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

518. The onset of PTSD symptoms is usually within persisting symptoms of PTSD or depression are not
the first month after the experience of torture, but presented at the time of the psychological assessment,
there may also be a delay of months or years before but symptoms described for the peritraumatic or
symptoms start to appear. Symptoms of PTSD can be early post-traumatic period can, from a clinical point
chronic or fluctuate over extended periods of time. of view, be consistent with the alleged torture.
During some intervals, symptoms of hyperarousal
and irritability may dominate the clinical picture. (d) Substance use disorder
At these times, the survivor will usually also report
increased intrusive memories, nightmares and 520. Clinicians have observed that substance use disorder
flashbacks. At other times, the survivor may appear often develops secondarily in torture survivors as a
relatively asymptomatic or emotionally constricted way of suppressing traumatic memories, regulating
and withdrawn. Consistent avoidance behaviour unpleasant effects, managing anxiety and chronic pain
sometimes is not easy to detect, but can result in low or mitigating sleep disturbances (self-medication).
levels of intrusive symptoms. External stressors, the Trauma survivors often present comorbidity of PTSD
breakdown of individual coping mechanisms and and substance use disorder. 466 The findings of large
loss of social support are among the factors that epidemiological studies showed that between one third
influence the course of the disorder and possible (34 per cent) 467 and almost one half (46 per cent) 468 of
aggravation. On the other hand, social support, persons with PTSD also met the criteria for substance
individual coping strategies, ideological or religious use disorder, mostly alcohol use, and that more than
commitment, justice and official recognition of 20 per cent met the criteria for substance dependence.
responsibility may contribute to a process of recovery. In summary, there is considerable evidence from
other populations at risk of PTSD that substance
(c) Acute stress disorder use disorder is a potential co-morbid diagnosis for
torture survivors. This co-morbidity seems to be
519. Acute stress disorder (DSM-5) 465 captures post- gender-related, more often seen in men than women. 469
traumatic symptoms that may begin immediately after There is also a co-morbidity between substance use
trauma exposure but do not persist longer than one disorder and chronic pain, since torture survivors
month. It has essentially the same symptoms as PTSD often have chronic pain that is difficult to treat.
from any of the categories of intrusion, negative mood,
dissociation, avoidance and arousal, with dissociative (e) Other diagnoses
symptoms often being predominant. In contrast to
PTSD, which requires symptoms to be present for at 521. There are other diagnoses to be considered
least a month, the symptoms of acute stress disorder in addition to those described above.
disappear within the first month after trauma exposure. These include but are not limited to:
Many torture survivors who do not present PTSD at
a later stage will nevertheless report symptoms that (a) Anxiety disorders: (i) generalized anxiety disorder
amount to acute stress disorder for the first weeks after features excessive anxiety and worry about a variety
torture has taken place. Clinicians evaluating torture of different events or activities, motor tension and
survivors shortly after torture has taken place should increased autonomic activity; (ii) panic disorder is
therefore enquire explicitly about such symptoms. In manifested by recurrent and unexpected attacks
addition, when evaluating months or years after the of intense fear or discomfort, including symptoms
alleged traumatic events, the course of the symptoms such as sweating, choking, trembling, rapid heart
over time as well as eventual peritraumatic symptoms rate, dizziness, nausea, chills or hot flushes; and
and symptoms that might have occurred in the period (iii) phobias, such as social phobia, agoraphobia or
right after torture should be asked about. Sometimes claustrophobia;

465 In ICD-11, the category of “acute stress disorder” was modified into “acute stress reaction”. It is not a diagnostic category anymore, but a non-pathologic reaction in which
symptoms emerge after the trauma in some hours or days and fade within a week.
466 Jenna L. McCauley and others, “Posttraumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment”, Clinical Psychology: Science
and Practice, vol. 19, No. 3 (2012), pp. 283–304.
467 Katherine L. Mills and others, “Trauma, PTSD, and substance use disorders: findings from the Australian National Survey of Mental Health and Well-Being”, American Journal
of Psychiatry, vol. 163, No. 4 (2006), pp. 652–658.
468 Robert H. Pietrzak and others, “Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from Wave 2 of the National
Epidemiologic Survey on Alcohol and Related Conditions”, Journal of Anxiety Disorders, vol. 25, No. 3 (2011), pp. 456–465.
469 Marianne Kastrup and Libby Arcel, “Gender specific treatment of refugees with PTSD”, in Broken Spirits: the Treatment of Traumatized Asylum Seekers, Refugees and War
and Torture Victims, John P. Wilson and Boris Drozdek, eds. (New York, Routledge, 2005), pp. 547–571.

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