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Chapter 8
The Psychiatric Care of Survivors of Torture, Refugee Trauma, and
Other Human Rights Abuses - Summary
Introduction – General Psychiatric Issues * Variability in Symptomatology among Survivors * Pre-Morbid Conditions * Co-Morbid Conditions * Posttraumatic Conditions * PTSD: Normative or Pathological Response? Psychiatric Evaluation and Diagnosis Psychiatric Treatment - Psychopharmacology * Biological Models * Medication: Anxiolytics/hypnotics Antidepressants Antipsychotics Mood stabilizers Pain medications Psycho stimulants Cognition improving medication Adrenergic blocking agents * Psychopharmacology and the Meaning of Medication * Hospitalization Summary The Psychiatric Care of Survivors of Torture, Refugee Trauma, and
Other Human Rights Abuses
Introduction – General Psychiatric Issues Psychiatry has an important role in the identification, evaluation and treatment of the consequences of torture and refugee trauma. Torture has been practiced around the world, throughout history. The penetration of torture into the modern and current human experience has gained more focused attention in recent time owing to: increased number of people re- located as a result of government repression and wars, amplified media coverage of conflict and events of torture, resurgence of terrorist group violence, and the ever-present debate regarding whether torture is ever Survivors of torture and refugee trauma are a diverse group of men, women and children who have undergone and or witnessed human rights abuses for a long list of reasons, including: their gender, race, religion, political affiliation, social connection and/or sexual orientation. Many of the survivors suffer forced re-location in hostile and unfamiliar environments. They are frequently separated from their family, community, and culture. Survivors of torture and refugee trauma may concentrate in large urban centers where anonymity may be a protective factor in their arduous situation. This anonymity may also result in profound isolation. The context in which these survivors access health care is important. Increased awareness among health care providers of the prevalence of torture and life altering experiences among immigrants and refugee populations is of extreme importance, given the growing number of survivors of torture and refugee trauma. Implementing identification and screening methods, and reaching out to the communities most affected by such trauma, are necessary steps to improve access to care. The psychiatric involvement with survivors of torture and refugee trauma encompasses areas of immigrant health, refugee/war trauma, cross-cultural psychiatry, consultation-liaison psychiatry and psychosomatic medicine. Clinical studies have established that the mental health consequences of torture are usually more persistent and protracted than the physical aftereffects, even though there is frequently significant overlap between the physical and psychiatric sequelae (Engdahl & Eberly,1990; Keller & Gold, 2005). Physical consequences of torture are visible, such as scars, burns and amputations as opposed to the emotional/psychological scars that are not as evident on exam (see Chapter 7). These psychological scars are much harder The emotional experience of torture is a very subjective life altering experience. For some types of torture, such as rape, head trauma, malnutrition (and many others), it is difficult to determine whether the origin of the presenting symptoms is physical, psychological, or a result of co- morbid medical and/or psychiatric conditions. The occurrence of co-morbid medical and psychiatric conditions compels collaboration with primary care providers and medical specialists. Availability of resources plays an integral role in access to care, the evaluation process and the choice of treatment modalities provided. In addition, multiple biological models attempt to provide an understanding of the variety of reactions to traumatic experiences that survivors may manifest. The integration and interpretations of these biological models may suggest a framework for the most effective interventions for particular symptomatic The Bellevue/NYU Program for Survivors of Torture (PSOT) evolved from a strong collaboration between primary care medicine, behavioral health psychology and consultation liaison psychiatry/psychosomatic medicine. This integration has increased the range of available interventions, and enabled the program to offer a wide range of multi-disciplinary treatment options. This is a collaborative model in which mental health, medical and social services combine forces to construct a new arena in which to provide care. In our program, patients are treated on site by multidisciplinary clinicians working in the biopsychosocial model. In such a collaborative style, the treatment plan is tailored to the specific needs of each Variability in Symptomatology among Survivors Survivors of torture and refugee trauma often present with symptoms of posttraumatic stress disorder (PTSD), but clinical experience shows that their presentation is more varied and complex. Although most studies focus on PTSD, neuropsychiatric symptoms are often difficult to diagnose because of the presence of co-morbid conditions and ongoing stressors (Briere & Scott, 2006). Data from studies in treated and untreated populations, in countries of resettlement, refugee camps, and countries of origin, indicate that PTSD and depression are the most common diagnoses (Kinzie, Leung, & Boehnlein, 1997). Furthermore, clinical studies have shown that depression is the most common psychiatric disorder diagnosed in survivors of torture and refugee trauma (Kinzie, Leung, & Boehnlein, 1997; Mollica, Suicide is more closely correlated with major depression than with any other psychiatric diagnosis (McGirr et al., 2007). Suicidality also manifests itself among tension reduction behaviors some trauma survivors may use to reduce the abuse-related stress (Briere, 1996; Briere & Scott, 2006; Zlotnick, Donaldson, Spirito, & Pearlstein, 1997). As such, clinicians must be mindful of suicidal risk when treating a client with significant Suicidal ideation and suicide attempts are significantly higher among women who have been victims of assaults (Koss & Kilpatrick, 2001). Ferrada–Noli et al. (1998) studied 65 refugees with PTSD and suicidal behavior (defined as suicidal ideation, plan, or attempt), and found that the choice of method in attempting suicide was related to the trauma they had experienced. A history of blunt force to the head and body was associated with jumping from dangerous heights; water torture was associated with attempted drowning; and sharp force was associated with self-inflicted stabbing or cutting (Ferrada-Noli et al., 1998). There is a need to review and understand a client’s current presentation of symptoms in the context of the client’s individual life. The possibility of the existence of pre-morbid conditions, developmental/environmental issues, co-morbid issues, and general life exposure, are essential in the formulation of the diagnosis and treatment. Our experience has been that the majority of the patients suffered from the sequelae of their traumatic experience with no obvious pre-morbid conditions. However, the patients that were identified as having pre-morbid conditions benefited from treatment that addressed the pre-morbid conditions simultaneously. Constant re-evaluation of symptoms and response to treatment should be monitored to avoid under treatment or continued treatment when patients are stable and no longer in need of Epidemiological studies of “high risk” individuals (i.e. those exposed to traumatic events) have revealed varying rates of PTSD occurrence. Estimates of PTSD prevalence among those exposed to traumatizing stressors (as defined by Criterion A in DSM IV-TR [APA, 2000]) range from 3% to 58% (Yehuda & McFarlane, 1995). Careful examination of these rates reveals differing percentages depending on types and severity of Studies have shown low prevalence rates reported for populations exposed to natural disasters, and varying but much higher rates for populations exposed to what can be described as “man-made” traumas such as war and crime. Specifically, the lifetime prevalence of PTSD among crime victims has been shown to be anywhere from 19% to 75% (Kilpatrick & Resnick, 1993). Persistent PTSD among prisoners of war and concentration camp survivors has been estimated to occur in 47%-50% (Kluznick et al. 1986; Yehuda & McFarlane, 1995). A study conducted by the Bellevue/NYU Program for Survivors of Torture (Keller et al., 2006) which represents one of the largest systematic analyses of an ethnically diverse sample of torture survivors, found high levels of psychological distress as measured by standardized symptom rating scales. Roughly half of all patients (46%) fell above the cutoff for identifying clinically significant PTSD, while more than 80% fell above this threshold on measures of depression and anxiety. These levels of distress are particularly striking given that most participants had immigrated to the United States months or years earlier, suggesting that the traumatic experiences described by this sample had lasting and profound effects on The prevalence of PTSD following a variety of traumatic events can thus be summarized in the following way: the rates vary, depending in part on type and severity of traumatic stressor, but cannot be explained solely in relation to the traumatic experience. For example, the prevalence of PTSD is relatively high given stressors such