Transcript Brain trauma - Istanbul Protocol Implementation

The Istanbul Protocol- issues and
perspectives
Prof. Thomas Wenzel, Medical University of Vienna,
Austria
Medical Director, Wellcome Centre for Torture
Survivors, Vienna
with:
Project ATIP (Advanced and Training for the Istanbul
Protocol)
Istanbul Protocol
The Manual on Effective Investigation and
Documentation of Torture and Other Cruel,
Inhuman or Degrading Treatment or
Punishment
A. History of the IP
Aug. 1999:
IP finished by more
than 75 experts,
representing
40 organisations in
15 countries
March 2001:
IP published as
part of the
UN‘s Professional
Trainings Series
Dec. 2000:
IP adopted by UN
General Assembly
and
High Comissioner for
Human Rights
Istanbul Protocol
Supported by international organisations and
umbrellas including the
• United Nations
• World Medical Association
• World Psychiatric Association
• World Council for Psychotherapy
• International Council of Nurses
The Istanbul Protocol
Is referred to by (for example)
• European Court on Human Rights
• Interamerican Court on Human Rights
The Istanbul protocol is• A comprehensive interdisciplinary framework
to guide training (and practice) in
documentation and investigation of alleged
torture
• It is not a standard handbook of all relevant
medical knowledge
Outline of the IP content
I.
II.
III.
IV.
V.
VI.
Relevant international legal standards
Relevant ethical codes
Legal investigation of torture
General considerations for interviews
Physical evidence
Psychological evidence
Annexes: I. Principles, II. Diagnostic tests, III. Anatomical
drawings for documentation, IV. Guidelines for medical
documentation
Examples for application
Prisons
• Prison visits
• Preventive
monitoring
Asylum
procedures
Court
cases
• Protection
• Documentation
• Monitoring
• Civil law
• International
courts
• Criminal law
Aspects: Medical/Psychological
forensic evaluation
Identify and document injuries, preservation
of evidence
Consistency: between medical findings and
narrative, between medical and psychological
findings, regional torture practices, culture
Expert interpretation, referral and
recommendations
See also six principles
Special challenges
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Implementation
Mental Health
DSM V, changes
DSM V and Culture
Indirect victims
Brain trauma
Redress and recompensation
Special challenges
• „Curative“ justice- therapeutic aspects,
prevention of undue distress and
retraumatisation
• Assessment of impact and needs
• Indirect victims
• Immaterial reparation, complex social and
legal approaches to redress and reparation
• Children
• Preventive monitoring (Birk, Nowak, et al.)
Implementation
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Translation
Local manual
Country strategy
Reference cases
Reference in legal standards and law
Reference point in pre-graduate health care
education and training
• Reference point in post-graduate health care
education and training (CME)
Implementation
• IPIP
• FEAT
• ARTIP/ATIP
Implementation
Implementing Istanbul Protocol standards for forensic evidence of
torture in Kyrgyzstan
Alejandro Moreno a, b, Sondra Crosby a, c, Stephen Xenakis a, Vincent Iacopino a, d, e, *
Journal of Forensic and Legal Medicine 30 (2015) 39e42
The Kyrgyz government declared a policy of “zero tolerance” for torture and began reforms to stop such
practice, a regular occurrence in the country's daily life. This study presents the results of 10 forensic
evaluations of individuals alleging torture; they represent 35% of all criminal investigations into torture
for the January 2011eJuly 2012 period. All individuals evaluated were male with an average age of 34
years. Police officers were implicated as perpetrators in all cases. All individuals reported being subjected
to threats and blunt force trauma from punches, kicks, and blows with objects such as police batons. The
most common conditions documented during the evaluations were traumatic brain injury and chronic
seizures. Psychological sequelae included post-traumatic stress disorder and major depressive disorder,
which was diagnosed in seven individuals. In all cases, the physical and psychological evidence was
highly consistent with individual allegations of abuse. These forensic evaluations, which represent the
first ever to be conducted in Kyrgyzstan in accordance with Istanbul Protocol standards, provide critical
insight into torture practices in the country. The evaluations indicate a pattern of brutal torture practices
and inadequate governmental and nongovernmental forensic evaluations.
