Looking Beyond PTSD Emerging Practices for Treating Psychiatric Sequelae of Torture

Transcription

1 Looking Beyond PTSD Emerging Practices for Treating Psychiatric Sequelae of Torture James L. Griffith, M.D. Professor of Psychiatry and Neurology Interim Chair and Director, Psychiatry Residency Program The George Washington University Medical Center Washington, DC

2 What is Torture? The deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons, acting alone or on the orders of any authority, to force a person to yield information, make a confession, or for any other reason -- World Medical Association, Declaration of Tokyo, 1985

3 Torture Produces Posttraumatic Stress Disorder (PTSD) Select traumatic events and the estimated risk for developing PTSD* % 49.0% 40 Risk of PTSD (%) % 23.7% 16.8% 15.4% 14.3% 10.4% 7.3% 3.8% 0 Held captive/ tortured/ kidnapped Rape Severe beating Other sexual assault Serious accident or injury Shooting or stabbing Sudden unexpected death of a close friend or relative Child s lifethreatening illness Witnessing killing/ serious injury Natural disaster *Based on results from the Detroit Area Survey of Trauma, which was a telephone survey conducted among a representative sample of 2181 individuals aged 18 to 45 years in the Detroit area in Breslau 1998.

4 Psychopharmacology for PTSD May Be Needed to Enable Psychotherapy Treat symptoms by patient s priority of concern, usually poor sleep as first priority. SSRI s or other antidepressants to reduce nightmares/flashbacks, avoidance, hyperarousal. Low-dose atypical antipsychotics for poor sleep or agitation.

5 Psychopharmacology for PTSD Symptoms Target specific residual symptoms: Nightmares Prazosin or Topiramate Irritability or Excessive Startle Clonidine or Guafacin Headaches Dual-Action Antidepressant (venlafaxine, tricyclic), Topiramate Hallucinations Low-dose atypical antipsychotics

6 Torture PTSD

7 What Are Psychiatric Sequelae of Torture? TRAUMA (PTSD, Dissociative Symptoms) TORTURE HATRED (Discrimination, Coercion, Internalized Stigma) LOSS (Demoralization, Traumatic Grief, Ambiguous Loss)

8 PTSD and Dissociative Disorders Are Co-Sequelae of Traumatic Stress Posttraumatic Traumatic Stress Symptoms Events Terror, Horror, Helplessness, Humiliation Dissociative Symptoms

9 Dissociative Symptoms (1) Cognitive Dissociation Impaired concentration, memory, self-reflection, or problem-solving skills when feeling insecure, unsafe, or alarmed; (2) Depersonalization Feeling numb, empty, or outside one s body (3) Derealization Distortions in visual or auditory perceptions or sense of time (4) Conversion (Somatic Dissociation) Loss of conscious awareness or control over physical body, resulting in medically-unexplainable physical

10 PTSD and Dissociative Disorders Often Co-Occur 86% of patients with PTSD also have some dissociative symptoms (such as amnesia) 30% of PTSD patients in research studies respond to traumatic memories with no increase in heart rate, but rather by feeling distanced from their experience, zoned out, or out of my body 100% of patients with Dissociative Identity Disorder also have PTSD

11 What Are Psychiatric Sequelae of Torture? TRAUMA (PTSD, Dissociative Symptoms) TORTURE HATRED (Discrimination, Coercion, Internalized Stigma) LOSS (Demoralization, Traumatic Grief, Ambiguous Loss)

12 Ambiguous Loss Ambiguous loss occurs when: The reality of the loss is uncertain The loss is unwitnessed by other people There is no social validation of the significance of the loss.

13 Ambiguous Loss Uncertainty of reality of loss obstructs both normal grief and needed practical life adjustments. This un-named loss and melancholy that never went away (Boss, 1995)

14 Traumatic (Complicated) Grief Traumatic grief is a disabling chronic pattern of grief that shares features of both depression and PTSD: 1) Sense of disbelief regarding the loss 2) Anger and bitterness over the loss 3) Recurrent pangs of painful emotions 4) Preoccupation with thoughts of the loss, including distressing intrusive thoughts 5) Avoidance of reminders of the loss

15 Traumatic Grief Poor response to either grief counseling or standard treatments for depression High rates of co-morbidity: 1) 21-54% co-occurrence with Major Depressive Disorder 2) 30 to 50% co-occurrence with PTSD

16 The Torturers Aim Induce Profound Demoralization Self-perceived incapacity to act at some minimal level according to one s internalized standards. -- John de Figueiredo & Jerome Frank. Comprehensive Psychiatry, 1982

