Chronic pain in torture survivors

Forensic Science International 108 (2000) 155–163 www.elsevier.com / locate / forsciint

Chronic pain in torture survivors a, a b Annemarie B. Thomsen *, Jørgen Eriksen , Knud Smidt-Nielsen a

Multidisciplinary Pain Center, Department 7122, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Ø Copenhagen, Denmark b Rehabilitation and Research Center for Torture Victims ( RCT), Borgergade 13, DK-1014 K Copenhagen, Denmark Received 30 March 1998; received in revised form 18 December 1998; accepted 22 December 1998

Abstract According to Amnesty International government-sanctioned torture is verified in one third of the countries in the world. The physical and psychological sequelae are numerous. This study focuses on pain diagnosis, characterising pain types as nociceptive, visceral or neuropathic. Torture victims from the Middle East, treated at the Rehabilitation and Research Centre for Torture Victims (RCT) in Copenhagen, participated in the study. The patients were referred to a pain specialist for evaluation of unsolved pain problems. Eighteen male torture victims were examined. Twelve patients experienced pain at more than three locations. Nociceptive and neuropathic pain were demonstrated in all patients. Specific neuropathic pain conditions were related to the following four types of physical torture: Palestinian hanging, falanga, beating and kicking of the head, and positional torture. When treating torture victims, it is important to know about torture methods, to think differently than normal on etiological and pathogenetic factors and always consider the presence of neuropathic pain.  2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Torture; Chronic pain; Neuropathy; Neuralgia; Rehabilitation

1. Introduction During the past ten years, the number of refugees who have fled political, religious or ethnic persecution, has increased enormously. An increasing proportion of the refugees

*Corresponding author. Tel.: 145-3545-7136; fax: 145-3545-7349. 0379-0738 / 00 / $ – see front matter  2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0379-0738( 99 )00209-1

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are survivors of torture. A recent Danish study on adult Middle Eastern refugees concluded that 30% had been exposed to torture (55% of the males, 12% of the females) [1]. According to Amnesty International, government-sanctioned torture is verified in about one third of the countries in the world [2]. Rehabilitation centres for torture victims have been established in several countries. However, these specialised units do not have sufficient capacity for treatment of all torture survivors. All parts of the health care system can expect to be exposed to these patients and it is therefore important that health care providers have knowledge about types of torture and the resulting psychological and physical complications [3]. Pain is one of the most frequent complaints of torture survivors, and even though psychological complications are no doubt a major problem, most of the patients experience and present their symptoms as somatic diseases. Overemphasising the importance of the psychological aspects may result in insufficient somatic pain diagnoses and treatment. In these patients, a careful examination and a few, valid diagnostic procedures are important to diagnose somatic disease. As is the case with all other patients, psychosomatic disease is a diagnosis of exclusion [4,5]. In this paper, we have focused on pain diagnosis, and have characterised pain types as nociceptive, visceral or neuropathic [6]. We have also tried to relate specific pain conditions to well known torture types.

2. Method In 1996 forty torture survivors from the Middle East were treated at the Rehabilitation and Research Centre for Torture Victims (RCT) in Copenhagen. All patients took part in the multidisciplinary treatment offered at the RCT, the main emphasis being on psychotherapy and physiotherapy. Pain was a serious problem for most patients and about half of the patients experienced relief as a result of the existing multidisciplinary treatment. However, the 18 patients focused on in this investigation continued to experience severe pain complaints and were referred to a pain specialist for the establishment of a diagnosis of pain and a more specific treatment of pain. In most cases the examination by the pain specialist took place in the presence of an interpreter to ensure a correct description of pain. The patients underwent a general clinical examination. If neuropathic disorders were suspected, a conventional clinical sensory test was performed using a cotton swab for light touch, figure writing for tactile discrimination, pinprick for mechanically evoked pain and an object for cold and warm sensation. The diagnosis of neuropathic pain was made if spontaneous pain (continuous or paroxysmal) and / or abnormal evoked pain or sensory dysfunction in the distribution of peripheral sensory nerves were present [6]. Information about exposure to different physical torture methods was gained from detailed case records based on several thorough personal interviews primarily performed by psychologists and psychiatrists but also by other members of the multidisciplinary team.

