Physical and psychological sequelae to torture. A controlled clinical study of exiled asylum applicants

Reported Methods, Distributions, and Frequencies of Torture Globally: A Systematic Review and Meta-Analysis

Importance

Despite its prohibition by the United Nations Convention against Torture and other international treaties, torture has been perpetrated against countless individuals worldwide, and health care practitioners globally are increasingly encountering refugee torture survivors in their clinical practices. The methods, geographic distribution, and frequency of torture globally are not well described, which limits health care practitioners' ability to adequately diagnose and treat the sequelae of torture.

Objective

To rank the commonness of torture methods and identify the regions of the world with which they are associated.

Data Sources

For this systematic review and meta-analysis, Ovid MEDLINE, Ovid Embase, Web of Science, and The Cochrane Library were searched from inception to July 2021.

Study Selection

Included studies were peer-reviewed articles in English, contained an independent sample population of individuals who experienced torture, and outlined the type(s) of torture experienced. Excluded studies were not peer reviewed, lacked an independent sample population, or did not specify torture methods. Articles were chosen for inclusion by 2 independent and blinded reviewers, and a third, independent reviewer resolved discrepancies. Overall, 266 articles-15.3% of the 1739 studies initially identified for full review-met the inclusion criteria.

Data Extraction and Synthesis

Data abstraction and quality assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were extracted by 2 independent and blinded reviewers into predefined templates, and a third, independent reviewer resolved discrepancies. The risk of bias was evaluated using the Downs and Black Checklist.

Main Outcomes and Measures

Torture methods were ranked by their average frequencies, numbers of reporting studies, and numbers of countries wherein the methods occurred.

Results

A total of 9937 titles and abstracts were screened, and 266 studies encompassing 103 604 individuals (13 350 men, 5610 women, and 84 644 unspecified) were analyzed. Torture was reported for 105 countries; 21 methods accounted for 84% of all reported methods and 10 methods accounted for 78% of all physical tortures. The top 3 methods were beating or blunt-force trauma (reported in 208 studies and 59 countries; average frequency, 62.4%; 95% CI, 57.7%-67.1%), electrical torture (reported in 114 studies and 28 countries; average frequency, 17.2%; 95% CI, 15.0%-19.4%), and starvation or dehydration (reported in 65 studies in 26 countries; average frequency, 12.7%; 95% CI, 10.2%-15.2%). According to the Downs and Black appraisal tool, 50 studies were rated as good or excellent and 216 as fair or poor.

Conclusions and Relevance

The findings of this study suggest that torture remains widespread. Although innumerable torture methods exist, a limited number account for the vast majority of reported tortures. So that targeted therapies may be developed, additional investigation is needed to better elucidate the sequelae associated with the most common torture methods, described here.

Head Trauma in Refugees and Asylum Seekers: A Systematic Review

BACKGROUND AND OBJECTIVES

Refugees and asylum seekers are at risk of head trauma. They endure blows to the head due to exigent circumstances necessitating resettlement (e.g., torture, war, interpersonal violence) and during their dangerous journeys to refuge. Our objective was to assess the global prevalence of head trauma in refugees and asylum seekers and describe its clinical characteristics in this population.

METHODS

The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42020173534). PubMed/MEDLINE, PsycInfo, Web of Science, Embase, and Google Scholar databases were searched for relevant studies. We included all studies in English that comprised refugees or asylum seekers of any age and examined the prevalence or characteristics of head trauma. We excluded studies that were not peer-reviewed original research. Information was recorded on the prevalence of head trauma, method of ascertaining head trauma, severity, mechanism of injury, other trauma exposures, and comorbidities. Descriptive analyses and narrative syntheses were performed.

RESULTS

A total of 22 studies were included, of which 13 with 6,038 refugees and asylum seekers reported head trauma prevalence. Prevalence estimates ranged from 9% to 78%. Heterogeneity among studies precluded meta-analysis. Most studies were US based (n = 9, 41%), followed by the Middle East (n = 5, 23%). Most refugees or asylum seekers were from the Middle East (n = 9, 41%), with those from Latin America least represented (n = 3, 14%). Studies disproportionately involved younger (pooled mean age = 29 years) adult samples composed of men. Recruitment settings were predominantly hospitals/clinics (n = 14, 64%), followed by refugee camps (n = 3, 14%). The most common mechanism of injury was direct impact through a beating or blow to the head. Studies varied greatly in how head trauma was defined and ascertained; no study used a validated traumatic brain injury (TBI)-specific screening tool. Similarly, TBI severity was not uniformly assessed, although hospital-based samples captured more moderate-to-severe head injuries. Mental health comorbidities were more frequently documented rather than physical health ones. Only 2 studies included a comparison with local populations.