as war and concentration camp experiences, but there are a significant percentage of people exposed to these stressors who do not develop the clinically significant threshold of symptoms for a diagnosis of PTSD. This finding, that trauma itself does not always lead to the development of full or persistent PTSD suggests that additional variables play a role in the development of this cluster of It has become evident over time that a diagnosis of PTSD alone is insufficient to describe the magnitude and the complexity of the effects of torture. PTSD was never intended to encompass the entire range of sequelae following torture, which is severe and usually repetitive in nature (Friedman & Jaranson, 1994). However, the diagnosis and symptom descriptions do provide clinicians with the opportunity to share common knowledge base and terminology from which they can begin formulating treatment interventions (Briere & Scott, 2006). Various contributing factors have been investigated to explain what is thought to be an underlying emotional vulnerability to the development of pathological reactions to traumatic events. These have included: genetic factors, family history, previous exposure to trauma (see the discussion of ‘kindling’ below), personality structure, developmental history, and other A flamboyant male dancer from the former Soviet Union was arrested and beaten by the police in his former country multiple times, following what was perceived by the local authorities to be socially unacceptable, provocative behavior in public places. At the time he presented for treatment at our program, he suffered from several symptoms of PTSD such as flashbacks, difficulty sleeping, and hyper-vigilance. After careful evaluation, a more prominent psychiatric diagnosis of Bipolar Disorder was formulated. The symptoms of Bipolar Disorder were thought to be most likely pre- morbid and persisted with the co-morbid symptoms of PTSD reported at the time of the evaluation. This better understanding of the patient’s psychopathology allowed more focused remedy with Mood Stabilizer medication (Depakote) resulting in better outcome of treatment of the target symptoms and improved longitudinal adherence to therapy. The psycho-pharmacological treatment enabled the patient to participate in a meaningful form of psychotherapy ultimately achieving better control of symptoms, better adjustment to the new life circumstances and successful relief from his long-standing suffering. The concept of ‘kindling’ has been described in the literature, and is a useful model for understanding some of the points discussed above (McFarlane, 1996). On the basis of clinical experience with affective disorders, it has been learned that life events play a significant role in first episodes of affective disease, but their importance decreases as the neurobiology of the disorder takes on a life of its own and becomes relatively autonomous of instigating events. This understanding is the basis According to this model, there is a “biological memory” of initial episodes of an illness, and later episodes or phases of affective disorder are a consequence of the progressive, now neuro-biologically based vulnerability. Thus, further affective disorder results from heightened sensitivity to affective destabilization, which now requires only mild instigating events or stimuli to develop (Breslau, Chilcoat, Kessler, & Davis, 1999; McFarlane, 1996). As applied to PTSD, this model is used to explain the observation of a modification in the stress responsiveness of individuals previously exposed to trauma. Such a modification is viewed as an important factor in the individual’s vulnerability to symptomatic exacerbation in the face of even relatively mild stressors that, in and of themselves, are not traumatic. The kindling model suggests that anti-kindling agents (i.e., anti- epileptics), in addition to having some therapeutic value, may also have preventative value. The stress and cortisol-induced neurotoxicity model of PTSD (Hypothalamic-pituitary-Adrenal Axis) suggests that medications that have been found to block stress-induced hippocampal damage, including anti-epileptic and SSRIs and possibly anti-cortisol drugs, may also be useful Psychiatric co-morbidity has been reported in 50% to 90% of individuals with chronic PTSD (Yehuda & McFarlane, 1995). In terms of co-morbid conditions, PTSD and depression commonly occur among survivors of torture and refugee trauma. For example, rates of co-morbid depression and PTSD in refugees have ranged from 21% to 40% (Mollica et al., 1999; Momartin, Silove, Manicavasagar, & Steel, 2004). In addition to depression, a common co-morbid diagnosis in individuals suffering from PTSD is alcohol and substance abuse. Research has shown that people with PTSD are four times more likely to abuse alcohol and drugs than those without PTSD, regardless of their trauma histories (Chilcoat & Breslau, 1998). This suggests that there is a secondary psychopathological process that unfolds following the onset of PTSD, perhaps as a result of individuals’ efforts to self-medicate (Briere & Scott, 2006). It is also possible that substance abuse disorders may have existed prior to the development of PTSD. In such cases, substance abuse may be related to predisposing factors, such as previous trauma, or other personality A 35 year old Tibetan patient was tortured for his activism and forced to flee leaving his wife and two small children behind. In New York City he managed to find some employment in construction and lived with a number of roommates in a very small and overcrowded environment. He had such severe symptoms of depression and anxiety that he was self-medicating by abusing alcohol, “drinking myself to sleep.” The recurrent and intrusive recollection of his torture, his sleep disturbance, and his separation from his family were overwhelming for him, affecting his ability to function, support himself, and foresee and plan for a better future. Hopelessness and helplessness were dominant symptoms that influenced his ability to work with his attorney representing his case in immigration court for his application for political asylum. This patient was started on a Benzodiazepine, Clonazepam 0.5 mg PO at bed time and Mirtazapine 15 mg PO at bed time. He was seen and given prescriptions as frequently as possible but at least every two weeks and he continued to participate in psychotherapy. The medication had to be regulated, increasing Mirtazapine to 30 mg at bed time, and slowly tapering the Benzodiazepine’s frequency until it was discontinued. After about 8-10 weeks of treatment this patient was able to sleep better and was able to stop drinking. His functioning had improved, he was granted political asylum, and he was working on bringing his family to join him in America. The challenges in the treatment of this patient were many:  The intensity of the symptoms was paralyzing for him and required acute intervention with the expectation of quick relief.  The co-morbid concurrent alcohol abuse needed to be addressed. The prescribing of psychotropic medication to patients who are also actively abusing alcohol is, at least, controversial.  The patient was so trapped in feeling guilty and thinking that he deserved to suffer, that the notion of feeling well was contrary to  The alternative to out-patient treatment may have led to an involuntary psychiatric hospitalization for a patient currently re- experiencing the trauma of forced imprisonment and torture.  The safety and management of psychotropic medications including monitoring compliance for an out-patient who works in a A number of studies have noted the effectiveness of psychopharmacological treatment with people suffering from PTSD and other co-morbid conditions. More detailed discussion of these treatments will be covered later in this chapter, in the section on Psychiatric Treatment Posttraumatic conditions, such as the presence or absence of social supports, and exposure to subsequent reactivating events or reminders of the trauma, have also been considered to affect the experience of survivors of A study of populations exposed to traumas in Turkey revealed that those who remained in their familiar environment fared better than those who immigrated following the events (Basoglu, 1993). This suggests the importance of considering other contributing factors related to the re- location experience itself. Separation from the family is an important contributing factor, particularly in cultures that place a great deal of importance on the family and emphasize each member’s interdependence on the family for material and emotional support. PTSD: Normative or Pathological Response? It is important to regularly revert to the debate as to whether the presence of PTSD is a “normal reaction to abnormal circumstances” (see Chapter 1). There are practical as well as conceptual pitfalls of using the PTSD diagnosis too globally or loosely to capture the often variegated The PTSD diagnosis falls under the rubric of anxiety disorders, and therefore a diagnosis of PTSD indicates, or dictates, a treatment targeting symptoms of anxiety. However a significant number of patients present with a broader array of symptoms than such a specific diagnosis of an anxiety disorder can fully explain. When symptoms of depression, psychosis, dementia, or mood instability secondary to trauma are more salient, or when patients suffer from profound feelings of loss, sadness and demoralization, not currently captured in the DSM IV-TR formulation of PTSD, there is a need to formulate a more comprehensive understanding and tailor treatment