Psychological Evidence of Torture and Ill Treatment: Prevention Through Documentation Project

MODULE 6
Prevention through Documentation Project
Psychological Evidence of Torture and Ill

Treatment
CONTRIBUTORS:
Trkcan Baykal MD, Human Rights Foundation of Turkey
Caroline Schlar, PhD, Human Rights Foundation of Turkey
Emre Kapnn, Human Rights Foundation of Turkey
Kathleen Allden, MD, Indochinese Psychiatric Clinic
Vincent Iacopino, MD, PhD, Physicians for Human Rights
PtD Project (IRCT, HRFT, REDRESS, PHR)
Module 6 Outline
Psychological evaluation
Central role
Conducting an evaluation
Findings and diagnostic considerations
Components
Children
and Torture
International
Statistical Classification of
Diseases and Related Health Problems, Annex
The Central Role of the

Psychological Evaluation
Can
provide critical evidence of abuse

among torture victims
Any
evaluation of torture should

include a psychological assessment
The Central Role of the

Because:
One of main objectives of torture is destruction of
psychological and social integrity of victim
All kinds of torture inevitably comprise psychological processes

Torture :
Often causes devastating psychological symptoms
Methods can leave no physical lesions
Physical findings may resolve or lack specificity
Contrary to physical effect of torture, psychological symptoms
are more persistent and troublesome
Conducting the Psychological Evaluation:

General Considerations
Torture is an extraordinary life

experience capable of causing
wide range of physical/
psychological suffering
Extreme nature of torture event

powerful enough on its own to
produce mental and emotional
consequences, regardless of
individuals pre-torture
psychological status

It
is important to recognize that not

everyone who has been tortured develops a
diagnosable mental illness
However,
many victims of torture

experience profound emotional reactions
and psychological symptoms

Even though 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

Distress and suffering are not in

themselves pathological conditions;
sometimes normal response to societal
pathology

Evaluation and interpretation should always

be made with awareness of cultural,
political and social context as well as
conditions of the interview and assessment
Psychological Findings and

Diagnostic Considerations
Consequences of torture: individual, family and

social levels
Despite variability, clusters of symptoms and

psychological reactions have been observed
frequently among torture survivors
PTSD and Major Depression most common
One doesnt have to be tortured to develop PTSD or
Major Depression
Everyone who has been tortured does not develop PTSD
and Major Depression
Psychological Findings and

Diagnostic Considerations
Psychological
effects of torture should not

be oversimplified . Besides PTSD and Major
Depression, consider:
Anxiety Disorders
Substance Abuse
Enduring Personality Change
Somatoform Disorders
Dissociation
Psychosis
Be
familiar with ICD-10 and DSM-IV

classifications
Consequences of Torture
TORTURE CAUSES TRAUMA
SOCIETY
FAMILY
INDIVIDUAL
INDIVIDUAL
INDIVIDUAL
FAMILY
FAMILY
SOCIETY
SOCIETY
can terrorize entire

population
creates an atmosphere
of pervasive threat,
chronic fear, terror,
inhibition, hopelessness
creates repressive
ecology: a state of
generalized insecurity,
lack of confidence and
rupture of social
fabric.
can break or damage
will and coherence of
entire communities
can lead to family

traumas that cause:
different forms of
family dysfunction
disruptions in
course of family
development
Assessing the effects

of torture on survivors
family dynamics can be
important in torture
assessment
INDIVIDUAL
INDIVIDUAL
FAMILY
FAMILY
SOCIETY
SOCIETY
INDIVIDUAL
INDIVIDUAL
On individual
On relationship
between individual and
his/her intimate
relationship
On relationship
between individual and
society
FAMILY
FAMILY
SOCIETY
SOCIETY
Psychological Consequences of
Torture
Torture is a complex mechanism that
can traumatize, damage;
body
personality
cognitive, emotional,
dreams, hopes, behavioral functioning
aspirations for the future
self actualization
Beliefs
Sense of being grounded
system of meaning about
in a family and society
himself and the world
the autonomy
sense of safety and survival
relationships between
spouse,
parents,
Connectedness
children,
community
Attachment
Torture
There is a complex relationship between
torture and the symptomatology
The psychological responses to torture are
affected by multiple factors
SOCIAL CONTEXT
BEFORE, DURING, AFTER
TORTURE
MEANNG OF TORTURE
BELIEF SYSTEM
PREPAREDNESS
ADDITIONAL LOSSES
CONDITIONS OF TORTURE
PSYCHOLOGICAL
RESPONSE
AGE,
DEVELOPMENTAL
PHASE
COPING CAPABILITIES
SUPPORT SYSTEM
PREVIOUS
TRAUMAS
PRE-EXISTING
PSYCHOLOGICAL
DISORDERS
PHYSICAL HEALTH
Psychological Consequences
of Torture
Nevertheless, there are clusters of
symptoms and psychological reactions that
have been observed and documented in
torture survivors with some regularity
Torture
RE-EXPERIENCING THE
TRAUMA
-Intrusive memories of
traumatic event
-Recurrent nightmares
-Distress at exposure to
cues that resemble the
trauma
-Flashbacks
-Foreshortened future
-Damaged self-concept and
self-esteem
-Guilt and shame feelings
AVOIDANCE AND EMOTIONAL

