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Ombrydning1-2011.inddMedical best practices
for the treatment of torture survivors
Richard F. Mollica, M.D.*
cological problems. A head injury might be- Accurate identification of torture survivors, come evident during the neurological review including a history of the torture experi- and the physical sequelae of a burn injury ences and injuries, is essential for the medi- will emerge during questioning on the skin. cal care of torture survivors. This remains The early historical focus on the discov- a challenge, although the importance was ery of a “torture syndrome”1 which failed definitively described in the late 1980’s by to materialize in the 1980s and 1990s has Goldfeld and her colleagues.1 An accurate diagnosis, of course, is mandatory to im- mounting interest in caring for survivors of torture using “best practices” that are also treatment.2,3 Traumatic life events, including culturally efficacious in culturally diverse the torture events of the patient must be a populations.6,7 The latter is no small task central focus of clinical thinking. This en- since little research that meets the highest tails considering the effects of the patient’s standards of a randomized control trials trauma story on the medical history, review (RCT) have been conducted testing the ef- fectiveness and cultural validity of specific laboratory studies.4 A comprehensive review forms of treatment for torture survivors.
should not only be guided by the informa- the medical problems of torture survivors tion obtained during the preceding medical includes mostly anecdotal studies in this interview but also by the patient’s torture new field that primarily meet the criteria history.5 The patient’s traumatic experiences will help direct the physician to possible practices as well as the best practices (B) es- areas of the body that may have been dam- tablished in related and overlapping medical aged. For example, a potential rape victim areas. These studies are listed in accompany- will need detailed questions related to gyne- Specialized Clinics for the Care
of Torture Survivors
The most clinically effective and cost-effec- tive approach at the clinic and systems levels for the care of torture survivors have not
Table 1. Medical Best Practices
Type of Practice
Adams KM, Gardiner LD, Assefi N. Healthcare challenges from the de- veloping world: post-immigration refugee medicine. British Med J 2004; 328(7455):1548-1552.
Allden K, Baykal T, Iacopino V, Kirschner R, Özkalipçi O, Peel M, Reyes R, Welsh W, editors. Istanbul Protocol: manual on the effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment. Geneva: United Nations. Office of High Commissioner for Human Rights, 2001.
Babamoto KS, Sey KA, Camilleri AJ, Karlan VJ, Catalasan J, Morisky DE. Im- proving diabetes care and health measures among Hispanics using community health workers: results from a randomized controlled trial. Health Educ Behav 2009;36(1):113-126.
Boehnlein JK, Kinzie JD, Ben R, Fleck J. One-year follow-up study of posttrau- matic stress disorder among survivors of Cambodian concentration camps. Am J Psychiatry 1985;142(8), 956-959.
Carlsson JM, Mortensen EL, Kastrup M. A follow-up study of mental health and Promisinghealth-related quality of life in tortured refugees in multidisciplinary treatment. J Nerv Ment Dis 2005;193(10):654-7.
Cathcart LM, Berger P, Knazan B. Medical examination of torture victims apply- ing for refugee status. CMAJ 1979;121:179-84. Grigg-Saito D, Och S, Liang S, Toof R, Silka L. Building on the strengths of a Cambodian refugee community through community-based outreach. Health Promot Pract 2007;9(4):415-25.
Harlacher U, Jansen GB, Kastrup M, Madsen A, Montgomery E, Prip K, Sjölund BH. RCT Field Manual on Rehabilitation. Sjölund BH, editor. Copenhagen: The Rehabilitation and Research Centre for Torture Victims, 2007.
Kinzie JD, Fredrickson RH, Ben R, Fleck J, Karls W. Posttraumatic stress dis- order among survivors of Cambodian concentration camps. Am J Psychiatry 1984;141(5):645-650. Kinzie JD, Riley C, McFarland B, Hayes M, Boehnlein J, Leung P, Adams G. High prevalence rates of diabetes and hypertension among refugee psychiatric pa-tients. J Nerv Ment Dis 2008;196(2):108-112. Kinzie JD, Tran KA, Breckenridge A, Bloom JD. An Indochinese refugee psy- chiatric clinic: culturally accepted treatment approaches. Am J Psychiatry Mollica RF, Wyshak G, Lavelle J, Truong T, Tor S, Yang T. Assessing symptom change in southeast Asian refugee survivors of mass violence and torture. Am J Psychiatry 1990;147(1):83-8. Moreno A, Piwowarczyk L, LaMorte WW, Grodin MA. Characteristics and utili- zation of primary care services in a torture rehabilitation center. J Immigr Minor Health 2006;8(2):163-71.