to address all the pertinent clinical issues. Review of the literature provides a reasonable framework that the "emergence of PTSD following exposure to a trauma may represent the manifestation of an underlying diathesis rather than a normative adaptation to environmental challenge” (Yehuda & McFarlane, 1995, p. 1709). Such a statement is important to consider, but must be placed within a context that is extremely complex, and differentiates among types and severity of Recall that populations that suffer “man-made” traumas have higher prevalence rates of PTSD, in general, than those exposed to natural disasters (Yehuda & McFarlane, 1995). On the basis of clinical experience, it is worth considering that people who are exposed to malevolent, intentionally harmful perpetrators must contend with a psychological embodiment that is different from the one found in the aftermath of acts of nature (or “acts of God” as some people view them) that do not undermine the capacity to trust and rely upon other people (Laub & Auerhahn, 1993). In the event of terrorism, for example, people often struggle to comprehend the meaning of the act. Questions are raised regarding the relationship between the perpetrators and the victims. For example, survivors may ask “Why do they hate us?” – reflecting a need to make sense of the disparity in values between the two groups, which are assumed to belong to the same world community with its usually shared core values regarding human life. As such, perceptions of the nature, the severity, and the intent of the violence will affect how individuals experience and react to Additionally, underlying diatheses and tolerance levels vary from individual to individual. It is critically important to recognize the contribution of development and personality, not only to the emergence of PTSD, but also to the way PTSD symptoms are experienced and how survivors may react to them. There is also mounting evidence that variations in symptomatology are associated with neuro-biological factors. This topic will be explored further later in this chapter. Clearly, there are significant areas of inquiry (including: the nature, extent and purpose of the violence; an individual’s pre-existing neuro- anatomical, executive, emotional, and hormonal functioning; and an individual’s previous trauma history) that will affect one’s reactions to traumatic events in very individualized and subjective ways. How ought such an understanding shape the approach to the evaluation, diagnosis and treatment of our patients? How ought this wide-ranging understanding shape our approach to training? How ought we to "label" those patients whose suffering, while profound, does not precisely fit the PTSD diagnosis as it is currently defined? Are we too limited by current criteria? Are we affected -- by our counter-transference and the accepted diagnostic categories as they currently exist -- to utilize PTSD as the insufficient but only sanctioned and thus effective tool for mobilizing resources? These questions bring up to date the foundation of the efforts to provide comprehensive, uniquely-tailored care to our diverse patient population. In our program, the focus has been on treatment of symptoms - not diagnoses. This practice is put forth as an undertaking to avoid the extremes of over-generalizing treatment with a “catch-all diagnosis,” and /or not providing adequate services when an individual does not meet full Perhaps the introduction of a more detailed presentation of aspects of the approach to evaluation and treatment can be illustrated with some A 34 year old woman from Mauritania survivor of FGM (Female Genital Mutilation) came to New York from Ohio where she had been living with a husband that she married after her arrival in the US about 3 years earlier. She came to the program asking for help and assistance with her pending political asylum case, family re- unification (her 5 year old daughter had been left back in Mauritania), and her inability to keep up with her computer course (she had registered for the course to learn a marketable skill to support herself). At the time she was earning some money by braiding hair, wandering from home to home of her clients, staying for few days and moving constantly. She reported that she had left her home and her husband in Ohio due to being mistreated. She did not want to During the psychiatric evaluation it became apparent that her thinking was highly disorganized. Her reporting of past events was vague, inconsistent, and at times, incoherent. Her mood was labile, laughing and crying with minimal stimuli, and being unable to describe her thoughts articulately. She engaged in treatment with a plan to participate in individual and group psychotherapy. Her attendance of group sessions was minimal due to her feeling of shame and discomfort in sharing her experience with other people. Her ability to engage in psychotherapy was also impaired due to her inability to adhere to a schedule and to a methodical exploration of her emotional experience. At that point her treatment was enhanced with the addition of a Sertraline 50 mg daily and low dose neuroleptic, Risperidone 0.5 mg at bed time. The target symptoms of this medication regimen were the disorganized thinking, mood lability, anxiety and insomnia. It was a challenge to get an accurate sense of her adherence/ compliance with the medication but she kept coming back for appointments requesting renewal of prescriptions. The treatment with medication continued over few months and her ability to participate in treatment increased. At the same time she was able to advance her immigration case and brought her daughter to the US to avoid her exposure to FGM. Currently, the patient is on Sertraline 200 mg daily and her overall functioning has much A young Bosnian woman who had been raped by a Serbian official presented for treatment. She was one of an estimated 50,000 women raped as part of the ethnic violence in the former Yugoslavia. The patient was kept in detention camp throughout the pregnancy to prevent any plan of termination/abortion. As a result she carried the baby to term and then gave it up for adoption. The patient was being treated with psychotherapy and psychopharmacology for symptoms of Depression and PTSD. She was on Sertraline 100 mg daily and During the course of psychotherapy, the patient’s therapist became pregnant. Issues regarding pregnancy were discussed within the therapeutic dyad, and the patient eventually became pregnant, as she and her husband had initially planned. Once pregnant, the medications had to be stopped with the understanding that the patient needed to remain medication-free for the duration of the pregnancy. During the pregnancy the patient suffered re-occurrence of symptoms that had already responded to treatment with medications. These symptoms included: irritability, nightmares, flashbacks, and reliving the experience of the traumatic rape and the symptoms of the She was treated with intensive psychotherapy throughout the pregnancy and was restarted on anxiolytic and anti- depressant medications soon after giving birth. She made the decision not to breastfeed so she could be started on medication immediately post partum. Psychotropic medications are not recommended during Psychiatric services at the Bellevue/NYU Program for Survivors of Torture generally follow the framework and model of a Consultation-Liaison Psychiatry service. Psychiatrists and psychiatry residents are often referred patients for evaluation from other clinicians for more specific diagnostic evaluation and for targeted psycho-pharmacological interventions. The clinicians in other disciplines, most frequently staff psychologists and psychology trainees such as psychology interns and psychology externs, are assigned to evaluate and treat patients within the program. They work closely with the psychiatrists in a team approach with bi-directional referrals. In this way clinicians progressively familiarize themselves with other treatment modalities, increase their level of comfort in integrating these modalities in treatment, and enhance the effectiveness of the Patients are seen for an initial intake appointment and go through a screening interview, which includes a mental status examination and two psychological measures (see Chapter 5). Those patients who score high on anxiety and trauma symptoms scales and/or report symptoms suggestive of significant distress and difficulty coping are referred for more focused evaluation. Most of the initial referrals for mental health treatment are referred to psychologists for individual and/or group therapy. Alarming symptoms such as suicidal ideation, with or without a specific plan, extreme despair or high anxiety, will trigger an immediate, high priority referral for further psychological and psychiatric evaluation. After the initial evaluation and a decision that the patient would be able to benefit from the comprehensive services provided by the program, the patient is generally referred to an orientation group. The purposes of the orientation group are to provide psychoeducation regarding common symptoms and reactions among survivors of torture and refugee trauma, to provide some training on relaxation and deep breathing techniques, to inform patients of the resources and services available to them (in the hospital and the community), and to empower them to proactively access The initial clinical presentation may be affected by such factors as: problems in communication, language, and clients under-reporting or over- reporting of symptoms on the questionnaires. Clients may not be