17 Countering Demoralization How Does This Loss Affect You? How Do You Survive It? Vulnerability Resilience Confusion Coherency Isolation Communion Helplessness Agency Despair Hope Meaninglessness Purpose Resentment Gratitude -- Griffith & Gaby, Psychosomatics, 2005

18 What Are Psychiatric Sequelae of Torture? TRAUMA (PTSD, Dissociative Symptoms) TORTURE HATRED (Out-Group Discrimination & Violence, Internalized Stigma) LOSS (Demoralization, Traumatic Grief, Ambiguous Loss)

19 Treating Sequelae of Hatred Salman Aktar s Formulation for Hateful Acts: 1) Something bad is done (anger) 2) Something good is taken away (sorrow) 3) Everyone pretends this is normal (numbness)

20 Treating Sequelae of Hatred Therapeutic Steps: 1) Something bad is done Deconstruct the torturer s intent & practice defiance. 2) Something good taken away Take inventory, acknowledge, and bear the losses. 3) Everyone pretends this is normal Affirm the reality of evil 4) Help the person to tailor good enough revenge

21 Deconstructing the Torturer s Aim: Profound Demoralization The effect of isolation is compounded by verbal induction of helplessness and hopelessness, a common practice both before and during the infliction of torture. The torturers attempt to undermine any sense of hope or self-reassurance in the detainees by suggestions, threats, and bluffs during interrogation. -- Metin Basoglu, 2001

22 What Good Has Been Taken Away? Losses are often ambiguous, unseen, without validation in the wider culture: Loss of home Separation from family Separation from culture Loss of career Change in social status Physical and economic instability

23 What Good Has Been Taken Away? Loss of a Relational World Impaired relatedness with self, family members, other people, or one s God, ancestors, or other spiritual beings Loss of a sense of self due to impaired concentration, memory, affects, or perceptions.

24 What is Good-Enough Revenge? Large enough to restore sense of dignity Small enough to avoid guilt Optimally, an effective action is taken against the system and power structure that enabled the torture, rather than targeting a single individual Time-limited

25 What Are Psychiatric Sequelae of Torture? TRAUMA (PTSD, Dissociative Symptoms) TORTURE HATRED (Out-Group Discrimination & Violence, Internalized Stigma) LOSS (Demoralization, Traumatic Grief, Ambiguous Loss)

26 Emerging Practices in Psychiatric Care of Trauma-Survivors Treat PTSD and depression to remission in order to enable psychotherapy; Teach survivors how to manage cognitive dissociation; Utilize psychotherapeutic strategies effective for traumatic grief, ambiguous loss, and rebuilding morale; Utilize psychotherapeutic strategies that aid recovery from discrimination, out-group violence, and internalized stigma.

27 References on Management of Dissociative Symptoms Rothschild, B. (2010). Eight Keys to Safe Trauma Recovery. New York: W.W. Norton. Levine, P. (2005). Healing Trauma: A Pioneering Program for Restoring the Wisdom of Your Body. Boulder, CO: Sounds True. Levine, P. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley, CA: North Atlantic Books.

28 References on Ambiguous Loss Boss, P. (1999). Ambiguous Loss: Learning to Live with Unresolved Grief. Cambridge, MA: Harvard University Press. Griffith, J. L., & Griffith, M. E. (2002). Chapter 10: Living Beyond Medical and Mental Illness. Encountering the Sacred in Psychotherapy: How to Talk with People about their Spiritual Lives. New York: Guilford Press, 2002.

29 References on Traumatic Grief Shear, K., Frank, E., Houck, P.R., & Reynolds, C.F. (2005). Treatment of complicated grief: A randomized controlled study. JAMA 293: Cohen, J.A., & Mannarino, A.P. (2004). Treatment of childhood traumatic grief. Journal of Clinical Child and Adolescent Psychology 33:

30 References on Demoralization Griffith JL, & Gaby L. (2005). Brief psychotherapy at the bedside: Countering demoralization from medical illness. Psychosomatics 46: Slavney, P.R. (1999). Diagnosing demoralization in consultation-liaison psychiatry. Psychosomatics 40:

31 References on Recovery from Stigmatization and Out-Group Hatred Weingarten, K. (2003). Common Shock: Witnessing Violence Every Day How We Are Harmed, How We Can Heal. New York: Dutton Press. Weingarten, K. (2003). On hating to hate. Family Process 45: