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Psychiatric Disorders Among Tortured Bhutanese Refugees in Nepal
Mark Van Ommeren, PhD;
Joop T. V. M. de Jong, MD, PhD;
Bhogendra Sharma, MBBS, MSc;
Ivan Komproe, PhD;
Suraj B. Thapa, MBBS;
Etzel Cardeña, PhD
Arch Gen Psychiatry. 2001;58:475-482.
ABSTRACT
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Background The impact of torture on the distribution of psychiatric disorders among
refugees is unknown.
Methods We surveyed a population-based sample of 418 tortured and 392 nontortured
Bhutanese refugees living in camps in Nepal. Trained interviewers assessed International Classification of Diseases, 10th Revision (ICD-10) disorders through structured diagnostic psychiatric interviews.
Results Except for male sex, history of torture was not associated with demographics.
Tortured refugees, compared with nontortured refugees, were more likely to
report 12-month ICD-10 posttraumatic stress disorder,
persistent somatoform pain disorder, and dissociative (amnesia and conversion)
disorders. In addition, tortured refugees were more likely to report lifetime
posttraumatic stress disorder, persistent somatoform pain disorder, affective
disorder, generalized anxiety disorder, and dissociative (amnesia and conversion)
disorders. Tortured women, compared with tortured men, were more likely to
report lifetime generalized anxiety disorder, persistent somatoform pain disorder,
affective disorder, and dissociative (amnesia and conversion) disorders.
Conclusions Among Bhutanese refugees, the survivors had higher lifetime and 12-month
rates of ICD-10 psychiatric disorder. Men were more
likely to report torture, but tortured women were more likely to report certain
disorders. The results indicate the increased need for attention to the mental
health of refugees, specifically posttraumatic stress disorder, persistent
somatoform pain disorder, and dissociative (amnesia and conversion) disorders
among those reporting torture.
INTRODUCTION
SINCE 1990, Nepal has received more than 100 000 Bhutanese refugees.
These Nepali-speaking refugees are descendants from Nepali migrants who were
invited to settle in Bhutan several generations ago. The refugees left Bhutan
because of persecution and torture by the Bhutanese government's security
services. The autocratic government likely felt threatened by the country's
growing Nepali-speaking population and the launch of a democracy movement.1, 2, 3
The literature on refugee mental health has been limited in that most
studies of refugees have involved samples with participants who found refuge
in the West.4, 5, 6, 7, 8, 9
These studies have indicated that symptoms of posttraumatic stress disorder
(PTSD), depression, and anxiety, as well as somatic complaints, are common.5, 8, 10, 11, 12, 13, 14, 15
However, the results may not necessarily generalize to the more than 70%16 of the world's refugees living in low-income countries,
where refugees experience different problems with respect to hazards, deprivation,17 and acculturation.18, 19
Representative data on mental disorder are rarely available. The only previous
population-based study20 of adult refugees
outside the West identified high levels of anxiety and depression among Cambodian
refugees, which is consistent with refugee studies5, 8
conducted in the West. More work needs to be conducted in sites where most
of the world's refugees live.4, 6, 7, 8, 9
Similarly, the study of the impact of torture on refugees has been limited
because of lack of access to population-based samples. Obtaining access to
representative samples of torture survivors has been difficult.21
In 1995, researchers conducted the only population-based survey of torture
survivors thus far.22 Comparisons between 526
tortured and 526 matched nontortured Bhutanese refugees displaced in Nepal
indicated torture as a risk factor for elevated levels of anxiety and depression
symptoms and for PTSD. However, this survey was limited in scope, focusing
on few variables and on symptoms of disorders rather than on a range of diagnosed
disorders. Because of the unique research opportunities inherent in this representative
sample of torture survivors, we decided to further interview the participants
to study a range of International Classification of Diseases,
10th Revision (ICD-10)23
disorders with correlates.
We address 3 questions. First, is history of reporting torture associated
with certain demographic correlates? Demographic correlates might indirectly
affect the distribution of psychiatric disorders among tortured and nontortured
refugees, by increasing the chances of exposure to torture. Depending on the
reasons for torture, perpetrators of torture may target specific groups of
people. Moreover, exposure to different traumatic events has been shown to
be associated with certain individual characteristics, such as sex and ethnicity.24, 25, 26
Second, what psychiatric disorders are likely sequelae of torture in
this refugee population? Studies10, 27
have indicated there are increased symptoms of disorder among tortured refugees
but have not evaluated disorders as such. In the only previous controlled
study of disorders among torture survivors, Basoglu and colleagues28 reported significantly more PTSD diagnoses among
a selected sample of 55 tortured Turkish political activists than among the
matched comparison group. The 2 groups did not differ in terms of prevalence
of anxiety or affective disorders. However, pain and dissociative disorders
were not assessed.