DISCUSSION

Refugees and asylum seekers are vulnerable to head trauma, but studies using systematic approaches to screening are lacking. Increased attention to head trauma in displaced populations will allow for optimizing equitable care for this growing vulnerable population.

Suicide rates and suicidal behaviour in displaced people: A systematic review

Background

Refugees, and other forcibly displaced people, face mental distress and may be disproportionately affected by risk factors for suicide. Little is known about suicidal behaviour in these highly mobile populations because collecting timely, relevant, and reliable data is challenging.

Methods and findings

A systematic review was performed to identify studies of any design reporting on suicide, suicide attempts, or suicidal ideation among populations of displaced people. A sensitive electronic database search was performed in August 2020, and all retrieved studies were screened for relevance by two authors. Studies were categorised by the population being evaluated: refugees granted asylum, refugees living in temporary camps, asylum seekers, or internally displaced people. We distinguished between whether the sampling procedure in the studies was likely to be representative, or the sample examined a specific non-representative subgroup of displaced people (such as those already diagnosed with mental illness). Data on the rates of suicide or the prevalence of suicide attempts or suicidal ideation were extracted by one reviewer and verified by a second reviewer from each study and converted to common metrics. After screening 4347 articles, 87 reports of 77 unique studies were included. Of these, 53 were studies in representative samples, and 24 were based on samples of specific target populations. Most studies were conducted in high-income countries, and the most studied population subgroup was refugees granted asylum. There was substantial heterogeneity across data sources and measurement instruments utilised. Sample sizes of displaced people ranged from 33 to 196,941 in studies using general samples. Suicide rates varied considerably, from 4 to 290 per 100,000 person-years across studies. Only 8 studies were identified that compared suicide rates with the host population. The prevalence of suicide attempts ranged from 0.14% to 15.1% across all studies and varied according to the prevalence period evaluated. Suicidal ideation prevalence varied from 0.17% to 70.6% across studies. Among refugees granted asylum, there was evidence of a lower risk of suicide compared with the host population in 4 of 5 studies. In contrast, in asylum seekers there was evidence of a higher suicide risk in 2 of 3 studies, and of a higher risk of suicidal ideation among refugees living in camps in 2 of 3 studies compared to host populations.

Conclusion

While multiple studies overall have been published in the literature on this topic, the evidence base is still sparse for refugees in camps, asylum seekers, and internally displaced people. Less than half of the included studies reported on suicide or suicide attempt outcomes, with most reporting on suicidal ideation. International research networks could usefully define criteria, definitions, and study designs to help standardise and facilitate more research in this important area.

Registration

PROSPERO CRD42019137242.

Suspension torture and its physical sequelae

Suspension torture is one of the most common and widespread methods of torture. The objective of the study is to conduct a systematic literature review and produce an overview of suspension torture and its health implications, thus improving the diagnosis of suspension torture victims and documentation of their injuries. The review includes the prevalence, geographical distribution and description of variations of suspension torture. Physical sequelae like nerve injuries, e.g. brachial plexus injuries, scars, joint dislocation and possible causes of death will be described in detail. The results of the review are discussed resulting in recommendations on torture identification and documentation practices and possible future research questions.

Psychopathology in refugees subjected to the Dublin Regulation: an Italian study

BACKGROUND

Literature shows that migrants-a generic definition for persons who leave their own country of origin-have increased psychopathological vulnerability. Between 2014 and 2017, 976 963 non-European Union (non-EU) people arrived in Italy, of which 30% for humanitarian reasons. This study is aimed at a better understanding of the experience of asylum seekers who transferred to Italy were subjected to the EU Dublin Regulation and most of them suspended in their asylum application.

