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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
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
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
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Topical Amitriptyline and Ketamine in Neuropathic PainMary Elizabeth Lynch,* Alexander John Clark,† Jana Sawynok,‡ and Michael J. Sullivan§ Abstract: Twenty eight subjects with refractory, moderate to severe peripheral neuropathic pain participated in an open label prospective trial examining perceived analgesic effect, patient satisfac- tion, and safety of topical amitriptyline 2%/ketamine
ESTATUTOS DE LA ASOCIACIÓN CULTURAL CORE acts TÍTULO I DISPOSICIONES GENERALES Artículo 1.- Denominación: La Asociación “Core Acts” se constituye por tiempo indefinido al amparo de la Ley Orgánica 1/2002, de 22 de marzo, reguladora del Derecho de Asociación, y al amparo de lo dispuesto en el artículo 22 de la Constitución, careciendo de ánimo de lucro. Artículo 2.- Pers