Third, what are the demographic correlates of disorders among Bhutanese
tortured refugees? The US National Comorbidity Survey29
data indicate that the prevalence of most disorders declines with age and
higher socioeconomic status and that women are more likely to report anxiety
and affective disorders. Knowledge of demographic correlates of disorder among
tortured refugees is useful for program development in refugee camps.
The survey was conducted by a Nepali nongovernmental organization familiar
with the context. The organization had provided medical and psychosocial care
to more than 1200 Bhutanese torture survivors for 6 years and had completed
a narrative study, focus groups, a case-control survey, and a survey of local
idioms of distress.22, 30
PARTICIPANTS AND METHODS
PARTICIPANTS
The sample frame consisted of 526 tortured and 526 nontortured Bhutanese
refugees who had previously been interviewed in 1995.22
The tortured refugees had been randomly sampled from a list, consisting of
registered physically tortured Bhutanese refugees living among the 85 078
Bhutanese refugees in refugee camps in Nepal. The list had been created by
the community-based Center for Victims of Torture, Nepal, between 1991 and
1994. In cooperation with political parties, human rights organizations, collaborating
agencies, and a hut-to-hut survey, the center's refugee staff identified and
registered 2331 Bhutanese refugees who reported a history of physical torture. Physical torture, consistent with the World Medical Association's31 definition, was defined as deliberate, systematic,
or wanton infliction of physical suffering by 1 or more persons acting alone
or on the orders of any authority to yield information, to make a confession,
or for any other reason. As the identification process included a hut-to-hut
survey, it is likely that virtually all survivors of physical torture in the
camps were included. Nevertheless, because of cultural stigma associated with
rape, not all female torture survivors may have registered themselves. The
nontortured comparison participants were refugees living in the same camps
and were neighbors of the tortured participants. Tortured and nontortured
refugees were matched on age and sex. Matching on sex was exact. Ten years'
difference was accepted as an age match. In 1995, the 2 groups had, on average,
the same age (mean age, 41 years).22
Of 1052 refugees in our sampling frame, we were able to approach 946
(89.9%) between March 20, 1997, and July 31, 1997, the latest date we had
permission to collect these data. Of 946 approached refugees, 879 (92.9%)
were interviewed, 32 (3.4%) refused, 20 (2.1%) were away from camp, 4 (0.4%)
were not found, 5 (0.5%) had died, and 6 (0.6%) were too disabled by mental
or physical illness to attend the interview. Of 879 interviewed refugees,
20 interviews (2.3%) were not completed because of mental status problems
or deafness. Moreover, 49 completed interviews (5.6%) were discarded because
the interviewees had not been in the sample frame and had been approached
and interviewed by mistake. The remaining 810 participants included 418 tortured
and 392 nontortured refugees.
ASSESSMENT
The battery of instruments included specific phobias and affective,
generalized anxiety, persistent somatoform pain, posttraumatic stress, and
dissociative (amnesia and conversion) disorder modules of the Composite International
Diagnostic Interview (CIDI).32 The CIDI assesses Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV33) and ICD-1023 diagnoses. We report ICD-10 disorders because the ICD-10,
in contrast to the DSM-IV, has been specifically
developed for international use. For each disorder, the CIDI elicits the time
of first and last occurrence, allowing for the determination of lifetime and
12-month disorder.
The CIDI covers ICD-10 dissociative amnesia,
dissociative motor disorder, dissociative convulsions, and dissociative anesthesia
and sensory loss. The latter 3 disorders are parallel to DSM-IV33 conversion disorder with motor
symptom or deficit, conversion disorder with seizures or convulsions, and
conversion disorder with sensory symptom or deficit, respectively. In contrast
to DSM-IV, ICD-10 categorizes
these 3 conversion disorders as dissociative disorders. The CIDI covers neither
fugue nor dissociative identity disorder. The ICD-10
dissociative motor disorder pertains to loss of coordination of voluntary
muscle movement, including paralysis, loss of voice, and the ability to stand
unaided.
