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Research Articles
Published: 2020-09-14

Features of mental disorders in victims of violent action

State Institution "Research Institute of Psychiatry of the Ministry of Health of Ukraine"
mental disorders violent crimes victims Istanbul Protocol forensic psychiatric examination

Abstract

Objective. Victims of violent crimes, regardless of the way the crime affects the victim - psychological, financial, physical, and spiritual - can have significant psychosomatic health problems for a long time. The dangers of violence, including torture and other ill-treatment, were highlighted in the Istanbul Protocol, which is an international guide to the effective investigation and documentation of torture and other cruel, inhuman, or degrading treatment or punishment.

Methods and materials. A pilot study was conducted to verify the mental disorders of 22 victims of violent crimes according to forensic psychiatric examinations. Verification of mental disorders was carried out in accordance with the provisions of the Istanbul Protocol and the criteria of the International Classification of Diseases (ICD-10).

Results. All subjects reported traumatic events that met the stress criterion (A) for PTSD. 63.6% of the victims were prisoners in the temporarily occupied territories of Donbas, where they were subjected to torture and other inhuman treatment; 18.1% were victims of police violence; 18.1% were victims of sexual violence. According to the PTSD criteria, 100% of the subjects showed manifestations of the intrusion cluster, 54.5% - manifestations of the numbing cluster, and 31.8% - manifestations of the hyperexcitation cluster. 31.8% of victims were diagnosed with PTSD.

More than 1/3 of the subjects showed signs of depression, but only 9.1% met the criteria for moderate depressive disorder. Anxiety was a pervasive symptom present at the same time as other disorders in 95.5% of cases. Symptoms of somatization (15 people; 68.1%) were mainly chronic pain of various localizations. Alcohol consumption at the level of domestic drunkenness was 40.9%, occasional cannabis use - 27.2%. Mental disorders due to violence can remain at the level of fragmentary or subclinical manifestations of mental disorders, not reaching the nosological level and reduce over time, as well as be the initial or residual phase of a certain mental disorder.

Conclusions. Early diagnosis of mental disorders in victims of violent crimes will allow the timely application of medical and psychosocial measures, which will accelerate the rehabilitation of victims and reduce mental illness

Background

According to the prevailing biopsychosocial paradigm in modern medicine, human health increasingly depends on anthropogenic factors, namely the aggression of society against humans [1]. To describe such an unfriendly modern world, there is even a well-established term - VUCA: in our world there are Volatility, Uncertainty, Complexity, Ambiguity combined [2].

Unfortunately, despite the efforts of the international community, aggression, violence, abuse, and even torture one person to another are becoming more common in the world [3]. It should be noted that all actions that cause a person special physical pain, mental or moral suffering are considered cruel and insulting to human dignity. In practice, they can be implemented in the illegal use of special means (handcuffs, rubber truncheons, poison gas, water cannons, etc.), deprivation of food, water, heat, leaving in harmful conditions; depriving a person of any of one's natural senses: sight, hearing, spatial or temporal orientation; the humiliation of human dignity (standing naked against the wall; putting a bag on his head, keeping in basements where there are rats, etc.). Torture, cruel inhuman treatment, etc., occurs when the suffering is caused by public officials or other persons acting as officials, or with their incitement, known or tacit consent [4].

Ukraine modernity manifests itself in such realities, socio-economic tensions in public life, growing impoverishment of the population masses, and many years of hostilities in our country, which together puts the problem of violent crime in a number of priority problems at the state level [5,6]. Victims of violent crimes, regardless of the manner in which the crime affects the victim - psychological, financial, physical, and spiritual - can have significant psychosomatic health problems for a long time [7].

Assessing the consequences of aggressive (cruel, inhuman, and degrading) actions is quite complex and depends on the duration and intensity of such abuse, its existing and hidden consequences for the physical health of the person, and the mental state and other individual characteristics of the victim (age, sex, etc.) [8]. Moreover, physical injuries are more obvious, cause deterioration of physical health, and force a person to seek medical help on their own or with the help of a close environment in their verification and further treatment.

