Module 6: Psychological Evidence of Torture and Ill-Treatment

Components of the Psychological/Psychiatric Evaluation

The psychological evaluation starts at the beginning of the interview, with the very first contact. The individual’s overall appearance and manner of dress, posture, the manner of recalling and recounting the trauma, signs of anxiety or emotional distress, numbness or over-excitement, moments of emotional intensity, startled responses, posture and bodily expression while relating the events of torture, avoidance of eye contact, and emotional fluctuations in his/her voice can give important clues about the personal history and psychological functioning of an individual. Not only the verbal content of the examinee (what he/she says), but also his/her manner of speaking (how he/she says it) are important for the psychological evaluation. The individual may have difficulties in recollecting and recounting what s/he experienced or in talking about his/her complaints. Therefore, non-verbal communication may provide important information about his/her symptoms, as well as some clues for establishing and maintaining an effective relationship that allows the interviewer to elicit relevant information.

The psychological evaluation should provide a detailed description of the individual’s history, a mental status examination, an assessment of social functioning, and a formulation of clinical impressions/opinions. The impact of the symptoms on daily life can be highly relevant for forensic procedures or questions of compensation in torture cases. If appropriate, a psychiatric diagnosis should be given.

The components of psychological/psychiatric evaluation are as follows:

Identifying Data

  • Individual’s name, age, ethnicity, country of origin, marital status, number of children
  • Referral source
  • Summary of collateral sources (such as medical, legal, psychiatric records)
  • Methods of assessment utilized (interviews, symptom inventories and checklists, neuropsychological testing, etc.)

History of Torture and Ill-treatment

Every effort should be made to document the full history of torture, persecution and other relevant traumatic experiences (see Module 3 [3] [2] [1]). This part of the evaluation is often exhausting for the person being evaluated. Therefore, it may be necessary to proceed in several sessions (if it is possible). The interview should start with a general summary of events before eliciting the details of the torture experiences and include:

  • Summary of detention and abuse: Before obtaining a detailed account of events, elicit summary information, including dates, places, duration of detention, frequency and duration of torture sessions
  • Circumstances of apprehension: What time, from where, by whom (with details, if possible); other persons around, witnesses/bystanders; interaction with family members; violence/threats used during the apprehension; use of restraints or blindfold
  • Place and conditions of detention: What happened first, where, any identification process, transportation, distinctive features; other procedures; condition of the cell/room; size/dimensions, ventilation, lighting, temperature, toilet facilities, food; contact with third persons (family members, lawyer, health professionals); conditions of overcrowding or solitary confinement, etc.
  • Methods of torture and ill-treatment:
    • Assessment of background: Where, when, how long, by whom; special features of the environment, perpetrators, devices/instruments; usual “routine”, sequences and other information
    • For each for of abuse: body position, restraint, nature of contact, duration, frequency, anatomical location, the area of the body affected and how and other information
    • Sexual assaults
    • Deprivations (sleep, food, toilet facilities, sensory stimulation, human contact, motor activities); threats, humiliations, violations of taboos, behavioural coercions and other methods
    • Previous medico-legal reporting process (if any)

As mentioned in Module 3 [3] [2] [1], a method-listing approach may be counter-productive, as the entire clinical picture produced by torture is much more than the simple sum of lesions produced by methods on a list.

Current Psychological Complaints

Assessment of current psychological functioning constitutes the core of the evaluation:

  • All affective, cognitive, and behavioural symptoms that appeared since the torture should be described. For each symptom: first emergence, duration, intensity, frequency, content, fluctuation of each symptom should be asked and recorded with examples and all details.
  • Adaptative and maladaptive strategies and triggers such as anniversary reactions, specific stimuli or places, situations and topics causing avoidance should be noted.
  • Specific questions about the most common symptoms and diagnostic criteria for most common diagnosis need to be asked.

Post-torture History

The clinician should inquire about current life circumstances including:

  • Sources of additional stress, traumas, losses, difficulties (i.e. other traumatic experiences or ongoing persecution to the individual or his/her family, refugee displacement, etc.)
  • Formal and/or informal social support resources.
  • Marital and family situation.
  • Employment status, livelihood.
  • Vocational, social status and conditions.
  • Life conditions and quality of life of the interviewee and his/her family.