Clinical experience and narrative interviews had indicated the relevance
of studying medically unexplained pain.30 The ICD-10 persistent somatoform pain disorder, as measured
by the CIDI, pertains to serious, medically unexplained, physical pain causing
a great deal of distress for at least 6 months.
The CIDI affective disorders module covers ICD-10 mild, moderate, and severe depressive episodes and dysthymia. We did
not include the CIDI mania module. We defined the scope of generalized anxiety
disorder (GAD) to include worries related to daily refugee life, such as realistic
concerns about well-being of family in the camps, lost property, well-being
of relatives in Bhutan, and an uncertain future.
The CIDI PTSD module includes a checklist of traumatic events. The PTSD
criteria were evaluated for the most stressful or upsetting event reported.
We relaxed the ICD-10 criteria for PTSD to include
those with a delayed onset, ie, onset of symptoms more than 6 months after
the event.
The interview included 5 questions about separation experienced before
age 13 years, covering death of mother, death of father, parental separation
or divorce, living alone, and living with relatives other than parents. Early
separation was operationalized as scoring positive on at least 1 of these
5 questions. The first section of the Harvard Trauma Questionnaire,34 a section designed to assess trauma among Southeast
Asian refugees, measured the number of childhood traumatic events (range,
0-16) before age 13. Mental disease in the family was operationalized as the
number of endorsements of 5 dichotomous questions (range, 0-5) covering mental
disease in the family. On the basis of a brief medical investigation, the
physician assessed the presence of significant current and past disease, including
diabetes, hypertension, heart disease, head injury, meningitis, encephalitis,
and history of thyroid functioning.
The instruments were systematically translated and adapted for 3 months,
using (1) 7 bilingual Nepali translators, who had been trained to translate
each item, with content, criterion, technical, conceptual, and semantic equivalence
as goals,35 (2) a bilingual Nepali physician
who independently evaluated the translation, (3) 2 focus groups, consisting
of uneducated Bhutanese refugees, who evaluated each translated item for comprehension
and suggested revisions, and (4) a Western expatriate mental health researcher,
who evaluated 1 back-translation and 1 blind back-translation of all items
for each type of equivalence. As described in detail elsewhere,36
this process was monitored for each item with a Translation Monitoring Form,
to systematically identify and improve translated items that were not fully
equivalent to the originals.
The instruments were administered by the Nepali translators: 2 male
physicians as well as 3 male and 2 female undergraduate students in unrelated
disciplines. The translators received 3 weeks of interviewing training. The
first week of training was conducted by the expatriate researcher, who had
previously been trained by a World Health Organization (WHO)-designated CIDI
trainer. The second week, the translators (now interviewers) pilot-tested
the translations. The WHO-designated trainer conducted the final week of training.
Testing revealed that the CIDI probe flow chart was not functioning
as intended.37 The CIDI probe flow chart is
a series of structured questions to assess whether somatic complaints are
probably psychiatric (ie, medically unexplained). Nepali physicians observed
that the flow chart questions administered by the lay interviewers did not
always lead to the proper identification of medically explained vs medically
unexplained symptoms. The flow chart presupposes that respondents attribute
their symptoms as the outcomes of either mental, physical, or substance-induced
processes and that local physicians communicate diagnoses to patients. These
assumptions are false in this context where physicians rarely share diagnoses
with patients and where headaches and other body aches are typically considered
physical illnesses, caused by physical injury, supernatural processes, or
both. Thus, the physicians, instead of the lay interviewers, administered
the CIDI section covering somatoform symptoms. The physicians applied their
knowledge of medicine to probe beyond the structured flow chart questions
and accordingly coded whether the symptoms were medically unexplained.37
PROCEDURES
The interviews consisted of a medical and a nonmedical section. The
medical section, administered to all participants by 1 of the 2 physicians,
included the somatoform and dissociative disorders section of the CIDI, history
of medical problems, and the brief physical examination mentioned in the "Assessment"
subsection. The physicians provided and referred participants for medical
treatment when deemed necessary. The 5 lay interviewers administered the other
instruments. Because of the limited time allotted by local authorities to
conduct the survey, we chose not to administer all questionnaires to all participants,
to reduce the overall duration of the survey. A random subsample of 523 (65%)
of 810 respondents received the Harvard Trauma Questionnaire34
and the questions about early separation and mental illness in the family.
All interviews took place in the confidential environment of our clinic. The
interviewers were not blinded with regard to torture status because PTSD assessment
requires a reference event. Male and female lay interviewers interviewed male
and female respondents, respectively.