familiar with the existence of symptoms as such, and may have difficulties conceptualizing or verbalizing them with transparency. Many emotional symptoms are described and manifested differently from culture to culture. Consequently, subtle somatic complaints linked to emotional distress require active solicitation with cross cultural sensitivity and competence. Primary care physicians and/or psychologists participate in ongoing dialogues with their psychiatric colleagues to further explore such Given this interdisciplinary functioning within our program, the psychiatric evaluation functions in a narrower context than it might with a different population; or even within a different program treating a similar population in a different programmatic system. In our program, the psychiatric evaluation captures a “snap-shot” in time of a client’s functioning. The evaluation is symptom focused, and it is structured to provide a guide on how to best provide treatment geared toward symptom With a general outpatient population, the psychiatric evaluation would also explore and pay meticulous attention to a client’s life history, and the emotional meaning they attach to the salient life events. But since the evaluating psychiatrist is receiving the referral through the “filters” of other clinicians that are already working on some of the somatic symptoms and psychodynamic formulations, we tend to focus more strictly on identification and alleviation of current psychiatric symptoms. Fears, sadness, insomnia and other somatic complaints have been common complaints. When there is a history of traumatic brain injury, special attention is paid to issues of memory impairment, difficulties with concentration, and other symptoms of impaired cognition. As such, symptoms are elicited and referrals are made for neuro-psychiatric and neurological examinations. As a member of an evaluating team of clinicians, the evaluating psychiatrist is compelled to offer the patient a more targeted The multi-tiered, programmatic evaluation assesses dimensions of the patient’s experience and presentation, in order to collect an inclusive synopsis. Such an outline is captured by the DSM-IV TR multi-axial system (APA, 2000), which covers the following: Clinical Disorders, Personality Disorders and Mental Retardation, General Medical Conditions, Psychosocial and Environmental Problems, and Global Assessment of Functioning (GAF). Once such a summary is produced, a working diagnosis is formulated and a treatment plan is tailored to the patient’s specific needs Some patients clearly meet diagnostic criteria for Posttraumatic Stress Disorder (PTSD), without significant clusters of symptoms that would be sufficient to warrant an additional diagnosis. To warrant such a diagnosis, a client must be exposed to traumatic circumstances in which his or her physical or emotional integrity is threatened, and have significant positive symptoms along three axes: symptoms of intrusion, symptoms of avoidance and withdrawal, and symptoms of hypervigilance. However, survivors of torture and refugee trauma frequently present with a history of multiple traumatic experiences and describe painful feelings of loss or alienation that while difficult, do not fit any psychiatric category suggesting psychopathology captured by a diagnosis of PTSD (Briere & Scott, 2006). We re-emphasize the point that our program clinicians identify and treat symptoms, not diagnoses. Patients suffering intense reactions do merit treatment, even in the absence of a specific and definitive psychiatric Other survivors present with an intricate clinical representation suggestive of multiple diagnoses. A patient may suffer symptoms of PTSD, but relate a life narrative that indicates the presence of poor coping skills and/or other personality dimensions that pre-date the trauma. For instance, a person may have a life-long history of difficulty establishing meaningful or stable relationships, problematic dealings with authority figures, or a tendency for impulsive or self-destructive actions and behavior. Additionally, patients may have developmental deficits such as learning disabilities. These deficits may have affected their ability to function and adjust to novel situations even before the traumatic event, and continue to do so subsequent to the event. Other survivors present with substance abuse histories, which also predate the trauma and certainly complicate coping once the trauma has occurred. In such cases, the treatment plan includes psychotherapeutic and psychopharmacological interventions reflecting a psychodynamic formulation that places the person’s current symptoms within the context of his or her life and pre-trauma, base-line A 52 year-old woman from China fled following her arrest, prolonged detention in isolation, and risk of repeated interrogations. During the detention she was frequently beaten all over her body. These actions were inflicted reportedly because of suspected contacts with the Once in New York, she found herself in the streets, collecting soda cans in an attempt to support herself. At that time she was robbed of her few belongings which included her passport that was her only identifying document. Subsequently, she was hospitalized in a psychiatric unit, and referred to the Bellevue/NYU Program for Survivors of Torture upon discharge. Due to her level of disorganization, she missed the deadline for filing her asylum application. Her overall presentation was one of great disorganization, with labile, silly, regressed affect. Ms. L was diagnosed with a psychotic disorder in the range of schizophrenia, disorganized type vs. schizoaffective disorder and treated with both antipsychotic (Risperdal 2mg po BID) and antidepressant (Zoloft 100 mg po Daily) medications. Her symptoms improved dramatically. Ms. L was able to mobilize resources through her church, obtain legal representation, and was able to go through the asylum process successfully. She was able to apply for her husband to join her in the An Afghani couple that escaped the Taliban presented to our clinic, seeking help for the husband who had reportedly been injured in the war. The referring agency believed that he had sequelae from this war injury, and viewed him as “shell-shocked.” The wife, an articulate, pleasant woman in traditional clothing, described their marriage as an arranged marriage and hinted that her husband was developmentally impaired. They had three young children and the husband was unable to work and support the family. The husband would have angry, violent outbursts, would walk out of the home in the middle of the night, could not be trusted with the children, and generally required constant care and supervision. Careful assessment of this man revealed that he suffered from a severe developmental disorder. He was recruited to fight the war in Afghanistan during the conflict with the old Soviet Union despite his deficit, and was injured at that time. He did suffer PTSD symptoms from the war trauma, such as flashbacks, that were super-imposed on his baseline of limited functioning, mood lability, and violent outbursts. His symptoms were targeted with anti-depressant and antipsychotic medications, which were selected in order to enhance his cognition and achieve behavioral control. His functioning stabilized and improved, leading to a more successful adjustment for Psychiatric Treatment-Psychopharmacology As discussed above, survivors of torture and refugee trauma present with very diverse psychological and physical symptoms. Psychopharmacology is an important tool in the treatment of these symptoms. Keeping in mind that there are many biological models conceptualized in the understanding of PTSD, anxiety, and depression, it is obvious that the armamentarium of medications available is vast. Conceptualizing psychopharmacological treatment for survivors of torture and refugee trauma follows the biological models most associated with posttraumatic reactions. These biological models provide explanations for the emergence of symptoms associated with such life experiences, and attempt to illustrate the physical changes that follow. Torture and other traumatic events cause changes in an individual’s life experience, and there is mounting evidence that these changes are associated with neuro-biological functioning. A comprehensive model remains elusive, as no one model will suffice to describe the entire pathophysiology involved in the manifestation of posttraumatic stress (Scott & Briere, 2006). Most neuro-biological studies associating sequelae of traumatic events on the CNS have primarily focused on two systems. First, there are differences between individuals in terms of their neuro-anatomical make up. These differences cause variations in terms of individual vulnerability and pre-disposition to severe emotional reactions subsequent to traumatic events (Du & Lu, 1997). One must also consider the extent of the neuro-anatomical changes caused by the trauma itself (Scott & Briere, 2006). The extent of the changes will greatly impact an individual’s ability to cope with the trauma, emotionally and physically. Secondly, neuro-transmitters are highly involved in the way the brain processes and reacts to acute traumatic events. The brain responds to acute stress by releasing various neurotransmitters that allow the body to respond adaptively. Such sympathetic release is implicated in the hyper-arousal The brain’s utilization of neuro-transmitters in response to a traumatic event will impact upon two systems directly linked to an individual’s hormonal and emotional processing: the sympathetic nervous