The peculiarity of determining the harm to the mental health of the victim is that psychological and mental trauma, which can cause stress, horror or anxiety, feelings of humiliation and resentment, even to break the physical or moral resistance of the person, are partially incomprehensible or remain conscious or unconsciously hidden, continuing the destruction of human mental health [9]. Additional difficulties in verifying mental disorders of such conditions are caused by the fact that objective facts (actions) in assessments can be proved, and the subjective assessment judgments of the victim, their truthfulness is very difficult to prove, sometimes almost impossible.

On the other hand, it is the cognitive component (self-assessment of each person, whether this or that treatment is such that degrades their honor and dignity), but not only the perceptual component of bullying itself that determines further affective response and behavioral changes and initiates probable formation mental disturbance or disorders [10].

The dangers of violence, including torture and other forms of ill-treatment, were highlighted in the Istanbul Protocol. [11] It is an international guide to the effective investigation and documentation of torture and other cruel, inhuman, or degrading treatment or punishment.

Thus, special attention from medical science and practice deserves psychological disorders and mental disorders of a person who could potentially be a victim of violent crimes.

Methods and materials

As a part of a scientific study, namely the development of an integrative model of psychological and psychiatric intervention for victims of violent crimes, which will combine standardized forensic psychiatric assessment and a system of specific rehabilitation measures, we conducted a pilot study to verify mental disorders of 22 victims according to forensic psychiatric experts. Verification of mental disorders was performed in accordance with the provisions of the Istanbul Protocol and the criteria of the International Classification of Diseases of the Tenth Revision (ICD-10) [11,12].

Results and discussion

Among the surveyed persons there were men (19 people, 86.3%) exceeded, the average age of the victims was 32.7 ± 12.4 years. Among the victims of violence, 14 people (63.6%) were prisoned in the temporarily occupied territories of Donbas, where they were subjected to torture and other inhuman treatment; 4 people (18.1%) were victims of police violence; 4 people (18.1%) were victims of sexual violence. All persons reported traumatic events that met the stress criterion (A-criteria) for PTSD.

We determined that 20 victims (90.9%) were subjected to various types of deprivation: T73.0 (starvation) - 11 people (50.0%), T73.1 (thirst) - 13 people (59.1%), T73.2 (exhaustion due to prolonged stay in adverse conditions) - 16 people (72.7%), T73.4 (exhaustion due to overexertion) - 8 people (36.4%), T73.8 (other manifestations of deprivation) - 17 people (77.2%). Moreover, in most cases (68.1%) it was a combination of deprivation. All surveyed persons were subjected to harsh treatment, namely: physical (T74.1) - 21 persons (95.5%), sexual (T74.2) - 12 persons (54.5%), psychological (T74.3) - 22 people (100%).

12 people (54.4%) considered physical abuse to be the most stressful factor, while 9 people (40.9%) emphasized the stressfulness of psychological abuse. Underestimation of the stressfulness of psychological violence was reported by Bichescu D. and co-authors [13] when describing the long-term consequences of torture of victims of political repression in Romania when 40.7% of respondents considered physical abuse to be the most stressful aspect of the detention, 19 (32.2%) - psychological abuse, and 6 (10.3%) - isolation.

100% of the victims of violent crimes we surveyed, there was a recurrence of trauma as a manifestation of the cluster of intrusion from the criteria of post-traumatic stress disorder (PTSD): 14 people (63.6%) mentally return to past events; 12 people (54.5%) suffer from obsessive memories in which they again experienced traumatic events. 9 people (40.9%) reported memories of being awake, and 13 people (59.1%) reported periodic nightmares with elements of torture/violence in a true or symbolic form.

Consequences of repeated trauma (negative cognitive and emotional drift) can be considered features of behavioral reactions of the surveyed persons in the form of distrust (15 people; 68.2%) and fear (6 people; 27.3%) in the process of forensic psychiatric examination, which can be explained by the perception of doctors and psychologists as persons "endowed with power" and, accordingly, the impact on the future lives of victims.

12 persons (54.5%) showed some manifestations of avoidance and emotional inhibition of the numbing cluster according to the PTSD criteria. Moreover, 10 people (45.5%) reported the desire to avoid thoughts and conversations, and 5 people (22.7%) reported their inability to remember one or another important aspect of the traumatic situation. Avoidance was partly accompanied by a feeling of emotional tightness of personal alienation, which sometimes led to changes in behavior in the form of social exclusion.

