The main psychological sequelae of torture are PTSD, depression, anxiety disorders, and chronic pain syndromes. Of torture survivors seeking treatment, 50% to 67% have PTSD, 33% have depression, 10% have generalized anxiety disorders, and another 10% have other psychiatric diagnoses.32,33 Forty percent to 70% of torture survivors have chronic pain or somatoform disorders,7,22,31,34 making it critical that physicians screen for a history of torture with any refugee presenting with recurrent, complex, or unexplained pain.
Many tortured refugees have experienced multiple traumas, including political terror, war, and dislocation. A complex meta-analysis involving 82,000 refugees found that torture is especially correlated with PTSD, whereas stressors such as exposure to conflict and displacement were more strongly associated with depression.35,36
Researchers have not found correlations between the types, severity, or duration of torture (including physical vs psychological techniques) and the severity of post-torture PTSD or depression.7,37 Head trauma received during torture may lead to frontal and temporal cortical thinning that is highly associated with post-torture depression.38 Rape during torture is associated with high levels of chronic distress and sexual dysfunction.30,39,40 Psychological resilience may be somewhat more robust in individuals who expected to be tortured.21
The social situation of resettled refugees affects the severity of psychiatric distress in torture survivors. Two large studies found that refugees were more distressed if they were institutionalized (in camps or compounds as opposed to homes), feared repatriation, were underemployed, or lacked economic opportunities in their new homeland.35,41 Persistent pain or physical disability related to tissue damage or a superimposed somatoform disorder correlates strongly with persistent psychiatric morbidity.42 Although the intensity of PTSD decreases over years, the core symptom complex often endures and may be disabling.32,37,43
How to connect patients with resources
The International Rehabilitation Council for Torture Victims (www.IRCT.org) and the Center for Victims of Torture (www.CVT.org) offer links to many torture survivor treatment programs. Other torture treatment centers can be found with Web searches or through international clinics or community organizations serving specific ethnic groups. Treatment programs help clients—many of whom are uninsured and, as non-US nationals, ineligible for public entitlement programs—navigate barriers to getting help. Treatment centers must address language barriers between therapists and clients. One caution: In small ethnic communities, translators may know clients and thereby raise fears of lack
of confidentiality. Treatment options. Standard interventions recommended for torture survivors include physical therapy and cognitive behavioral therapy, especially for flashbacks and disabling social avoidance behaviors that are part of PTSD.7 Narrative exposure therapy, a brief psychotherapy in which the patient repeatedly retells and re-experiences painful events, shows promise.44,45 Psychological care for depression and anxiety, interdisciplinary pain desensitization, psychosocial supports, and assistance with asylum petitions are also important. The lack of validated torture survivor treatments reflects a paucity of research on this issue. It does not mean that standard effective therapies for PTSD or depression are ineffective.32,46 It is reasonable to assume that inadequate treatment of PTSD, depression, and pain disorders magnifies and prolongs the personal, familial, and social cost of torture sequelae.
Following through on medical documentation. About 41,000 people, nearly all from countries where torture is common, sought asylum from persecution in the United States in 2011.47 The United States grants asylum if an otherwise eligible immigrant can establish a “significant possibility” of future persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.48 This is a government determination, not a medical certification. A study of 2400 asylum seekers found that 90% who had medical documentation of past torture were granted asylum, compared with just 37% of those lacking such medical support.49
CORRESPONDENCE Steven H. Miles, MD, Center for Bioethics, N504 Boynton, 410 Church Street SE, Minneapolis, MN 55455; Miles001@umn.edu