Psychological and physical long-term effects of torture. A follow-up examination of 22 Greek persons exposed to torture 1967-1974

Assisting refugee survivors of torture and trauma: An existential perspective

Consistent exposure to refugee narratives of trauma and torture can profoundly impact trauma therapists. This secondary analysis reanalyzed data from a narrative inquiry investigating the lived experiences of refugee trauma therapists. We aimed to explore emergent concerns through an existential lens to enrich understanding and provide additional insights into the lived experiences of these individuals. Participants in this purposive sample (N = 19) were therapists who had provided interventions to refugees for 2-34 years. Narrative construction, theory-guided data analysis, and memo writing were used to reanalyze data generated by semistructured interviews augmented by photo elicitation. The findings indicate that being forced to reevaluate familiar beliefs consequent to one's professional roles induced intense existential moments, described as "a dark night of the soul," "the paradox of life and death," "uncanny feelings of not being at home," and "a falling." Acknowledging the complexities of the field, an existential framework to assist refugee trauma therapists in metabolizing and living with the professional challenges they encounter instead of focusing on alleviating decontextualized symptoms of distress is recommended. Research to inform requirements of the space to enable refugee trauma therapists to share their concerns and facilitate transitions toward more authentic, nonevasive sense of "being-in-the-world" is suggested.

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.

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.

Clinical findings in men with chronic pain after falanga torture

OBJECTIVES

To explore clinical findings in men with chronic pain after falanga torture as compared with controls, and to try to understand the nature of the pain mechanisms responsible.

METHODS

Eleven male torture victims from the Middle East with chronic pain after falanga, and 11 age, sex, and ethnically matched controls with no history of torture were recruited. All participants were interviewed regarding pain characteristics in the feet and lower legs at rest and when walking. Structural changes and motor and sensory function were clinically assessed according to a standardized protocol. The walking pattern was observed for compensatory gait patterns.

RESULTS

The torture victims had pain in their feet and lower legs and a compensated gait pattern, usually with severe pain during walking. Reduced light touch and thermal sensation, tactile dysesthesia, allodynia, and tenderness on palpation were common findings. Structural changes in the feet were found in more than half of the victims, but did not correlate with pain reports. These clinical findings were nonexistent or seen only rarely in controls.

DISCUSSION

We found clear clinical signs of nerve injury in the feet. The sensory findings indicated 2 neuropathic pain mechanisms, one dominated by a peripheral pain generator and other by irritative phenomena (dysesthesia, allodynia), indicating central sensitization. It is reasonable to assume that these changes are due to the falanga exposure. A nociceptive contribution cannot be excluded. It is important to perform an individual diagnostic analysis to facilitate adequate treatment.

The experience of mental death: The core feature of complex posttraumatic stress disorder

Exposure to extreme interpersonal stress, exemplified by the experience of torture, represents a threat to the psychological integrity of the victim. The experience is likely to result in mental death, in the loss of the victim's pretrauma identity. Mental death is characterized by loss of core beliefs and values, distrust, and alienation from others, shame and guilt, and a sense of being permanently damaged. Mental death is a primary feature of a distinct posttrauma syndrome, complex posttraumatic stress disorder (PTSD), which is refractory to standard exposure therapies. We identify cognitive mechanisms that mediate the symptoms of complex PTSD, and suggest how current treatments need to be modified to obtain enhanced treatment outcomes.

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.

The influence of exile and repatriation on mental and physical health. A population-based study

This study tested the association between psychosocial stressors extracted from a previous qualitative study, and psychological distress, long-term illness and self-rated ill-health among Latin American refugees in Lund, Sweden, and among repatriated Latin Americans. The study was designed as a population-based cross-sectional study. A structured questionnaire from the Swedish Annual Level-of-Living Surveys 1989: 2 was translated into Spanish. Latin American refugees in Lund (n = 338) and those who had lived in Lund and were repatriated to Santiago de Chile (n = 51) and Montevideo, Uruguay (n = 9), were interviewed in their homes in Sweden and in Latin America. The data were analysed unmatched with logistic regression in main effect models. Torture was an independent risk indicator for psychological distress, with an estimated odds ratio of 2.71 (1.45-4.85). There was a significant association between discrimination, not feeling secure in everyday life and psychological distress, with estimated odds ratios of 1.93 (1.02-3.56) and 3.23 (1.62-6.16), respectively. Torture and not feeling secure in everyday life were independent risk factors for long-term illness. Torture, discrimination and not feeling secure in everyday life were significant strong risk factors for ill-health. Repatriated refugees had significantly higher shares of not feeling secure compared with Latin Americans in Sweden. As risk factors of psychological distress and illness, torture, discrimination and not feeling secure proved to be as important as traditional risk factors such as material factors and lifestyle.

