Chronic pain, including neuropathic pain, has a high prevalence in torture survivors and a low rate of spontaneous resolution [9]. Prevalence is hard to establish, but estimates are around 80% [6,9]. Since pain can exist without tissue pathology or findings on investigation, a thorough grounding in pain science is necessary for adequate assessment, with attention to the following:
- Torture can involve disruption of nervous, immune and endocrine systems, all of which can affect pain physiology and subjective experience [2,6,8].
- Central sensitization induces hypersensitivity to pain and other somatic symptoms. Descending pain modulation modulates the urgency of the pain signal according to situational variables, particularly threat. Torture often induces a long-lasting sense of threat (post-traumatic stress) that facilitates pain signaling and decreases pain inhibition [2,5]. Pain should therefore not be interpreted as a nonspecific symptom of stress or considered ‘psychosomatic,’ but investigated fully as a problem in its own right. Physical and psychological sequelae worsen each other.
- There is almost no research on injuries of the type inflicted in physical torture, nor on the added effects of detention in conditions of poor hygiene; deprivation of food, water, and sleep; extreme temperatures; and severe and prolonged fear [3].
- Assessment, bearing in mind the points above, may require interpretation, either face-to-face or by phone: it should always be offered. It is important to ask directly about torture or violence; most goes undisclosed in medical consultations [4]. It is also important to build rapport, appreciating how difficult trust can be for survivors of torture. Content of assessment should include:
- Detailed questions about torture and other ill-treatment experienced, explaining why this is necessary in order to understand the pain better. However, the patient should not be required to repeat this information to each new member of a healthcare team, who should instead share information fully.
- Thorough pain assessment, with examination of the musculoskeletal system and neurological evaluation for negative and positive symptoms and signs, is necessary. This should be accompanied by explanation of what information is sought, by sensitive feedback of findings, and explanation of chronic pain.
- Awareness of pain that is specific to the site(s) and methods of torture, such as foot pain after falaka (beating the soles of the feet [7]), shoulder pain after suspension by the arms, or genital pain after sexual torture, may be generalized as widespread musculoskeletal pain. Headache and back pain are common [6].
- Physical assessment may need to be spread over several episodes, or even deferred, if physical examination, touch, or being partly or fully undressed is too aversive. It is important to ask whether the patient is willing to undergo each stage of examination.
- The patient should be asked directly about his or her beliefs about what is wrong, and those beliefs addressed in explanation by the healthcare team. Many patients may be unfamiliar with a multidimensional model of pain, so information needs to be shared in order for questions about psychological and social aspects of the pain to make sense.
- The patient should also be asked about current conditions and ongoing risks to health: poor accommodation or homelessness, disrupted sleep, poor diet/inadequate money for food, isolation, uncertain immigration and civil status, and any other ongoing problem.
- Many standard assessment scales are not available in necessary languages, but pain may be assessed with simple pain scales, function by pain interference scales, or quality of life inventories; distress is harder to assess, and may need extra clinical expertise.
- There are several additional considerations for assessment in children: pain is one of the most common results of torture experienced by children. Failure to recognize and treat a child’s pain is common, but can have physical and psychological sequelae into adult life, and reduce treatment effectiveness.
- Little is known on prevalence and type of pain in children who have directly experienced torture or witnessed torture of people close to them (parents, siblings, friend, other member of family and community).
- Pain assessment is essential for proper pain treatment but can be complex and difficult. Standard assessment tools for children’s pain should be used (for more information, consult the 2019 Global Year fact sheets on pain assessment in children). Clinical history taking and examination can determine if pain experience is associated with torture or other factors [1]. Neither physiological markers (heart rate, blood pressure) nor behavior can be used as a substitute for the child’s account of his or her pain experience, although they can contribute to pain assessment.
REFERENCES
[1] Alayarian A. Handbook of working with children, trauma, and resilience: an intercultural psychoanalytic view. London, United Kingdon: Karnac Books, 2015. E-book https://www.karnacbooks.com/author.asp?AID=128
[2] Amris K, Williams A. Chronic pain in survivors of torture. Pain: Clin Updates 2007;XV(7):1-4. https://www.iasp-pain.org/PublicationsNews/NewsletterIssue.aspx?ItemNumber=2108
[3] Burnett A, Peel M. The health of survivors of torture and organised violence. Brit Med J 2001;322:606-9. http://www.bmj.com/content/322/7286/606
[4] Crosby SS, Norredam M, Paasche-Orlow M-K, Piwowarczyk L, Heeren T, Grodin MA. Prevalence of torture survivors among foreign-born patients presenting to an urban ambulatory care practice. J Gen Intern Med 2006;21:768–84. DOI: 10.1111/j.1525-1497.2006.00488.x
[5] Jensen MP, Turk DC. Contributions of psychology to the understanding and treatment of people with chronic pain: why It matters to ALL psychologists. Amer Psychol 2014;69(2):105–18. DOI: 10.1037/a0035641
[6] Olsen D, Montgomery E, Bojholm S, Foldspang S. Prevalent musculoskeletal pain as a correlate of previous exposure to torture. Scand J Public Health 2006;34:496–503. DOI: 10.1080/14034940600554677
[7] Prip K, Persson AL, Sjolund BH. Sensory functions in the foot soles in victims of generalized torture, in victims also beaten under the feet (falanga) and in healthy controls – a blinded study using Quantitative Sensory Testing. BMC Internat Health Human Rights 2012;12:179. doi:10.1186/1472-698X-12-39.
[8] Rasmussen OV. Medical aspects of torture.” Danish Med Bull 1990;37:1–88.
[9] Williams ACdeC, Peña CR, Rice ASC. Persistent pain in survivors of torture: a cohort study. J Pain Symptom Manage 2010;40:715-22. http://www.ncbi.nlm.nih.gov/pubmed/20678891
AUTHORS
Amanda C de C Williams PhD CPsychol
Associate Professor in Clinical Health Psychology
Research Department of Clinical, Educational & Health Psychology
University College London
London, United Kingdom
Aida S Alayarian PhD, CPsychol, FUKCP
Refugee Therapy Centre,
London United Kingdom
Representing the IRCT