28 A practical guide to the Istanbul Protocol – for psychologists and delusions of persecution (care must be taken when defining paranoid delusions since in some countries persecution during and/or after detention is frequent). (See § 247 in the Istanbul Protocol.) 7. SUBSTANCE ABUSE The clinician should inquire about substance use before and after the torture, changes in the pattern of use and abuse, and whether substances are being used to cope with some trauma-related health problems such as insomnia, anxiety, pain or others. In many studies of trauma survivors, higher rates of substance use are observed after the traumatic event (American Psychiatric Associaction (APA), 2004). 8. NEURO-PSYCHOLOGICAL IMPAIRMENT Torture can involve physical trauma that lead to various levels of brain impairment. Blows to the head, suffocation and prolonged malnutrition may have long-term neurological and neuro-psychological consequences that may not be readily assessed during the course of a medical examination. Frequently, the symptoms for such assessments have significant overlap with the symptomatology arising from PTSD and major depressive disorders. Fluctuations or deficits in level of consciousness, orientation, attention, concentration, memory and executive functioning may result from functional disturbances as well as organic causes. (See § 249 in the Istanbul Protocol.) (See § 248 in the Istanbul Protocol.) III. MOST COMMON DIAGNOSTIC CATEGORIES “While the chief complaints and most prominent findings among torture survivors are widely diverse and relate to the individual’s unique life experiences and his or her cultural, social and political context, it is wise for evaluators to become familiar with the most commonly diagnosed disorders among trauma and torture survivors[...]” ( Istanbul Protocol, § 250). There are clusters of symptoms and psychological reactions that have been observed and documented in torture survivors with some regularity: “[...]Also, it is not uncommon for more than one mental disorder to be present, as there is considerable symptom overlap as well as co-morbidity among trauma-related mental disorders. Various manifestations of anxiety and depression are the most common symptoms resulting from torture[...]” (Istanbul Protocol, § 250). The two prominent classification systems are the International Classification of Diseases and Related Health Problems (ICD-10) (WHO, 1994, 2007) Classification of Mental and Behavioural Disorders and the American Psychiatric Association’s Diagnostic and Statistical Manual, Fourth Edition-Text Version (DSM-IV-TR) (APA, 2000). For complete descriptions of diagnostic categories, please refer to ICD-10 and DSM-IV-TR. The most common trauma-related diagnoses