METHODS

We elaborate a descriptive study based on a population of refugees and asylum seekers who have suffered from social and personal migratory stressful factors. Clinical data was collected between 2011 and 2013 at the "A. Gemelli" General Hospital IRCCS, Rome, Italy. Minors, elderly people, and patients who are unable to declare a voluntary consensus and economic migrants were excluded from the study. Candidates for the status of refugee or asylum seekers were included.

RESULTS

The sample consisted of 180 asylum seekers aged 25.52 ± 5.6 years. Most frequently diagnosis was post-traumatic stress disorder (PTSD) (53%), subthreshold PTSD was reported in 22% of subjects. We found phenomenological patterns highly representative of PTSD of the dissociative subtype. Around 20% of the sample suffered from psychotic symptomatology.

CONCLUSIONS

Loss of the migratory project and the alienation mediated by chronic social defeat paradigm may trigger a psychopathological condition described by the failure to cope with the negative emotional context of social exclusion and solitude. A common and integrated treatment project is needed, with the scope of reintegrating the migrant's personal and narrative identity.

Asylum seekers: Forensic remarks regarding 185 cases

The medical examination of asylum seekers plays a significant role in helping them to obtain any form of international protection (refugee status or subsidiary or humanitarian protection). The Brescia Institute of Forensic Medicine has been increasingly involved in the medical examination of alleged victims of torture. Based on the Istanbul Protocol, the purpose of this study was to correlate the degree of consistency between the information provided by asylum seekers and the results of clinical examinations. A total of 185 asylum seekers were examined between September 2008 and September 2017. Almost all of the victims were male (94.0%) and aged between 11 and 30 years old (89.2%). Most victims were from Nigeria (23.2%), Gambia (16.2%) and Mali (10.8%), and the majority of the aggressions happened in Nigeria (18.9%), Gambia (14.5%) and Libya (12.9%). More than half of the instances of torture were related to political motives (57.3%); in 22% of cases, the victims referred to more than one act of aggression at different times. Blunt instruments were the most frequent means of injury (33.8%), followed by sharp instruments (23.3%). The most commonly involved anatomical regions were the lower and the upper limbs (23.6% and 20.5%, respectively). In terms of the degree of consistency between the lesion and the alleged torture, 50.4% of lesions were consistent with the information provided by the asylum seekers.

Mental health, violence and psychological coercion among female and male trafficking survivors in the greater Mekong sub-region: a cross-sectional study

BACKGROUND

Human trafficking is a pervasive global crime with important public health implications that entail fundamental human rights violations in the form of severe exploitation, violence and coercion. Sex-specific associations between types of violence or coercion and mental illness in survivors of trafficking have not been established.

METHODS

We conducted a cross-sectional study with 1015 female and male survivors of trafficking (adults, adolescents and children) who received post-trafficking assistance services in Cambodia, Thailand or Vietnam and had been exploited in various labor sectors. We assessed anxiety and depression with the Hopkins Symptoms Checklist (HSCL-25) and post-traumatic stress disorder (PTSD) symptoms with the Harvard Trauma Questionnaire (HTQ), and used validated questions from the World Health Organization International Study on Women's Health and Domestic Violence to measure physical and sexual violence. Sex-specific modified Poisson regression models were estimated to obtain prevalence ratios (PRs) and their 95% confidence intervals (CI) for the association between violence (sexual, physical or both), coercion, and mental health conditions (anxiety, depression and PTSD).

RESULTS

Adjusted models indicated that for females, experiencing both physical and sexual violence, compared to not being exposed to violence, was a strong predictor of symptoms of anxiety (PR = 2.08; 95% CI: 1.64-2.64), PTSD (PR = 1.55; 95% CI: 1.37-1.74), and depression (PR = 1.57; 95% CI: 1.33-1.85). Among males, experiencing physical violence with additional threats made with weapons, compared to not being exposed to violence, was associated with PTSD (PR = 1.59; 95% CI: 1.05-2.42) after adjustment. Coercion during the trafficking experience was strongly associated with anxiety, depression, and PTSD in both females and males. For females in particular, exposure to both personal and family threats was associated with a 96% elevated prevalence of PTSD (PR = 1.96; 95% CI: 1.32-2.91) and more than doubling of the prevalence of anxiety (PR = 2.11; 95% CI: 1.57-2.83).

