactive psychosis NOS
Selections from the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10 Version:2007). (Complete, updated ICD-10 Version:2010 available at http://www.who.int/classifications/apps/icd/icd10online.) Mood [affective] disorders (F30-F39) F32 Depressive Episode In typical mild, moderate, or severe depressive episodes, the patient suffers from … Continue reading
Download Module 6: Psychological Evidence of Torture and Ill Treatment (PowerPoint Presentation) (ppt)
- All medical evaluations and documentation of torture and ill treatment should include a detailed psychological evaluation because:
- One of the primary objectives of torture and ill treatment is destruction of the psychological and social integrity of victim
- Torture and ill treatment often cause devastating psychological symptoms
- Torture and ill treatment may leave no physical signs or symptoms
- Psychological symptoms are often more persistent and troublesome than physical symptoms
- All of the above
- Which of the following is/are true about psychological sequelae of torture and ill treatment?
- Not everyone who has been tortured develops a diagnosable mental illness
- Distress and suffering associated with traumatic experiences are not in themselves pathological conditions
- Clinical diagnoses of Major Depression, anxiety disorders and PTSD are not specific for torture and ill treatment
- Fear, shame, mistrust, guilt and rage are common emotional reactions among survivors of torture and ill treatment
- All of the above
- Torture and ill treatment may have profound effects on individuals, but rarely affect families and society.
- Which of the following reasons may explain why survivors of torture and ill treatment may not trust examining clinicians?
- Clinicians may have participated in their torture and ill treatment
- Survivor’s fear of not being believed
- Survivor’s fear of being overwhelmed by psychological symptoms
- Survivor’s fear that information revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments
- All of the above
- It is important for clinicians to be aware of potential countertransference reactions because such reactions may result in:
- Underestimating the severity of consequences of torture and ill treatment
- Forgetting details of the case
- Leading to disbelief regarding the veracity of alleged torture and ill treatment
- Failure to establish necessary empathic approach
- Over-identification with survivor
- Vicarious traumatisation, burn-out
- Difficulty in maintaining objectivity
- All of the above
- Diagnostic criteria for PTSD include the following categories:
- Re-experiencing symptoms
- Hyperarousal symptoms
- Aviodance/Numbing symptoms
- All of the above
- Symptoms of PTSD commonly increase or recur under which of the following circumstances?
- Anniversary of traumatic experiences
- Prior to a medical evaluation for torture and ill treatment
- After gaining asylum in another country
- When individuals have any interactions with police or security forces
- All of the above
- Which of the following symptoms is/are characteristic of Major Depressive Disorder?
- Depressed mood
- Appetite disturbance
- Sleep disturbance
- Psychomotor retardation or agitation
- Fatigue, poor energy
- Feelings of worthlessness
- Poor attention, concentration and memory
- Thoughts of death
- Suicidal ideation
- Suicide attempts
- All of the Above
- Psychological effects of torture should not be oversimplified. In addition to PTSD and Major Depression, the following should be consider:
- Anxiety Disorders
- Substance Abuse
- Enduring Personality Change
- Somatoform Disorders
- All of the above
- Repeated presentation of physical symptoms together with persistent requests for medical investigations, despite repeated negative findings and reassurances by doctors that the symptoms have no physical basis are characteristic of?
- Anxiety disorders
- Somatiform disorders
- Neurotic disorders
- Affective disorders
- Neuropsychological assessment may be useful in evaluating individuals suspected of having brain injury and in distinguishing brain injury from PTSD.
- Which of the following are not components of the mental status examination?
- General appearance
- Motor activity
- Mood and affect
- Thought content
- Thought process
- Cranial nerve assessment
- Suicidal and homicidal ideation
- Cognitive exam
- Insight and judgment
- None of the above
- Severe torture always results in significant psychological symptoms.
- In the course of your psychological evaluation of a 26 year-old women, you learn of several inconsistencies in her account of torture and ill treatment. What should you do next?
- Ask for further clarification
- Document your suspicion and continue the interview
- Refer to another clinician to ask for second opinion
- Use a standardized psychological instrument to assess for possible malingering
- Obtaining detailed pre-torture psycho-social information is often helpful in establishing trust during a medical evaluation, but such information should not be included in the interpretation of psychological evidence.
- According to Istanbul Protocol guidelines, which of the following types of psychological instruments should be routinely administered in medico-legal evaluations?
- Clinician-administered instruments such as CAPS (Clinician-Administered PTSD Scale)
- Self-administered instruments that the alleged victim fills out
- Both clinician-administered and self-administered instruments
- None of the above
- In conducting the psychological evaluation, the assessment and interpretation should always be made with awareness of cultural, political and social context as well as conditions of the interview and assessment.
- According to the Istanbul Protocol, interpretations of psychological evidence of alleged torture and ill treatment should include:
- Consistency between psychological symptoms and allegations of alleged torture and ill treatment
- Consistency between expected reactions to extreme stress within the cultural and social context of the individual
- The temporal relationship between psychological symptoms and alleged torture and ill treatment
- Identification of coexisting stressors and their impacts on the individual
- Physical conditions complicating the clinical picture
- Comments on the possibility of false allegations of torture and ill treatment
- All of the above
- Evaluation for documentation of torture for medico-legal reasons should be combined with an assessment for other needs of the individual. Those who appear to be in need of further medical or psychological care should be referred to the appropriate services.
- Which of the following is true about the effects of torture on children?
- Children often express their thoughts and emotions regarding trauma behaviorally rather than verbally
- If a child has been physically or sexually assaulted it is important, if at all possible, for the child to be seen by an expert in child abuse
- A child’s reactions to torture depends on age, developmental stage and cognitive skills
- The symptoms can be similar to those observed in adults but the clinician must rely more heavily on observations of the child’s behavior than on verbal expression
- In order to preserve cohesion in the family, dysfunctional behaviors and delegation of roles may occur
- All of the above
All medical evaluations and documentation of torture and ill treatment should include a detailed psychological evaluation because: One of the primary objectives of torture and ill treatment is destruction of the psychological and social integrity of victim Torture and ill … Continue reading