Type of Practice
Gurr R, Quiroga J. Approaches to torture rehabilitation: a desk study cover- ing effects, cost effectiveness, participation and sustainability. Torture 2001;11(suppl 1).
Rasmussen OV, Amris S, Blaauw M, Danielsen L. Medical physical examination in connection with torture (Section I). Torture 2004;14(1):48-55.
Rasmussen OV, Amris S, Blaauw M, Danielsen L. Medical physical examination in connection with torture (Section II). Torture 2005;15(1):37-45.
Rasmussen OV, Amris S, Blaauw M, Danielsen L. Medical physical examination in connection with torture (Section III). Torture 2006;16(1):48-55.
Buchwald D, Manson SM, Brenneman DL, Dinges NG, Keane EM, Beals J, Kinzie JD. Screening for depression among newly arrived Vietnamese refugees in primary care settings. West J Med 1995; 163(4):341-345.
Mirzaei S, Knoll P, Lipp RW, Wenzel T, Koriska K, Köhn H. Bone scintigraphy in screening of torture survivors. Lancet 1998;352:949-51.
Mollica RF, Caspi-Yavin Y. Measuring torture and torture-related symptoms. J Consult Clin Psychol 1991;3(4):581-7.
Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring tor-ture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis 1992;180(2):111-116.
Mollica RF, Wyshak G, Lavelle J, Truong T, Tor S, Yang T. Assessing symptom change in southeast Asian refugee survivors of mass violence and torture. Am J Psychiatry 1990;147(1):83-8. Oruc L, Kapetanovic A, Pojskic N, Miley K, Forstbauer S, Mollica R, Henderson DC. Screening for PTSD and depression in Bosnia and Herzegovina: validating the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist. Int J Cult and Ment Health 2008;1(2):105-116.
Thomsen AB, Eriksen J, Smidt-Nielsen K. Chronic pain in torture survivors. Albucher RC, Liberzon I. Psychopharmacological treatment in PTSD: a critical review. J Psychiatr Res 2002;36(6):355-367.
Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G, Kerse N, MacGillivray S. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009, Issue 3. Art. No.: CD007954. DOI: 10.1002/14651858.CD007954.
Baso ˘glu M, Marks IM, Sengün S. Amitriptyline for PTSD in a torture survivor: a case study. J Trauma Stress 1991;5(1):77-83.
Berger W, Mendlowicz MV, Marques-Portella C, Kinrys G, Fontenelle LF, Marmar PromisingCR, Figueira I. Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review. Prog Neuropsychopharmacol Biol Psychiatry Bisson JI. Pharmacological treatment to prevent and treat post-traumatic stress Type of Practice
Cohen JA, Mannarino AP, Perel JM, Staron V. A pilot randomized controlled trial Bestof combined trauma-focused CBT and sertraline for childhood PTSD symptoms. J Am Acad Child 2007;46(7):811-9.
Cooper J, Carty J, Creamer M. Pharmacotherapy for posttraumatic stress dis- order: empirical review and clinical recommendations. Aust N Z J Psychiatry 2005;39:674-82.
DeMartino R, Mollica RF, Wilk V. Monoamine oxidase inhibitors in posttraumatic Promisingstress disorder: promise and problems in Indochinese survivors of trauma. J Nerv Ment Dis 1995;183(8):510-5.
Fernandez M, Pissiota A, Frans O, von Knorring L, Fischer H, Fredrikson M. Brain function in a patient with torture related post-traumatic stress disorder before and after fluoxetine treatment: a positron emission tomography provo-cation study. Neurosci Lett 2001;297:101-4. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database Syst Rev 2006, Issue 1. Art. No.: CD002795. DOI: 10.1002/14651858.CD002795.pub2.