CONCLUSIONS

The experiences of violence and coercion in female and male trafficking survivors differed and were associated with an elevated prevalence of anxiety, depression, and PTSD in both females and males. Mental health services must be an integral part of service provision, recovery and re-integration for trafficked females and males.

Diagnosis of torture after 32 years: assessment of three alleged torture victims during the 1980 military coup in Turkey

Torture is a crime against humanity and it is frequently encountered in countries that have a history of military intervention such as Turkey. Torture still exists despite absolute prohibition by human rights and humanitarian law. More than 1 million people were tortured in Turkey since 1980 coup d'état. Documentation of medical evidence is a prominent step for prevention of torture. Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol) provides international standards for medical documentation of torture. A holistic approach to trauma stories together with physical and psychological findings has been the main frame of the Protocol. The aim of this study is to discuss physicians' responsibility for prevention of torture, and to emphasize the importance of holistic approach to the assessment of particularly chronic patients. A team of two forensic medicine experts and a psychiatrist examined three male patients, who allegedly had been tortured severely during the 1980 military coup. The team arranged necessary referrals and diagnostic examinations. After conducting a comprehensive medical examination, some physical and psychological findings of trauma were observed and documented even after 32 years. The medico-legal evaluation and documentation of these cases many years after torture under the guidance of Istanbul Protocol were presented and significance of psychological assessment was especially emphasized. Furthermore, possible evidence of torture after a long period and physicians' responsibility for prevention of torture is discussed.

Traumatisierte Mütter – traumatisierte Kinder?

Hintergrund: Die Prävalenz von Traumafolgestörungen bei erwachsenen Flüchtlingen ist bekanntermaßen hoch. Gleichzeitig zeigen auch Flüchtlingskinder multiple psychische Auffälligkeiten und Funktionseinschränkungen. Theorien zu generationsübergreifender Traumatisierung vermuten, dass die Posttraumatische Belastungsstörung (PTBS) der Eltern sowie familiäre Gewalt die psychische Gesundheit der Kinder maßgeblich beeinflussen. Doch auch andere Faktoren wie eigene traumatische Erfahrungen im Herkunfts- und Aufnahmeland oder die Lebensbedingungen im Exil stehen möglicherweise mit der psychischen Gesundheit der Kinder in Zusammenhang. Fragestellung: Ziel der vorliegenden Arbeit ist es, den Zusammenhang von PTBS, weiteren Traumafolgeerkrankungen und Gewalterfahrungen von Flüchtlingsmüttern und ihren Kindern transgenerational zu untersuchen. Methode: 41 Flüchtlingsmütter und ihre Kinder (Alter 11-18 Jahre) wurden mit Hilfe von standardisierten, psychodiagnostischen Instrumenten unabhängig voneinander interviewt. Bei den Kindern wurde das Ausmaß der erlebten familiären Gewalt, erlebte traumatische Ereignisse, Ängstlichkeit, Depressivität sowie PTBS erfasst. Bei den Müttern wurde das Ausmaß der erlebten familiären Gewalt in der Kindheit, Gewalterfahrungen in der Partnerschaft in den letzten 12 Monaten ebenso wie andere traumatische Ereignisse sowie PTBS und Depressivität erhoben. Ergebnisse: Die Schwere der PTBS-Symptomatik bei den Müttern zeigt keinen direkten Zusammenhang mit der PTBS-Symptomatik, der Ängstlichkeit und der Depressivität der Kinder. Die Schwere der mütterlichen PTBS-Symptomatik ist aber mit der vom Kind erlebten familiären Gewalt positiv assoziiert. Die von den Kindern berichtete Anzahl unterschiedlicher traumatischer Ereignistypen und das Ausmaß der familiären Gewalt korrelieren wiederum positiv sowohl mit deren PTBS-Symptomatik als auch mit deren Depressivität und Ängstlichkeit. Schlussfolgerung: Die Ergebnisse veranschaulichen, dass nicht die PTBS-Symptomatik der Mutter, sondern die von den Kindern selbst erlebten traumatischen Erfahrungen, einschließlich der erlebten familiären Gewalt, mit den Traumafolgeerkrankungen der Kinder in Zusammenhang stehen. Die PTBS-Symptomatik der Mutter steht jedoch mit der vom Kind erlebten familiären Gewalt in Zusammenhang. Psychotherapeutische, trauma-fokussierte Interventionen sind daher sowohl für Mütter als auch Kinder indiziert. Darüber hinaus können Elterntrainings sinnvoll sein, um langfristig den Zyklus der Gewalt zu durchbrechen.

