C-1 efforts to avoid thoughts, feelings or conversations associated with the trauma
C-2 efforts to avoid activities, places or people that arouse recollections of the trauma
C-3 inability to recall an important aspect of the trauma
C-4 markedly diminished interest or participation in significant activities
C-5 feelings of detachment or estrangement from others
C-6 restricted range of affect (e.g. unable to have loving feelings)
D-2 irritability or outbursts of anger
D-3 difficulty concentrating
In addition to these partial symptoms of PTSD in DSM-IV, feelings of shame, blame, guilt, fear, horror and anger, all of which can also serve as obstacles to the exploration, are listed as partial symptoms of PTSD in DSM-5 (APA 2014).
It becomes clear (even from the non-medical perspective) that these symptoms are an obstacle to medical exploration and diagnosis. The assessment of victims of torture with psychological sequelae differs radically from the assessment of patients who suffer from other psychiatric disorders. The decisive difference between the assessment of survivors of torture with mental sequelae and the assessment of persons with other mental disorders is that in survivors of torture, it is the symptomatology itself which can hinder exploration and thus lead to errors. This is by no means a new discovery, but a phenomenon known from studies on the reactive mental sequelae seen in victims of the National Socialist concentration camps (“Abkapselung extremtraumatischer Erfahrungen von der Umwelt, weil sie nicht kommunizierbar sind”, “Widerstand gegen die Exploration”4 (von Baeyer et al. 1964)).
The clinical pictures of this latter group of traumatised victims would – following the present diagnostic classification in ICD-10 – most likely be defined as “Enduring personality change after catastrophic experience” as F62.0. Here as well one can find symptoms that oppose the exploration:
Hostile or distrustful attitude towards the world
Social withdrawal
Feelings of emptiness or hopelessness
A chronic feeling of “being on edge” as if constantly threatened
Estrangement
Feelings of shame and guilt are not represented as partial symptoms in the definitions of the diagnoses of PTSD in DSM-IV and personality change, but are now included in DSM-5. In our context they must be especially accentuated, for we will never come to know the real number of victims who choose to remain silent for this reason – consider especially the victims of sexual abuse (Wenk-Ansohn 2002).
Case 1 of Mr. C. from South-East Anatolia/Turkey5
Mr. C. is a Kurdish farmer from Turkey. He comes from south-east Anatolia and has been living for 2 years in Germany as an asylum seeker. He complained about having trouble sleeping and concentrating, as well as about anxiety, nightmares, general anhedonia and a lack of vitality. He reported that he had fled to Germany in the early summer of 1995 after having been detained, interrogated and tortured by the Turkish police for about 20 days over each of the previous 2 years and that it was likely that he would have been arrested and tortured again in the future. As the owner of an isolated farmhouse 4 km from the nearest village, he had been suspected of providing members of the PKK with food. The first time he was arrested, the military police had burned down his house and forced the whole family to move to the next village.
When I asked him what form of torture he had undergone, Mr. C. answered that he had been beaten with clubs over his whole body, had the soles of his feet beaten (Falanga), had been hosed down with pressurised cold water while naked, had been subjected to electric shocks and had been kept in solitary confinement without sufficient food.
At 44, Mr. C. had aged prematurely. His manner at the interview was pleasant. Initially somewhat reserved and speaking quietly but hurriedly, he modestly did his best to answer all questions as quickly as possible. However, at the same time he appeared breathless and agitated, and this became worse when he began to tell the story of his persecution. He was sweating profusely. He started to mix up details and the chronological order of events, which confused the interpreter; as an examiner, I began to doubt the authenticity of his story. When I asked him to repeat the contradictory information, at the same time assuring him that we had plenty of time for the interview, he was able to rectify the jumbled order of events in his report, reassembling them into a more plausible and comprehensible whole. His basic mood was depressed. He showed evidence of emotional rigidity. Outwardly his drive appeared reduced, while inwardly he showed clear signs of increased arousal. When I made a hand movement that he had evidently not expected during the physical examination, he started and involuntarily shrank back. At the physical examination I noticed a large number of small scars spread across his back for which he was unable to account. He also had a roughly 2.5-in.-long, sickle-shaped scar on his left shoulder. He reported that this had been caused by a blow with the butt of a gun during his first term of imprisonment. It had been treated in a makeshift manner with a few large stitches. A second, very obvious scar that ran across the inside of his right thigh, around 2 in. long and 1 in. wide, was below the surface of the skin and showed no signs of surgical stitches; this he attributed to an untreated stabbing during his second period of imprisonment. He reported that from time to time the soles of his feet became painful after he had been walking for some time. The balls of his feet were soft and could be easily depressed onto the underlying bones. When he walked, he placed his feet flat on the ground, failing to place his heels down first and roll forward on to his toes. This is an indication that he was subjected to torture by “Falanga”, i.e. blows to the feet (Skylv 1993).
At the second and third case history interviews, the dissociation of events and their chronological sequencing were repeated in the same way as during the first interview, and again, like during the first interview, Mr. C. was able to piece them together again and add further details when I took time to put my questions patiently and calmly. Despite the fact that Mr. C. shifted his perspective on the events and actions several times, in the end his report was free of contradictions.
