Anxiety and depression are common among survivors of torture and other ill-treatment. Drug and alcohol misuse are also seen more than in the general population, probably as a way of avoiding unpleasant feelings and memories. Questions must be asked about these symptoms.
Anxiety and depression can recur and present with feelings of hopelessness or helplessness. There is a risk of having panic attacks, nightmares, reliving the trauma and fear of recurrence.
Depression presents as sadness, difficulty concentrating, tiredness and lethargy, loss of libido, inability to enjoy things, insomnia and early wakening, changes in eating pattern, mainly loss of appetite but sometimes binge eating, apprehension and fear, feelings of hopelessness and guilt. When severe there may be a preoccupation with death, thoughts of suicide, and sometimes attempts at self-harm.
Acute stress reactions and post-traumatic stress disorder (PTSD) are both seen in victims of torture. They arise as a consequence of an event that threatens death or serious injury of self or others, leading to a response of intense fear, helplessness, or horror. Both are characterised by a specific set of symptoms. While the acute stress reaction occurs immediately after a traumatic event, PTSD occurs after a few weeks.
Survivors of torture often complain of pain in different parts of their body; sometimes the description of the pain changes. The pain can be described as more or less intense and its location can change over time. Often there is nothing to find on physical examination. These are somatic symptoms and can be direct physical consequences of being tortured, or may be purely psychological.
Hallucinations, especially auditory hallucinations, are not uncommon, and are not necessarily symptoms of psychosis. They cannot always be differentiated from the re-experiencing phenomena of PTSD.
Dissociation, the feeling of being detached from one’s self, is seen in victims of torture. It happens when a person lives through experiences that cannot become part of his/her memory (autobiographical memory) because of their intense character, as can happen during torture. There is a breakdown in the integration of consciousness, perception and behaviour. The person may feel as though he or she is observing him- or herself from outside.
True psychosis may be identified, but before making the diagnosis, the symptoms must be evaluated in the individual’s cultural context. For example, the person may hold ideas of being possessed or other forms of magical thinking, which may be culturally appropriate. A further complicating factor, regardless of culture, is that individuals may describe intrusive memories in a way that might appear to be hallucinations.
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