Medical evidence of human rights violations against non-Arabic-speaking civilians in Darfur: a cross-sectional study

BACKGROUND

Ongoing conflict in the Darfur region of Sudan has resulted in a severe humanitarian crisis. We sought to characterize the nature and geographic scope of allegations of human rights violations perpetrated against civilians in Darfur and to evaluate their consistency with medical examinations documented in patients' medical records.

METHODS AND FINDINGS

This was a retrospective review and analysis of medical records from all 325 patients seen for treatment from September 28, 2004, through December 31, 2006, at the Nyala-based Amel Centre for Treatment and Rehabilitation of Victims of Torture, the only dedicated local provider of free clinical and legal services to civilian victims of torture and other human rights violations in Darfur during this time period. Among 325 medical records identified and examined, 292 (89.8%) patients from 12 different non-Arabic-speaking tribes disclosed in the medical notes that they had been attacked by Government of Sudan (GoS) and/or Janjaweed forces. Attacks were reported in 23 different rural council areas throughout Darfur. Nearly all attacks (321 [98.8%]) were described as having occurred in the absence of active armed conflict between Janjaweed/GoS forces and rebel groups. The most common alleged abuses were beatings (161 [49.5%]), gunshot wounds (140 [43.1%]), destruction or theft of property (121 [37.2%]), involuntary detainment (97 [29.9%]), and being bound (64 [19.7%]). Approximately one-half (36 [49.3%]) of all women disclosed that they had been sexually assaulted, and one-half of sexual assaults were described as having occurred in close proximity to a camp for internally displaced persons. Among the 198 (60.9%) medical records that contained sufficient detail to enable the forensic medical reviewers to render an informed judgment, the signs and symptoms in all of the medical records were assessed to be consistent with, highly consistent with, or virtually diagnostic of the alleged abuses.

CONCLUSIONS

Allegations of widespread and sustained torture and other human rights violations by GoS and/or Janjaweed forces against non-Arabic-speaking civilians were corroborated by medical forensic review of medical records of patients seen at a local non-governmental provider of free clinical and legal services in Darfur. Limitations of this study were that patients seen in this clinic may not have been a representative sample of persons alleging abuse by Janjaweed/GoS forces, and that most delayed presenting for care. The quality of documentation was similar to that available in other conflict/post-conflict, resource-limited settings.

The Trauma of Torture and the Rehabilitation of Torture Survivors

The aim of torture is to cause severe pain and suffering in order to destroy the structure of the personality and the identity of the victim. Torture is applied in over a 100 countries worldwide, and its consequences affect millions of survivors. The rehabilitation of those who have experienced torture is a lengthy and complex process; treatment centers all over the world are constantly developing their methods to assist the mental and physical healing of torture survivors. The present article offers insights into the nature of torture, applied torture techniques, the psychological sequelae of torture, and diagnostic developments. Furthermore, current issues of rehabilitation and reparation are discussed, including the debate on evidence-based practice in treatment. The aim of the authors is to offer a brief but comprehensive review on torture and rehabilitation for professionals of mental health care and other relevant fields.

Defining torture: a review of 40 years of health science research

The current review critically examines the body of torture research (N = 209), focusing on the definition and operationalization of the primary construct. Almost three-quarters (69.9%) of the studies reviewed did not reference any definition of torture. Few studies identified important contextual variables related to defining torture such as identities and motivations of perpetrators and severity of abuse. Definitional ambiguity further impacted how individuals were queried about their experiences and the extent to which torture was distinguished from other forms of maltreatment. Although there are notable exceptions, the methods used in the torture literature are variable and often undefined, impacting the interpretation of findings of risk factors, consequences, and treatment of torture events.