Pre-torture History

This component of the psychological evaluation obtains information about current life circumstances and stresses. The summary of pre-trauma history is important to assess mental health status and level of psychosocial functioning of the alleged torture victim prior to the traumatic events. In this way, the interviewer can compare the current mental health status with that of the individual before he or she was tortured. In evaluating background information the interviewer should keep in mind that the duration and severity of responses to trauma is affected by the severity and duration of the trauma events, the meaning assigned to the individual’s experiences, genetic and biological predisposition, developmental phase, age, prior trauma, pre-existing personality, and social support system. A Pre-torture History should include:

  • Developmental history
  • Family history: family background, family illnesses, family composition
  • Educational history
  • Occupational history
  • Social history: activities, including political activities, interests, group interactions
  • History of past trauma: childhood abuse, war trauma, domestic violence, etc
  • Cultural and religious background

Medical History

The medical history summarises pre-trauma and current health conditions and should include:

  • Pre-trauma health conditions.
  • Current health conditions.
  • Body pain, somatic complaints.
  • Physical injuries and findings: physical findings that might be related to trauma should be noted. It is important that the health professional that is making the psychological evaluation should also look for and document the physical findings of trauma. In some instances, the clinician who conducts the psychological evaluation may be the first or the only health professional with whom the alleged victim comes in contact with.
  • Use of medications, including possible side effects and obstacles in using medications.
  • Relevant sexual history.
  • Past surgical procedures and other medical data.

Past Psychiatric History

One should inquire whether the individual has a past history of mental or psychological disturbances, the nature of the problems, and whether they received treatment or required psychiatric hospitalisation. Inquire which, if any, psychotropic medications were used in treatment.

Substance Use and Abuse History

The clinician should inquire about substance use before and after the torture, changes in the pattern of use and abuse, and whether substances are being used to cope with insomnia or psychological/psychiatric problems.

Neuro-psychological Assessment

Torture can involve physical trauma that leads to various levels of brain impairment. Blows to the head, suffocation and prolonged malnutrition may have long-term neurological and neuro-psychological consequences that may not be readily assessed during the course of a medical examination. Frequently, the symptoms for such assessments have significant overlap with the symptomatology arising from PTSD and major depressive disorders. Fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning may result from functional disturbances as well as organic causes.

Clinical neuropsychology is an applied science concerned with the behavioural expression of brain dysfunction. Neuropsychological assessment, in particular, is concerned with the measurement and classification of behavioural disturbances associated with organic brain impairment. The discipline has long been recognised as useful in discriminating between neurological and psychological conditions and in guiding treatment and rehabilitation of patients suffering from the consequences of various levels of brain damage. Neuropsychological evaluations of torture survivors are performed infrequently and to date neuropsychological studies of torture survivors is limited in the literature.[1]

Despite significant limitations, neuropsychological assessment may be useful in evaluating individuals suspected of having brain injury and in distinguishing brain injury from PTSD. Neuropsychological assessment may also be used to evaluate specific symptoms, such as problems with memory that occur in PTSD and related disorders.

Mental Status Examination

The mental status exam begins the moment the clinician meets the subject. The interviewer should make note of the person’s appearance (such as signs of malnutrition, lack of cleanliness, etc.), changes in motor activity during the interview, use of language, presence of eye contact, and the ability to relate to the interviewer. The following list summarises the components of the exam: general appearance, motor activity, speech, mood and affect, thought content, thought process, suicidal and homicidal ideation, cognitive status (alertness, orientation, concentration and calculation, long term memory, intermediate recall, and immediate recall), and insight.

The individual’s responses to specific mental status items are affected by their culture of origin, educational level, literacy, language proficiency, and level of acculturation. The mental status examination of torture survivors requires flexibility on the part of the examiner, who must have a good understanding of the individual’s cultural, linguistic, and educational background before attempting any formal assessment. The level of education is an important factor in determining the appropriate questions and tasks.

Assessment of Social Function

Trauma and torture can affect a person’s ability to function. The psychological consequences of the experience may impair the individual’s ability to care for him/herself, earn a living, support a family, or pursue education. The clinician should assess the individual’s current level of functioning by inquiring about daily activities, social role function (as housewife, student, worker, etc), social and recreational activities, and perceptions of health status. For obvious reasons, one cannot accurately assess the social functioning of an individual held in detention.