We followed the Declaration of Helsinki38
recommendations for ethical research. Because of illiteracy and distrust toward
written contracts, we did not seek written consent. Rather, after a description
of the study was read to the respondents, verbal informed consent was obtained
and recorded on paper. Research involving either trauma stories39
or sensitive questions40 unlikely has a negative
impact on respondents and is therefore ethical.
STATISTICAL ANALYSES
We used 2-tailed  2 and t tests
for univariate comparisons and multivariate logistic regression to identify
predictors of torture status. The multivariate regression involved a random
subsample of 523 respondents and had sufficient statistical power to identify
fairly small effect sizes as significant.41
All other analyses were conducted on the full sample. We applied multivariate
analysis of covariance to test whether the general profile of disorders differed
between the tortured and nontortured groups. Age and sex were covariates;
Wilks  was the criterion. We used univariate logistic regression to
assess differences in rates of disorder between the groups. The pattern of
results did not change when using standard multivariate or hierarchical logistic
regression analyses involving the addition of demographic variables to the
equation. Because odds ratios overestimate relative risk in studies of common
outcomes, we estimated risk ratios.42 Significance
was set at P<.05 except for analyses identifying
demographic correlates of disorders. For the latter analyses, significance
was set at P<.01 to reduce chance significance
caused by multiple tests. All analyses were performed with commercially available
software.43
RESULTS
Details on the torture have been previously published.22
In brief, the mean ± SD duration of torture was 21.4 ± 83.3
days (range, 1-1095 days). Ninety percent of physically tortured respondents
also reported torture that did not involve the body. More than 50% reported
severe beatings (97.1%), threats (89.0%), humiliations (79.2%), forced incongruent
acts (66.3%), social isolation (54.3%), sleep deprivation (52.2%), or hygiene
deprivation (51.9%). Incongruent acts are acts that violate local religious
norms (eg, eating beef).
TORTURE STATUS
The present data were collected a mean ± SD of 6.0 ± 0.9
years (range 3-11 years) after the torture. Tortured and nontortured refugee
groups were similar in terms of age, sex, marital status, employment status,
years of schooling, early separation, childhood trauma, and mental illness
in the family (Table 1). Tortured
refugees had had somewhat higher family incomes in Bhutan. Nontortured refugees
were more likely to be Buddhist and had been displaced slightly longer. Tortured
refugees who had had better access to treatment facilities in the camps30 were less likely to suffer from current or past disease.
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Table 1. Univariate Comparisons Between Tortured and Nontortured Bhutanese
Refugees
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We performed logistic regression analysis on having a history of torture,
with family income in Bhutan, religion, early separation, membership in a
political or human rights organization in Bhutan, childhood trauma, and mental
illness in the family as predictors. Age and sex were also entered but were
not expected to be significant because the sample was drawn from groups matched
on age and sex. The results revealed no significant predictors (P>.05). Among these nonsignificant predictors, family income in Bhutan
(P = .09) was the most significant. Nevertheless,
torture status among the Bhutanese is significantly associated with sex because
76.8% of the population-based sample frame of torture survivors were men (21 = 151.2, P<.001).22 In short, other than male sex, torture status was
not associated with assessed demographics.
PSYCHIATRIC DISORDERS
Multivariate analyses of covariance indicated that torture status was
associated with lifetime and 12-month disorder. The general profile of disorders
was significantly affected not only by torture status (F6,801 =
88.5, P<.001) but also by the combined covariates
of age and sex (F12,1602 = 9.1, P<.001).
The analysis was repeated for 12-month disorders, with similar results (F6,801 = 44.6, P<.001 and F12,1602
= 7.5, P<.001; respectively).
Risk ratios showed that tortured refugees, compared with nontortured
refugees, were more likely to have 12-month posttraumatic stress, dissociative,
and persistent somatoform pain disorders (Table 2). In addition, tortured refugees were more likely to have
had posttraumatic stress, dissociative, persistent somatoform pain, affective,
and generalized anxiety disorders at some point in their lives.
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Table 2. Lifetime and 12-Month Prevalence of ICD-1023 Psychiatric
Disorders Among 418 Tortured and 392 Nontortured Bhutanese Refugees*
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The most frequent reported lifetime disorder among torture survivors
was PTSD. Approximately 3 of 4 tortured refugees had this disorder at some
point in their lives. More than 4 of every 10 tortured refugees had PTSD within
the year before the interview. Among 365 refugees with lifetime PTSD, only
9 (2.5%) reported an onset of symptoms that was more than 6 months after the
event. Onset of PTSD was always within 2 years of the event.