Chronic pain in torture victims

Torture is widely practiced throughout the world. Recent studies indicate that 50% of all countries, including 79% of the G-20 countries, continue to practice systematic torture despite a universal ban. It is well known that torture has numerous physical, psychological, and pain-related sequelae that can inflict a devastating and enduring burden on its victims. Health care professionals, particularly those who specialize in the treatment of chronic pain, have an obligation to better understand the physical and psychological effects of torture. This review highlights the epidemiology, classification, pain sequelae, and clinical treatment guidelines of torture victims. In addition, the role of pharmacologic and psychologic interventions is explored in the context of rehabilitation.

Household exposure to violence and human rights violations in western Bangladesh (II): history of torture and other traumatic experience of violence and functional assessment of victims

BACKGROUND

Organised crime and political violence (OPV) and human rights violations have marred Bangladesh history since 1971. Little is known about the consequences for the oppressed population. This study describes the patterns of OPV and human rights violations in a disturbed area of Bangladesh and assesses the physical, emotional and social functioning of victims.

METHODS

A total of 236 of selected participants in a household survey in Meherpur district were recruited for a detailed study. Interviews and physical examinations were used to obtain information about history of torture and other cruel, inhuman or degrading treatment or punishment (TCIDTP), and about injuries, pain frequency and intensity. Handgrip strength and standing balance performance were measured. The "WHO-5 Well-being" scale was used to assess the subjective emotional well-being of study participants.

RESULTS

The majority of the reported cases of TCIDTP occurred in 2000-2008, 51% of incidents occurred during winter; 32.0% between 20:00 and midnight. Police involvement was reported in 75% of cases. Incidents took place at victims' homes (46.7%), or at the police station, military camp, in custody or in prison (21.9%). Participants experienced 1-10 TCIDTP methods and reported 0-6 injury locations on their bodies; 77.5% reported having at least two injuries. Less than half of the participants were able to stand on one leg for 30 seconds. Only 7.5% of males aged 25-44 had handgrip strength in both hands exceeding average values for healthy people at the same age. Over 85% of participants scored low (<13) on the 25-point "WHO-5 Well-being" scale. The number of years since the TCIDTP event, pain frequency, the need to quit a job to take care of an injured family member, political involvement, personal conflicts and the fear of neighbourhood violence strongly affected emotional well-being. Good emotional well-being correlated with increased political and social participation.

CONCLUSION

A detailed picture of characteristics of the victimisation is presented. The participants showed poor emotional well-being and reduced physical capacity. The results indicated that the simple and rapid method of assessment used here is a promising tool that could be used to monitor the quality and outcome of rehabilitation.

The range of symptoms in refugees of war: the New Mexico Refugee Symptom Checklist-121

The range of symptoms experienced by refugees of war has not been empirically assessed. The New Mexico Refugee Symptom Checklist-121 (NMRSCL-121) was developed utilizing established guidelines and evaluated for its psychometric properties. Community-dwelling Kurdish and Vietnamese refugees reported 48 (SD = 31) persistent and bothersome somatic and psychological symptoms on the NMRSCL-121. Internal consistency and test-retest reliability for the total scale and for most subscales were acceptable, and construct and concurrent validity for the NMRSCL-121 data was shown. There were modest ethnic group differences on symptom severity and psychometric properties of NMRSCL-121 subscales. The NMRSCL-121 produces reliable and valid assessments of a wide range of symptoms in 2 broad community samples of displaced adult refugees.

The long-term impact of torture on the mental health of war-wounded refugees: findings and implications for nursing programmes

Today, nurses from many disciplines are expected to provide nursing care to refugees severely traumatized in war and conflict. The general aim of this study was to explore the long-term impact of torture on the mental health of war-wounded refugees. The study group consisted of 22 tortured and 22 nontortured male refugees who had been injured in war. Standardized interview schedules, exploring different background characteristics, and three instruments for assessment of mental health were used: the Hopkins Symptom Checklist, the Post Traumatic Symptom Scale and a well-being scale. The prevalence of psychiatric symptoms was high in both groups. However, there were no significant differences in mental health between the tortured and the nontortured refugees. The patterns of associations between background characteristics and mental health were different in the two groups. The strongest associations with lower level of mental health were higher education in the tortured group and unemployment in the nontortured group. Methodological difficulties in research on sequelae of prolonged traumatization remain. Further studies within the caring sciences can broaden the present understanding of the impact of torture and other war traumas.