Signs of overexcitation, representing a cluster of behavioral manifestations of PTSD, were found in 7 people (31.8%) mainly in the form of irritability (7 people; 31.8%), outbursts of anger (5 people; 22.7%), and increased tremor (2 persons; 9.1%). Such victims also experienced general anxiety with symptoms of autonomic arousal (rapid breathing, sweating, dry mouth or dizziness, gastrointestinal disorders, etc.). For ICD-10, signs of overexcitation should be verified using codes R45.1 (Anxiety and Excitement) and R45.4 (Irritability and Anger).

Among the surveyed 22 victims of violence according to the results of forensic psychiatric examination, 7 surveyed (31.8%) were diagnosed with PTSD. Only one person surveyed had no symptoms of PTSD, while the majority (16 persons, 72.7%) reported at least six symptoms of PTSD. In a study by Bichescu D. and co-authors [14], it was also reported that ¾ previously tortured individuals had more than six symptoms of PTSD, and only 3% of victims did not report such symptoms. According to these authors, the most common specific symptoms in the group of survivors were memories of trauma (78%), distress when reminded of the trauma (68%), bad dreams or nightmares about trauma (64%), and avoidance of thoughts about trauma (63%). The least common symptoms were limited affect (19%) and limited expectations for the future (22%).

Impaired self-esteem and a sense of limited perspective, which were demonstrated by 9 people (40.9%) and 7 people (31.8%), respectively, largely depended on the personal perception of the victim of the most traumatic situation and personal characteristics of the victim. It is known that impaired self-esteem and a sense of limited perspective often initiate the further development of mental disorders, including depression, exacerbation of chronic diseases, and even leads to suicide [14]. The coding of these violations in ICD-10 is focused primarily on the state of demoralization (R45.3).

8 of surveyed persons (36.4%) showed signs of depression in the form of hypothymia (3 persons; 13.6%), anhedonia (31.8%), insomnia (5 persons; 22.7%) feelings of worthlessness, and excessive guilt (4 individuals; 18.2%), difficulty in attention focusing, concentrating, or recalling (6 individuals; 27.3%), and suicidal ideation (2 individuals; 9.1%). Among those surveyed with signs of depression, 2 persons (9.1%) met the criteria for the depressive disorder of moderate severity; 2 individuals (9.1%) were clinically verified as R45.3 (Demoralized condition and apathy); 4 persons (18.2%) - as R45.2 (Feelings of unhappiness). Bichescu D. and co-authors also described the presence of depression in the range of 27% when describing the long-term consequences of torture in victims of political repression in Romania [13]. They also emphasized the prevalence of drug abuse (37%), dissociative disorders (34%), and the presence of symptoms of somatization (48%). Separately, there was a strong positive association between PTSD and the prevalence of dissociative disorders, as well as PTSD with depression.

Among the signs of dissociation, depersonalization, and atypical behavior, depersonalization was the most common (4 people; 18.2%), while dissociation such as self-observation ("fly on the ceiling") was reported by 2 people (9.1%). Previously atypical for the surveyed persons, unreasonably risky behavior was identified in 3 people (13.6%). According to the scientific medical literature, the most commonly diagnosed dissociative disorder among former prisoners was also a personalization disorder (20.3%) [13].

Earlier clinical studies of the effects of the Holocaust in later life have highlighted the increasing severity of depressive and somatic symptoms as a result of failed emotional processing of trauma [15]. Indeed, some somatic symptoms often occur in people who have been ill-treated, including torture, in the form of pain or other physical ailments, regardless of whether there are objective reasons for this [16]. Somatic symptoms can be caused directly by the physical consequences of torture, but now we are talking about pathological manifestations of psychological genesis. In such cases, it is a matter of somatization of mental symptoms such as anxiety, depression, aggression, etc. [16].