© 2014 Elsevier Ltd and Faculty of Forensic and Legal Medicine.
4. Medical examination
Any iindicators of false
allegation ?
Impact of other stressors
(like persecution, flight,
displacement)
Physical and
psychological findings
consistent with the
report ?
Time frame as to mental
health impact and
recovery ?
Physical factors that
contribute
Six
principles
in the IP
medical
part
Psychological symptoms
to be expected in this
cultural and social
background ?
See also later chapters !
Importance of mental health aspects
Interfere with reporting, limit
disclosure, cause contradictions
Immediate
treatment needs
and secondary
prevention including
suicidality
Mental health problems– psychological problems,
brain trauma
Can be consequences
and proof/e vidence
of torture and IDTt
being common, persistant and
potentially severe
©:Thomas Wenzel/
WPA, 2010
Inadequate legal
and medical
procedures lead to additional
stress, trauma and
injury
Importance of mental health aspects
Trauma-specific
disorders: or symptoms
example: PTSD, cultural
idioms of distress, ICD
10 F 62.0 (persistant
personality change)
Unspecific Disordersor
symptoms caused by
trauma
Pre-existing Disorders/symptoms
aggrevated by trauma
©:Thomas Wenzel/
WPA, 2010
Complications:
Substance abuse
Suicidality
Sexual
dysfunction
Impairment
“Harmless” medical
procedures can trigger
memories of violence.
Examples:
Electrical contacts in an
Electrocardiogram (to monitor the
heart)
Spreading the legs for a gynecological
examination triggers memories of
rape
Gastroscopy triggers memories of
oral rape
©:Thomas Wenzel/
WPA, 2010
Moving a leg leads to pain triggering
flash-backs (intense unwanted
memories) in examination or
physiotherapy
DSM V changes
• PTSD now includes „complex“ symptoms as
additional group of symptoms
• Extended definition of posttraumatic
disorders in children
• Emphasis on culture
• Cultural Idioms of Distress
Culture
Culture
• The new DSM V framework provides a much
improved structured system to describe culture
specific reactions.
• The IP is based on the DSM III R/IV, ICD 11 is
expected for 2017.
• DSM V lists especially cultural idioms of distress –
highly relevant for assessment of specific, causally
related reactive symptoms reflecting
traumatisation.
Culture
• Due to the wide range of observed patterns an
exhaustive „handbook“ of idioms is again not
realistic.
• DSM V provides the „Cultural formulation
interview“ (CFI), which is using a structure
similar to the McGill University MINI interview
and qualitative research.
• It could serve as a standard to map idioms and
might be used in specific assessment if the time
frame permits.
DSM V
(1) cultural syndromes: “clusters of symptoms and
attributions that tend to co-occur among individuals
in specific cultural groups, communities, or contexts .
. . that are recognized locally as coherent patterns of
experience” (p. 758);
(2) cultural idioms of distress: “ways of expressing
distress that may not involve specific symptoms or
syndromes, but that provide collective, shared ways
of experiencing and talking about personal or social
concerns” (p. 758); and
(3) cultural explanations of distress or perceived causes:
“labels, attributions, or features of an explanatory
model that indicate culturally recognized meaning or
etiology for symptoms, illness, or distress” (p. 758)
Historical Idiom of distress: „Faint“
World War I: Shell shock, „tremblers“ „Kriegszitterer“
(Conversion disorders)
DSM V
Cultural Formulation Interview:
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16 questions referring to four domains of assessment:
Cultural Definition of the Problem (questions 1-3);
Cultural Perceptions of Cause, Context, and Support
(questions 4-10);
Cultural Factors Affecting Self-Coping and Past Help Seeking
(questions 11-13); and
Cultural Factors Affecting Current Help Seeking (questions
14-16)
Indirect victims
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Family members
Peers, friends
Helpers, therapists
Civil society and rule of law
Indirect victims
Grand Chamber judgment in the case of Cyprus v.