NUMBING
-Emotional constriction
-Personal detachment
-Social withdrawal
-Inability to recall some aspect
of trauma
HYPERAROUSAL
-Difficulty either falling or
staying asleep
-Irritability or outburst of
anger
-Difficulty concentrating
-Hypervigilance, exagerrated
startled response
-Generalized anxiety
-Shortness of breath,
sweating, dry mouth
Torture
-Constriction of consciousness,
-Narrowing the attention
-Inability to comprehend stimuli
-Disorientation
-Withdrawal from the surrounding
situation
-Agitation
-Autonomic signs of panic anxiety
-Somatic symptoms
-Dissociations, depersonalisation
-Sexual dysfunctions
-Psychotic reactions
-Substance abuse
-Incrased risk seeking behaviours
-Depressed mood
-Anhedonia
-Appetite disturbance
-Disturbed sleep
-Fatigue and loss of energy
-Feelings of worthlessness
and excessive guilt
-Difficulty in paying attention,
concentration or recalling
from memory
-Thoughts of death and dying;
suicidal ideation or attempt
Impact of Torture
Traumaspecific
Traumaspecific disorders
disorders
Torture,
Extreme life
events
Acute Stress
Disorder, PTSD,
Personality
change, Brief
Reactive Psychosis
Relationship
Relationship
to
to torture:
torture:
Increase
Increase and
and triggering
triggering
of
of preexisting
preexisting or
or
previously
previously hidden
hidden
disorders
disorders
Unspecific
Unspecific
disorders
disorders and
and
symptoms,
symptoms, related
related
to
to torture
torture
The ICD 10 system- Chapter V

Most Relevant Categories
Reactions to
severe stress
PTSD
Mood
disorders
Personality
Change
Core anxiety
mood disorders
Somatoform
disorders
Brief reactive
psychosis
Anxiety
disorders
Dissociative
disorders
Postconcussional
syndrome
Reactions to Extreme Life Events:

ICD 10 *
(must not be all present in each case)
Acute stress
reaction/ disorder
Post-traumatic
stress disorder
(PTSD)
Personality
change after
catastrophic
experience
ICD 10:
F 43.0
ICD 10:
F 43.1
ICD 10:
F 62.0
Hours to days
after event
Days to
years
2 years
or later
*International Classification of Diseases, Rev.
10, WHO
Posttraumatic Stress Disorder

Intrusive memories
(Associated
symptoms:
Guilt/Shame
feelings)
Symptom
groups
Avoidance
Hyperarousal

(PTSD)
Re-experiencing: intrusive distressing memories,

nightmares, flashback/reliving the event,
nightmares, hallucinations
Hyperarousal: insomnia, irritability, angry

outbursts, exaggerated startle response
Avoidance of stimuli associated with the trauma,

detachment and estrangement from others,
foreshortened sense of future
Longitudinal Course
(Acute stress
disorder
Triggers
might be
present)
Time
Symptom
level
A) Chronic PTSD,
Personality change
B) Remission
PTSD might be
missed in
examination
Clinical PTSD
Avoidance
Intrusion
Hyperactivation
Mainly avoidance or low symptom level
Major Depression
Depressed
mood
Anhedonia
Appetite
disturbance
Sleep disturbance
Psychomotor retardation or agitation
Fatigue, poor energy
Major Depression
Feelings
of worthlessness
Poor attention, concentration and
memory
Thoughts of death
Suicidal ideation
Suicide attempts
Trauma and Diagnosis