Stein DJ, Pedersen R, Rothbaum BO, Baldwin DS, Ahmed S, Musgnung J, Dav- idson J. Onset of activity and time to response on individual CAPS-SX17 items in patients treated for post-traumatic stress disorder with venlafaxine ER: a pooled analysis. Int J Neuropsychopharmacol 2008;12:23-31. U.S. Department of Health and Human Services. Chapter 2: The Fundamentals of Mental Health and Mental Illness. In Mental Health: A Report of the Sur-geon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Men-tal Health Services, National Institutes of Health, National Institute of Mental Health. 1999.p.27-116.
Buysse, DJ. Chronic Insomnia. American Journal of Psychiatry 2008;165(6): 678- Buysse DJ, Reynolds C, Monk T, Berman S, Kupfer D. The Pittsburgh sleep qual- ity index: A new instrument for psychiatric practice and research. Psychiatry Research 1989;28(2):193-213. Fürstenwald U. Group therapy for severely traumatized refugees with a focus on sleep disorders. Hemi-Sync J 2005; XXIII(3-4):v-vi.
Glovinsky PB, Yang CM, Dubrovsky B, Spielman AJ. Nonpharmacologic strate- gies in the management of Insomnia: Rationale and implementation. Sleep Krakow B, Hollifield M, Johnston L, Ross M, Schrader R, Warner TD, Tandberg D, Lauriello J, McBride L, Cutchen L, Cheng D, Emmons S, Germain A, Melen- drez D, Sandoval D, Prince D. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized con-trolled trial. JAMA 2001;286(5):537-545.
Krakow B, Johnston L, Melendrez D, Hollifield M, Warner T, Chavez-Kennedy D, Herlan MJ. An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD. Am J Psychiatry 2001;158:2043-7.
Silber MH. Chronic Insomnia. New Engl J Med 2005;353(8):803-810. Type of Practice
Mollica R, Lyoo K, Chernoff M, Bui H. Lavelle J, Yoon S, Kim JE, Renshaw PF. Brain structural abnormalities and mental health sequelae in South Vietnamese ex-political detainees who survived trauamatic head injury and torture. Arch Gen Psychiatry 2009;66(11):1-12.
Danneskiold-Samsøe B, Bartels EM, Genefke I. Treatment of torture victims – a longitudinal clinical study. Torture 2007;17(1):11-7.
Krisanaprakornkit T, Sriraj W, Piyavhatkul N, Laopaiboon M. Meditation therapy Promisingfor anxiety disorders. Cochrane Database Syst Rev 2006, Issue 1. Art. No.: CD004998. DOI: 10.1002/14651858.CD004998.pub2.
Grodin MA, Piwowarczyk L, Fulker D, Bazazi AR, Saper RB. Treating survivors of torture and refugee trauma: a preliminary case series using qigong and t'ai chi. J Altern Complement Med 2008;14(7):801-6.
Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Ex- ercise for depression. Cochrane Database Syst Rev 2009, Issue 3. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub4. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomized clinical trials with acupuncture, placebo acu-puncture, and no acupuncture groups. BMJ 2009;338:a3115. Smith CA, Hay PPJ, MacPherson H. Acupuncture for depression. Cochrane Da- tabase Syst Rev 2010, Issue 1. Art. No.: CD004046. DOI: 10.1002/14651858.
