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

disturbance, reported symptoms are predominantly Furthermore, PTSD does not conform to the classical
cognitive in nature or a differential diagnosis between paradigm of an analysis of identifiable brain lesions
brain impairment and PTSD has to be made. that can be confirmed by medical techniques. With
an increased emphasis on and understanding of
560. The selection of neuropsychological tests and the biological mechanisms involved in psychiatric
procedures is subject to the limitations specified above disorders generally, neuropsychological paradigms
and, therefore, cannot follow a standard battery have been invoked more frequently than in the
format, but rather must be case specific and sensitive past. However, the findings so far are diverse and
to individual characteristics. The flexibility required thus not applicable for diagnostic purposes.
in the selection of tests and procedures demands
considerable experience, knowledge and caution on 563. There is great variability among the samples used
the part of the examiner. As has been pointed out for the study of neuropsychological measures in
above, the range of instruments to be used will often post-traumatic stress. This may account for the
be limited to non-verbal tasks, and the psychometric variability of the cognitive problems reported from
characteristics of any standardized tests will most likely these studies. It was pointed out that “clinical
suffer when population-based norms do not apply to observations suggest that PTSD symptoms show the
an individual subject. An absence of verbal measures most overlap with the neurocognitive domains of
represents a very serious limitation. Many areas of attention, memory and executive functioning”. 476 This
cognitive functioning are mediated through language is consistent with complaints heard frequently from
and systematic comparisons between various verbal torture survivors. Subjects describing difficulties in
and non-verbal measures are typically used in order to concentrating and feeling unable to retain information
arrive at conclusions regarding the nature of deficits. and engage in planned, goal-directed activity.

561. The choice of instruments and procedures in 564. Neuropsychological assessment methods appear
neuropsychological assessments of alleged torture able to identify the presence of neurocognitive
victims must be left to the individual clinician, who will deficits in PTSD, even though the specificity of these
have to select them in accordance with the demands deficits is more difficult to establish. Some studies
and possibilities of the situation. Neuropsychological have documented the presence of deficits in PTSD
tests cannot be used properly without extensive subjects when compared with normal controls
training and knowledge in brain-behaviour but they have failed to discriminate these subjects
relations. Comprehensive lists of neuropsychological from matched psychiatric controls. 477 In other
procedures and tests and their proper application words, it is likely that neurocognitive deficits on
can be found in standard references. 475 test performances will be evident in cases of PTSD,
but insufficient for diagnosing it. As in many other
(c) Post-traumatic stress disorder types of assessment, the interpretation of test results
must be integrated into a larger context of interview
562. The considerations offered above should make it information. In that sense, specific neuropsychological
clear that great caution is needed when attempting assessment methods can make a contribution to
neuropsychological assessment of brain impairment the documentation of PTSD in the same manner
in alleged torture victims. This must be even more that they do for other psychiatric disorders
strongly the case in attempting to document PTSD associated with known neurocognitive deficits.
in alleged victims through neuropsychological
assessment. Even in the case of assessing PTSD subjects 565. Despite significant limitations, neuropsychological
for whom population-based norms are available, assessment may be useful in evaluating individuals
there are considerable difficulties to consider. PTSD suspected of having brain injury and in distinguishing
is a psychiatric disorder and traditionally has not brain injury from PTSD. Neuropsychological
been the focus of neuropsychological assessment. assessment may also be used to evaluate specific

475 Esther Strauss, Elisabeth M.S. Sherman and Otfried Spreen, A Compendium of Neuropsychological Tests: Administration, Norms and Commentary, 3rd ed. (New York,
Oxford University Press, 2006).
476 Jeffrey A. Knight, “Neuropsychological assessment in posttraumatic stress disorder”, in Assessing Psychological Trauma and PTSD, John P. Wilson and Terence M. Keane, eds.
(New York, Guilford Press, 1997), pp. 448–492.
477 John E. Dalton, Sanford L. Pederson and Joseph J. Ryan, “Effects of post-traumatic stress disorder on neuropsychological test performance”, International Journal of Clinical
Neuropsychology, vol. 11, No. 3 (1989), pp. 121–124; and Tzvi Gil and others, “Cognitive functioning in post-traumatic stress disorder”, Journal of Traumatic Stress, vol. 3,
No. 1 (1990), pp. 29–45.

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