One
doesnt have to be tortured to

develop PTSD or Major Depression
PTSD
and Major Depression appear in

the general population.
Everyone
who has been tortured does

not develop PTSD and Major
Depression
Course of Major Depression and

Variable
time of onset of symptoms
Can have delayed onset

Symptoms emerge over time
Episodes
can recur
Need
to consider where survivor is in the

recovery process
Frequently Overlooked Diagnoses

Symptoms of complex PTSD,
Co-morbidity (such as
depression, somatoform
disorders, generalized anxiety
disorder)
Behavioural consequences
Functional sexual disorders *
Culture specific reactions
Mild traumatic brain injury
Difficulties in Recalling and Recounting
Factors directly related to the

torture experience
Factors related to the

psychological impact of
torture
Cultural factors
Factors related with the interview

conditons or communication barriers
PtD Project (IRCT, HRFT,

REDRESS, PHR)
Credibility
Accurate
details of torture and

trauma experiences necessary
because details will be used in:
legal affidavits
political asylum hearings
human rights investigations
war crimes tribunals
Inconsistency
If
any inconsistency in story:
Ask for further clarification

If not possible, look for other
evidence/supporting details that can corroborate

and clarify individuals story
If
Schedule additional interviews with family and friends

and witnesses
Conduct additional examinations
still suspect fabrication:
Refer to another clinician to ask for second
opinion
Suspicion should be documented by two separate
clinicians
! Beware:
Negative finding in regard to
psychological sequels
Evaluate possible
reasons
Additional diagnostic
strategies,
additional interview
Good coping
or other factors prevent
PTSD development
or other reactions
No diagnosis
- Does NOT exclude

torture
The Psychological Evaluation

Overall goal: assess degree of consistency
between individuals account of torture and
psychological findings observed during
course of the evaluation.
Clinical Inquiry Must Include

Evaluating
symptoms
presence or absence of
Beliefs
about experiences
Beliefs
about meanings of symptoms
Evaluation starts at the very first contact;
appearance/dress
posture
the manner of recalling and recounting the trauma
signs of anxiety or emotional distress
numbness or over-excitement
the moments of emotional intensity
startled responses
his/her posture and bodily expressions while relating the
events of torture
avoidance of eye contact
emotional fluctuations in his/her voice
Can give important clues about the personal history

and psychological functioning of the person.
Components of the
History
of torture and ill-treatment

Current psychological complaints
Post-torture history
Pre-torture history
Medical history
Psychiatric history
Substance use and abuse history
Components of the
Mental
status examination
Assessment of social functioning
Psychological testing and the use of
checklists and questionnaires
Clinical impression
Recommendations
Components of the
The entire clinical picture produced by

torture is much more than the simple
sum of lesions produced by methods
on a list.
Identifying Data
Individuals
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.)
Components of the
History
of
torture and illtreatment
Pre-torture history
Medical history
Psychiatric history
Mental status examination
Psychological testing and
the use of checklists and

questionnaires
Clinical impression
Recommendations
Full history of torture,

persecution and other relevant
traumatic experiences
A method-listing approach may

be counter-productive
Components of the
Affective, cognitive, and behavioral

symptoms
in detail: include frequencies and
examples
Adaptative strategies and triggers such as

anniversary reactions
specific stimuli or places
situations and topics causing avoidance
Physical and psychological complaints that

appeared since the torture. Include:
first emergence
duration
intensity
fluctuations
History of torture and ill-treatment
Current
psychological
complaints
Pre-torture history
Medical history
Psychiatric history

questionnaires
Clinical impression
Recommendations
Components of the
Sources of additional stress

trauma
losses
ongoing persecution of self/family
refugee displacement
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

Post-torture
history
Pre-torture history
Medical history
Psychiatric history

questionnaires
Clinical impression
Recommendations
Components of the

Pre-torture
history
Medical history
Psychiatric history


questionnaires
Clinical impression
Recommendations
Developmental history
Family history: family background,
family illnesses, family composition
Educational history
Occupational history
History of past trauma: childhood
abuse, war trauma, domestic violence,
etc
Cultural and religious background
Components of the

