By Dr Muffazal Rawala, Consultant Adult Psychiatrist and member of the Expert in Mind Expert Witness Panel
Psychiatrists, the general public and the Courts are aware about the widely used terminology of Post-traumatic stress disorder (PTSD). The psychological consequences of exposure to trauma were extensively researched in Vietnam War veterans, which led to the development of diagnostic criteria for posttraumatic stress disorder.
In the 90s, research in the experience of (domestic) violence in children and women suggested that a meaningful clinical distinction may be made between single traumatic events and repeated, prolonged, interpersonal traumatic events occurring in a context of an authoritarian control. This clinical definition of complex trauma has since gone virtually unchanged - “exposure to repeated or prolonged instances or multiple forms of interpersonal trauma, often occurring under circumstances where escape is not possible due to physical, psychological, maturational, family/environmental, or social constraints”.
PTSD may present with a range of symptoms including re-experiencing the trauma, avoidance, hyper-arousal, depression, emotional numbing, drug or alcohol misuse and anger as well as unexplained physical symptoms. The symptoms of PTSD are extreme and encompass more than just remembering the event or dreams, but a combination of disabling recall, dreams and memories. A large percentage of trafficked women and men present with anxiety, depression or PTSD. PTSD sufferers may not present for treatment for months or years after the onset of symptoms despite the considerable distress experienced.
Complex-PTSD is a subtype where adults or children who have experienced repeated traumatic events like neglect, abuse or trauma over a longer time period may develop signs and symptoms of PTSD. Complex PTSD is thought to be much more severe if the abuse and trauma happened early in life and caused by a parent or carer, the person experienced repeated incidents over a number of years and felt entrapped with complete control of the abuser over the victim, for example, in the case of asylum seekers from totalitarian regimes or victims of human trafficking. Children with complex-PTSD could show behavioural problems, affect their personality development, develop negative coping mechanisms and as adults may become socially isolated and unable to form trusting relationships.
It is a widely held view that traumatic incidents are an extraordinary life experience capable of causing a wide range of physical and psychological suffering. Most clinicians and researchers agree that the extreme nature of the traumatic event is powerful enough on its own to produce mental and emotional consequences, regardless of the individual’s pre-morbid psychological status. The psychological consequences of repeated trauma, however, occur in the context of personal attribution of meaning, personality development and social, political and cultural factors. It is important to recognize that not everyone who has been repeatedly abused develops a diagnosable mental illness. However, many victims experience profound emotional reactions and psychological symptoms. The emotional restriction and inability to consistently recall details of the abuse do not lead to any dispute in either the authenticity of being a victim of abuse nor does it question the diagnosis of complex-PTSD. The emotional withdrawal, defensive indifference to traumatic memories and inability to consistently recall all details during asylum interview or statements, suggest a defence mechanism to safeguard from reliving and re-experiencing the horrific traumatic abuse, features commonly seen in victims of abuse and complex PTSD rather than feigning of symptoms.
In refugee samples, PTSD has been shown to be common amongst victims of human trafficking, domestic violence and torture, though complex-PTSD has received little attention in this area. Two small studies in non-refugee samples investigated German victims of torture and domestic violence and found high complex-PTSD prevalence, whilst none have investigated human trafficking. The effect of major human rights violations on the presence of complex-PTSD in asylum-seeking populations’ and victims of human trafficking, torture and domestic violence has not been consistently researched although is widely seen in clinical practice of Psychiatrists with experience of working with asylum seekers.
Many asylum seekers and refugees have fled their country of origin to escape the horrors of war, persecution, organised violence, or torture. Psychiatrists with experience of working with asylum seekers routinely see that individuals would either have difficulty in elaborating their statements, might have gaps in their history in their witness statements or make conflicting statements during their asylum interviews or hearings. This makes it crucial that such individuals are referred to specialist psychiatry services with knowledge and experience of working with asylum seekers and their ability to interview them in a supportive environment to help overcome the emotional constriction and guarded behaviour.
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