PTSD is a diagnosable syndrome amenable to treatment biologically and psychologically.101 As much as possible, the evaluating physician or psychologist should attempt to relate to mental suffering in the context of the individual’s beliefs and cultural norms. This includes respect for the political context as well as cultural and religious beliefs. Given the severity of torture and its consequences, when performing a psychological evaluation, an attitude of informed learning should be adopted rather than one of rushing to diagnose and classify. Ideally, this attitude will communicate to the victim that his or her complaints and suffering are being recognized as real and expectable under the circumstances. In this sense, a sensitive empathic attitude may offer the victim some relief from the experience of alienation. cultural study of depression provides helpful information.99 While some symptoms may be present across different cultures, they may not be the symptoms that concern the individual the most. 2. The context of the psychological evaluation 238. Evaluations take place in a variety of political contexts. This results in important differences in the manner in which an evaluation should be conducted. The physician or psychologist must adapt the following guidelines to the particular situation and purpose of the evaluation (see chapter III, sect. C.2). 239. Whether or not certain questions can be asked safely will vary considerably and depends on the degree to which confidentiality and security can be ensured. For example, an examination in a prison by a visiting physician, that is limited to 15 minutes, cannot follow the same course as a forensic examination in a private office that may last for several hours. Additional problems arise when trying to assess whether psychological symptoms or behaviours are pathological or adaptive. When a person is examined while in detention or living under considerable threat or oppression, some symptoms may be adaptive. For example, diminished interest in activities and feelings of detachment or estrangement would be understandable in a person in solitary confinement. Likewise, hypervigilance and avoidance behaviours may be necessary for persons living in repressive societies.100 The limitations of certain conditions for interviews, however, do not preclude aspiring to application of the guidelines set forth in this manual. It is especially important in difficult circumstances that governments and authorities involved be held to these standards as much as possible. 2. Common psychological responses (a) Re-experiencing the trauma 241. A victim may have flashbacks or intrusive memories, in which the traumatic event is happening all over again, even while the person is awake and conscious, or recurrent nightmares, which include elements of the traumatic event in their original or symbolic form. Distress at exposure to cues that symbolize or resemble the trauma is frequently manifested by a lack of trust and fear of persons in authority, including physicians and psychologists. In countries or situations where authorities participate in human rights violations, lack of trust and fear of authority figures should not be assumed to be pathological. (b) Avoidance and emotional numbing (i) Avoidance of any thought, conversation, activity, place or person that arouses a recollection of the trauma; B. Psychological consequences of torture (ii) Profound emotional constriction; 1. Cautionary remarks (iii) Profound personal detachment and social withdrawal; 240. Before entering into a technical description of symptoms and psychiatric classifications, it should be noted that psychiatric classifications are generally considered to be Western medical concepts and that their application to non-Western populations presents, either implicitly or explicitly, certain difficulties. It can be argued that Western cultures suffer from an undue medicalization of psychological processes. The idea that mental suffering represents a disorder that resides in an individual and features a set of typical symptoms may be unacceptable to many members of non-Western societies. Nonetheless, there is considerable evidence of biological changes that occur in PTSD and, from that perspective, (iv) Inability to recall an important aspect of the trauma. (c) Hyperarousal (i) Difficulty either falling or staying asleep; (ii) Irritability or outbursts of anger; (iii) Difficulty concentrating; (iv) Hypervigilance, exaggerated startled response; (v) Generalized anxiety; (vi) Shortness of breath, sweating, dry mouth or dizziness and gastrointestinal distress. 99 N. Sartorius, “Cross-cultural research on depression”, Psychopathology, vol. 19 (2) (1987), pp. 6-11. 100 M. A. Simpson, “What went wrong?: diagnostic and ethical problems in dealing with the effects of torture and repression in South Africa”, Beyond Trauma: Cultural and Societal Dynamics, R. J. Kleber, C. R. Figley, B. P. R. Gersons, eds. (New York, Plenum Press, 1995), pp.188-210. 101 M. Friedman and J. Jaranson, “The applicability of the posttraumatic stress disorder concept to refugees”, Amidst Peril and Pain: The Mental Health and Well-being of the World’s Refugees, A. Marsella and others, eds. (Washington, D. C., American Psychological Association, 1994), pp. 207-227. 46