Personality related to coping and social support among Iranian refugees in Sweden

The aim of this study was to investigate the interrelatedness between temperament and character according to Cloninger's biosocial theory of personality, coping behavior, and social support among traumatized refugees. Personality, psychopathological disturbances, coping resources, and social support were assessed in 100 Iranian refugees resettled in Sweden who had been exposed to various extreme traumatic life events in Iran before their escape. Individuals traumatized by war experiences as soldiers, with low Beck Depression Inventory scores showed the lowest scores in Harm Avoidance and the highest in Self-Directedness and Cooperativeness. Concerning coping resources and social support, these subjects scored slightly higher and the traumatized refugees with high Beck Depression Inventory scores scored slightly lower compared with nontraumatized subjects. Resilient refugees are characterized by low harm avoidance, high self-directedness, and high cooperativeness scores which enables them to develop effective coping strategies to obtain sufficient social support and thus to become more resistant against severe trauma.

Chronic pain in torture survivors

According to Amnesty International government-sanctioned torture is verified in one third of the countries in the world. The physical and psychological sequelae are numerous. This study focuses on pain diagnosis, characterising pain types as nociceptive, visceral or neuropathic. Torture victims from the Middle East, treated at the Rehabilitation and Research Centre for Torture Victims (RCT) in Copenhagen, participated in the study. The patients were referred to a pain specialist for evaluation of unsolved pain problems. Eighteen male torture victims were examined. Twelve patients experienced pain at more than three locations. Nociceptive and neuropathic pain were demonstrated in all patients. Specific neuropathic pain conditions were related to the following four types of physical torture: Palestinian hanging, falanga, beating and kicking of the head, and positional torture. When treating torture victims, it is important to know about torture methods, to think differently than normal on etiological and pathogenetic factors and always consider the presence of neuropathic pain.

The dose-effect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group

The purpose of this study was to determine in Vietnamese ex-political detainees newly arrived into the United States a) the prevalence of torture and psychiatric symptoms and b) the dose-effect relationships between cumulative torture experience and the psychiatric symptoms of posttraumatic stress disorder (PTSD) and major depression. The study population included Vietnamese ex-political detainees (N = 51) and a comparison group (N = 22). All respondents received culturally validated instruments with known psychometric properties including Vietnamese versions of the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire. The ex-political detainees, in contrast to the comparison group, had experienced more torture events (12.2 SD = 4.2 vs. 2.6 SD = 3.1) and had higher rates of PTSD (90% vs. 79%) and depression (49% vs. 15%). Dose-effect relationships between cumulative torture experience and psychiatric symptoms were positive with the PTSD subcategory of "increased arousal" revealing the strongest association. These findings provide evidence that torture is associated with psychiatric morbidity in Vietnamese refugees. The demonstration of significant dose-effect responses supports the hypothesis that torture is a major risk factor in the etiology of major depression and PTSD. The generalizability of these results to other torture survivor groups is unknown. The interaction between torture and other pre- and post-migration risk factors over time in different cultural settings still needs to be examined.

Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and post-traumatic stress in Tamil asylum-seekers: comparison with refugees and immigrants

Compared to research on displaced persons whose refugee status has been endorsed prior to arriving in Western countries, there is little systematic information available about levels of past trauma, postmigration living difficulties and psychiatric symptoms amongst asylum-seekers who claim refugee status only after arrival. Asylum-seekers, authorized refugees and immigrants of Tamil background were recruited by personal contact and mail-out in Sydney, Australia. A total of 62 subjects, constituting approximately 60% of the estimated pool of Tamil asylum-seekers, agreed to participate in the study. They returned statistically significantly higher scores than immigrants (n = 104) on measures of past trauma, symptoms of anxiety, depression and post-traumatic stress, and on all dimensions of postmigration difficulties. Asylum-seekers did not differ from refugees (n = 30) on measures of past trauma or psychiatric symptoms, but they scored higher on selective components of postmigration stress relating to difficulties associated with their insecure residency status. Although limited by sampling and diagnostic constraints, the present study suggests that asylum-seekers may be a high-risk group in relation to ongoing stress in the postmigration period.

