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

plus related diagnoses. While both sets of conditions include scars on the head, but absence of scars does
overlap in some aspects, and will often coincide, it not exclude significant brain injury. Brain lesions
is only the former that is a typical and traditional sometimes cannot be detected by diagnostic imaging
application of clinical neuropsychology, whereas of the brain. Mild to moderate levels of brain damage
the latter is relatively new, not well researched and might be overlooked or underestimated by mental
rather problematic. A typical neuropsychological health professionals because symptoms of depression
assessment will include a clinical interview with and PTSD are likely to figure prominently in the
the patient to determine: highest level of formal clinical picture, resulting in less attention being paid
education obtained, the presence of pre-existing to the potential effect of head trauma. Commonly, the
learning difficulties, medical and psychological subjective complaints of survivors include difficulties
history, previous head injuries, including ones from with attention, concentration and short-term memory,
childhood, and a more detailed review of the patient’s which can either be the result of brain impairment or
cognitive complaints and emotional status. Based reflect the psychological consequences of torture. Since
on the information gathered during the interview these complaints are common in survivors suffering
and from the documentation and referral questions, from PTSD or depression, the question whether they
the neuropsychologist then decides which cognitive are actually due to head injury may not even be asked.
and emotional domains need to be assessed and
may identify tests that are validated, reliable and 558. The diagnostician must rely, in an initial phase of
culturally appropriate for the person, or choose not the examination, on reported history of head trauma
to use tests but rely on a detailed clinical interview. and the course of symptomatology. Deciding when
Most neuropsychologists now use a flexible battery to refer for a neuropsychological assessment needs to
approach, in which the tests are chosen based on be done on a case-by-case basis. As is usually the case
the information gathered, systematic hypotheses with brain-injured subjects, information from third
testing and an understanding of the underlying parties, particularly relatives, may prove helpful. It
medical condition that is purportedly responsible must be remembered that brain-injured subjects often
for the cognitive and emotional difficulties. have great difficulty articulating or even appreciating
their limitations because they are, so to speak, “inside”
556. Brain injury and resulting brain damage may result the problem. In gathering first impressions regarding
from various types of head trauma and metabolic the difference between organic brain impairment and
disturbances inflicted during periods of torture or PTSD, an assessment concerning the chronicity of
ill-treatment. This may include gunshot wounds, symptoms is a helpful starting point. If symptoms
the effects of poisoning, malnutrition as a result of of poor attention, concentration and memory are
starvation or forced ingestion of harmful substances, observed to fluctuate over time and to co-vary with
the effects of hypoxia or anoxia resulting from levels of anxiety and depression, this is more likely due
asphyxiation or near drowning and, most commonly, to the phasic nature of PTSD. On the other hand, if
from blows to the head suffered during beatings. impairment seems to appear chronic, lacks fluctuation
Blows to the head are frequently inflicted during and is confirmed by family members, the possibility
periods of detention and torture. For example, in of brain impairment should be entertained, even in
one sample of torture survivors, 91 per cent reported the initial absence of a clear history of head trauma.
beating of the head. 474 The potential for resulting
brain damage is high among torture survivors. 559. Once there is a suspicion of organic brain
impairment, the first step for a mental health
557. Closed head injuries resulting in mild to moderate professional is to consider a referral to a physician
levels of long-term impairment are perhaps the most for further neurological examination. Depending
commonly assessed cause of neuropsychological on initial findings, the physician may then consult a
abnormality. The cognitive and emotional domains neurologist or order diagnostic tests. An extensive
that are typically assessed in a comprehensive medical work-up, specific neurological consultation
neuropsychological assessment are: intellect; higher and neuropsychological evaluation are among
cognitive abilities (executive functioning); attention; the possibilities to be considered. The use of
memory; visual-spatial abilities; motor and sensory neuropsychological evaluation procedures is usually
abilities; and emotional status. Signs of injury may indicated if there is a lack of gross neurological

474 Dorte Reff Olsen and others, “Prevalent pain and pain level among torture survivors: a follow up study”, Danish Medical Bulletin, vol. 53, No. 2 (2006), pp. 210–214.

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