More than half of the tortured refugees reported a lifetime history
of persistent somatoform pain disorder. In contrast, among nontortured refugees,
only 1 of 4 reported this lifetime disorder. Lifetime dissociative disorder
was common among tortured refugees (19.4%) but not among nontortured refugees
(4.6%). The 12-month prevalence rates of persistent somatoform pain disorder
and dissociative disorder were similar to the lifetime rates, indicating that
these were chronic disorders. The lifetime rates of affective disorder and
GAD were higher among tortured refugees (35.6% and 20.6%, respectively) than
among nontortured refugees (15.6% and 12.5%). However, 12-month affective
disorder and GAD rates were much lower for tortured and nontortured refugees,
indicating remission.
Approximately 5 of 6 tortured refugees had at least 1 lifetime disorder,
and 3 of 4 had at least one 12-month disorder. In contrast, more than half
of nontortured refugees had a lifetime disorder within their life, and almost
half had a 12-month disorder.
With respect to comorbidity (Table
3), approximately three quarters of the tortured and nontortured
refugees with lifetime PTSD reported a comorbid disorder. Tortured refugees
with lifetime PTSD, compared with tortured refugees without lifetime PTSD,
were more likely to report each of the assessed disorders. Moreover, nontortured
refugees with lifetime PTSD, compared with nontortured refugees without lifetime
PTSD, were more likely to report affective disorder and simple phobia.
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Table 3. Comorbidity of Lifetime Posttraumatic Stress Disorder (PTSD)
With Other Lifetime Disorders in Tortured and Nontortured Refugees*
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Demographic correlates of the different disorders among torture survivors
are shown in Table 4. Tortured
female refugees, compared with tortured male refugees, were at higher risk
for most disorders. Survivors living without a spouse (eg, being single, living
separated, or widowed) had more GAD and specific phobia.
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Table 4. Demographic Correlates of Lifetime ICD-1023 Psychiatric
Disorders Among 418 Tortured Bhutanese Refugees*
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COMMENT
In this population-based sample of tortured Bhutanese refugees, male
sex was identified as the only demographic predictor of reporting a history
of torture. Other demographics (including membership in a political or human
rights organization in Bhutan) did not predict torture status. Among the Nepali-speaking
Bhutanese refugees from southern Bhutan, torture occurred across demographic
groups.
Multivariate analyses of covariance showed an association between torture
and psychiatric disorder. Risk ratios showed that each of the assessed disorders,
except specific phobias, occurred more likely in the lifetime of a tortured
refugee than it did in the lifetime of a nontortured refugee. Affective disorder
and GAD were common lifetime disorders, but their much lower 12-month prevalence
rates indicate that these disorders frequently remitted over time. With respect
to 12-month disorders, tortured refugees were much more likely to report PTSD,
dissociative (amnesia and conversion) disorders, and persistent somatoform
pain disorder.
We found that 5 of every 6 tortured refugees had a lifetime disorder,
and we noted a high rate of PTSD among tortured refugees. This is not inconsistent
with data from the National Comorbidity Survey.44
In this US community survey, about half of all rape survivors reported a lifetime
history of PTSD. Torture, frequently involving the unspeakable, may be even
more traumatic. The prevalence (14.5%) of lifetime PTSD among nontortured
Bhutanese refugees was almost twice the rate reported by Americans in the
National Comorbidity Survey.44 High PTSD rates
among nontortured refugees may be explained by refugees' increased risk of
exposure to life-threatening events, other than torture. The high rates of
dissociative (amnesia and conversion) disorders among tortured refugees are
consistent with theory and research relating trauma and dissociation45, 46, 47 and underscore the
relevance of assessing amnesia and conversion in studies on the consequences
of extreme stress.48
More than half (56%) of the nontortured refugees reported a lifetime
disorder. Similarly, 2 large community surveys conducted in the US, the National
Comorbidity Survey29 and the Epidemiological
Catchment Area study, have identified high rates of lifetime mental disorder
among adults younger than 55 years (48% and 47%, respectively).49
Such high rates of disorder are of concern for health care planning. However,
diagnosis and need for treatment are not necessarily the same.50, 51
Our survey did not seek to identify severe mental disorder requiring immediate
treatment. Nevertheless, the high rates of disorder in the Bhutanese refugee
community argue for the presence of quality mental health services. Such services
are typically not present in refugee camps.