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3. Results Eighteen male torture victims were examined (mean age 35.8 years, range 28–50). Mean time since exposure to torture was 14.9 years (range 7–29). As presented in Table 1, all patients have been exposed to several types of physical torture. Pain conditions were categorised according to localisation. Each patient presented a multitude of pain locations and 67% of the patients experienced pain from more than three locations. The most frequent pain sites were the lower limbs (94%), head and lower back (each 83%) and shoulders or upper limbs (61%). Characterising pain types as nociceptive, neuropathic or visceral, we found that all patients presented a mixture of nociceptive and neuropathic pains. Visceral pain was a minor problem seen in only four patients: one had angina pectoris and three dyspepsia. Table 2 demonstrates the association between specific neuropathic pain syndromes and the exposure to four common torture types. Most striking was the high prevalence (81%) of peripheral neuropathy in patients exposed to falanga (beating with a stick under the soles of the feet, Fig. 1) and that 64% of the patients presented partial brachial plexus injury following Palestinian hanging (suspension by wrists with the arms tied behind the back, Fig. 2). Four patients exposed to Palestinian hanging, reported shoulder dislocation during torture. They all suffered from brachial plexus injury. Only sensory nerve damage was seen except for one patient having signs of paresis. Additionally, this

Table 1 Age, time since exposure to torture, torture types, and pain locations in the 18 torture victims investigated. Torture methods are described in Appendix A Patient Years since Age at Beating Suspension Falanga Positional Electric Sexual Burning Telefono Asphyxia/ Pain number exposure examination torture torture violation submercio localizations a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

15 16 12 17 23 22 11 18 16 10 29 8 7 14 14 13 11 13 a

33 36 36 50 36 40 30 39 40 32 47 28 34 34 34 29 34 32

* * * * * * * * * * * * * * * * * *

* * * * * * * * * * * * *

* * * * * * * * * * * * * *

* * *

* *

* * * * *

*

* * *

* * * * * * * * * *

*

*

*

*

* *

* * * *

* * * *

* *

* * * *

0, 0, 0, 0, 0, 2, 0, 0, 0, 0, 1, 0, 0, 0, 3, 0, 0, 0,

2, 1, 1, 1, 5 6, 2, 5, 1, 2, 2, 2, 2, 1, 5, 5, 1, 1,

5, 2, 3, 2, 8 6 6 2, 5, 5, 5, 5, 2, 6 6 5, 5,

6 5, 6 6 5, 6

5, 6 6 6 6 6 5, 6

6 6

0: Head. 1: Cervical. 2: Shoulders or upper limbs. 3: Thoracic. 4: Abdominal. 5: Lower back. 6: Lower limbs. 7: Pelvic. 8: Anal or genital.

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Table 2 Four common torture methods associated with specific neuropathic pain syndromes Torture methods

No. exposed

Beating of the head

18

3

Suspension Palestinian hanging

16 11

8 7

6 5

1 0

16

13

5

4

Suspension by legs Other types of suspension Falanga Positional torture in very small cells or boxes

No.

Specific neuropathic pain syndromes Trigeminal neuralgia Partial brachial plexus injury. Four cases of shoulder dislocation. One case of reflexdystrophia Partial lumbosacral plexus injury Peripheral neuropathy of the feet Back pain associated with segmentary loss of normal sensibility and neuropathic pain. Two cases of intervertebral disc herniation.

patient suffered from a severe reflex dystrophia in his right arm. During Palestinian hanging, his left arm escaped the ropes tied around his wrists, leaving the patient suspended by only one arm for almost 24 h. The symptoms presented by torture survivors exposed to Palestinian hanging were constant, superficial, burning or stinging pain located in the shoulders and upper limbs, and intermittent spontaneous shooting or electric shock like pain accompanied by reflex muscle cramps. Pain often included dermatomes innervated from C4 to T1–T2. Almost all patients exposed to falanga complained of burning and itching sensations often combined with paraesthesiae in the soles of the feet, extending upwards to the lower legs. Disturbed cutaneous sensation and impaired proprioception were demonstrated in the affected areas. Following beating and / or kicking of the head, three patients presented symptoms consistent with trigeminal neuralgia.

4. Discussion The first medical group within Amnesty International was formed in Denmark in 1974 [7]. The primary assignments were to document torture allegations, to give descriptions of torture methods and to carry out research about torture sequelae. These investigations uncovered an enormous need for rehabilitation of torture victims and their families and led in 1984 in Copenhagen to the establishment of the first Rehabilitation and Research Centre for Torture Victims (RCT). Starting with no experience in the field, great efforts have been invested to find reliable instruments for measuring torture and its consequences. However, there is still a need for valid instruments that are simple, culturally sensitive, and capable of improving the clinical management of torture survivors [8]. Many reports on torture sequelae show that neurological disorders affecting the central as well as the peripheral nervous system are frequent [7,9–12]. Sequelae from

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Fig. 1. Falanga torture. Painting by the Kurdish artist Arif Serving.