CD004046.pub3. Sutherland JA. Getting to the point. Am J Nurs 2000;100(9):40-5. been demonstrated. For years there has been a debate whether torture survivors need to vivors and their need for a comprehensive be treated in their own specialized clinics or mainstreamed into conventional psychiatric been well established in the Istanbul Pro- and primary health care settings. It has not tocol.11 And there exists a large body of been proven that primary health care and medical experience on the identification community mental health centers can read- and treatment of the wide range of medical ily identify survivors of torture and provide problems affecting resettled refugees, mainly them with the services they need. In con- those who have been tortured.12,13 This body trast, Kinzie et al8 and Mollica et al9 along of work provides best practice baseline for with the Danish Rehabilitation and Research all clinics initially approaching the assess- Center for Torture Victims have shown that ment and care of torture survivors mostly specialized clinics have promising results.10 under the broader designation of refugee who now generally fall under statewide and an ideal addition to the physician’s clinical local public health services for newly arrived assessment of the torture survivor. It is very difficult for highly traumatized patients to present their symptoms of emotional distress refugees, including those who are torture to the doctor in any coherent fashion with- survivors, now receive their greatest atten- tion and government funding, chronic care models such as those used for diabetes are being applied to refugee communities and 25) and the Harvard Trauma Questionnaire their subset of torture survivors. This seem (HTQ), are almost mandatory in the clinical to be a promising practice since a number of assessment of torture survivors.24-26 The Har- randomized trials have demonstrated in His- has had extensive experience training PCPs the effectiveness of community health work- in the use of screening instruments such as ers, along with other adaptations of primary care, prompted improved diabetes control. 25) and the Harvard Trauma Questionnaire Outcome studies of chronic disease control for diabetes, heart disease, stroke, hyperten- Likert scale (1=not at all, 4=extremely) that sion and the metabolic syndrome in torture in the past week. Based on previous research on the optimal cut-off point that maximizes Assessment and Screening
sensitivity while maintaining high specificity, Over the past three decades extensive scien- scores greater than 1.75 indicate the presence tific data on the most frequent medical and of major depressive disorder. The HTQ was psychiatric disorders affecting torture survi- originally developed by Mollica and colleagues vors have been well documented.16-20 These as a companion measure to the HSCL-25 to references provide more detailed information assess traumatic events and trauma-related beyond the scope of this review, and must be studied by any medical provider caring diagnosis of PTSD at a cut off of 2.0. The for torture survivors in order to be aware of the major medical and psychiatric sequelae associated with torture. At this time few medical findings are definitely pathognomic, of the first culture-specific screening instru- except for biopsies of skin lesions associated ments for depression28 has not been widely with cigarette burns and electric shocks1 used as a model for other torture survivors in and bone scans to assess damage to the al- spite of its excellent ethnographic features.
leged area of injury secondary to torture.21 Medical Interventions
in torture survivors is a promising area of Proven best practices (BP) for the care of medical problems of torture survivors is lim- ited and relies heavily on the accepted stand- traumatic life experiences of the patient in ard of care found for mainstream medical a yes/no format and that can be given as a problems in the Cochrane Reports (www.
medical ‘test’ have been demonstrated to be exists on the medical care of torture survi- vors. The following is a review of anecdotal head and other forms of traumatic head in- clinical reports as well as related practices jury (THI), strangulation, anoxia secondary to waterboarding, and near drowning, and suffocation (e.g. placing a plastic bag over a Depression and
Posttraumatic Stress Disorder
Mollica et al.47 in their landmark study Turning our attention to direct medical in- of torture survivors have demonstrated the terventions, the effectiveness of psychotropic deleterious effects of THI on the brain of drugs have been anecdotally described for torture survivors and its correlation with de- refugee and torture survivors29 and definitely pression. The neuropsychological literature on THI in mainstream patients suggests that traumatic stress disorder (PTSD) as best these THI patients can be successfully re- practices in mainstream populations.30-38 habilitated through specialized psychosocial One caveat, however, clearly exists. Spe- and cognitive training.47 In addition, it is cial attention must be given to the proper possible that depression and PTSD second- dosing of psychotropic drugs in culturally ary to THI may be associated with chronic diverse populations. This field of ethnopsy- post-concussive symptoms that may be diffi- chopharmacology is revealed in Chapter 2 cult to treat with standard approaches using of the Surgeon General’s Report on Mental Health39 and a scientific toolkit guide for medication and depression is available from Physical Rehabilitation
Massage,48 physical therapy,48 meditation,49 diet and exercise,50,51 and acupuncture52-54 are promising and emerging best practices in Insomnia
the physical rehabilitation of torture survivors.