system (i.e. Brender, 1982; Malloy, Fairbank, & Keane, 1983), and the hypothalamic- pituitary-adrenal axis (i.e. Mason, Giller, Kosten, Ostroff, & Podd, 1986). These processes impact on a survivor’s emotional functioning in the * Symptoms of intrusive memories and symptoms of hyper-arousal are thought to be in part due to adrenergic hyperactivity. * Chronic hyperactivity of the catecholamine, subsequent to continued and repeated stress, can result in down-regulation of receptors in the locus coeruleus. This contributes to the avoidant, depressive, numbing, and social withdrawal symptoms frequently reported by survivors of torture and traumatized refugees. * Serotonergic depletion seems to be responsible for impulsivity, irritability, and affective dysregulation. * The endogenous opioid system, with the increased release of endogenous opiates, seems to be responsible for numbing and These reactions will also vary from person to person, and therefore create a wide-range of emotional and physical reactions to trauma between different individuals. As such, a firm grasp of these biological systems can be a good starting point for gaining insight on how the brain is reacting to repetitive traumas, and providing some bio-physiological basis for understanding the symptom profile of a particular survivor of torture. During the psychiatric evaluation the psychiatrist must elicit the psychiatric symptoms in order to formulate a psychiatric diagnosis, when and if present. After evaluating a client’s presenting symptoms, a psychiatrist will develop a treatment plan, which may, when indicated include a psychopharmacological intervention. The premise is that there is no one treatment that is effective for all. The evaluation and the treatment plan are symptom based, and include different categories: Target symptoms, breakthrough symptoms, residual symptoms, associated symptoms, and adverse events. Remission of symptoms is the desired outcome criteria. The asymptomatic state may remain elusive for a long period of time, and possibly never be reached. Reduction in the intensity of symptoms may be an initial amelioration that should be considered as an improvement and an indication to continue treatment, and not as the ultimate desired outcome. The crucial distinction to be considered is between patients getting better and reaching a durable asymptomatic state of well being. It is common to under-medicate and not maximize treatment based on self reporting of some improvement in the presenting symptoms. The outcome measure has an objective observable component but it is mostly based on self reporting. Patients may be very eager to report improvement and could become resistant to change or increase in medication. It may require great conviction on the part of the treating psychiatrist in following recommended treatment algorithms, keeping constantly in mind the goal of The treatment decision between classes of medications is based on the patient’s presentation of symptoms, and a review of the most current body of knowledge and literature, and understanding of which class of medication is proven to be the most effective class for the particular symptom profile. The choice of a particular medication within each class is most frequently based on the side-effect profile, pharmacy formulary, and the familiarity and experience of the psychiatrist with the specific medications. Different medications within a class engender different secondary effects, some which may help target symptoms and others that may not be tolerated as well and cause some discomfort. The choice of medication is therefore predicated on finding the medication and the right balance that will maximize the positive effects and minimize the disconcerting ones. We begin a discussion of psychopharmacological treatment by identifying the classes of medications most often used to treat the presenting symptoms we see in our client population: Anxiolytics are indicated when the symptoms of anxiety are prevalent, acute, and require fast relief. This group of medication has high addiction potential and their use should be controlled and for short term use only. The fast action of this class makes it useful while waiting for other classes of medication to take effect. Tolerance and dependence make long-term management with these medications complex and potentially unsafe. Anxiolytics are classified by their long or short-term action properties. Half-lives of anxiolytics range from 1-6 hours to 24-36 hours. Different rates of absorption vary according to lipophylic properties. Equivalent doses of different anxiolytics refer to a base dose of Diazepam 5mg. These medications are used for their hypnotic effect as well. The medications with short and intermediate half life are more effective in inducing sleep and the longer half-life in maintaining sleep. Benzodiazepine Dose
Half Lives
Equivalent
Antidepressant medications are indicated when symptoms of depression are prevalent and/or when symptoms of anxiety and depression co-exist and should be targeted at the same time. Different classes of antidepressants have different mechanisms of action and side effect profiles. These different properties are beneficial to target clusters of symptoms and can provide guidance in the selection of a particular medication. The metabolism of these medications by liver cytochromes is an important indicator for side effects profile. Drug-drug interactions and adverse effects must always be considered carefully. The most frequently used groups are: SSRI- Serotonin Selective Reuptake Inhibitors: Research and clinical experience have overwhelmingly established the effectiveness of SSRIs as a class of medication in the treatment of symptoms of depression and associated anxiety. As such, SSRIs are considered as the first line of treatment, and some of the specific medications have gained FDA approval for the use in the treatment of PTSD. It is this writer’s experience that symptom focused treatment is better managed than diagnosis Frequent and careful adjustment of these medications is indicated to monitor response to treatment and maximize outcome. Addressing side effects is crucial to assure compliance and adherence over time. A familiar reaction of patients to treatment is that when they start feeling better, they stop taking the medication, preventing them from reaching a completely Antidepressant Dosage
NSRI- Non-Selective Reuptake Inhibitor Non-selective reuptake inhibitors have a different mechanism of action by regulating 3 biogenic amines (serotonin, epinephrine, and dopamine) and can be used as first line of treatment based on the desired side effects profile, such as being more or less activating or sedating. Mirtazapine, being relatively more sedating, is frequently used as a bed time dose to help with regulating sleep and avoiding the use of a second sleeping Medication Dosage
Tricyclics are the oldest class of antidepressant medication. Currently they are less commonly prescribed but are very important for their historical value and as part of the useful armamentarium of anti-depressant treatment. TCA are also used in different combination for augmentation of treatment. These medications have been used worldwide and may have been a part of the treatment that some of the patients received in their country of origin. Familiarity with these medications is useful in the reporting of treatment experience. Amitriptyline has been used extensively in many countries as a treatment for depression, anxiety, induction of sleep and to increase pain *Amitriptyline (Elavil, Endep, Tryptizol; Loroxyl) Antipsychotic medications are effective in the treatment of acute and chronic psychotic symptoms. The use of this class of medication is not common for treatment of patients who do not suffer clear psychotic and/or severe anxiety symptoms. At times it may be a challenge to elicit, distinguish, and clearly define impairment in reality testing. In these instances careful prescribing from this class of medications can be safe and Psychotic symptoms should be treated with antipsychotic medications independent of co-morbid conditions that may exist simultaneously. Depression with psychotic features, or a patient suffering from PTSD who is very fearful and paranoid of people, could be indications for anti-psychotic The typical anti-psychotics are generally dopamine receptor antagonists, based on the theory that excess dopamine could be contributing to the etiology of disorganized thinking leading to poor reality testing and psychotic states. Typical anti-psychotics are also mostly known for their historical value, and have been used (as well as abused) in several countries as a treatment for survivors of torture. Antipsychotic Medication
Dose Equivalent
The atypical anti-psychotics are newer medications. These have been established as a first line of treatment for their effectiveness, side effects profile, and safety. They are both serotonin and dopamine receptors antagonists. They are very effective for both positive symptoms such as delusions and hallucinations, and also for negative symptoms such as social Atypical Antipsychotic Medications
The class of Mood Stabilizing medication is indicated primarily in the treatment of Seizure Disorders and Epilepsy. They have also been established as the treatment of choice for Bipolar Disorder and severe symptoms of mood instability, impulsivity and agitation. Some of these medications have been used for a long time worldwide, and some patients may report having been prescribed such treatment. These medications are also not commonly indicated in our patient population, but familiarity with them is essential. Survivors of torture may suffer pre-morbid conditions such as Bipolar Disorder, or they may have a history of Traumatic Brain Injury (TBI ) and co- morbid Seizure Disorder. Except lithium, most of the medications in this class are primarily anti- seizure medications, and require careful monitoring of compliance and blood Mood Stabilizing Medication