falanga have received much attention. Even though most other peripheral nerve injuries have been described, only falanga sequelae have been linked to specific torture methods. All torture victims investigated in this study presented not only nociceptive pain but also neuropathic pain. Generally, neuropathic pain conditions have been confused with nociceptive pain or in some cases psychosomatic symptoms. Early theories about the pathophysiology of the symptoms following falanga [5,7,13] and Palestinian hanging [14] propose, that pain symptoms may be caused by fibrosis replacing damaged muscle

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Fig. 2. Palestinian hanging combined with electrical torture. Drawing from the Turkish weekly ‘Nokta’, 1986.

and soft tissue, leading to pathological pressure on vessels, nerves and muscles. Using this theory, brachial plexus injury following Palestinian hanging is mentioned as a very rare condition and the clinical implications have favoured physiotherapy as a primary treatment modality. In contrast, other authors report that Palestinian hanging may cause brachial plexus injury within 15 to 20 min and that this complication is rather usual [15–17]. Knowledge about the pathophysiology of damaged nerves should be applied to the clinical analysis of torture survivors and might replace some of the earlier theories.

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Conventional clinical sensory testing for neurogenic disorders may be done in a simple way, using a cotton swab for light touch, figure writing for tactile discrimination, pinprick for mechanically evoked pain and an object for cold and warm sensation. Sensory dysfunction may be manifested as hypo- and / or hyperaesthesia for one or more modalities, increasing pain to normally painful stimuli or pain to normally not painful stimuli. Temporal and spatial sensory dysfunction are common. It is important to test all somatosensory modalities since dysfunction confined to a single modality may otherwise escape detection [6]. More sophisticated examinations such as quantitative sensory testing, EMG, evoked potentials, CT and MRI are not possible as they will often provoke flash back and panic in torture victims previously exposed to electric torture, asphyxia, suspension and positional torture e.g. being locked into a very small room or cage. There are differences in vulnerability and pathophysiologic reactions in different nerve fibres. Sensory cell somata in dorsal root ganglia are highly sensitive to mechanical distortion and the incidence of spontaneous and evoked dorsal root ganglion discharge is significantly augmented by chronic peripheral nerve injury. Experiments on purely cutaneous and mixed nerves following deafferentiation have shown that the great bulk of spontaneous neuroma activity is generated in sensory rather than in motor or autonomic nerve fibres [18]. These facts might contribute to explaining the primary localisation of symptoms to the sensory nerve system seen in the patients in this study. A correct pain diagnosis allows for the tailoring of a specific pain treatment. Current drug and non-drug therapies for patients with neuropathic pain may offer substantial pain relief to about half of the patients [6]. Our experiences treating neuropathic pain conditions in torture survivors are very sparse. Tricyclic antidepressants and / or anticonvulsants have been tried in several patients without much success because of low compliance and a very high incidence of unacceptable side effects even at very low starting doses and a slow uptitration. A few patients accepted and benefited from transcutaneous electrical nerve stimulation (TENS). A systematic set up with very close patient contacts for the current ‘trial and error’ strategy testing different treatment modalities has not yet been established. For some patients a reasonable explanation of the symptoms often misinterpreted as psychosomatic was a help. Obtaining a better pain control might contribute to improving results in other important treatment modalities in a multidisciplinary team. In a selected group of 18 torture survivors not responding to conventional therapy, all patients suffered from severe neuropathic pain conditions which could be related to torture. The clinical implications of these findings are important, as a shift in the treatment approach could be expected. Future investigations in the area are needed. New knowledge of pathophysiologic mechanisms underlying neuropathic pain may offer many possible approaches for pharmacological as well as non-pharmacological treatments.

Appendix A Beating: Often extensive beating with blunt instruments, punching with fists, or kicking with feet.

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Suspension: The victim is usually suspended by the wrists with the arms above the head or by the arms tied behind the back. Other variations are suspension by one arm and one leg, by both legs, by the arms tied together around the bent knees so that a stick can be pushed between the hollow of the knees and the elbows. Falanga: Beating with a stick under the soles of the feet. Positional torture: Forced to maintain abnormal body positions for hours without being able to move or change position. The victim may be kept in a cell so small that he is not able to stretch his body for weeks. Electric torture: Can be performed with electrodes placed at different, usually very sensitive, areas of the body with a mobile electrode such as a shock baton, or a fixed electrode such as an iron bed. Sexual violation: Maltreatment of the genital and the anal region in the form of homoor heterosexual rape, electric torture, or maltreatment with various tools or animals. Burning: Burns from cigarettes, heated metallic instruments, acid. Telefono: Simultaneous beating of both ears with the palms of the hands. Asphyxiation: A plastic bag forced over the head or a towel pressed against the nose and mouth until the victim is nearly suffocated. Submercio: Forcing the victim’s head into a bathtub often filled with a mixture of water, blood, vomit, excrement, and keeping the victim there until nearly suffocated.

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