Pre-torture history
Medical
history
Psychiatric history


questionnaires
Clinical impression
Recommendations
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
Use of medications, including possible
side effects and obstacles in using
medications
Relevant sexual history
Past surgical procedures and other
medical data
Components of the
Pre-torture history
Medical history
Past
Psychiatric
history
Past history of mental or

psychological disturbances
The nature of the problems
Previous treatment or
psychiatric hospitalisation
The use of any psychotropic

medications


questionnaires
Clinical impression
Recommendations
Components of the
Substance use before and after

the torture
Psychiatric history
Changes in the pattern of use

and abuse
Reason for substance us:

specifically are they being used
to cope with insomnia or
psychological problems
Pre-torture history
Medical history
Substance
use
and abuse history


questionnaires
Clinical impression
Recommendations
Components of the
Pre-torture history
Medical history
Psychiatric history
Mental
status
examination

questionnaires
Clinical impression
Recommendations
All aspects including:
appearance
speech
mood and affect
thinking and perception
sensorium
alertness
orientation
concentration
,emory impairment
judgement
Components of the

Pre-torture history
Medical history
Psychiatric history
Assessment
of
social functioning

questionnaires
Clinical impression
Recommendations
Assess individuals ability to:
care for self

earn a living
support family
pursue education
Inquire about:
daily activities
social role function (as
housewife, student, worker,

etc)
social and recreational
activities
perception of health status
Components of the
Pre-torture history
Medical history
Note limited utility because

interpretations limited by lack
of established norms for
torture survivors
May complement clinical

evaluation as secondary source
of corroborating information
Should not be given more weight

than clinical evaluation
Clinician decides when to use

psychological tests
Psychiatric history
Psychological
testing and
the use of
checklists and
questionnaires
Clinical impression
Recommendations
Components of the

Pre-torture history
Medical history
Psychiatric history

questionnaires
Clinical
Recommendations
impression
History of detention and

torture
Pre torture conditions
Post torture conditions
Behavioral, cognitive and
emotional aspects of
individual observed during
verbal and non-verbal
communication; symptoms
with details should be
described
Components of the
Pre-torture history
Medical history
Psychiatric history

questionnaires
Clinical
Recommendations
impression
Findings should be
considered altogether
Relationship of individual
components to each other
should be taken into
consideration
Components of the
Trauma history, clinical
Pre-torture history
Medical history
Psychiatric history

questionnaires
Clinical
Recommendations
impression
history, mental status

exam and physical exam
Knowledge of political
context of country
where the torture took
place
Cultural idioms, beliefs,
and social customs
Barriers to full
disclosure
Components of the
Medico-legal
Pre-torture history
Medical history
Psychiatric history

questionnaires
Clinical
Recommendations
impression
investigations require
understanding of the
psychological
phenomena, not only
diagnosis
Interpretation of the Findings and

Clinical Impression
Critical questions for establishing a clinical
picture:
Are the psychological findings consistent with the

alleged report of torture?
Are the psychological findings expected reactions to
extreme stress within the cultural and social context
of the individual?
Given the fluctuating course of symptoms over time,
what is the time frame in relation to the torture
events? Where is the individual in the course of
recovery?

Clinical Impression
Critical questions for establishing a clinical
picture:
What are the coexisting stressors and their impacts

on the individual?
Are there physical conditions complicating the clinical

picture?
Does the clinical picture suggest a false allegation of

torture?

Clinical Impression
If the individual has symptom levels consistent with

one or more DSM IV or ICD 10 diagnosis, the diagnosis
should be stated.
If not,
the relationship and consistency between the
psychological findings, symptoms and the history
of the individual should be evaluated as a whole and
stated in the report.
Components of the
Pre-torture history
Recommendations may depend on

purpose of the evaluation
Note: Medico-legal role does not

absolve clinicians of making
appropriate therapeutic
referrals
Recommendations can be for:
Medical history
Psychiatric history

questionnaires
Clinical impression
Recommendations
further assessments
neuro-psychological testing
medical or psychiatric
treatment
Treatment Considerations
Address basic human necessities (food, shelter, source

of income)
Be aware of local clinical and social support resources
Refer for clinical treatment and rehabilitation

programs, with individuals consent
Online course available on Caring for Torture

Survivors offered by the Boston Center for Refugee
Health and Human Rights. See
http://www.bcrhhr.org/pro/course/course_index.html
#
Neuro-psychological
Assessment
Torture
can involve physical trauma that

leads to various levels of brain impairment
Symptoms
of brain impairment may overlap

with PTSD and major depressive disorders
Neuropsychological
assessment:
may be useful in discriminating between
neurological and psychological conditions

performed infrequently and to date
neuropsychological studies of torture survivors
is limited in the literature
Children and Torture
Torture can affect a child directly or indirectly
Child should receive support from caring individuals

so he/she feels secure during evaluation
Children often do not express their thoughts and

emotions regarding trauma verbally, but rather
behaviorally
Degree to which a child is able to verbalize thought

and affect depends on age and developmental level as
well as on other factors, such as family dynamics,
personality characteristics and cultural norms

