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

(f) Recurrence of psychotic disorders or mood disorders procedures, a diagnosis might have to be based on
with psychotic features among those who have a a clinical symptom profile and neuropsychological
history of mental illness. Individuals with a past history assessment and testing may be the only reliable way
of bipolar disorder, recurrent major depression with of documenting the effects. Frequently, the target
psychotic features, schizophrenia and schizoaffective symptoms for such assessments have significant
disorder may experience an episode of that disorder as overlap with the symptomatology arising from
a result of the extreme stress of torture. PTSD and depressive disorder described above.
Therefore, specialized skills in neuropsychological
(k) Substance misuse assessment and awareness of problems in cross-cultural
validation of neuropsychological instruments are
510. Alcohol and drug misuse, including misuse of necessary when such distinctions and diagnostics
prescription medicine (e.g. sedatives, hypnotics are of relevance (see paras. 550–565 below).
and analgesics), often develop secondarily
in torture survivors as a way of obliterating 3. Diagnostic classifications
traumatic memories, regulating affect and
managing anxiety, pain and sleeping problems. 512. While the chief complaints and most prominent
findings among torture survivors are very diverse
(l) Neuropsychological and neurocognitive and relate to their unique life experiences, coping
impairment mechanisms and the cultural, social and political
context in which they live, it is wise for evaluators
511. Extensive alterations in cognitive processes may be to become familiar with the most commonly
found in persons who have been exposed to dramatic diagnosed disorders among trauma and torture
or ongoing exposure to life-threatening situations, survivors. Also, it is more common than not for
such as torture, and who develop PTSD. They are more than one mental disorder to be present, as
not necessarily related to brain injuries and may there is considerable co-morbidity among trauma-
also be found in persons who have been forced to related mental disorders. Various manifestations of
witness violence perpetrated against others. They depression, anxiety and trauma-related syndromes
may include changes in memory functions, attention, are the most common consequences resulting from
information processing, planning and problem torture. The two most widely accepted classification
solving. Methods of torture, such as isolation or sleep systems are the International Statistical Classification
and sensory deprivation, are also known to cause of Diseases and Related Health Problems (ICD),
severe cognitive impairment, including in the areas of produced by the World Health Organization, 463 and
memory, learning, logical reasoning, complex verbal the Diagnostic and Statistical Manual of Mental
processing and decision-making. 462 On the other Disorders (DSM), 464 produced by the American
hand, torture can cause physical trauma that leads Psychiatric Association. The current versions of ICD
to various levels of brain impairment. Blows to the and DSM are broadly compatible, but significant
head, suffocation and prolonged malnutrition may differences remain, which may result in differing
have long-term neurological and neuropsychological diagnoses. Both manuals are revised periodically and
consequences that may not be readily assessed during new editions reflect new research data and conceptual
the course of a medical examination. Diagnosis of developments. This review will focus on the most
blunt traumatic brain injury is especially challenging common trauma-related diagnoses: depression and
and even a correctly performed MRI of the brain PTSD. For complete descriptions of diagnostic
might yield negative results. Symptoms of blunt categories, the reader should refer to ICD-10/11 and
traumatic brain injury include headaches, confusion DSM-5, which are the latest editions currently in use.
or disorientation, concentration or memory problems,
irritability, emotional instability and disturbed sleep.
As in all cases of brain impairment that cannot be
documented through head imaging or other medical

462 Physicians for Human Rights, Break Them Down: Systematic Use of Psychological Torture by US Forces, (Cambridge, Massachusetts, 2005).
463 ICD-11 was adopted by the World Health Assembly in May 2019 and came into effect on 1 January 2022. Clinicians should always refer to the latest edition currently in use
in the specific region. See www.who.int/classifications/classification-of-diseases.
464 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. (Washington, D.C., 2013).

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