Psychological Testing and the Use of Checklists and Questionnaires

If an individual has trouble expressing in words his or her experiences and symptoms, it may be useful to use a trauma event questionnaire or symptom checklist. These tools may facilitate disclosure of severely traumatic memories and reduce the anxiety often experienced in an unstructured interview. There are numerous questionnaires available; however, none is specific to torture victims. Caution must be exercised in the interpretation of responses and scores because established norms do not exist for most refugee populations. Similarly, there is little published information about the use of standard psychological and neuropsychological tests among torture survivors. Due to the fact that there is such wide cultural and linguistic diversity among survivors, one should exercise extreme caution when requesting or employing psychological and psychometric tests of any kind, most of which have not been cross-culturally validated.

In some countries and/or situations, courts and/or other authorities tend to give more weight to the results of psychometric tests and consider them more “objective” than the clinical impressions that clinicians obtain as a result of several interviews. However, for the psychological evaluation of trauma, the clinical interview, evaluation and the subsequent clinical formulation the clinician reaches are fundamental, whereas psychological tests have only complementary value. It is the clinician himself/herself who decides whether there is any need to use psychological testing in the evaluation process. Furthermore, the clinician must make his/her own decision without any interference in his/her clinical independence.

Clinical Impression

An essential aspect of the psychiatric evaluation is the formulation of a concise statement of the interviewer’s analysis of the case. Interpretation of the findings and formulation of a clinical impression are the last stages where the entire interview is discussed and evaluated; therefore care must be taken while formulating a clinical decision.

Interpretation of the clinical findings is a complex task. The following questions from the Istanbul Protocol will help guide the formulation of the clinical impression and diagnostic conclusions.

  1. Are the psychological findings consistent with the alleged report of torture?
  2. Are the psychological findings expected or typical reactions to extreme stress within the cultural and social context of the individual?
  3. Given the fluctuating course of trauma-related mental disorders over time, what is the timeframe in relation to the torture events? Where in the course of recovery is the individual?
  4. What are the coexisting stresses impinging on the individual (e.g. ongoing persecution, forced migration, exile, loss of family and social role, etc)? What impact do these issues have on the victim?
  5. What physical conditions contribute to the clinical picture? Pay special attention to head injury sustained during torture and/or detention.
  6. Does the clinical picture suggest a false allegation of torture?

When writing reports, clinicians should comment on the emotional state of the person during the interview, symptoms, history of detention and torture, and personal history prior to torture. Factors such as the onset of specific symptoms in relation to the trauma, the specificity of any particular psychological findings, as well as patterns of psychological functioning should be noted. If the survivor has symptom levels consistent with one or more DSM IV or ICD 10 psychiatric diagnosis, the diagnosis should be stated. If not, the consistency between the psychological findings and the history of the individual should be evaluated as a whole and stated in the report. Additional factors such as forced migration, resettlement, difficulties of acculturation, language problems, loss of home, family, social status, as well as unemployment should be discussed. The relationship and consistency between events and symptoms should be evaluated and described. Physical conditions such as head trauma or brain injury may require further evaluation. Behavioural, cognitive and emotional aspects of the individual observed during verbal and non-verbal communication should be noted as well.

It is common in medico-legal contexts for the clinician to be asked whether psychological symptoms were caused by that alleged torture and ill-treatment or other traumatic experiences that may have occurred before or after the alleged events. Clinician should note temporal relationships between the onset of symptoms and the alleged torture and ill-treatment. They should also consider content-specific symptoms that may relate to the alleged torture and ill-treatment such as: the content of nightmares, triggers for intrusive recollection, reliving experiences, avoidance reactions, etc.

It is important for clinicians to make clear to any court or judicial authority that not everyone who has been tortured develops a diagnosable mental illness. It must be stressed that even though a diagnosis of trauma-related mental disorder supports the claim of torture, not meeting criteria for a psychiatric diagnosis does not mean the person was not tortured. The absence of conclusive physical and/or psychological signs and symptoms does not invalidate an allegation of torture. The clinician should also take into consideration the possibility that an absence of psychological symptoms can be due to the episodic or often delayed nature of PTSD or to denial of symptoms because of shame or other difficulties.

