Providing Care for Survivors of Torture

• Understand the historical context and relevance of torture for healthcare providers

• Recognize how torture can affect a patient’s health status

• Understand the possible influence of culture on manifestations of symptoms, specifically in reference to somatization, mental health, and chronic pain.

  • Somatization

  • Cultural differences in expression 

• Able to elicit and document a history of torture 

• Learn how to approach discussions about immigration status with patients

The number of forcibly displaced people around the world has been steadily rising over the past century, surpassing 100 million for the time in 2022 [1]. With unresolved crises around the world including the Russia-Ukraine war and the Taliban takeover of Afghanistan, this number has rapidly increased in 2023 [1]. 

Meta analyses based on United States populations estimate that about 44% of refugees are either primary or secondary survivors of torture, war trauma, and/or abuse [2]. This suggests that over the past 30 years, there were about 1.3 million survivors of torture living in the US [2]. 

The United Nations defines torture as: “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person” with the purpose of coercing, punishing, intimidating, or out of discrimination [3]. This practice is described as a deliberate and often systematic dismantling of a person’s identity and humanity. Survivors may have experienced “severe beatings, rape, deprivation, humiliation, threats, mock executions, sensory stress, kidnapping, forced postures, asphyxiation, burning, and witness to the murder and torture of family members” [2]. 

Survivors of torture have significantly higher rates of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) compared to immigrants who had not experienced torture [4]. Survivors of three or more types of torture and survivors of rape were at the highest risk for MDD and PTSD [4]. Often, the stress and sequelae of trauma significantly interferes with their ability to maintain employment and carry out activities of daily living [4]. A history of torture is frequently missed by providers, likely due to uncertainty about how to ask such a sensitive question [5]. Providers may also be afraid about re-traumatizing their patient by asking them to discuss traumatic events [5]. It is therefore crucial for primary care providers to receive specialized training in the recognition of torture and in the longitudinal care of this population.

You are a 3rd year medical student on your outpatient family medicine rotation. Your preceptor, Dr. Kim, introduces you to a new patient on her schedule, a 35-year old woman named “Sarah.” She asks you to see Sarah first and obtain a thorough history. You do some preliminary chart review beforehand and discover that Sarah has been to the emergency room ten times within the last year complaining of abdominal pain.

After introducing yourself to Sarah, you start by asking her some questions about her concerns today.

You: What brings you in today, Sarah?

Sarah: Well, I have had this pain in my belly for about a year now. It is really bothering me, and the doctors in the emergency room haven’t been able to do anything about it. They just keep sending me home and telling me that nothing is wrong. I’m hoping that you and Dr. Kim can help me.

You: I’m so sorry that you’re experiencing this, Sarah. Tell me more about this belly pain. 

Sarah: It’s an achey pain on the right side of my belly that comes and goes. When the pain gets really bad, it can feel more like a stabbing pain. I have tried ibuprofen for the pain, but it doesn’t really work so I stopped taking that. 

You: Does the pain radiate anywhere? How are your bowel movements? Any diarrhea or constipation?

Sarah: No, the pain doesn’t really radiate. It stays mostly on the right side. My bowel movements are fine, no diarrhea or constipation.

You: Do you feel like the pain is worsening over time? 

Sarah: No, it really feels about the same with flare-ups about once a month. I would appreciate it if you and Dr. Kim could find the cause, because I am very worried that something is happening to me.

You thank Sarah for sharing her concerns and finish obtaining the rest of the history and a review of systems. You learn that: 

• Sarah moved to the United States with her family (husband and two young children) from Trinidad 4 years ago and has been working in construction

• This is Sarah’s first time seeing a primary care provider. No medical or surgical history. No significant family history of diabetes, HTN, or cancer.

• She takes no medications and has no medication allergies. 

• She reports that she has never smoked a cigarette and drinks alcohol “socially” (1-2 drinks per week). She does not use any other substances. 

• She also has chronic headaches which started 4 years ago. They are bilateral. She points to her temples as the source of her pain. She also has associated neck pain, no aura. 

• She has no other concerns and otherwise feels “well”

• Review of systems: Positive for difficulty sleeping. She denies chest pain, shortness of breath, vision changes, rashes, and changes in mood. 

Your physical exam reveals the following: 

Vitals: Pulse 70, BP 130/75, RR 20, temperature 98.6 F, O2 saturation 99% on room air

General: Well-appearing, no acute distress. Sitting on an examination table. 

Neurological: Alert and oriented to person, place, and time. Cranial nerves II-XII grossly intact. 

Cardiovascular: Regular rate and rhythm. No murmurs or bruits auscultated. 