Ethnicity as a risk factor for mental illness. A population-based study of 338 Latin American refugees and 996 age-, sex- and education-matched Swedish controls

This article shows the influence of ethnicity on mental health compared with material factors and lifestyle, which are well-known risk factors for mental illness. The study was designed as a case-control study, with 338 Latin American refugees aged 16-74 years (response rate = 81.8%) in Lund, and a random sample of 996 age-, sex- and education-matched Swedish controls. The data were analysed unmatched with logistic regression in main effect models. The strongest independent risk mediator for mental illness was ethnicity, with an estimated odds ratio of 4.11 (2.31-6.92). Low material standard was associated with mental illness, with an odds ratio of 2.13 (1.07-4.11). Individuals who did not feel secure in daily life were at risk of mental illness, as were those with poor leisure opportunities. The combination of ethnicity, age over 44, and not feeling secure in daily life increased the odds ratio of mental illness to 26.62. Ethnicity, a low material standard, not feeling secure in daily life and poor leisure opportunities were significant risk factors for mental illness.

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.

Medical appraisal of allegations of torture and the involvement of doctors in torture

Today, torture is used in more than 90 countries. In most of these countries, the authorities try to conceal the use of torture. Therefore torture methods which do not leave marks are more often selected. Consequently, appraisal of statements of torture is mostly based on interviews with ex-prisoners. The statement of torture is compared with the description of symptoms in the period following imprisonment and with the result of the clinical examination, which is often normal. In the evaluation of the validity of a statement reservations often have to be made for minor disagreements between the single elements of the examination, for example because of impaired concentration during the examination and loss of consciousness during the torture. Furthermore, the statement may be incomplete because of psychological inhibitions and imperfect interpretation. Assessment of allegations of medical involvement in torture is also based on information given by the ex-detainee. The presumed doctor's examination technique and the treatment carried out and prescribed by him, are compared with the context in which he acted. Only very rarely do torture victims have marks from e.g. injections or suturing which can be related to medical treatment in torture centres. The critical evaluation of data collected during in-depth interviews with torture victims is the core of documentation of torture and medical involvement in torture. The national medical associations share the responsibility of ensuring that their country's doctors comply with the ethical rules and do not in any way participate in or omit to report torture.

The controlled study of torture victims. Epidemiological considerations and some future aspects

Sequelae to torture have only been described in recent years. Only few controlled and no longitudinal studies have been made. Such studies are encumbered with many difficulties. Torture victims included in documentary and scientific studies have been selected on several levels. Certain forms of exposure e.g. torture and exile, which often occur simultaneously, may cause identical clinical pictures. Thus, some of the health effects of torture may be concealed in controlled studies in which matching is very close. Small populations present a considerable risk of confounding. So far, only simple methods have been used to assess the health of torture victims quantitatively. The validity of these methods is not known. In the future, methods used for health assessment of torture victims should be evaluated. Longitudinal studies may disclose characteristics for victims with specific prognostic features and may thereby be helpful when setting priorities and choosing strategies for treatment.

Torture: a nursing concern

Survivors of torture report that their tormentors have included physicians and nurses. Such misuse of medical and nursing knowledge to engage in unconscionable acts is unethical, unprofessional and a violation of human rights. Torture and its use, ways in which health professional participate and steps taken by nursing toward its prevention are discussed.

Sleep disturbances in torture survivors

One of the main complaints in torture survivors is sleep disturbance with nightmares, too little sleep and daytime fatigue. Seven subjects, who had been exposed to torture from 6 months to seven years previously, were examined by polysomnography. All had abnormal sleep patterns compared with normal age- and sex-matched controls. The subjects woke frequently from REM sleep, had reduced REM sleep duration, absent Stage 4 sleep, short total sleep time and low sleep efficiency. This study revealed that previously healthy young persons subjected to extreme stress may develop an abnormal sleep pattern.