More than ½ of the persons we surveyed were present somatization symptoms (15 persons, 68.1%), and 14 persons (63.6%) complained of pain and 3 persons (13.6%) had pseudoneurological symptoms. It is important that in 5 people (22.7%) the pain was the only obvious symptom with variable localization and was felt with different intensity. In general, subjects complained of back pain, musculoskeletal pain, or headache, often from head injuries. Headache is very common in those who have been tortured and often leads to chronic post-traumatic pain [17]. According to ICD-10, such conditions can be verified as R52 (Pain, not elsewhere classified).

The peculiarity of sexual disorders in persons who have been sexually tortured or raped is a very frequent attempt to hide them, i.e., aggravation of symptoms in terms of self-stigmatization and often their stigmatization by society [18]. We also faced the problem of partial concealment, including unconsciousness, when verbal threats, insults, or ridicule of a sexual nature were not associated by the victim with further sexual problems (3 persons (13.6%)). It should also be noted that the consequences of sexual torture of prisoners in the temporarily occupied territories of Donbas (sexual assaults and electric shocks) in 7 people (31.8%) had not only certain problems of intimate life but also interpersonal relationships and/or painful behavioral changes, including abuse psychoactive drugs.

Signs of alcohol and psychoactive drug abuse, which are common in survivors of torture, ill-treatment, or inhuman treatment, are examples of secondary abuse. That is, in such cases, the initial abuse of alcohol and drugs is a method of erasing painful memories, restraining emotional reactions, and calming anxiety [19]. Among the 22 people we surveyed, alcohol consumption at the level of domestic drunkenness was determined in 9 people (40.9%), episodic cannabis use - in 6 people (27.2%); alcohol abuse at the level of dependence was recorded in 1 person (4.5%), dependence on psychoactive drugs abuse was not determined. The low level of addicts compared to the literature can be explained by the fact that victims of violence were examined by us in the early post-traumatic period before the potential formation of addictive disorders [19].

Among the psychological disorders that mostly caused behavioral changes in the surveyed persons should be noted thinking disorders in the form of obsessive or even delusional ideas (3 persons; 13.6%), the plot of which is associated with a traumatic event and related to intervention, surveillance or persecution. It is worth noting that such ideas were associated with a high level of anxiety and did not meet the criteria for psychotic disorders in ICD-10. These painful conditions were verified as R46.5 (Suspicion and noticeable bias). According to Priebe S. and co-authors [20], paranoid ideas in combination with anxiety were considered the most severe psychological symptoms that can most often be found in older people with diverse war experiences and more traumatic experiences after the war.

Finally, anxiety was a pervasive symptom present at the same time as the disorders described above in 21 individuals (95.5%). According to our study, older people were more likely to be associated with PTSD and depressive disorders; similar correlations have been described by Song S.J. and co-authors [21].

It should be noted that mental disorders due to violence can remain at the level of fragmentary or subclinical manifestations of mental disorders, not reaching the nosological level and alternate over time, as well as be the initial or residual phase of a certain mental disorder and behavior. Hollifield M. and co-authors [22] emphasized that torture is not an independent predictor of poor mental health, whereas it is the premorbid level of mental well-being and personality response that largely causes mental health disorders due to violence.

The need for timely and adequate diagnosis of mental disorders in victims of violent crimes and further restoration of mental health of victims in the early post-traumatic period is evidenced by the fact that even after 18.5 years, more than 80% of victims of the terrorist attack in Oklahoma reported symptoms of anxiety and depression in combination with alcohol consumption (≥5 beverages), deterioration of mental health and social activity [23].

Conclusion

Timely diagnosis of mental disorders in victims of violent crimes will allow differentiated and personalized application of medical and psychosocial measures, which will accelerate the rehabilitation of victims and reduce mental illness.

Additional information

Study limitations

The article presents the data of a pilot study with a small number of examined persons within the forensic psychiatric examination. A further study with a larger contingent of victims is planned. It will clarify the identified pathopsychological disorders and determine the associative links between them.

Conflict of interests

The authors declare no competing interests exist.

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How to Cite

1.
Shum С. Features of mental disorders in victims of violent action. PMGP [Internet]. 2020 Sep. 14 [cited 2024 Mar. 28];5(3):e0503267. Available from: https://e-medjournal.com/index.php/psp/article/view/267