Turkey (application no. 25781/94)-reg. Article 41
(just satisfaction): awarded 30,000,000 euros (EUR)
in respect of the non-pecuniary damage suffered by
the relatives of the missing persons
Key points:
- Psychological suffering of secondary/ indirect
victims
- Lack of efficient and prompt investigation
Indirect victims
Inter-American Court of Human Rights:
Miguel Castro Castro Prison v. Peru
Key points:
- Psychological suffering of secondary/ indirect
victims
- Role of experts and standards, IP used
- Non-pecunary recompensation/reparation
Brain Trauma
Advanced module
Joint project Brain Trauma:
ARTIP/ATIP
WPA Section of Sport Psychiatry
Thomas Wenzel (Austria)
David Baron (USA)
Brain trauma
• Brain trauma (Traumatic Brain Injury, TBI) in
its wide range of forms has been frequently
underestimated as a source of short and long
term symptoms and impairment*.
• It is very common in torture survivors.
• Assessment of brain trauma is a corner stone
in the investigation of torture.
Keatley, E., Ashman, T., Im, B., & Rasmussen, A. (2013). Self-Reported Head Injury Among Refugee
Survivors of Torture. The Journal of head trauma rehabilitation.
Example: Questionnaire (I)
A concussion requires a blow to the head.
• Strongly Agree
• Agree
• Disagree
• Strongly Disagree
A single mild concussion can result in long-term effects, with
symptoms that occur in the days and weeks following the injury.
• Strongly Agree
• Agree
• Disagree
• Strongly Disagree
Although a major concussion is very serious, mild concussion
symptoms can be ignored.
• Strongly Agree
• Agree
• Disagree
• Strongly Disagree
There is no cumulative effect of multiple concussions.
• Strongly Agree
• Agree
• Disagree
• Strongly Disagree
Brain trauma
• (Blunt) Brain trauma due to beatings, fall,
asphyxiation or other forms of torture is
frequently overlooked, but extremely common.
• Repeated brain trauma (also during torture) can
lead to different sequels then a single event.
• Repeated blunt brain trauma in a short time can
lead to immediate death (second impact
syndrome).
• Symptoms can vary.
Brain trauma
TBI can be separated in
• Immediate sequels (including intracranial
bleeding)
• Long term sequels
• Sequels commonly caused only by repeated
events (such as Chronic traumatic
encephalopathy (CTE))
Brain trauma
• Symptoms can be identical, similar or overlapping
with PTSD (and depression) – concentration and
memory problems, sleep disorder and irritability are
most common shared symptoms.
• Suicide risk is increased.
• MRI or other radioimaging requires special strategies
and might be inconclusive especially after time.
Diagnosis must often be based on clinical
symptomatology.
• Different treatment strategies might be required.
Pathophysiology
• Dysregulation of ions
• Causes strain on ion pumps
• Leads to increased energy demand
• Hypermetabolic state
• Larger than normal amounts of glucose
consumed
• Reduction of brain blood flow
• Combined with hypermetabolic state, results in
“energy crisis”
Postconcussional syndrome (PCS)
ICD 10 F07.81
- A history of TBI (Traumatic Brain Injury)
- and the presence of three or more of the
following eight symptoms:
1) headache, 2) dizziness, 3) fatigue, 4)
irritability, 5) insomnia, 6) concentration or 7)
memory difficulty, and 8) intolerance of stress,
emotion, or alcohol.
Postconcussional syndrome (PCS)
ICD 10 F07.81
Besides clinical psychiatric and neurological
testing the following methods can be applied:
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Nuclear Magnetic Resonance Imaging
SPECT, PET
(EEG)
Neuropsychological testing
Cave: Posttraumatic Stress Disorder
(PTSD) and PCS
• Posttraumatic Stress Disorder (PTSD) and PCS are
common results of the same events.
