Istanbul Protocol Model Medical Curriculum

Psychological evaluations may take place in a variety of settings and contexts; as a result, there are important differences in the manner in which evaluations should be conducted and how symptoms will be interpreted. For example, whether or not certain sensitive questions can be asked safely will depend on the degree to which confidentiality and security can be assured. An evaluation by a clinician visiting a prison or detention centre may be very brief and not allow for as detailed an evaluation as one performed in a clinic or private office that may take place over several sessions and last for several hours. At times some symptoms and behaviours typically viewed as pathological may be viewed as adaptive or predictable, depending on the context. For example, diminished interest in activities, feelings of detachment and estrangement would be understandable findings in a person in solitary confinement. Likewise, hypervigilance and avoidance behaviours may be necessary for those living under threat in repressive societies.

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. An interpreter from the alleged victim’s country of origin will facilitate an understanding of the language, customs, religious traditions, and other beliefs that will need to be considered during the evaluation.

Clinicians should be aware of the potential emotional reactions that evaluations may elicit in survivors (see Transference and Counter-transference [3] [1] in Module 3). Fear, shame, rage and guilt are typical reactions. A clinical interview may induce mistrust on the part of the torture survivor and possibly remind him or her of previous interrogations thereby “re-traumatizing” him or her. To reduce the effects of re-traumatisation, the clinician should communicate a sense of empathy and understanding. A torture survivor may suspect the clinician of having voyeuristic and sadistic motivations or may have prejudices towards the clinician because he/she hasn’t been tortured. The clinician is a person in a position of authority and, for that reason, may not be trusted with certain aspects of the trauma history. Alternatively, individuals still in custody may be too trusting in situations where the clinician cannot guarantee that there will be no reprisals for speaking about torture. Torture victims may fear that information that is revealed in the context of an evaluation cannot be safely kept from being accessed by persecuting governments. Fear and mistrust may be particularly strong in cases where physicians or other health workers were participants in the torture. In the context of evaluations conducted for legal purposes, the necessary attention to details and the precise questioning about history is easily perceived as a sign of doubt on the part of the examiner. Under these pressures, survivors may feel overwhelmed with memories and affect or mobilize strong defences such as withdrawal, affective flattening or numbing during evaluations.

As mentioned in Module 3 [2], if the gender of the clinician and the torturer is the same, the interview situation may be perceived as resembling the torture more than if the genders were different. For example, a woman who was raped and tortured in prison by a male guard is likely to experience more distress, mistrust, and fear when facing a male clinician than she might experience with a female. On the other hand, it may be much more important to the survivor that the interviewer is a physician regardless of gender so as to ask specific medical questions about possible pregnancy, ability to conceive later, and future of sexual relations between spouses.

When listening to individuals speak of their torture, clinicians should expect to have personal reactions and emotional responses themselves (see Transference and Counter-transference [3] [1] in Module 3). Understanding these personal reactions is crucial because they can have an impact on one’s ability to evaluate and address the physical and psychological consequences of torture. Reactions may include 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.

Psychological evaluations may take place in a variety of settings and contexts; as a result, there are important differences in the manner in which evaluations should be conducted and how symptoms will be interpreted. For example, whether or not certain … Continue reading →

It is prudent for clinicians to become familiar with the most commonly diagnosed disorders among trauma and torture survivors and to understand that it is not uncommon for more than one mental disorder to be present as there is considerable co-morbidity among trauma-related mental disorders. The two most common classification systems are the International Statistical Classification of Diseases and Health Related Problems (ICD-10)^[1] Classification of Mental and Behavioural Disorders and the Diagnostic and Statistical Manual of the American Psychiatric Association-Edition IV (DSM-IV).^[2] Non-mental health clinicians such as internists and general practitioners who perform evaluations of torture survivors should be familiar with the common psychological responses to torture and be able to describe their clinical findings. They should be prepared to offer a psychiatric diagnosis if the case is not complicated. A psychiatrist or psychologist skilled in the differential diagnosis of mental disorders related to severe trauma will be needed for particularly emotional individuals, cases involving multiple symptoms or atypical symptom complexes, psychosis, or in cases presenting confusing clinical pictures.