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

The study comprised 24 male Lebanese refugees living in Denmark. Twelve of them alleged having been tortured in Lebanon during the period 1981-85. The remaining twelve had neither been imprisoned nor tortured and thus acted as control persons. All the testimonies were found to be valid according to a method previously used by the author. The most common forms of torture were blows against the head, body and foot soles, suspension and asphyxiation. Threats and solitary confinement were frequent, and sexual violations were also reported. At the time of examination (March-November 1986), the main complaints were headaches, various cardiopulmonary symptoms, sleep disturbances with nightmares, impaired concentration and memory, and emotional lability. Suicide attempts were reported. Prior to the torture all the probands had been healthy except for several cases of gunshot wounds. The clinical examination revealed different scars possibly related to torture in nearly all the cases. Missing or fractured teeth, peripheral nerve damage and mental depression were also found. The 12 controls had several mental and physical complaints, but significantly fewer than the probands. Almost all of them had scars from gunshot wounds. The present study clearly indicates that torture plus exilation has a more deteriorating effect on the health status than exilation alone.

Rehabilitation of refugee victims of torture and trauma: principles and service provision in New South Wales

A number of recently-arrived refugees who are suffering from psychological disturbances and physical injuries that have resulted from torture or severe trauma has come to the attention of welfare workers and health personnel in New South Wales. A tentative estimate of more than 2000 refugees in New South Wales who are so affected, and clear evidence of extensive human rights abuses in the countries from which they came, indicate an urgent need for specialized care for the victims. Organized violence, including detention, torture and severe deprivation, is a tool of governments in many countries of the world. The varied forms of torture are all designed to destroy the trust, personality and self-esteem of the victims and to foster dependency, debility and dread, both in the victims and in the societies in which they live. Those persons who survive torture and detention often are affected severely in body, mind and spirit. Many victims exhibit acute and chronic symptoms that are described commonly by the diagnostic categories "post-traumatic stress disorder" and "torture syndrome". Their kin, especially spouses and children, also suffer psychological and familial disturbances frequently, as a result of the arrest, detention and torture of the victim. Their suffering is compounded by the distress of fleeing their home country and the stresses of adjusting to a new country and way of life. In Europe and North America, services have been established to treat and to rehabilitate sufferers of these disorders. Treatment programmes differ in structure and size, but include commonly psychotherapy, physiotherapy, specialized medical care and parallel assistance with resettlement and social adjustment for both the patients and their families. This article cites illustrative case material from New South Wales and summarizes the recommendations for a community-based rehabilitation service for victims both of torture and of other forms of organized violence, such as detention in "re-education" camps or the genocide in Kampuchea.

Sequelae to torture. A controlled study of torture victims living in exile

Twenty-eight Turkish refugees living in Denmark were examined by the authors in the period 1984-85. Fourteen of the persons alleged having been tortured in Turkey during the period 1980-83. The remaining 14 persons reported that they had not been tortured and thus acted as controls. All the testimonies were found valid according to a method previously used by us. The most common forms of violence reported were blows and electrical torture. Blindfolding, solitary confinement and threats were also frequent. At the time of examination the main mental complaints were sleep disturbances with nightmares and impaired memory. Emotional lability and concentration disturbances were also frequent. Physically the torture victims suffered from headache, various cardio-pulmonary and muscular pains, dyspepsia and reading disturbances. All reported that they had been healthy before torture. The clinical examination revealed only a few signs related to torture, although examples of minimal scars, fractured or missing teeth, discrete neurological disorders and mental depression were found. The 14 controls had significantly fewer complaints, and almost no abnormalities were found during the clinical examination. The present study clearly demonstrates the traumatic effects of torture.

Severe threat in the genesis of panic disorder

The hypothesis that panic disorder is a separate biological disease has attracted a great deal of controversy in recent years. One of the cornerstones of this theory is that panic attacks arise spontaneously, suggesting that the illness is generated by an autonomous physiological process. A number of cases are reported that illustrate Beck's theory that cognitive factors are central to the genesis of acute anxiety. Evidence for a developmental/cognitive theory of anxiety is discussed, and it is concluded that a purely biological model for panic disorder is inadequate.

Psychical and physical symptoms after torture. A prospective controlled study

This is the first controlled study of torture victims published. Ten persons who alleged subjection to torture were examined by two different medical teams during the first months after torture. The testimonies of the probands were found to be credible and the method of examination was found to be reliable. The state of health of the probands was inferior to that of the control persons (P less than 0.01) which reflects the effect of torture on health. The most frequent symptoms were psychological: depression, anxiety, emotional lability, reduced ability for contact, disturbed sleep, nightmares, impaired concentration and memory.