Pain is a very common symptom, especially among our traumatized client population. It becomes more challenging when there is no direct organic, easily recognizable, etiology. Pain is considered as the 5th vital sign, and needs to be addressed. Pain medication is divided into different The first line of treatment is Acetaminophen (Tylenol) and non- steroidal anti-inflammatory preparations such as: Aspirin and Ibuprophen. These medications are available “over the counter” and are easily managed. More potent non-steroidals are available by prescription. It is important to note the significant potential for gastrointestinal symptoms from these The second line of treatment is comprised of the Opiates, such as: Codeine, Morphine, and Fentanyl. These medications have high addiction potential and are controlled substances. They should be prescribed with When it is perceived that the pain may have psychological and emotional influences, anxiolytics, antidepressants, and mood stabilizing medications can be used. As a psychological component is involved, these psychopharmacological medications have proven to be helpful in addressing physical sensations. Trials of antidepressant medications have been described as alleviating pain symptoms by increasing the pain threshold (i.e. Peghini, Katz, & Castell, 1998). Anti seizure and mood stabilizing medications have also been effective in addressing pain symptoms. These may be indicated in situations when pain symptoms have been resistant to Psycho-stimulant medications are an effective class of medications that are indicated predominantly for conditions such as ADHD (Attention Deficit Hyper Activity Disorder) and Narcolepsy. They are very fast acting and as a result have high addiction potential. In treatment of depressive symptoms, psycho-stimulants are used for augmentation of treatment. This augmentation is indicated in situations in which waiting for a few days for the antidepressant medication may be of serious concern. In such situations, an antidepressant regimen is initiated simultaneously with a psycho-stimulant for more immediate effect. Subsequently, the psycho-stimulant is discontinued when there is some clinical response to the anti-depressant regimen. Psycho-stimulants are rarely prescribed for extended periods of time. Dementia is a marked deterioration in cognitive functions and is a very serious condition. Dementia has a long list of possible etiologies including traumatic brain injury and substance abuse. In situations in which no other co-morbid medical condition could provide a possible etiology, there are medications that can be used to slow the progression of these Survivors of torture may suffer cognitive decline, even though it has only been recognized sporadically with clients in our program. Regardless of its prevalence, and because of the devastating implication of such symptoms, the evaluation of cognitive functions should always be included in a comprehensive medical and/or psychiatric evaluation. Medications that are available to address such cognitive decline include:  Donepzil Hcl (Aricept),  Rivastigmine tartare (Exel),  Galantamine hydrobromide (Reminyl)  Cognex The above listed medications perform by delaying the breakdown of acetylcholine. This is achieved by inhibiting cholinesterase, the enzyme that is responsible for its embolism. Since acetylcholine is an important neurotransmitter for cognitive functions, having more acetylcholine available in the neuronal synapse can improve symptoms for those suffering from diminished cognition. Mematine (Namenda) is a new agent that can extend memory and cognitive functioning by blocking excess amounts of Symptoms of intrusive memories and symptoms of hyper-arousal are thought to be in part due to adrenergic hyperactivity. In our experience with adrenergic blocking agents, we have observed that beta adrenergic blocking agents (like Propanolol), and alfa adrenergic agonists (like Clonidine), have resulted in improvement of such symptoms, both in acute and chronic Medication and Co-Morbid Conditions As mentioned earlier in this chapter, psychopharmacological interventions have proven to be effective in treating many co-morbid psychiatric conditions. Brady, Sonne, and Roberts (1995), studied the treatment of co-morbid PTSD and alcohol abuse with SSRI anti-depressants. The medications were well tolerated, and were related to decreased alcohol Dow and Kline (1997) found that when treating patients with co- morbid depression and PTSD, that SSRIs (Sertraline and Fluoxetine) were more effective than TCAs (Nortriptyline and Desiparmine), when patients were treated with the anti-depressant at therapeutic levels for at least one month. Brady and Clary (2003) also concluded that treating patients suffering from PTSD, as well as current co-morbid depressive and anxiety disorders, with Sertraline 50-200 mg/d was effective and well tolerated. Smajkic et al. (2001) used three antidepressants to treat Bosnian refugees in the Chicago area. They also found that Sertraline and Paroxetine produced statistically significant improvement at 6 weeks in PTSD symptoms, severity in depression, and Global Assessment of Functioning. They reported that Velafaxine produced improvement in PTSD symptom severity and Global Assessment of Functioning, but did not yield improvement in symptoms of Major Depressive Disorder. Velafaxine also had high rates of side effects. Notwithstanding improvement of symptoms, all patients remained PTSD positive at the diagnostic level at the 6-week Hamner et al. (2003) worked with survivors of torture who presented with positive and negative symptoms of psychosis co-morbid with PTSD. They reported that the use of Risperidone was linked with a significant decrease in the global psychotic symptoms associated with PTSD, and was linked with improvement in core re-experiencing symptoms as well. Psychopharmacology and the Meaning of Medications Referral for psychiatric evaluation and the decision to recommend medication are complex issues, reflective of the conceptualization of trauma, symptoms, coping, and the therapeutic context. Furthermore, other influencing variables are: the background preparation and level of comfort with medications among the different clinicians, and the range of attitudes toward receiving psychiatric medications conveyed by culturally diverse Some patients express familiarity with medications and a strong desire for those medications which may have been readily available in their home countries. They may have the conviction that these medications helped them survive previous hardships. Such attitude leads to the belief that these medications could be useful in “pulling them through” present and possibly future difficulties. Some of these patients may meet criteria for a diagnosis of Benzodiazepine dependence. Other patients may be distrustful of authorities subsequent to their abuse (Scott & Briere, 2006), or may come from countries where medications are culturally incongruent. Or they may reject the notion of medication, viewing it as an assault on their integrity. These positions represent two extremes. In the middle lie those patients who have had mixed experiences and some knowledge of psychiatric medications. Other patients may have different levels of ambivalence about medications and those who accept the doctor's prescription out of submission to authority and a strong wish to please the Frequently, patients who are open to the idea of psychiatric medications are comfortable accepting medications for specific symptom relief such as sleep or pain, as these are viewed as physical symptoms and therefore less stigmatized, guilt-free, and more socially acceptable. Corresponding diversity is present among clinicians. Internists, specialists, psychologists and social workers will have different rates of referrals for psycho-pharmacological evaluation based on their prior experience, recognition of symptoms and confidence in the outcome and effectiveness of It is important to recognize, however, that patients who have suffered the multiple traumas of persecution, torture, and immigration, often experience sadness and deep feelings of loss and displacement, which cannot be "cured" with medication alone. Medication can offer symptom relief and enable patients to engage in psychotherapy, which then facilitates the painful process of addressing profound changes in one's self and worldview. In fact, it is important to recognize that the practice of psychopharmacology includes a consideration of psychodynamics, and a comprehensive understanding of the patient’s experience. Psychotherapy and psychopharmacology should not be viewed as disjunctive, but rather as points along a continuum of care. Medications can help patients in their efforts to build a new life while navigating multiple stressors. However, outcome measures of treatment with psychotropic medications should be The following case is an example of a patient who discontinued her treatment with psychotropic medications because she experienced it as Ms. Q is a professional woman in her early thirties from a nation in Northwestern Africa. Her traumatic experiences dated back almost twenty years prior to her arrival at the Bellevue/NYU Program