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VI. PSYCHOLOGICAL EVIDENCE OF TORTURE AND ILL-TREATMENT ISTANBUL PROTOCOL

(c) Hyperarousal or subject to exclusion, it makes individuals want
to withdraw or hide themselves. Sexual violence
502. Hyperarousal includes: particularly brings about feelings of shame and guilt.

(a) Difficulty either falling or staying asleep; (f) Symptoms of depression

(b) Irritability or outbursts of anger; 505. The following symptoms of depression may be present:
depressed mood, anhedonia (markedly diminished
(c) Difficulty concentrating; interest or pleasure in activities), appetite disturbance
or weight loss, insomnia or hypersomnia, psychomotor
(d) Hypervigilance, exaggerated startled response. agitation or retardation, fatigue and loss of energy,
feelings of worthlessness and excessive guilt, difficulty
(d) Damaged self-concept and negative changes paying attention, concentrating or recalling from
in cognition and mood memory, thoughts of death and dying, suicidal ideation
or attempted suicide. The assessment of suicide risk is
503. For many survivors, the experience of torture marks a critical, and clinicians should keep in mind that some
profound rupture in their lives. They have a subjective persons will not readily admit such behaviour and
feeling of having been irreparably damaged and having thoughts as they may be seen as a sign of weakness and
undergone an irreversible personality change, 461 often are often stigmatized. The exploration of self-harming
believing that they will never be the same person behaviour may lead to additional disclosure of torture,
again. Overly negative beliefs and assumptions such as sexual torture, not revealed previously.
about oneself and the world – distrust, expectations
of the worst to happen, hopelessness and blame of (g) Dissociation, depersonalization
self and others for causing the trauma – frequently and atypical behaviour
characterize the relation with the environment.
Feelings of detachment from others further affect 506. Dissociation is a disruption in the integration of
relationships and can also lead to social withdrawal consciousness, self-perception, memory and actions.
and isolation. Survivors have a sense of a foreshortened Individuals may be cut off or unaware of certain
future without expectation of a career, marriage, actions and may feel detached from themselves or
children or normal lifespan. Difficulties experiencing their bodies as if observing themselves from a distance
positive feelings, such as happiness or love, and/or the (depersonalization). Derealization describes the
predominance of negative emotions (e.g. fear, horror, subjective experience of the unreality or distortion
anger, guilt and shame), as well as general emotional of the outside world or environment. Dissociative
constriction, are also common in torture survivors. phenomena can be present during traumatic events
as a result of the extreme physical and psychological
(e) Feelings of guilt and shame stress, leading to changes in perception and
information processing with a feeling of distance
504. Guilt and shame are self-conscious emotions. and detachment from the traumatic event and the
Shame is caused by an internal belief of inadequacy, accompanying emotions. Certain sensory impressions
unworthiness, dishonour or regret, which others are not registered whereas others might be perceived
may or may not be aware of. Another person, a very intensely. Peritraumatic dissociation, as well as
failure or particular circumstance may trigger shame. repression and avoidance of traumatic memories,
Guilt is a cognitive or an emotional experience may cause incomplete or fragmented memories of
that occurs when individuals believe or realize, the traumatic event and may impede a coherent
accurately or not, that they have compromised their and complete narration of it. Dissociation can
own standards of conduct or violated a universal also occur when the victim is confronted with the
moral standard and bear significant responsibility for traumatic event during the evaluation. In this case,
that violation. It is closely related to the concept of individuals frequently appear to be distant, cut
remorse. Given that feelings of guilt and shame may off from their emotions, showing indifference or
lead to conclusions that the whole self is flawed, bad other emotional states incongruent with the trauma

461 Neal R. Holtan, “How medical assessment of victims of torture relates to psychiatric care”, in Caring for Victims of Torture, James M. Jaranson and Michael K. Popkin, eds.
(Washington, D.C., American Psychiatric Press, 1998), pp. 107–113.

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