emerged as a major medical problem in sur- Future Directions
vivors of violence and torture.40,41 Extensive The medical care of torture survivors has research has revealed the effective non-phar- made enormous scientific advances over the macological strategies for sleep disturbances past three decades in documenting and de- regardless of whether it is of primary or scribing the major medical and psychiatric secondary to a medical or psychiatric disor- sequelae of torture. The health impact of der.42-46 Randomized trials demonstrating torture can be severe and chronic and lead to the efficacy of non-drug treatment of night- major disability and even premature death. Clearly, since there are not enough special- ized clinics to care for torture survivors in the United States and abroad, mainstream pri- mary care practitioners and certain specialists Neuropsychological problems
such as psychiatrists need to be taught how to of Traumatic Head Injury (THI)/
identify and treat the medical problems asso- Traumatic Brain Injury (TBI)
ciated with torture. Evidence-based medicine TBI has been well known and described as a from mainstream approaches to patient care common and major sequelae of torture.45,46 must be applied to the medical care of tor- ture survivors. However, every diagnosis and treatment must be contextualized not only Albers LJ, Hahn RK, Reist C. Handbook of Psy-chiatric Drugs, 2008 edition. Blue Jay, CA: Cur- to the cultural and social environment of the rent Clinical Strategies Publishing, 2008. patient, but to those unique barriers to treat- American Psychiatric Association, Committee on ment and healing that affect individuals who Nomenclature and Statistics. Diagnostic and Sta- have experienced cruel and degrading human tistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Associa- abuse of a horrific and unspeakable nature by other human beings. Longitudinal studies Carlson, KJ, Eisenstat, SA, and Ziporyn, T. The of the medical impact of torture overtime on New Harvard Guide to Women’s Health. Cam- survivors as well as specific hypothesis based bridge, MA: Harvard University Press, 2004. Goroll AH, Mulley AG, editors. Primary care medicine: office evaluation and management of what standard best practices need to be mod- the adult patient, 6th edition. Philadelphia, PA: ified in order to maximize clinical outcomes Lippincott Williams & Wilkins, 2009. Kolevzon A, Katz C. Psychiatry History Taking, in the care of survivors. At the minimum all 3rd edition. Laguna Hills, CA:Current Clinical current clinics that care for survivors need to carefully monitor their treatment outcomes Mollica RF. Healing Invisible Wounds: Paths to and in partnership with research institutions Hope and Recovery in a Violent World. Orlando, FL: Harcourt Press, Inc, 2006. scientifically evaluate their treatment out- Mollica RF, McDonald LS, Massagli MP, Silove comes. The findings would be strengthened if DM. Measuring Trauma, Measuring Torture. they could be compared against suitable con- Instructions and Guidance on the utilization trol groups. Each torture treatment center of the Harvard Program in Refugee Trauma’s Versions of the Hopkins Symptom Checklist-25 must measure up well in comparison to the (HSCL-25) & the Harvard Trauma Question- “best” general medicine has to offer, and ide- naire (HTQ). Cambridge, MA: Harvard Program ally even do better in adapting current best practices to the unique cultural, social and Spratto GR, Woods AL. PDR Nurse’s Drug Handbook, 2009 edition. Florence, KY:Cengage psychological realities of the torture survivor.
The “best practices” for treating the medical problems of torture survivors re- mains the “best practices” available to-date 1. Goldfeld AE, Mollica RF, Pesavento BH et al. for caring for mainstream patients with more The physical and psychological sequelae of torture. Symptomatology and diagnosis. JAMA conventional causes of their medical and psychiatric illnesses. As with all medical and 2. Bates B, Bickley LS, Hoekelman RA, eds. A guide to physical examination and history taking. 8th ed. Philadelphia: JB Lippincott, 1995.
3. Bates B. A guide to clinical thinking. 6th ed. manner of thinking about cause and effect and linking the latter to treatment.55,56 The 4. Mollica RF. Healing invisible wounds: paths to hope and recovery in a violent world. Orlando: special conditions that characterize the tor- ture experience and which may have a major 5. Mollica RF. Global health perspective: surviving impact on adapting standard medical best torture. New Engl J Med 2004;351:5-7.
