COMMENTARY

Evaluation and Treatment of Survivors of Torture and Refugee Trauma

Allen S. Keller, MD

Disclosures

May 13, 2009

In This Article

BT (Part IV)

When BT is again evaluated in the local hospital's walk-in clinic, he sees a clinician, Dr. L, who worked as a medical volunteer in a refugee camp in Chad. Although Dr. L speaks some French, he nevertheless uses an interpreter certified by the hospital. Dr. L reviews the records from BT's previous visit.

On further questioning, Dr. L learns that BT's cough has lasted for about 1.5 months and is nonproductive. BT denies hemoptysis, fevers, night sweats, or weight loss. BT describes his stomach pain as a burning sensation that occurs most often when he is hungry. He has 1 normal stool a day without any blood. BT's headaches and muscle aches come and go. Recently, BT has noted more pain on his left side when he coughs. He shows Dr. L pills (ibuprofen) brought from his country that he takes for the pain.

Dr. L learns that BT was a student at a university. He did not smoke, drink, or use drugs. Before coming to the United States, BT was treated for malaria and a stomach infection in a "camp" located just over his country's border where many of his fellow countrymen now live. "It was really filthy there," BT adds.

Dr. L asks, "Why did you leave your country?" BT looks down at the ground and then softly responds, "Because I had problems." "What kind of problems?" Dr. L asks. "Problems with the government," BT says in a trembling voice. After several quiet moments, Dr. L tells BT: "I know this must be difficult to talk about, but it's important I understand what happened so that I can try and help you."

After another long pause, BT tells Dr. L about his imprisonment and abuse and then fleeing his country. "This is the first time I have talked to anyone about these things," BT says. BT also describes to Dr. L his many psychological symptoms.

BT's physical exam is significant for tenderness over one of his left ribs. A dermatologic evaluation shows multiple scars on BT's body. The remainder of the physical, including neurologic and musculoskeletal examination, is unremarkable.

Addressing the Health Needs of Torture Survivors and Refugee Trauma

Survivors of torture and refugee trauma commonly experience multiple medical, psychological, and social health concerns.[4,11,12,13,14,15,16,17] These dimensions of health are interdependent in the symptoms that they produce and in the need for effective, comprehensive treatment.[11,12] For example, hunger or musculoskeletal pain (physical symptoms) can trigger disturbing memories of past experiences resulting in significant symptoms of anxiety and depression. These psychological responses may result in additional physical symptoms, such as palpitations, and social consequences, including isolation or substance abuse. Similarly, assisting a traumatized immigrant who speaks little or no English to find an English class may enhance the patient's self-esteem, in addition to teaching practical skills. Removing the language barrier can facilitate improvement in the patient's psychological symptoms.

Although the health problems and needs of survivors of torture and refugee trauma are not necessarily unique, the frequency of health concerns, such as musculoskeletal pain; infectious diseases, including tuberculosis; and psychiatric disorders, such as anxiety and depression, is likely higher than in the general population or in nontraumatized immigrant populations. Furthermore, the context in which these health problems arose (human inflicted, suffering from war, displacement, and violation of basic human rights) may heighten their impact compared with natural illnesses or chance accidents. Empathic communication skills and cultural sensitivity are important both for rapport building and providing effective care. Many physical symptoms may well be at least partly somatic in nature. As with any patient, it is important to rule out underlying physical causes.

Approximately 25 specialized centers that are members of the National Consortium of Torture Treatment Programs (NCTTP) are located throughout the United States and provide services for torture survivors. In addition to direct services for which you can refer patients, these programs provide useful training and consultation concerning the evaluation and treatment of victims of torture and refugee trauma. The Bellevue/NYU Program for Survivors of Torture provides comprehensive medical, mental, social, and legal services to immigrants, particularly refugees and asylum seekers, who live in the New York City area. A partial list of information sources for medical, legal, and social services for torture survivors, refugees, and asylum seekers can be found in the Table.

Musculoskeletal Pain and Neurologic Complaints

Musculoskeletal pain is frequently reported by torture survivors and those from refugee populations.[11,12,13,14,15,16] In a recent study of Iraqi refugees resettled in the United States who were seeking mental health services, 70% complained of lower back pain.[19] Such pain may result from beatings, being restrained in painful positions, or enduring extremely difficult travel circumstances, including fleeing with what belongings that could be carried. Clinical evaluation can help identify clear etiologies for reported pain, including fractures, soft-tissue injuries, or torn ligaments. As noted above, pain may have, at least in part, a somatic component. Adequate pain management, including medications, physical and occupational therapy, and treatment of underlying psychological symptoms can be beneficial. Headaches and dizziness are also common among patients in this population.[10,11,12,13,14,15] Exploring whether there is a history of head trauma as well as cognitive dysfunction is important.

Infectious Diseases and Gynecologic/Genitourinary Problems

Infectious diseases, such as tuberculosis and hepatitis, are endemic in many of the developing countries from which immigrants come. Survivors of torture and refugee trauma may be at even greater risk, however, as a result of mistreatment, overcrowding, and poor sanitation in prisons or refugee camps.[11,12,13,14,15,16] The beatings and other physical injuries that BT endured can cause infected wounds and subsequent scarring -- or even more seriously, osteomyelitis. Rape and sexual humiliation are common forms of abuse suffered by traumatized refugees and torture victims. A study conducted by the Bellevue/NYU Program for Survivors of Torture found that approximately one third of all clients reported rape or sexual assault.[17] Given the deep shame and humiliation associated with sexual abuse, it is likely to be substantially underreported. The use of rape against women as an act of war is a well-documented horror.[20,21] Rape and sexual assault can result in sexually transmitted infections, including HIV, unwanted pregnancy among women survivors, chronic urinary complaints, sexual dysfunction, and profound symptoms of anxiety and depression.

Gastrointestinal and Other Trauma-Related Symptoms

Blunt trauma can result in bruises, broken bones, scars, detached retinas, premature cataracts, and broken teeth.[16,17] Acid injuries can cause severe scarring and visual impairments. Beatings over the ears can cause perforated eardrums, hearing loss, and chronic tinnitus. Long-term abdominal complaints may be caused by infectious etiologies, such as hepatitis and parasitic infections, dyspepsia, or gastroesophageal reflux, or may be somatic in nature.[16,17]

Psychological Symptoms

For many survivors of torture and refugee trauma, the psychological symptoms and scars are the most significant and long-lasting.[4,11,12,13,14,15,16,17,22] Depression and anxiety, particularly PTSD, are much higher among refugees and torture survivors than in the general population or even in other immigrant populations.[1,3,4] For example, in the general population, the estimated lifetime prevalence of PTSD is 8%.[23] In countries exposed to mass violence and conflict the prevalence rate is double that or more (16%-37%).[1,3,4] Depression is believed to be even more common. Furthermore, individuals may suffer from both depression and PTSD. Other common psychological symptoms include cognitive impairments, feelings of helplessness, shame and humiliation, and sleep difficulties. When caring for traumatized populations, clinicians must take a thorough sleep history, including duration of sleep, how long it takes to fall asleep, and whether sleep is interrupted.

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