Mental Health

Torture-Related Mental Health Disorders

Many survivors of torture are affected emotionally by their torture experiences. In order to create a treatment plan, assess the need for medication, and write an affidavit, it is important to evaluate the presence of psychiatric symptoms and their impact on functioning. For example, using Western nomenclature according to the Istanbul Protocol, clients may present with posttraumatic stress disorder, major depression, somatic complaints, substance abuse, neuropsychological impairments, psychosis, bipolar disorders, enduring personality change, generalized anxiety disorder, panic disorder, acute stress disorder, somatoform disorders, and phobias. Note that formal diagnostic tools are generally not culturally validated and that cultural variations in how clients present mental disorders must be taken into account.

Posttraumatic Stress Disorder (PTSD)

PTSD can be acute, chronic, or delayed and has 5 diagnostic criteria according to the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) IV (1):

1.The first criterion and key element for the diagnosis is exposure to an event outside the usual human experience, such as combat experience, a major natural catastrophe, or torture.
2. The second criterion is presence of symptoms for at least a month.
3. The third criterion is re-experiencing the initial event in at least one of the following forms:

• Recurrent and intrusive recollections of the trauma. For example, an African patient described how the voice of his captors were present all day and all night, no matter if he was working or resting, happy or sad.
  
• Recurrent distressing dreams about the trauma.
  
• Acting/feeling as if the events were recurring (i.e. hallucinations, flashbacks, and illusions). For instance, an Algerian man recounts seeing his captors beating him during an interrogation and consequently trying to protect his head from the imaginary blows.  He has noticed that the smell of urine triggers the flashbacks since this smell was strongly present in the interrogation room of his past.  
   
• Emotional and physical distress when exposed to cues that symbolize or initiate the remembrance of the trauma. A patient from Sub-Saharan Africa, for example, becomes very anxious every time he has to take an elevator because it reminds him of the narrow cell in which he was imprisoned for several months.

4. The fourth criterion is persistent avoidance of stimuli associated with the traumatic event in at least three of the following forms:

• Avoidance of thoughts or feelings that may arouse memories from the trauma. For instance, a female patient can no longer remember intimate moments with her husband because she immediately remembers being gang raped.
  
• Avoidance of activities or situations that resemble the trauma. An African male patient, for example, has experienced sexual dysfunction since tortured because every time he tries to have intercourse with his wife he remembers being raped and his captors saying "you are no longer a man."
  
• Inability to recall an important aspect of the traumatic event. For instance, a female patient recalled all the details of her detention, except for the period of time when she was raped.
  
• Diminished interest in daily activities
  
• Detachment and estrangement
  
• Restricted range of affect expressed as inability to love or be loved
  
• Sense of foreshortened future

5. The fifth criterion is persistent state of increased arousal manifested in at least two of the following ways:

• Difficulty falling or staying asleep
  
• Irritability
  
• Difficulties concentrating
  
• Hyper-vigilance
  
• Exaggerated startle response. A patient from Central America , for example, who received multiple threats by phone cannot control jumping whenever she hears a phone ringing.

Major Depression

According to the DSM IV, at least five of the following criteria should be present in the absence of organic brain damage, a medical condition such as hypothyroidism, or other psychiatric problem (1):

1. Anhedonia
2. Decreased interest in all or almost all daily activities
3. Insomnia or somnolence
4. Psychomotor agitation or retardation
5. Sadness
6. Feeling worthlessness or inappropriate guilt
7. Suicidal ideas
8. No evidence

Depression and PTSD have some symptoms in common such as insomnia, decreased interest in daily activities, and sense of foreshortened future.

Reference:
1. American Psychiatric Association. Diagnostic and Statistical Manual on Mental Disorders, 4th edition. Washington , DC , 1994.