practices to the care of survivors has been 6. Whaley AL, Davis KE. Cultural competence widely discussed and need to be considered and evidence-based practice in mental health ser-vices: a complementary perspective. Am Psychol in caring for all those human beings that 7. Aisenberg E. Evidence-based practice in mental health care to ethnic minority communities: has its practice fallen short of its evidence? Soc Work 22. Thomsen AB, Eriksen J, Smidt-Nielsen K. Chronic pain in torture survivors. Forensic Sci 8. Kinzie JD, Tran KA, Breckenridge A et al. An Indochinese refugee psychiatric clinic: culturally 23. Mollica RF. Assessment of trauma in primary accepted treatment approaches. Am J Psychiatry 24. Mollica RF, Caspi-Yavin Y, Bollini P et al. 9. Mollica RF, Wyshak G, Lavelle J et al. Assess- The Harvard Trauma Questionnaire. Validat- ing symptom change in southeast Asian refugee ing a cross-cultural instrument for measuring survivors of mass violence and torture. Am J Psy- torture, trauma, and posttraumatic stress disor- der in Indochinese refugees. J Nerv Ment Dis 10. Harlacher U, Jansen GB, Kastrup M et al, eds. RCT field manual on rehabilitation. Copenha- 25. Mollica RF, Caspi-Yavin Y. Measuring torture gen: The Rehabilitation and Research Centre for and torture-related symptoms. J Consult Clin 11. Allden K, Baykal T, Iacopino V et al, eds. Istan- 26. Mollica RF, Wyshak G, de Marneffe D et al. bul Protocol: manual on the effective investiga- Indochinese versions of the Hopkins Symptom tion and documentation of torture and other Checklist-25: a screening instrument for the cruel, inhuman or degrading treatment or pun- psychiatric care of refugees. Am J Psychiatry ishment. Geneva: United Nations, Office of High Commissioner for Human Rights, 2001.
27. Oruc L, Kapetanovic A, Pojskic N et al. Screen- 12. Adams KM, Gardiner LD, Assefi N. Health- ing for PTSD and depression in Bosnia and care challenges from the developing world: Herzegovina: validating the Harvard Trauma post-immigration refugee medicine. Br Med J Questionnaire and the Hopkins Symptom Check- list. Int J Cult and Ment Health 2008;1:105-16.
13. Cathcart LM, Berger P, Knazan B. Medical ex- 28. Buchwald D, Manson SM, Brenneman DL et al. amination of torture victims applying for refugee Screening for depression among newly arrived status. Can Med Assoc J 1979;121:179-84. Vietnamese refugees in primary care settings. 14. Grigg-Saito D, Och S, Liang S et al. Building on the strengths of a Cambodian refugee community 29. DeMartino R, Mollica RF, Wilk V. Monoamine through community-based outreach. Health Pro- oxidase inhibitors in posttraumatic stress disor- der: promise and problems in Indochinese survi- 15. Kinzie JD, Riley C, McFarland B et al. High vors of trauma. J Nerv Ment Dis 1995;183:510- prevalence rates of diabetes and hypertension among refugee psychiatric patients. J Nerv Ment 30. Fernandez M, Pissiota A, Frans O et al. Brain function in a patient with torture related post- 16. Babamoto KS, Sey KA, Camilleri AJ et al. Im- traumatic stress disorder before and after fluox- proving diabetes care and health measures among etine treatment: a positron emission tomography Hispanics using community health workers: re- provocation study. Neurosci Lett 2001;297:101- sults from a randomized controlled trial. Health 31. Albucher RC, Liberzon I. Psychopharmacologi- 17. Gurr R, Quiroga J. Approaches to torture re- cal treatment in PTSD: a critical review. J habilitation: a desk study covering effects, cost effectiveness, participation and sustainability. 32. Arroll B, Elley CR, Fishman T et al. Antidepres- sants versus placebo for depression in primary 18. Rasmussen OV, Amris S, Blaauw M et al. Medi- care. Cochrane Database Syst Rev 2009, Issue 3. cal physical examination in connection with tor- Art. No.: CD007954. DOI: 10.1002/14651858.
ture (Section I). Torture 2004;14(1):48-55.
