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

(a) Depressive disorders 515. DSM-5 classifies PTSD under the category of “trauma
and stress-related disorders”. In order to diagnose
513. Depressive states are extremely common among PTSD, the individual must have been directly
torture survivors. In the context of evaluating the or indirectly exposed to death, life-threatening
consequences of torture, it is problematic to assume events, serious injury or sexual violence. This
that PTSD and depressive disorder are two separate definition of trauma underlines the severity of the
disorders with clearly distinguishable aetiologies. event and marks a clear difference between other
There is a significant overlap of symptoms and stressors, for example general insecurity. Four
co-morbidity between depression and PTSD is main groups of symptoms are distinguishable:
high. Depressive disorders can manifest as a single
or recurrent episode that may vary in severity (a) Intrusive symptoms: unwanted upsetting
(mild, moderate or severe). Depressive symptoms memories, nightmares, flashbacks, emotional distress
cause significant distress or impairment in social, or physiological reactions after exposure to trauma-
occupational or other important areas of functioning. related stimuli;
Depressive disorders can be present with or without
psychotic, catatonic, melancholic or atypical features. (b) Avoidance of trauma-related stimuli: memories,
The key symptoms of depressive disorders are: thoughts, feelings and external reminders, such as
places or persons;
(a) Depressed mood (sad, irritable, empty);
(c) Negative changes in cognitions and mood: inability
(b) Markedly diminished interest or pleasure in all or to recall important aspects of the trauma, persistent
almost all activities; overly negative thoughts and assumptions about
oneself and the world, exaggerated blame of self and
(c) Weight loss/gain or decrease/increase in appetite; others for causing the trauma, negative affect (e.g.
fear, shame and guilt), loss of interest, feelings of
(d) Insomnia or hypersomnia; isolation and detachment and difficulties experiencing
positive affect;
(e) Observable slowing down of thought and reduction
of physical movement; (d) Alterations in arousal and reactivity: irritability and
angry outbursts, risky or destructive behaviour.
(f) Fatigue or reduced energy;
516. The diagnosis requires that the symptoms last for
(g) Feelings of worthlessness or excessive or at least one month and the disturbance must cause
inappropriate guilt; significant distress or impairment in important areas
of functioning. DSM-5 also describes a dissociative
(h) Diminished ability to think or concentrate or subtype of PTSD that includes additional experience
indecisiveness; of high levels of depersonalization and derealization.

(i) Recurrent thoughts of death, recurrent suicidal 517. ICD-11 distinguishes between PTSD and Complex
ideation or suicide attempt or specific plan for PTSD. Complex PTSD includes the core symptoms
committing suicide. of re-experiencing, avoidance and hyperarousal,
as well as persistent and broad disturbances of
(b) Post-traumatic stress disorder affective functioning (emotional dysregulation,
elevated emotional reactivity, aggressive outbursts,
514. The diagnosis most commonly associated with the dissociative states), perception of self (negative
psychological consequences of torture is PTSD. self-perception and feelings of shame and guilt)
The association between torture and this diagnosis and social functioning (difficulties in maintaining
has become very strong in the minds of health social relations and difficulties in feeling close
providers, judges, immigration courts and the to others). The concept of Complex PTSD is
informed lay public. This has created the mistaken able to capture complex symptomatologies that
and simplistic impression that PTSD is the main and profoundly affect the victim’s capacity to integrate
inevitable psychological consequence of torture. and function in social relationships, respond to the
requirements of daily life and lead a fulfilling life.

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