mary, there is considerable evidence from other populations at risk of PTSD that substance abuse is a potential co-morbid diagnosis for torture survivors. (c) Enduring personality change 256. After catastrophic or prolonged extreme stress, disorders of adult personality may develop in persons with no previous personality disorder. The types of extreme stress that can change the personality include concentration camp experiences, disasters, prolonged captivity with an imminent possibility of being killed, exposure to life-threatening situations, such as being a victim of terrorism, and torture. According to ICD-10, the diagnosis of an enduring change in personality should be made only when there is evidence of a definite, significant and persistent change in the individual’s pattern of perceiving, relating or thinking about the environment and him or herself, associated with inflexible and maladaptive behaviours not present before the traumatic experience. The diagnosis excludes changes that are a manifestation of another mental disorder or a residual symptom of any antecedent mental disorder, as well as personality and behavioural changes due to brain disease, dysfunction or damage. (e) Other diagnoses 259. As is evident from the catalogue of symptoms described in this section, there are other diagnoses to be considered in addition to PTSD, such as major depressive disorder and enduring personality change. The other possible diagnoses include but are not limited to: (i) Generalized anxiety disorder features excessive anxiety and worry about a variety of different events or activities, motor tension and increased autonomic activity; (ii) Panic disorder is manifested by recurrent and unexpected attacks of intense fear or discomfort, including symptoms such as sweating, choking, trembling, rapid heart rate, dizziness, nausea, chills or hot flushes; 257. To make the ICD-10 diagnosis of enduring personality change after catastrophic experience, the changes in personality must be present for at least two years following exposure to catastrophic stress. ICD-10 specifies that the stress must be so extreme that “it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality”. This personality change is characterized by a hostile or distrustful attitude towards the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of “being on edge”, as if constantly threatened, and estrangement. (iii) Acute stress disorder has essentially the same symptoms as PTSD but is diagnosed within one month of exposure to the traumatic event; (iv) Somatoform disorders featuring physical symptoms that cannot be accounted for by a medical condition; (v) Bipolar disorder featuring manic or hypomanic episodes with elevated, expansive or irritable mood, grandiosity, decreased need for sleep, flight of ideas, psychomotor agitation and associated psychotic phenomena; (d) Substance abuse 258. Clinicians have observed that alcohol and drug abuse often develop secondarily in torture survivors as a way of suppressing traumatic memories, regulating unpleasant affects and managing anxiety. Although comorbidity of PTSD with other disorders is common, systematic research has seldom studied the abuse of substances by torture survivors. The literature on populations that suffer from PTSD may include torture survivors, such as refugees, prisoners of war and veterans of armed conflicts, and may provide some insight. Studies of these groups reveal that prevalence of substance abuse varies by ethnic or cultural group. Former prisoners of war with PTSD were at increased risk of substance abuse, and combat veterans have high rates of co-morbidity of PTSD and substance abuse.105, 106, 107, 108, 109, 110, 111, 112 In sum- (vi) Disorders due to a general medical condition often in the form of brain impairment with resultant fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning; (vii) Phobias such as social phobia and agoraphobia. C. The psychological/psychiatric evaluation 1. Ethical and clinical considerations 260. Psychological evaluations can provide critical evidence of abuse among torture victims for several reasons: torture often causes devastating psychological symptoms, torture methods are often designed to leave no physical lesions and physical methods of torture may result in physical findings that either resolve or lack specificity. 105 P. J. Farias, “Emotional distress and its socio-political correlates in Salvadoran refugees: analysis of a clinical sample”, Culture, Medicine and Psychiatry, vol. 15 (1991), pp. 167-192. 106 A. Dadfar, “The Afghans: bearing the scars of a forgotten war”, Amidst Peril and Pain: The Mental Health and Well-being of the World’s Refugees, A. Marsella and others (Washington, D. C., American Psychological Association, 1994). 107 G. W. Beebe, “Follow-up studies of World War II and Korean war prisoners: II. Morbidity, disability, and malajustments”, American Journal of Epidemiology, vol. 101 (1975), pp. 400-422. 108 B. E. Engdahl and others, “Comorbidity and course of psychiatric disorders in a community sample of former prisoners of war”, American Journal of Psychiatry, vol. 155 (1998), pp. 1740-1745. 109 T. M. Keane and J. Wolfe, “Comorbidity in post-traumatic stress disorder: an analysis of community and clinical studies”, Journal of Applied Social Psychology, vol. 20 (21) (1990), pp. 1776-1788. 110 R. A. Kulka and others, Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study (New York, Brunner/Mazel, 1990). 111 B. K. Jordan and others, “Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls”, Archives of General Psychiatry, vol. 48, No. 3 (1991), pp. 207-215. 112 A. Y. Shalev, A. Bleich and R. J. Ursano, “Posttraumatic stress disorder: somatic comorbidity and effort tolerance”, Psychosomatics, vol. 31 (1990), pp.197-203. 49