Psychological abuse in a setting of captivity that does not involve physical pain seems to cause as much mental distress as physical abuse, according to an article in the March issue of the Archives of General Psychiatry. Examples in wartime or terrorist settings include psychological manipulation, deprivation, humiliation and forced stress positions.

Metin Basoglu, MD, PhD, King's College, University of London, and colleagues interviewed 279 survivors of torture from Sarajevo in Bosnia and Herzegovina, Luka in Slovenia, Rijeka in Croatia, and Belgrade in Serbia between 2000 and 2002. The survivors (mean age 44.4 years, 86.4 percent men) were asked which of 54 war-related stressors and 46 different forms of torture they had experienced.

Each participant rated each event on scales of zero to four for distress (where zero was not at all distressing and four was extremely distressing) and loss of control (where zero was completely in control and four was not at all in control or completely helpless). Then, they reported how distressed or out of control they felt overall during the torture. Clinicians also assessed the survivors for post-traumatic stress disorder (PTSD) and other psychiatric conditions.

The participants reported an average of 19 war-related stressors and 19.3 types of torture. An average of 96.3 months had passed since their last torture experience. More than three fourths (174) of the survivors had PTSD related to their torture at some point in their lives, 55.7 percent (128) had current PTSD, 17 percent (39) were currently depressed and 17.4 percent (40) had a past episode of major depression.

Participants who had undergone physical torture rated their experiences from 3.2 to 3.8 on the distress scale. Sixteen of the 33 stressors from other categories were rated in the same range of distress. "Sham executions, witnessing torture of close ones, threats of rape, fondling of genitals and isolation were associated with at least as much if not more distress than some of the physical torture stressors," the authors wrote. "There was thus substantial overlapping between physical torture and other stressors in terms of associated distress. The control ratings also showed a similar pattern."

Physical torture was not significantly associated with PTSD or depression, suggesting that both physical and non-physical treatments caused the conditions at similar rates. "The traumatic stress impact of torture (physical or non-physical torture and ill treatment) seemed to be determined by perceived uncontrollability and distress associated with the stressors," the authors continued.

In an accompanying editorial, Steven H. Miles, MD, of the University f Minnesota, Minneapolis, wrote that the distinction between torture and degrading treatment is not only useless, but also dangerous.

"Basoglu and colleagues show that the severity of long-lasting adverse mental effects is unrelated to whether the torture or degrading treatment is physical or psychological and unrelated to objective measures of the severity of techniques," Dr. Miles wrote.

"The wrongness of these inflicted harms is compounded by the fact that most abused prisoners, including those in the present war on terror, are innocent or ignorant of terrorist activities. Innocent or not, torture survivors rarely get the mental health treatment they need. In addition, soldiers who participate in atrocities are themselves at increased risk of post-traumatic stress disorder."

The finding of comparable impact of physical and psychological abuse may also have an impact on understanding and treatment of people victimized in terrorist or criminal settings.