It is important to note that the association between torture and both PTSD and depression has become very strong in the minds of health providers, immigration courts and the informed lay public. This has created the mistaken and simplistic impression that PTSD and depression are the main psychological consequences of torture. Torture-related mental disorders are not limited to depression and PTSD and evaluators must have comprehensive knowledge of the most frequent diagnostic classifications among trauma and torture survivors. In this sense, a detailed evaluation is always very important. Overemphasising PTSD and depression criteria might result in missing other possible diagnoses and reinforcing the simplistic notion that the psychological evidence of torture can be reduced to the presence or absence of PTSD and depression. A wide range of diagnostic considerations are provided below and ICD-10 diagnostic criteria are included in the Appendix II at the end of this Module.

The diagnosis most commonly associated with torture is Post-traumatic stress disorder (PTSD). Typical symptoms of PTSD include re-experiencing the trauma, avoidance and emotional numbing, and hyperarousal. Re-experiencing can take several forms: intrusive memories, flashbacks (the subjective sense that the traumatic event is happening all over again), recurrent nightmares, and distress at exposure to cues that symbolize or resemble the trauma. Avoidance and emotional numbing include avoidance of thoughts, conversations, activities, places or people that arouse recollection of the trauma, feelings of detachment and estrangement from others, inability to recall an important aspect of the trauma, and a foreshortened sense of the future. Symptoms of hyperarousal include difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response.

Depressive states are very common among survivors of torture. Depressive disorders may occur as a single episode or be recurrent. They can present with or without psychotic features. Symptoms of Major Depression include depressed mood, anhedonia (markedly diminished interest or pleasure in activities), appetite disturbance, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue and loss of energy, feelings of worthlessness and excessive guilt, difficulty concentrating, and thoughts of death, suicidal ideation, or suicide attempts.

A survivor of severe trauma such as torture may experience dissociation or depersonalisation. Dissociation is a disruption in the integration of consciousness, self-perception, memory and actions. A person may be cut off or unaware of certain actions or may feel split in two and feel as if observing him or herself from a distance. Depersonalisation is feeling detached from oneself or one’s body.

Somatic symptoms such as pain and headache and other physical complaints, with or without objective findings, are common problems among torture victims. Pain may shift in location and vary in intensity. Somatic symptoms can be directly due to physical consequences of torture, be of psychological origin, or both. Also, various types of sexual dysfunction are not uncommon among survivors of torture particularly, but not exclusively, among those who have suffered sexual torture or rape.

Psychotic symptoms may be present such as delusions, paranoia, hallucinations (auditory, visual, olfactory or tactile), bizarre ideation, illusions or perceptual distortions. Cultural and linguistic differences may be confused with psychotic symptoms. Before labelling someone as psychotic, one must evaluate the symptoms within the individual’s cultural context. Psychotic reactions may be brief or prolonged. It is not uncommon for torture victims to report occasionally hearing screams, his or her name being called, or seeing shadows, but not have florid signs or symptoms of psychosis. Individuals with a past history of mental illness such as bipolar disorder, recurrent major depression with psychotic features, schizophrenia and schizoaffective disorder may experience an episode of that disorder. .

The ICD-10 includes the diagnosis “Enduring Personality Change.” PTSD may precede this type of personality change. To make the ICD-10 diagnosis of enduring personality change, the following criteria must have been present for at least two years and must not have existed prior to the traumatic event or events. These criteria are: hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, chronic feelings of “being on edge” as if constantly threatened, and estrangement.

Alcohol and drug abuse may develop secondarily in torture survivors as a way of blocking out traumatic memories, regulating affect and managing anxiety. Other possible diagnoses include: generalized anxiety disorder, panic disorder, acute stress disorder, somatoform disorders, 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.

^[1] American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th edition). Washington, DC:APA.

^[2] World Health Organisation, (1994). The ICD-10 Classification of mental and behavioural disorders and diagnostic guidelines. Geneva.

It is prudent for clinicians to become familiar with the most commonly diagnosed disorders among trauma and torture survivors and to understand that it is not uncommon for more than one mental disorder to be present as there is considerable … Continue reading →