Abdominal: Tender to palpation in the RLQ. No rebound tenderness or guarding. Otherwise non-tender to palpation. No masses, no obvious distension. Bowel sounds auscultated. 

Extremities: Asymmetric carrying angle noted in left upper extremity (see images). Hard, bony mass palpated in the left distal humerus. Non-tender to palpation. Flexion and extension limited on left side; 100 degrees of flexion and extension to 30 degrees compared to full flexion and extension on the right. Full range of motion throughout bilateral lower extremities. 

Skin: No rashes that can be seen.

Question

Based on the information you have gathered, what is on your differential for this patient’s abdominal pain? (Short answer)

Answer (Highlight the following text for the answer): Abdomen (Biliary colic, Pancreatitis, Duodenal ulcer, Gastroenteritis), Urologic (Kidney stones), Vascular (Abdominal aortic aneurysm), Musculoskeletal (Hernia, Abdominal wall strain), Psychiatric (Malingering, Factitious disorder imposed on self,  Illness anxiety disorder, Major depression, generalized anxiety, post-traumatic stress disorder), Iatrogenic (Medication induced)

You report your findings and share your broad differential with Dr. Kim. She discusses the patient and reviews the emergency room documentation with you. 

• Sarah consistently reports right sided abdominal pain that is tender to palpation on exam. She does not present to the emergency room with any associated symptoms

• Sarah has received multiple CT scans and MRIs of her abdomen as well as extensive lab work within the last year, all of which are completely negative

• Sarah typically receives toradol when she comes to the emergency room. She is usually sent home with instructions to take tylenol and ibuprofen. She has never been prescribed opiate medications and a recent urine drug screen was negative for all substances

Question

What kind of work-up would you suggest for this patient? 

A: Repeat MRI of abdomen/pelvis

B: Repeat CT scan of abdomen/pelvis

C: X-ray of abdomen/pelvis

D: Repeat labs: CBC, CMP, urine drug screen

E: A & D

F: None of the above

Answer ((Highlight the following text for the answer): The answer is F, none of the above.     Dr. Kim: This patient has had an extensive negative work-up. There’s no benefit in repeating those tests today, especially since they were completed so recently. I do wonder if this patient’s abdominal pain is a somatic symptom of depression or PTSD rather than a gastrointestinal cause.

She returns with you to talk to Sarah and performs her own physical exam. Her exam findings are consistent with yours.

• Dr. Kim: Sarah, I’ve heard a lot about your story from our medical student. I’m curious about your immigration history. Why did you and your family decide to move here from Trinidad? 

• Sarah: It’s a long story but it was simply not safe for us anymore.

• Dr. Kim: Would you be willing to share your immigration status with me? I understand this can be a sensitive topic for many. This information would only be used to help me understand your history better. I do not plan to share this information with anybody or document this in your chart.

• Sarah: I don’t mind. We were finally granted asylum in the US about a year ago. The application process was hard but worth it because things are much better now.

• Dr. Kim: I’m really happy that you’re here and that you’re safe now. However, I’m wondering if your symptoms today, like your headache and bellyache, might be related to your history. Would you be willing to discuss some of that today?

• Sarah: Sure. 

After a lengthy conversation, Sarah shares that she became a target of gang violence in Trinidad about 5 years ago. She often lived in fear for her life. At its worst, Sarah was abducted by gang members and tortured for several days. During this time, she sustained a left arm fracture. Out of fear, Sarah did not seek healthcare for her injuries and instead let the fracture heal on its own. She often wonders if the fracture did not heal correctly, as she has noticed the bump and the limited range of motion.

Question

What additional questions would you ask Sarah? (Short answer)

Answer (Highlight the following text for answer): Suggested answers: What is your mood like these days? What has the transition to America been like for you? Did you experience any other injuries as a result of your abduction? Do you currently feel safe? 

Question

What is your differential diagnosis at this point in the case? Has your differential changed? (Short answer)

Answer (Highlight the following text for answer):  Answers may include but not limited to: Abdomen (Biliary colic, Pancreatitis, Duodenal ulcer, Gastroenteritis), Urologic (Kidney stones), Vascular (Abdominal aortic aneurysm), Musculoskeletal (Hernia, Abdominal wall strain), Psychiatric (Malingering, Factitious disorder imposed on self,  Illness anxiety disorder, Major depression, generalized anxiety, post-traumatic stress disorder), Iatrogenic (Medication induced)

Sarah also shares that she has been struggling with episodes of fatigue. She endorses low mood and is frequently tearful. These episodes often last for 1-2 months at a time. She frequently struggles to leave her bed and go to work. She is also worried “all the time” and has often felt as though she needs to “look over her shoulder” to make sure nobody is following him. She has nightmares about the abduction regularly. These symptoms have persisted since she fled from Trinidad. Dr. Kim listens and takes careful notes. She reviews all of her findings with Sarah, including all of the imaging and testing that has already been completed. 