It is possible that some people may falsely allege torture or exaggerate a relatively minor experience or symptoms for personal or political reasons. The clinician should keep in mind, however, that such fabrication requires a detailed knowledge about trauma related symptoms that individuals rarely possess. Also, inconsistencies can occur for a number of valid reasons such as memory impairment due to brain injury, confusion, dissociation, cultural differences in perception of time, or fragmentation and repression of traumatic memories (see Module 3 [3] [2] [1]). Additional sessions should be scheduled to help clarify inconsistencies and when possible, family or friends may be able to corroborate detail. Inconsistencies that are attributable to the psychological effects of an individual’s torture experiences may, in fact, support his or her allegations of abuse.

Recommendations

The recommendations following the psychological evaluation depend on the questions posed at the time the evaluation was requested. The issues under consideration may concern legal and judicial matters, asylum, resettlement, and a need for treatment. Recommendations can be for further assessments, such as neuro-psychological testing, medical or psychiatric treatment or a need for security or asylum. The clinician should not hesitate to insist on any consultation and examination that s/he considers necessary.

In the course of documenting psychological evaluation of torture allegations the clinicians are not absolved of their ethical obligations. 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. Clinicians should be aware of the local rehabilitation and support services.

Treatment Considerations

A full discussion of treatment is beyond the scope of this Module. To briefly summarise, intervention necessarily begins with establishing safety, protection, and basic human necessities for survival (food, shelter, income, etc.). Without these basic elements, no meaningful “treatment” can be effective. Any meaningful clinical treatment and rehabilitation program should include social services and if possible, legal services. Treatment can begin once basic necessities are secured, or perhaps even while they are being secured. Because torture affects an individual on so many levels, an integrated, coordinated multidisciplinary approach to treatment is essential. Mental health treatment modalities include individual, group, and family psychotherapy, psychopharmacology, psychoeducation, and somatic therapies. Traditional medicine practices should be respected and included in the treatment if the individual wishes, provided they are safe and that one avoids deleterious interactions between medications and herbal preparations.

NOTE: An online course, “Caring for Torture Survivors [4],” offered by the Boston Center for Refugee Health and Human Rights, is available at: http://www.bcrhhr.com/education/caring-for-survivors.html [5]


[1] Jacobs U, Iacopino V. Torture and its consequences: a challenge to neuropsychology. Professional Psychology: Research and Practice. 2001;32(5): 458–464.

The psychological evaluation starts at the beginning of the interview, with the very first contact. The individual’s overall appearance and manner of dress, posture, the manner of recalling and recounting the trauma, signs of anxiety or emotional distress, numbness or … Continue reading

Clinical Considerations

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

Apendix II: ICD-10

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 [5].)

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 [4])

  • recurrent depressive disorder (F33 [3])
  • when associated with conduct disorders in F91.- (F92.0 [1])
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.

  • Acute:
    • 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.

Includes:

  • conversion:
    • hysteria
    • reaction
  • hysteria
  • 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 [2])
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.

  • Psychalgia
  • Psychogenic:
    • backache
    • headache
  • Somatoform pain disorder
  • Excludes: backache NOS (M54.9 [6])
  • pain:
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.- [12])

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
  • disasters
  • prolonged:
  • captivity with an imminent possibility of being killed
  • exposure to life-threatening situations such as being a victim of terrorism
  • torture
  • 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
    Reactive psychosis

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

Role of the Family

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

Module 6 Presentation: Psychological Evidence of Torture and Ill-Treatment


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Download Module 6: Psychological Evidence of Torture and Ill Treatment (PowerPoint Presentation) (ppt)