for Survivors of Torture. Her family had been targeted because her father was involved in human rights advocacy. She and another sibling were arrested along with the father, and they were subsequently separated from him. The father was executed and the children were imprisoned. Ms. Q was sexually abused, beaten, and verbally humiliated. Her other imprisoned sibling was killed. Ms. Q was referred to our program by an international human rights group. She presented with symptoms of Major Depression and was referred for individual psychotherapy and psychopharmacological treatment. She was prescribed treatment with antidepressant medication. After only a few days on the medications, Ms. Q confided to her therapist that she wished to stop taking the antidepressant. Ms. Q reported feeling flat, uncomfortable and “not like myself” while medicated (even though her SSRI medication would not reach its therapeutic level for at least another couple of weeks). She stated that “When I feel sad at least I know that the pain is mine.” The idea of being relieved from some of her symptoms triggered such sentiments of guilt, loss, and emptiness that it was intolerable for her. Ms. Q discontinued her medication regimen, but continued with psychotherapy. Her symptoms of depression gradually remitted, but were occasionally reactivated by external stressors, particularly as she re-engaged in human rights advocacy. Supportive therapy helped her to try to strike an emotionally viable balance between her needs to In light of this discussion, the process of referrals for evaluation for psychiatric medications deserves additional attention. As mentioned earlier in this chapter, sometimes clients are not directly referred for psychiatric treatment after their intake interview. Frequently, it is the primary care physician that will first identify the need for psychopharmacological treatment. The primary care physicians in our program are trained in psychopharmacological interventions, and will generally prescribe the medicine that they feel is appropriate. A subsequent referral to a psychiatrist is generally facilitated in one of several ways. The first scenario is one in which the primary care provider prescribes the medication and monitors the patient’s progress. If the PCP is not satisfied with the response to treatment and finds that there is insufficient clinical progress, he or she will then refer to a psychiatrist for a consultation. The second scenario for referring is when the PCP provides the patient with the initial prescription, but will immediately refer the patient for psychiatric follow-up. Thirdly, the PCP may refer the patient for psychiatric evaluation without having prescribed any medication. All of these processes have been used in our program, largely depending on the primary care physician’s level of training in psychopharmacology, and their comfort in There are other factors that affect how psychiatric referrals are facilitated. Health professionals refer patients for psychopharmacological evaluations based on their own attitudes towards medication and counter- transferential reactions. Physicians following a more medical model may refer patients for medication evaluations more often than for psychotherapy. Psychotherapist may delay referring their psychotherapy patients for medication evaluations because of a wish to avoid “split” care. Furthermore, counter-transference, and a lack of familiarity with the range of available medications and biological theories, also limits the rate of referrals. The Bellevue/NYU Program for Survivors of Torture provides ongoing constructive exchange of information and ideas between clinicians from different disciplines that contributes to appropriate referrals, evaluations and What messages does the clinician give the patient by prescribing medications? Generally, when the clinician prescribes medications, he or she may communicate the hope of alleviating some symptoms by providing medication, or they may be perceived by the patient as conveying the sense that "I am powerful, I can cure you of your distress." If the patient continues to suffer despite taking the medications, such as when the patient continues to express sadness, feelings of loss, or a lack of complete relief from symptoms, a common response by clinicians is to rush to change medications, sometimes before maximizing and waiting for them to take effect. This rush to change often arises out of the clinician's need to be effective and not disappoint the patient's expectations. It is important to clarify the message perceived by the patient. Commonly, a prescription of medication suggests a disease to be treated, and patients may be reluctant to accept a disease model of their distress. Therefore a discussion regarding the meaning of the medication is essential. Medications have important meaning for patients, their significant others, and all involved in their care. This meaning should be explored and addressed. The clinician should continue the exploration and understanding of the meaning of medication for the duration of treatment, since such meaning may continue to evolve with treatment. Interpretation of the power, limits, and significance of the medications could become an important component of the overall treatment and care provided. If hidden meanings are not addressed, treatment with medications is more likely to fail, and patients are more prone to conclude, erroneously, that medications cannot be helpful, or alternatively that they themselves cannot be helped. The large majority of the patients at the Bellevue/NYU Program for Survivors of Torture are seen on an outpatient basis for medical care, psychotherapy, or psychiatric follow-up. At times, inpatient treatment and hospitalization may be indicated for medical, surgical or psychiatric Psychiatric hospitalizations are described as informal, voluntary, and involuntary. When hospitalization is indicated the clinician must weigh the patient’s past trauma experience carefully, so as to decide upon the proper treatment as well as introduce it to the patient in a sensitive manner that is culturally congruent and responsive to particular circumstances in the Patients may fear isolation and the temporary separation from their families or other supports systems. Others with limited supports may fear the loss of independence, freedom, and or the loss of a job or shelter. The meaning of hospitalization may expand to other implications and meanings and trigger symptoms related to trauma. Patients may worry that a hospitalization may negatively impact on their asylum-seeking process. These issues must be confronted directly and openly. If not addressed sufficiently there is a risk that the patient may be re- traumatized and continue fearfully to resist hospitalization and adherence to treatment with negative outcome. The following cases also describe situations for which A man from a West African country received news of his brother’s recent murder. Overwhelmed, he came to the hospital seeking protection from his own reaction. He was concerned about his suicidal impulses. He was hospitalized on a psychiatric unit for several days, received intensive psychiatric treatment, and was discharged when he felt safe and in control of his behavior and actions. For this man, hospitalization was a sought-after place of Upon discharge, this patient continued with individual and group therapy, as well as psychopharmacological follow-up. The patient was visited frequently at his home by “brothers and sisters” from his support group for French-speaking African survivors, who “checked in” and made sure the patient was eating well, and not feeling isolated in his grief (see Chapter 11). A young Tibetan monk in NYC required medical hospitalization for acute Tuberculosis. He was placed in an in-patient, negative-pressure isolation room for TB, and did not seem to be suffering from any psychiatric symptoms or distress. During the hospitalization, the patient noticed a Chinese American hospital policeman in uniform standing outside his hospital room. This triggered a flashback and acute episode of agitation, reliving the past experience of arrest and In an acute psychotic reaction, the patient barricaded himself in his room and planned his escape to freedom by jumping out of the hospital window. This window overlooking the building of the United Nations had magnified symbolic meaning in this patient’s mind. This patient required treatment with anti-psychotic medication (Risperdal) The patient responded well to treatment with complete resolution of his symptoms and discontinuation of the anti psychotic medications. He was able to be discharged safely to his community with continued A Middle Eastern professional, and mother of two, arrived to her regularly scheduled psychiatric appointment with her two sons. During the session, she expressed suicidal wishes, including a clearly spelled-out plan to jump off a bridge with her two young children. The patient’s husband was contacted so that he could take the children home. Once he arrived, the patient was escorted to the psychiatric emergency room for an evaluation for admission. That evaluation confirmed the need for hospitalization. The patient refused hospitalization and was admitted on an emergency status The patient’s suicide/infanticide plan was understood as stemming partly from her rage at her husband, whom she blamed for not having been there to protect her from a brutal rape. The patient’s husband had been out of the country at the time of her attack. The understanding of the complex dynamics underlying the patient’s plan made the