• Dr. Kim: Sarah, based on your description, I believe you have post-traumatic stress disorder (PSTD) as a result of the violence you experienced in Trinidad. You may also have major depressive disorder (MDD), which commonly goes hand-in-hand with PTSD. 

• Sarah: What is PTSD?

Question

How would you explain PTSD to your patient? Please write your explanation without medical jargon.

Answer (Highlight the following text for the answer): PTSD is a mental health condition that can develop after people have experienced or witnessed a traumatic event. People may notice upsetting thoughts, feelings, and behaviors, such as nightmares, anxiety, and sadness. These feelings and thoughts might be normal and are experienced by most people after trauma. However, people with PTSD will experience symptoms that may be more severe or last for a longer period time. 

Dr. Kim explains that PTSD is a disorder in which a person who has experienced a life-threatening event has difficulty recovering. Symptoms may include: recurrent flashbacks, nightmares, hypervigilance (which means an elevated state, constantly assessing threats), heightened reactions, anxiety, and depressed mood. 

• Dr. Kim: I believe that your belly pain and headaches may be related to the immense amount of stress, and likely are somatic manifestations of your PTSD and MDD. Tension headaches, like the ones you describe, often happen when we are very tense and hold our stress in our neck and shoulders. High levels of chronic stress can also affect your gut, causing pain and indigestion.

• Sarah: That actually makes a lot of sense. When I am feeling very anxious, I have noticed more bellyaches. 

You, Dr. Kim, and Sarah discuss options for treatment together, and ultimately decide on starting fluoxetine to help with her mood. She also agrees to meet with a specialized trauma trained therapist to establish care.

You and Dr. Kim return to her office after Sarah leaves. You remember that all new patients fill out a PHQ-9 when they establish care at this clinic. When you pull up Sarah’s screening forms, you see that she scored a 3.

• You: Dr. Kim, I wonder why Sarah didn’t screen positive for depression.

• Dr. Kim: I think there are a few reasons why that might be. One is that there are known cultural differences in the ways depression manifests across cultures [6]. For instance, Americans with depression tend to relate to the description of persistent sadness and decreased interest in activities. But patients from other cultures and backgrounds may be more likely to have somatic symptoms instead, like Sarah did. 

• Dr. Kim: Another possibility is that Sarah was not ready to share those feelings yet, especially before meeting us and establishing a connection. Sometimes, building trust and establishing a relationship is necessary before screening for depression. 

• Dr. Kim: Finally, it is important to keep language barriers in mind. Sarah was fluent in English, but you will likely have patients that aren’t as fluent and may struggle to interpret the questions on the PHQ-9. For those patients, it will be critical to have a translator present.

One month later, Sarah returns to clinic for follow-up. She is pleased to see you there. She shares that both counseling and the fluoxetine have been very helpful. She is also excited to share that her abdominal pain and headaches have significantly improved. She tells you that she has not had to visit the emergency room since. She thanks you and Dr. Kim for listening and figuring out the source of her symptoms.

1. 2023: A Moment of Truth for Global Displacement - UNHCR Spotlight. UNHCR Spotlight. https://www.unhcr.org/spotlight/2023/01/2023-a-moment-of-truth-for-global-displacement/. Published January 11, 2023.

2. Higson-Smith C. UPDATING the ESTIMATE of REFUGEES RESETTLED in the UNITED STATES WHO HAVE SUFFERED TORTURE.; 2015. https://www.cvt.org/wp-content/uploads/SurvivorNumberMetaAnalysis_Sept2015_0.pdf

3. United Nations. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. OHCHR. Published December 10, 1984. https://www.ohchr.org/en/instruments-mechanisms/instruments/convention-against-torture-and-other-cruel-inhuman-or-degrading.

4. Weinstein H, Dansky L, Iacopino V. Torture and war trauma survivors in primary care practice. PubMed. 1996;165(3):112-118.

5. Eisenman DP. Survivors of torture in a general medical setting: how often havepatients been tortured, and how often is it missed? Western Journal of Medicine. 2000;172(5):301-304. doi:https://doi.org/10.1136/ewjm.172.5.301

6. Dreher A, Hahn E, Diefenbacher A, et al. Cultural differences in symptom representation for depression and somatization measured by the PHQ between Vietnamese and German psychiatric outpatients. Journal of Psychosomatic Research. 2017;102:71-77. doi:https://doi.org/10.1016/j.jpsychores.2017.09.010