Tortured and nontortured Bhutanese refugees experienced much medically
unexplained pain, as is evident from the observed rates of persistent somatoform
pain disorder. Further research is needed to assess whether and to what extent
this unexplained pain results from physical or psychiatric disorders or from
direct exposure to physical or mental trauma. The observed comorbidity between
persistent somatoform pain disorder and PTSD among the tortured is consistent
with previous research52, 53 noting
a relation between medically unexplained somatic complaints and PTSD. Clinical
experience suggests that these unexplained complaints are associated with
mistaken beliefs in a damaged body.30 The frequent
reporting of somatic pain and somatoform symptoms of dissociation may also
be related to response styles, inflating prevalence rates. For example, some
of these symptoms may cover or tap into local idioms of expressing distress.54
We investigated demographic correlates of disorder among torture survivors.
The finding that female torture survivors have more likely experienced a range
of disorders not only is consistent with previous research indicating that
women are at greater risk of affective and anxiety disorders29
but also may be an indication of sociocultural stressors associated with being
a woman in South Asia.55 The finding that tortured
Bhutanese refugees in intact marriages are less likely to have had anxiety
disorders is consistent with research showing that Southeast Asian refugees
in intact marriages have less depressive affect56
and neuroticism.57
This survey has the following strengths and weaknesses. Even though
the generalizability of findings beyond the specific context is unknown, a
strength of the survey is that it involved a large population-based sample
of tortured refugees living in a non-Western setting. Moreover, the comparison
group, drawn from the same refugee camp population, was similar in terms of
demography and refugee status, although theoretically the groups may have
differed on variables not assessed. In contrast to other studies, we investigated
a broad range of disorders through a structured psychiatric interview. Yet,
determination of torture status was based on self-report, and retrospective
assessment several years after the persecution may have led to underreporting
of forgotten events and disorders.58 Furthermore,
the validity of the various CIDI diagnoses is still under investigation.51 The WHO is investigating the comparability of diagnoses
in different cultures assessed according to the ICD
and DSM diagnostic systems using the Schedules for
Clinical Assessment in Neuropsychiatry59 and
the CIDI. Preliminary results indicate that the outcome factor structure does
not vary significantly across groups (Chris Nelson, PhD, WHO CIDI, written
communication, April 7, 1999), suggesting construct validity of diagnoses.
This present survey indicates a greater risk for 12-month ICD-1023 PTSD than did our first survey
of DSM-III-R60 PTSD
among torture survivors, using data primarily from the same refugee group.22 The 2 surveys, however, are not entirely comparable.
The CIDI PTSD module, used in the present survey, may overestimate 12-month
PTSD. In CIDI research, if respondents with lifetime PTSD report having had
any PTSD symptoms within the last 12 months, they are diagnosed as having
12-month PTSD, possibly inflating the observed 12-month prevalence rate and
risk ratio. Data of the first survey were collected in the refugees' own huts,
possibly in the presence of other refugees, which may have resulted in an
underestimate. In contrast, the present survey was conducted in a confidential
environment. During the first survey, the preparation of the PTSD questions
in Nepali involved lexical translation and testing only. For the second survey,
we developed and applied a methodical approach to translation involving focus
groups and blind-back translation. As we have shown elsewhere,36
this approach provides a more understandable and equivalent translation.
Our data inform about clinical disorders that require more professional
attention. Although there is increasing evidence of the efficacy of treatments
for PTSD,61 the literature does not yet indicate
effective treatment for torture survivors with ICD-1023 persistent somatoform pain and dissociative (amnesia
and conversion) disorders. Service delivery efforts 62 and treatment
outcome research should be augmented to target these disorders to improve
care of tortured refugees.
AUTHOR INFORMATION
Accepted for publication October 10, 2000.
From the Center for Victims of Torture, Kathmandu, Nepal (Drs Van Ommeren,
Sharma, and Thapa); Transcultural Psychosocial Organization, World Health
Organization Collaborating Centre for Refugees and Ethnic Minorities, Vrije
Universiteit, Amsterdam, the Netherlands (Drs Van Ommeren, de Jong, and Komproe);
and Department of Psychology and Anthropology, The University of Texas–Pan
American, Edinburg (Dr Cardeña).
Corresponding author and reprints: Mark Van Ommeren, PhD, Center
for Victims of Torture, PO Box 5839, Kathmandu, Nepal (e-mail: mark_van_ommeren{at}hotmail.com).
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