• Symptoms are at least in parts similar or overlapping.
• Due to the larger range of, mainly unspecific
symptoms in PCS, symptom overlap with other
disorders is common.
• Patients can suffer from both PTSD and PCS, though
treatment might have to be adapted.
Cave: Posttraumatic Stress
Disorder (PTSD) and PCS
PTSD
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Somatoform
disorders
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Concentraion
difficultues
Memory
impairment
Disordered sleep
Irritability
PCS
Headaches
Seizures
Chronic Traumatic Encephalopathy (CTE)
First described in 1928 (“punch drunk
syndrome”)
Later called “Dementia Pugilistica”,
and more recently, “Chronic Traumatic
Encephalopathy”
Chronic Traumatic Encephalopathy
Common presenting symptoms include:
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memory loss
irritability
outbursts of aggressive or violent behavior
confusion
speech abnormalities
cognitive decline/dementia
gait abnormalities
Up-coming challenges
Are partly adressed by recent projects that provide
additional matrials and certification*:
• IPIP (IRCT)
• ARTIP (Awareness raising and training for the IP, EU,
lead Wenzel*, interdisciplinary), /ATIP
www.istanbulprotocol.info
• Training materials online (PHR) (Advanced)
• Torture Atlas (HFT)
• Torture Atlas (AI Medgroup/J. Oomen) (Especially
physical sequels)
EU Framework Directive
Thomas Wenzel
Medical University of Vienna,
Austria
Wellcome Centre Vienna, Austria
EU Framework Directive
Directive 2012/29/EU of the European
Parliament and of the Council of 25 October
2012 establishing minimum standards on the
rights, support and protection of victims of
crime, and replacing Council Framework
Decision 2001/220/JHA
Budapest roadmap
“In its resolution of 10 June 2011 on a roadmap for
strengthening the rights and protection of victims, in particular
in criminal proceedings (6)(‘the Budapest roadmap’), the Council
stated that action should be taken at Union level in order to
strengthen the rights of, support for, and protection of victims of
crime.
To that end and in accordance with that resolution, this Directive
aims to revise and supplement the principles set out in
Framework Decision 2001/220/JHA and to take significant steps
forward in the level of protection of victims throughout the
Union, in particular within the framework of criminal
proceedings.”
EU Framework Directive
9. “Crime is a wrong against society as well as a violation of the
individual rights of victims.
As such, victims of crime should be recognised and treated in a
respectful, sensitive and professional manner without
discrimination of any kind based on any ground such as race,
colour, ethnic or social origin, genetic features, language,
religion or belief, political or any other opinion, membership of a
national minority, property, birth, disability, age, gender, gender
expression, gender identity, sexual orientation, residence status
or health
EU Framework Directive
In all contacts with a competent authority operating within the
context of criminal proceedings, and any service coming into
contact with victims, such as victim support or restorative justice
services, the personal situation and immediate needs, age,
gender, possible disability and maturity of victims of crime
should be taken into account while fully respecting their
physical, mental and moral integrity. Victims of crime should be
protected from secondary and repeat victimisation, from
intimidation and from retaliation, should receive appropriate
support to facilitate their recovery and should be provided with
sufficient access to justice.”
EU Framework Directive - Application
This Directive does not address the conditions of the
residence of victims of crime in the territory of the
Member States. Member States should take the
necessary measures to ensure that the rights set out
in this Directive are not made conditional on the
victim's residence status in their territory or on the
victim's citizenship or nationality. Reporting a crime
and participating in criminal proceedings do not
create any rights regarding the residence status of
the victim.
EU Framework Directive- Geographical
This Directive applies in relation to criminal
offences committed in the Union and to
criminal proceedings that take place in the
Union. It confers rights on victims of extraterritorial offences only in relation to criminal
proceedings that take place in the Union.
Complaints made to competent authorities
outside the Union, such as embassies, do not
trigger the obligations set out in this Directive.