Towards the end of the third interview, when Mr. C. was persuaded to describe an aspect of a certain event in greater detail and to tell me at what time of the day he had been arrested the second time and which family members had been present, he broke down in tears.
All sources of information on the political situation in eastern Anatolia (Amnesty International, the German Foreign Office, press reports and coinciding reports from other persons subject to persecution in the same region) are in agreement that in the civil war between Turkey and the PKK, pressure is being exerted on the rural population either to join the so-called village guard system organised by the Turkish authorities or to provide the PKK with medical aid, food and logistic support. It is not possible for people living in rural areas to retain a neutral position between these two strongly opposed forces. “Attacks carried out against uninvolved parties by the security forces in the form of destruction of property, detention, physical or psychological abuse or homicide are widespread in this region” (German Foreign Office 1994, 1995).
Together with what we know about the political situation in this region, Mr. C.’s history and his mental and physical status indicated with almost absolute certainty that the information he had given in his application for asylum was correct. However, this clarity was only apparent to us, evidently to the Federal Office for the Recognition of Asylum – Mr. C.’s application was rejected. According to the minutes of the hearing, an event which torture victims often associate emotionally with the interrogations to which they have been subjected under torture in their own countries, Mr. C. had been given exactly 1 h to present his reasons for applying for asylum, with the aid of an interpreter.
This was a requirement with which Mr. C. was unable to comply in his current mental condition.6
Dissociative Symptoms of Complex PTSD
Mental sequelae of torture and incarceration are usually connected with dissociative symptoms of differing severity. By definition, the main characteristic of dissociation is the disruption of the integrative functions of consciousness, memory, identity or perception of environment (APA 1994; WHO 1992). Accordingly the intrusive symptomatology – including uncontrollable, sequential reliving of extreme traumatic events experienced in the past, either by day or by night in the form of nightmares, as well as acting or feeling as if the traumatic event was recurring in the presence with flashback episodes – can be regarded as a dissociative symptomatology. Likewise, the inability to recall an important aspect of the trauma (symptom C3 in DSM-IV or D1 in DSM-5) is seen as dissociative amnesia.
Dissociative phenomena are widespread; even mentally healthy people can be affected. The phenomena are to be viewed as concomitant symptoms in the entire psychopathological spectrum, similar to fever with somatic diseases. Severe, complex and chronic PTSD with a distinct degree of dissociative symptoms can cause complaints similar to a chronic schizophrenia (Haenel et al. 2000).
According to the definitions of DSM and ICD, an existing, partly dissociative disease such as schizophrenia or PTSD excludes the diagnosis of a dissociative disorder. Nevertheless, especially for complex sequelae of traumata, dissociative symptoms can exceed the degree of PTSD by far and create special difficulties during assessment, as shown in the following example.
Case 2 of Mr. Z. Kurdish, Male, from Turkey
Mr. Z., a bright, conscious man who appeared rather young for his 27 years, arrived for the assessment accompanied by a fellow countryman. During the examination, it was revealed that he had not been fully informed about the assessment’s purpose. He had merely been told that there was a doctor he was supposed to go to.
As regards this person, he showed normal awareness, but concerning the time, however, he appeared disorientated. He falsely believed the current date to be 1 day in the future. Initially Mr. Z. seemed cautious, somewhat sceptical, reserved, tense and self-controlled. He asked the interpreter spontaneously to repeat every question from the assessor twice, and when asked about this, he explained that he was tremendously excited and “fear was coming up”. Every time when he was asked about his past, he stated, memories of his incarceration in Karakol (police prison) would come up. At first, Mr. Z. focused his eyes predominantly on the interpreter and only addressed the assessor indirectly, e.g. by starting his answers with “Please tell him…” or “Ask him if he knows the feeling of leaving his parents and siblings”.
Mr. Z. behaved in a self-controlled manner and appeared somewhat helpless and anxious, distrustful and limited in emotions. At some points of his story however, such as when he was talking about his mother, he was temporarily unable to control his emotions and burst into tears. Throughout the assessment, Mr. Z. repeatedly asked to be questioned as little as possible about his antecedent family as well as his persecution and incarceration in Karakol because he would “lose” himself in the memories it triggered, as he stated.
Moreover, some questions had to be repeated because of Mr. Z.’s occasional mental absence. Later, when he had finally exposed many chapters of his story of persecution, he absent-mindedly stared into space for minutes and was retracted through being addressing continually.
His syntax and formal chain of thoughts were structured in a simple way, as the interpreter stated.
Sometimes, however, he said seemingly incomprehensible sentences that were only to be understood from the context, e.g. “I am after my bread” which meant that he was only living in the mountains for financial and not for political reasons.
Cognitive dysfunction, delusion and hallucination as signs of a psychotic genesis were not to be found, neither in the case history nor the present. Consistently, a light subliminal agitation and increased vegetative arousal could be observed.
Related posts:
The Epidemiology of Post-traumatic Stress Disorder: A Focus on Refugee and Immigrant Populations
Introduction: The Relevance of Trauma Among Immigrants
Gender and Trauma
Cross-Cultural Communication with Traumatised Immigrants
Traumatised Immigrants in an Outpatient Clinic: An Experience-Based Report
A Therapy Model for Traumatised Refugees in Denmark
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