26 A practical guide to the Istanbul Protocol – for psychologists tion or living under considerable threat or oppression, some symptoms may be adaptive[…]” (Istanbul Protocol, § 239). The evaluation of several symptoms may not be possible due to certain life conditions. For example, during detention avoidance symptoms can be harder to assess because they might represent coping strategies aiming to protect oneself. Likewise, hyper-vigilance and avoidance behaviours may be necessary, adaptive and crucial for those living in repressive societies. Markedly diminished interest in significant activities may be more difficult to demonstrate in detention where “significant” activities are prohibited. It is also difficult to assess the “feeling of detachment and estrangement from others” if there is solitary confinement or forced isolation (partial or complete). Such situations cause some additional difficulties in the evaluation, and can cause errors in assessments of the diagnostic criteria, and lead to underestimations of the extent of significant post-traumatic pathology. It is important to have a flexible and integrative approach so as not to cause false negative results. (Simpson, 1995) (See §§ 236-249 in the Istanbul Protocol and Becker, 1995; Burnett & Peel, 2001a; Gurr & Quiroga, 2001; Kagee, 2005; Kira, 2002; Mollica & Caspi-Yavin, 1992; Simpson, 1995; Summerfield, 1995, 2000, 2001.) 1. SYMPTOMS OF PTSD Re-experiencing the trauma such as intrusive memories, thoughts, recurrent nightmares or distressing dreams, intense psychological distress at and/or physiological reactivity to exposure to cues that symbolize or resemble the trauma, flashbacks. Avoidance and emotional numbing such as avoidance of any thought, conversation, activity, place or person that arouse a recollection of the trauma; profound emotional constriction; profound personal detachment and social withdrawal; inability to recall an important aspect of the trauma, feeling of estrangement from others, restricted range of affect, sense of foreshortened future. Hyperarousal such as difficulty in either falling or staying asleep, irritability or outbursts of anger, concentration difficulties, hyper-vigilance, exaggerated startled response, generalized anxiety, shortness of breath, sweating, dizziness and gastrointestinal distress. (See § 241 in the Istanbul Protocol.) 2. SYMPTOMS OF DEPRESSION • Depressed mood, markedly diminished interest or pleasure in activities • Appetite disturbance and weight loss • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue and loss of energy • Diminished ability to think or to concentrate in memory functions • Indecisiveness • Feelings of worthlessness and excessive guilt, diminish, difficulties in concentration, recurrent thoughts of death. (See § 242 in the Istanbul Protocol.) 3. SYMPTOMS OF DISSOCIATIVE DISORDERS Dissociation is a disturbance or alteration in the normally integrative function of consciousness, self-perception, memory and actions (van der Kolk et al., 1996). A person may be cut off or unaware of certain actions or may feel split in two and feel as if observing him or herself from a distance. It is a common response during extremely traumatic events that could lead to the underreporting and the misperception of vari-