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Module 6 Answers

  1. Answer: E

    Detailed psychological evaluations should be included in all medical evaluations for all of the reasons listed.

  2. Answer: E

    All of the items listed are true about psychological sequelae of torture and ill treatment.

  3. Answer: B

    Torture may not only have profound effects on individuals, but on families and society as well. It can terrorize entire populations and create an atmosphere of pervasive fear, terror, inhibition, and hopelessness. It can break or damage the will and coherence of entire communities. It often results in disruptions in family dynamics and may be associated with considerable family dysfunction.

  4. Answer: E

    All of the items listed may explain why survivors of torture and ill treatment may not trust examining clinicians.

  5. Answer: H

    When listening to individuals speak of their torture, clinicians should expect to have personal reactions and emotional responses themselves including avoidance and defensive indifference in reaction to being exposed to disturbing material, disillusionment, helplessness, hopelessness that may lead to symptoms of depression or “vicarious traumatisation,” grandiosity or feeling that one is the last hope for the survivor’s recovery and well-being, feelings of insecurity in one’s professional skills in the face of extreme suffering, guilt over not sharing the torture survivor’s experience, or even anger when the clinician experiences doubt about the truth of the alleged torture history and the individual stands to benefit from an evaluation.

  6. Answer: B, C, E

    According to DSM IV criteria, the diagnosis of PTSD requires that:

    A) A person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and the person’s response involved intense fear, helplessness, or horror.

    B) One or more re-experiencing symptoms are present following the trauma.

    C) Three or more avoidance symptoms are present following the trauma.

    D) Two or more hyperarousal symptoms are present following the trauma.
    E) The duration of symptoms in Criteria B, C, and D) is more than 1 month.

    F) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  7. Answer: E

    PTSD symptoms commonly occur under all of the circumstances listed above. Anniversary dates and interactions with police or security forces often serve as direct reminders of past traumatic experiences. Recalling traumatic experiences prior to, during, and following a medical evaluation often results in re-traumatisation. In gaining asylum, survivors of torture are often reminded of the loss of family, friends, job, language, etc. and/or may experience feelings of guilt in “abandoning” others who may still be detained.

  8. Answer: L

    Symptoms of Major Depression include all of the symptoms listed above. Depressive states are very common among survivors of torture. Depressive disorders may occur as a single episode or be recurrent. They can be present with or without psychotic features.

  9. Answer: G

    In addition to all of the items listed, other possible diagnoses include: generalized anxiety disorder, panic disorder, acute stress disorder, bipolar disorder, delusional disorder, disorders due to a general medical condition, (possibly in the form of brain impairment with resultant fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning), and phobias such as social phobia and agoraphobia.

  10. Answer: B

    Somatiform disorders manifest as repeated presentations of physical symptoms in the absence of physical findings. 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.

  11. Answer: A

    Neuropsychology 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, but 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.

  12. Answer: G

    All topics listed are components of the mental status examination with the exception of G, cranial nerve assessment.

  13. Answer: B

    Significant psychological symptoms may not be present among survivors of torture for a number of reasons. Clinicians may fail to consider diagnostic possibilities especially if they simply focus on the most common psychological diagnoses. Survivors may not have significant psychological symptoms due to effective coping strategies, social supports and/or a positive meaning assigned to their experiences (i.e. suffering for an important cause). Under such circumstances the reasons for symptom mitigation can and should be explained in the clinician’s medical evaluation.

  14. Answer: A

    The first step in addressing inconsistencies is to ask the individual for further clarification.

  15. Answer: B

    Pre-torture psycho-social information is highly relevant to the interpretation of psychological evidence as it is provides a context for understanding individual behaviour and the meaning assigned to torture experiences.

  16. Answer: D

    The administration of psychological instruments is up the discretion of the examining clinician. There are numerous questionnaires available. Though they may add complementary value to a clinical evaluation, routine use is not recommended. Caution must be exercised in the interpretation of responses and scores because established norms do not exist for many countries. The Istanbul Protocol makes clear that psychological instruments should not be given more weight than the clinical evaluation.

  17. Answer: A

    The clinician should attempt to understand mental suffering in the context of the survivor’s circumstances, beliefs, and cultural norms rather than rush to diagnose and classify. Awareness of culture specific syndromes and native language-bound idioms of distress is of paramount importance for conducting the interview and formulating the clinical impression and conclusion. When the interviewer has little or no knowledge about the alleged victim’s language and culture, the assistance of an interpreter is essential.

  18. Answer: G

    Interpretation of the clinical findings is a complex task. According to the Istanbul Protocol, all of the concerns listed should be included in clinical interpretations of psychological evidence of torture and ill treatment.

  19. Answer: A

    In the course of documenting psychological evidence of torture clinicians are not absolved of their ethical obligations. Those who appear to be in need of further medical and/or psychological care should be referred to appropriate services. Clinicians should be aware of local rehabilitation and support services.

  20. Answer: F

    All of the considerations listed are true about the effects of torture on children.