19. Rasmussen OV, Amris S, Blaauw M et al. Medi- 33. Berger W, Mendlowicz MV, Marques-Portella C cal physical examination in connection with tor- et al. Pharmacologic alternatives to antidepres- ture (Section II). Torture 2005;15(1):37-45.
sants in posttraumatic stress disorder: a system- 20. Rasmussen OV, Amris S, Blaauw M et al. Medi- atic review. Prog Neuropsychopharmacol Biol cal physical examination in connection with tor- ture (Section III). Torture 2006;16:48-55.
34. Bisson JI. Pharmacological treatment to prevent 21. Mirzaei S, Knoll P, Lipp RW et al. Bone scinti- and treat post-traumatic stress disorder. Torture graphy in screening of torture survivors. Lancet 35. Cohen JA, Mannarino AP, Perel JM et al. A pilot randomized controlled trial of combined trauma- et al. Meditation therapy for anxiety disorders. focused CBT and sertraline for childhood PTSD Cochrane Database Syst Rev 2006, Issue 1. symptoms. J Am Acad Child 2007;46:811-9.
Art. No.: CD004998. DOI: 10.1002/14651858.
36. Cooper J, Carty J, Creamer M. Pharmacother- apy for posttraumatic stress disorder: empirical 50. Mead GE, Morley W, Campbell P et al. Exer- review and clinical recommendations. Aust N Z J cise for depression. Cochrane Database Syst Rev 2009, Issue 3. Art. No.: CD004366. DOI: 37. Stein DJ, Pedersen R, Rothbaum BO et al. On- set of activity and time to response on individual 51. Grodin MA, Piwowarczyk L, Fulker D et al. CAPS-SX17 items in patients treated for post- Treating survivors of torture and refugee trauma: traumatic stress disorder with venlafaxine ER: a preliminary case series using qigong and t'ai a pooled analysis. Int J Neuropsychopharmacol chi. J Altern Complement Med 2008;14:801-6.
52. Madsen MV, Gøtzsche PC, Hróbjartsson A. 38. The fundamentals of mental health and mental Acupuncture treatment for pain: systematic re- illness. In: Mental health: a report of the surgeon view of randomized clinical trials with acupunc- general. Rockville: U.S. Department of Health ture, placebo acupuncture, and no acupuncture 39. Stein DJ, Ipser JC, Seedat S. Pharmacotherapy 53. Smith CA, Hay PPJ, MacPherson H. Acupunc- for post traumatic stress disorder (PTSD). ture for depression. Cochrane Database Syst Cochrane Database Syst Rev 2006, Issue 1. Rev 2010, Issue 1. Art. No.: CD004046. DOI: Art. No.: CD002795. DOI: 10.1002/14651858.
54. Sutherland JA. Getting to the point. Am J Nurs 40. Krakow B, Hollifield M, Johnston L et al. Im- agery rehearsal therapy for chronic nightmares in 55. Engel G. The need for a new medical model: sexual assault survivors with posttraumatic stress a challenge for biomedicine. Science April disorder: a randomized controlled trial. JAMA 56. Siebens H. The domain management model 41. Fürstenwald U. Group therapy for severely trau- - Aatool for teaching and management of older matized refugees with a focus on sleep disorders. adults in emergency departments. Acad Emerg 42. Buysse, DJ. Chronic Insomnia. American Journal 43. Buysse DJ, Reynolds C, Monk T et al. The Pitts- burgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193-213.
44. Krakow B, Johnston L, Melendrez D et al. An open-label trial of evidence-based cognitive behavior therapy for nightmares and insomnia in crime victims with PTSD. Am J Psychiatry 2001;158:2043-7.
45. Glovinsky PB, Yang CM, Dubrovsky B et al. Nonpharmacologic strategies in the management of insomnia: rationale and implementation. Sleep 46. Silber MH. Chronic Insomnia. New Engl J Med 47. Mollica R, Lyoo K, Chernoff M et al. Brain structural abnormalities and mental health se-quelae in South Vietnamese ex-political detainees who survived trauamatic head injury and torture. Arch Gen Psychiatry 2009;66:1-12.
48. Danneskiold-Samsøe B, Bartels EM, Genefke I. Treatment of torture victims - a longitudinal clinical study. Torture 2007;17:11-7.
49. Krisanaprakornkit T, Sriraj W, Piyavhatkul N
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