patient’s intent to carry out her plan seem credible. She was viewed as being dangerous to both self and others, clearly meeting criteria for an involuntary psychiatric admission. The patient’s initial reaction to the hospitalization was an expression of re-traumatization and one of severe disappointment and feelings of betrayal; she stated “How could you do what they did to me?” After in-patient treatment, including insight-oriented psychotherapy and mood-stabilizing medication, she began cooperating with her treatment. Upon discharge from the hospital, she continued with both psychotherapy and psychopharmacology as an outpatient. She expressed appreciation for the intervention. A young West African man developed paranoid psychosis, fearing all law enforcement personnel and imagining personally targeted persecution. These symptoms developed following a highly publicized case of police brutality against another West African young man in New York City. He was admitted to an in-patient psychiatric unit for treatment. During a relatively long hospitalization, the patient continued to be reluctant to leave the hospital, which he came to experience as a safe heaven. Upon release, he continued to receive individual and group therapy, as well as psychotropic medication on Psychiatric work with survivors of torture and refugee trauma is a challenging and complex field of psychiatric practice. Many professionals may engage in this area of work only to eventually feel helpless, impotent, and ineffective in the face of patients' horrific experiences and deep suffering. These clinicians may themselves disengage, experience burnout, and retreat from working with such patients (see Chapter 13). Conversely, clinicians may see that the overabundance of challenges leaves substantial room for varied and innovative responses. These responses may help to promote the individual clinician’s growth and development, and may also help to deepen understanding of how to best treat and advocate for survivors of torture and refugee trauma across the board. As the needs are vast, so are the ways that psychiatrists can get involved and be able intervene providing care to this underserved Beyond clinical evaluation and treatment, psychiatrists as physicians have an important social role in denouncing torture and other human rights abuses. This includes raising awareness of physicians’ participation in torture and other abuses. As such, advocacy is another realm in which psychiatrists can play an active role in advancing the cause of respecting Contemporary research and writings on PTSD (Shalev, 1996; Yehuda & McFarlane, 1995), as well as our clinical experience, suggest that at present we lack tools for accurately diagnosing clusters of symptoms with which traumatized patients present. There are, however, many ways in which psychiatrists doing rigorous quantitative and qualitative research can broaden and deepen the understanding of individuals’ complex reactions to trauma. Direct psychiatric treatment of traumatized survivors of torture by itself is a very rewarding area of practice. Psychiatrists can assume a more significant role in the struggle for human rights and human dignity by assisting people who have been directly wounded by oppression and American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. Text Revision). Washington DC: Author. Basoglu, M. (1993). Prevention of torture and care of survivors: An integrated approach. JAMA, 270 (5), 606-611. Brady, K. T., & Clary, C. M. (2003). Affective and anxiety comorbidity in post-traumatic stress disorder treatment trials of sertraline. Comprehensive Psychiatry, 44(5), 360-369. Brady, K.T., Sonne, S.C., & Roberts, J.M. (1995). Sertraline treatment of comorbid posttraumatic stress disorder and alcohol dependence. Journal of Clinical Psychiatry, 56, 502–505. Brender, J. (1982). Electrodermal responses in PTSD. Journal of Nervous and Mental Diseases, 170, 352-361. Breslau, N., Chilcoat, H., Kessler, R., & Davis, G. (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit Area Survey of Trauma. American Journal of Briere, J. (1996). Therapy for adults molested as children (2nd ed.). New Briere, J., & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluations, and treatment. Thousand Oaks, London, New Chilcoat, H., & Breslau, N. (1998). Investigation of causal pathways between PTSD and drug use disorders. Addictive Behaviors, 23, 827- Dow, B., & Kline, N. (1997). Antidepressant treatment of post-traumatic stress disorder and major depression in veterans. Annals of Clinical Du, N., & Lu, F. (1997). Assessment and treatment of posttraumatic stress disorder among Asian-Americans. In E. Lee (Ed.), Working with Asian-Americans: A guide for clinicians (pp. 275- 294). New York: Engdahl, B.E., & Eberly, R.E. (1990). The effects of torture and other maltreatment: Implications for psychology. In P. Suedfeld (Ed.), Psychology and torture (pp. 31-47). Washington , D.C.: Hemisphere Ferrada-Noli, M., Asberg M., Ormstad, K., Lundin, T., & Sundbom, E. (1998). Suicidal behaviour after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity and assessments of suicidal behaviour. Journal of Traumatic Stress, 11, 103-112. Friedman, M., & Jaranson, J. (1994). The applicability of the post-traumatic concept to refugees. In A. J. Marsella, T. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst peril and pain. The mental health and well-being of the world's refugees (pp. 207–227). Washington, DC: American Hamner, M.B., Faldowski, R.Q., Ulmer, H.G., Frueh, B.C., Huber, M.G., et al. (2003). Adjunctive risperidone treatment in post-traumatic stress disorder a preliminary controlled trial of effects on comorbid psychotic symptoms. International Clinical Psychopharmacology, 18, Keller, A.S., & Gold, J. (2005).Survivors of torture. In B. Sadock & V. Sadock (Eds.), Kaplan and Sadock’s Comprehensive Textbook of Psychiatry (pp.2398-2406). Philadelphia: Lippincot Williams & Keller, A.S., Lhewa, D., Rosenfeld, B., Sachs, E., Aladjem, A., Cohen, I., et al. (2006). Traumatic experiences and psychological distress in an urban refugee population seeking treatment services. Journal of Nervous and Mental Disease, 194 (3), 188-294. Kilpatrick, D. G., & Resnick, H. S. (1993). PTSD associated with exposure to criminal victimization in clinical and community populations. In J. R. T. Davidson & E. B. Foa (Eds.), Posttraumatic Stress Disorder: DSM-IV and Beyond (pp. 113-143). Washington, DC: American Kinzie, J.D., Leung, P.K., & Boehnlein, J.K. (1997). Treatment of depressive disorders in refugees. In E. Lee (Ed.), Working with Asian Americans: A guide for clinicians (pp.265-294). New York: The Kluznik, J.C., Speed, N., van Valkenburg, C., & Magraw, R. (1986). Forty- year follow-up of United States prisoners of war. American Journal of Koss, M.P., & Kilpatrick, D. (2001). Rape and sexual assault. In E. Gerrity, T. Keane & R. Tuma (Eds.), The mental health consequences of torture (pp. 177-194). New York: Kluwer Academic/Plenum Laub, D., & Auerhahn, N. (1993). Failed empathy: a central theme in survivors’ Holocaust experience. Psychoanalytic Psychology 6 (4), Malloy, P., Fairbank, J., & Keane, T. (1983). Validation of multi-method assessments of PTSD in Vietnam veterans. Journal of Clinical Mason, J., Giller, E., Kosten, T., Ostroff, R., & Podd, L. (1986). Urinary free cortisol in PTSD. Journal of Nervous and Mental Disease, 174, 145- McFarlane, A.C. (1996). Resilience, vulnerability and the course of posttraumatic reactions. In B. A. van der Kolk, L. McFarlene, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp.155- 181). NY: Guilford. McGirr, A., Renaud, J., Seguin, M., Alda, M., Benkelfat, C., Lesage, A., et al. (2007). An examination of DSM-IV depressive symptoms and risk for suicide completion in major depressive disorder: A psychological autopsy study. Journal of Affective Disorders, 97, 203-209. Mollica, R.F. (2004). Surviving torture. New England Journal of Medicine, Mollica, R.F., McInnes, K., Sarajlic, N., Lavelle, J., Sarajlic, I., & Massagli, M. (1999). Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. Journal of the American Medical Association, 282, 433-439. Momartin, S., Silove, D., Manicavasagar, V., & Steel, D. (2004). Comorbidity of PTSD and depression: Associations with trauma exposure, symptom severity and functional impairment in Bosnian refugees resettled in Australia. Journal of Affective Disorders, 80, Peghini, P.L., Katz, P.O., & Castell, D.O. (1998). Imipramine decreases oesophageal pain perception in human male volunteers. GUT, 42, Scott, C., & Briere, J. (2006). Biology and psychopharmacology of trauma. In J. Briere & C. Scott (Eds.), Principles of trauma therapy: A guide to symptoms, evaluations, and treatment (pp.185-229). Thousand Oaks, London, New Delhi: Sage Publications. Shalev, A. (1996). Stress versus traumatic stress: From acute hoemostatic reactions to chronic psychopathology. In B.A. van der Kolk, L. McFarlene, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp.72-101). Smajkic, A., Weine, S., Djuric-Bijedic, Z., Boskailo, E., Lewis, J., & Pavkovic, I. (2001). Sertraline, paroxetine, and venlafaxine in refugee posttraumatic stress disorder with depression symptoms. Journal of Traumatic Stress, 14, 445–452. Yehuda, R., & McFarlane, A.C. (1995). Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis. American Journal of Psychiatry, 152 (12), 1705-1713. Zlotnick, C., Donaldson, D., Spirito, A., & Pearlstein, T. (1997). Affect regulation and suicide attempts in adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 793-798.

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