Self-Assessment and Quiz

  1. All medical evaluations and documentation of torture and ill treatment should include a detailed psychological evaluation because:
    1. One of the primary objectives of torture and ill treatment is destruction of the psychological and social integrity of victim
    2. Torture and ill treatment often cause devastating psychological symptoms
    3. Torture and ill treatment may leave no physical signs or symptoms
    4. Psychological symptoms are often more persistent and troublesome than physical symptoms
    5. All of the above
  2. Which of the following is/are true about psychological sequelae of torture and ill treatment?
    1. Not everyone who has been tortured develops a diagnosable mental illness
    2. Distress and suffering associated with traumatic experiences are not in themselves pathological conditions
    3. Clinical diagnoses of Major Depression, anxiety disorders and PTSD are not specific for torture and ill treatment
    4. Fear, shame, mistrust, guilt and rage are common emotional reactions among survivors of torture and ill treatment
    5. All of the above
  3. Torture and ill treatment may have profound effects on individuals, but rarely affect families and society.
    1. True
    2. False
  4. Which of the following reasons may explain why survivors of torture and ill treatment may not trust examining clinicians?
    1. Clinicians may have participated in their torture and ill treatment
    2. Survivor’s fear of not being believed
    3. Survivor’s fear of being overwhelmed by psychological symptoms
    4. Survivor’s fear that information revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments
    5. All of the above
  5. It is important for clinicians to be aware of potential countertransference reactions because such reactions may result in:
    1. Underestimating the severity of consequences of torture and ill treatment
    2. Forgetting details of the case
    3. Leading to disbelief regarding the veracity of alleged torture and ill treatment
    4. Failure to establish necessary empathic approach
    5. Over-identification with survivor
    6. Vicarious traumatisation, burn-out
    7. Difficulty in maintaining objectivity
    8. All of the above
  6. Diagnostic criteria for PTSD include the following categories:
    1. Phobias
    2. Re-experiencing symptoms
    3. Hyperarousal symptoms
    4. Psychosis
    5. Aviodance/Numbing symptoms
    6. All of the above
  7. Symptoms of PTSD commonly increase or recur under which of the following circumstances?
    1. Anniversary of traumatic experiences
    2. Prior to a medical evaluation for torture and ill treatment
    3. After gaining asylum in another country
    4. When individuals have any interactions with police or security forces
    5. All of the above
  8. Which of the following symptoms is/are characteristic of Major Depressive Disorder?
    1. Depressed mood
    2. Anhedonia
    3. Appetite disturbance
    4. Sleep disturbance
    5. Psychomotor retardation or agitation
    6. Fatigue, poor energy
    7. Feelings of worthlessness
    8. Poor attention, concentration and memory
    9. Thoughts of death
    10. Suicidal ideation
    11. Suicide attempts
    12. All of the Above
  9. Psychological effects of torture should not be oversimplified. In addition to PTSD and Major Depression, the following should be consider:
    1. Anxiety Disorders
    2. Substance Abuse
    3. Enduring Personality Change
    4. Somatoform Disorders
    5. Dissociation
    6. Psychosis
    7. All of the above
  10. 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?
    1. Anxiety disorders
    2. Somatiform disorders
    3. Neurotic disorders
    4. Affective disorders
  11. Neuropsychological assessment may be useful in evaluating individuals suspected of having brain injury and in distinguishing brain injury from PTSD.
    1. True
    2. False
  12. Which of the following are not components of the mental status examination?
    1. General appearance
    2. Motor activity
    3. Speech
    4. Mood and affect
    5. Thought content
    6. Thought process
    7. Cranial nerve assessment
    8. Suicidal and homicidal ideation
    9. Cognitive exam
    10. Insight and judgment
    11. None of the above
  13. Severe torture always results in significant psychological symptoms.
    1. True
    2. False
  14. 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?
    1. Ask for further clarification
    2. Document your suspicion and continue the interview
    3. Refer to another clinician to ask for second opinion
    4. Use a standardized psychological instrument to assess for possible malingering
  15. 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.
    1. True
    2. False
  16. According to Istanbul Protocol guidelines, which of the following types of psychological instruments should be routinely administered in medico-legal evaluations?
    1. Clinician-administered instruments such as CAPS (Clinician-Administered PTSD Scale)
    2. Self-administered instruments that the alleged victim fills out
    3. Both clinician-administered and self-administered instruments
    4. None of the above
  17. 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.
    1. True
    2. False
  18. According to the Istanbul Protocol, interpretations of psychological evidence of alleged torture and ill treatment should include:
    1. Consistency between psychological symptoms and allegations of alleged torture and ill treatment
    2. Consistency between expected reactions to extreme stress within the cultural and social context of the individual
    3. The temporal relationship between psychological symptoms and alleged torture and ill treatment
    4. Identification of coexisting stressors and their impacts on the individual
    5. Physical conditions complicating the clinical picture
    6. Comments on the possibility of false allegations of torture and ill treatment
    7. All of the above
  19. 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.
    1. True
    2. False
  20. Which of the following is true about the effects of torture on children?
    1. Children often express their thoughts and emotions regarding trauma behaviorally rather than verbally
    2. 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
    3. A child’s reactions to torture depends on age, developmental stage and cognitive skills
    4. 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
    5. In order to preserve cohesion in the family, dysfunctional behaviors and delegation of roles may occur
    6. 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