Refugee trauma versus torture trauma: a retrospective controlled cohort study of Tibetan refugees

A retrospective cohort study of 35 refugee Tibetan nuns and lay students who were arrested and tortured in Tibet matched with 35 controls who were not arrested or tortured was carried out in India. Subjects were administered the Hopkins Checklist-25, evaluating anxiety symptoms, effective disturbances, somatic complaints, and social impairment. The prevalence of symptom scores in the clinical range for both cohorts was 41.4% for anxiety symptoms and 14.3% for depressive symptoms. The torture survivors had a statistically significant higher proportion of elevated anxiety scores than did the nontortured cohort (54.3% vs. 28.6%, p = .05). This was not true for elevated depressive scores. The results suggest that torture has long-term consequences on mental health over and above the effects of being uprooted, fleeing one's country, and living in exile as a refugee, though the additional effects were small. Political commitment, social support in exile, and prior knowledge of and preparedness for confinement and torture in the imprisoned cohort served to foster resilience against psychological sequelae. The contribution of Buddhist spirituality plays an active role in the development of protective coping mechanisms among Tibetan refugees.

Suicidal behavior after severe trauma. Part 2: The association between methods of torture and of suicidal ideation in posttraumatic stress disorder

The study reports on 65 refugees with diagnoses of posttraumatic stress disorder (PTSD) and manifest suicidal behavior (40% had suicide attempts; 29% detailed suicide plan; 31% recurrent suicidal thoughts). Our hypothesis was that the predominant kind of stressful experience in PTSD patients might be reflected in their choice of method when pondering or attempting suicide. Relationships were found to exist between the main stressors and the respective subjects' preference for suicide method. Particularly among PTSD patients with a history of torture, an association was found between the torture methods that the victim had been exposed to, and the suicide method used in ideation or attempts. Blunt force applied to the head and body was associated with jumping from a height or in front of trains, water torture with drowning, or sharp force torture with methods involving self-inflicted stabbing or cutting. Relationships between main stressors and content of suicidal ideation are discussed.

Anxiety, depression and PTSD in asylum-seekers: assocations with pre-migration trauma and post-migration stressors

BACKGROUND

Research into the mental health of refugees has burgeoned in recent times, but there is a dearth of studies focusing specifically on the factors associated with psychiatric distress in asylum-seekers who have not been accorded residency status.

METHOD

Forty consecutive asylum-seekers attending a community resource centre in Sydney, Australia, were interviewed using structured instruments and questionnaires.

RESULTS

Anxiety scores were associated with female gender, poverty, and conflict with immigration officials, while loneliness and boredom were linked with both anxiety and depression. Thirty subjects (79%) had experienced a traumatic event such as witnessing killings, being assaulted, or suffering torture and captivity, and 14 subjects (37%) met full criteria for PTSD. A diagnosis of PTSD was associated with greater exposure to pre-migration trauma, delays in processing refugee applications, difficulties in dealing with immigration officials, obstacles to employment, racial discrimination, and loneliness and boredom.

CONCLUSIONS

Although based on correlational data derived from'a convenient' sample, our findings raise the possibility that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised.

Stress disorders of families of the disappeared: a controlled study in Honduras

The effect of forced disappearance on the physical and psychological health of family members was assessed by interviews carried out in Honduras. Families of the disappeared were compared with two control groups: (1) families who lost a member due to accident or illness; and (2) families where no one had died within the past 10 years. Constellations of stress-related symptoms commonly seen in post-traumatic stress disorder and other anxiety disorders were approx. 2 times more prevalent in families of the disappeared as compared to the other two groups, indicating that families of the disappeared suffer over and above that due to normal grieving. It is suggested that the atmosphere of fear and isolation experienced by families of the disappeared is a causative factor in the prolongation of stress-related disorders years after the traumatic event.

Part I: Torture and mental health: a review of the literature

Torture affects a large number of people worldwide and poses a serious threat to mental health. This article presents an overview of torture as a current issue and reviews the literature that addresses the mental health effects of torture. Subtopics addressed include the effects of torture on the individual, the effects of torture on the community, studies of women who have survived torture, the ethics involved in studying torture victims, and the debate over identifying a torture syndrome.