Developmental
Considerations
< 3 yrs: reactions typically involve hyperarousal, such as
restlessness, sleep disturbance, irritability, heightened startle

reactions and avoidance
> 3 yrs: often tend to withdraw and refuse to speak directly
about traumatic experiences
8 or 9 yrs: develop the ability to provide a reliable chronology
of events
About 12 yrs: able to construct a coherent narrative
Adolescence: effects of torture can vary widely (i.e. profound
personality change resulting in antisocial behavior, similar to
those seen in younger children)
Clinical Considerations
PTSD symptoms similar to adults
Fears and aggressive behavior 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 phobia
May demonstrate sexual behavior inappropriate for age

May experience somatic reactions
Anxiety symptoms may appear, such as exaggerated fear of
strangers, separation anxiety, panic, agitation, temper tantrums and

uncontrolled crying
May develop eating problems

Role
of the Family
Dysfunctional behaviors 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 parent

Role
of the Family
When loved ones around a child have been tortured
or the child has witnessed severe trauma or torture,

he/she may develop dysfunctional beliefs, such as
that he/she is responsible for the bad events or
that he/she has to bear the parents burdens
These types of beliefs can lead to long-term
problems with loyalty conflicts, guilt, personal

development and maturing into an independent adult

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MODULE 6

Prevention through Documentation Project

Psychological Evidence of Torture and Ill

PtD Project (IRCT, HRFT, REDRESS, PHR)

PtD Project (IRCT, HRFT, REDRESS, PHR)

The Central Role of the

provide critical evidence of abuse

evaluation of torture should

PtD Project (IRCT, HRFT, REDRESS, PHR)

The Central Role of the

One of main objectives of torture is destruction of

psychological and social integrity of victim

All kinds of torture inevitably comprise psychological processes

are more persistent and troublesome

PtD Project (IRCT, HRFT, REDRESS, PHR)

Conducting the Psychological Evaluation:

PtD Project (IRCT, HRFT, REDRESS, PHR)

Torture is an extraordinary life

Extreme nature of torture event

Conducting the Psychological Evaluation:

is important to recognize that not

many victims of torture

PtD Project (IRCT, HRFT, REDRESS, PHR)

Conducting the Psychological Evaluation:

Even though diagnosis of trauma-related

PtD Project (IRCT, HRFT, REDRESS, PHR)

Conducting the Psychological Evaluation:

Distress and suffering are not in

PtD Project (IRCT, HRFT, REDRESS, PHR)

Conducting the Psychological Evaluation:

Evaluation and interpretation should always

PtD Project (IRCT, HRFT, REDRESS, PHR)

Psychological Findings and

Consequences of torture: individual, family and

Despite variability, clusters of symptoms and

PTSD and Major Depression most common

One doesnt have to be tortured to develop PTSD or

Psychological Findings and

effects of torture should not

familiar with ICD-10 and DSM-IV

PtD Project (IRCT, HRFT, REDRESS, PHR)

TORTURE CAUSES TRAUMA

PtD Project (IRCT, HRFT, REDRESS, PHR)

PtD Project (IRCT, HRFT, REDRESS, PHR)

can terrorize entire

can lead to family

Assessing the effects

PtD Project (IRCT, HRFT, REDRESS, PHR)

PtD Project (IRCT, HRFT, REDRESS, PHR)

PtD Project (IRCT, HRFT, REDRESS, PHR)

PtD Project (IRCT, HRFT, REDRESS, PHR)

PtD Project (IRCT, HRFT, REDRESS, PHR)

AVOIDANCE AND EMOTIONAL

The ICD 10 system- Chapter V

Reactions to Extreme Life Events:

Posttraumatic Stress Disorder

Posttraumatic Stress Disorder

Re-experiencing: intrusive distressing memories,

Hyperarousal: insomnia, irritability, angry

Avoidance of stimuli associated with the trauma,

PtD Project (IRCT, HRFT, REDRESS, PHR)

Mainly avoidance or low symptom level