Brain changes and more severe depression
found in political detainees experiencing head injury
Depression and other emotional symptoms in survivors
of torture and other traumatic experiences may be exacerbated by the effects of
head injuries, according to a study from the Harvard Program in Refugee Trauma
(HPRT), based in the Massachusetts General Hospital (MGH) Department of Psychiatry.
In the November 2009 Archives of General Psychiatry, the researchers report finding
structural changes in the brains of former South Vietnamese political detainees
who had suffered head injuries and clearly link those changes to psychiatric symptoms
often seen in survivors of torture.
"This is the first study since the 1950s to demonstrate
brain changes in survivors of extreme violence. That work looked at Holocaust
survivors, and now we are the first to connect similar brain damage with mental
health issues in survivors of political torture," says Richard Mollica, M.D.,
director of the HPRT and leader of the study. "We believe, although it has
not yet been proven, that these physical effects may help explain why survivors
of both torture and traumatic head injury often don't do well with standard therapies
for depression and anxiety."
Studies by Mollica's team and others have documented
the fact that head injures are a common form of torture among prisoners of war
and political detainees. But no previous work has investigated whether the neurologic
effects of head injuries were related to the chronic psychiatric disorders often
reported in torture survivors. The current study analyzed information from 42
Vietnamese immigrants, now resettled in the U.S., who had been detained in so-called
"re-education camps" and 15 Vietnamese immigrants of similar ages who
had not been detained.
All study participants completed questionnaires regarding
any history of head injuries and on their exposure to torture or other traumatic
experiences before being interviewed by study investigators to assess current
symptoms of depression and post-traumatic stress disorder. Comprehensive magnetic
resonance imaging studies measured the size and thickness of brain structures
that previous reports have associated with depression, anxiety and post-traumatic
stress disorder (PTSD) and also have suggested could be affected by traumatic
head injuries.
Among the former detainees, 16 reported having experienced
head injuries at some time, and 26 did not. Not only were detainees with a history
of head injury more likely than those without to report symptoms of depression,
the imaging studies showed they had significant reductions in the thickness of
the frontal and temporal lobes of the cerebral cortex, reductions not seen in
non-head-injured detainees. Participants whose head injuries were more severe
had even greater structural changes and more debilitating depression symptoms.
These head-injury-associated effects were independent of the effects of other
forms of torture or trauma participants had experienced. While head-injured ex-detainees
did not have a greater risk of being diagnosed with PTSD, their PTSD symptoms
were more severe.
"It's well known in neuropsychology that the frontal
and temporal lobes affect executive function - which includes planning, learning,
self-monitoring, and flexibility in social interactions," Mollica explains.
"It could be that torture survivors who don't do well with standard therapies
have head-injury-based cognitive deficits that interfere with standard approaches
like behavioral or exposure therapy. It's very rare for patients to relate subsequent
health problems to a head injury or to recognize that a head injury is affecting
their emotions.
"In some cultures," he adds, "patients
and families are relieved to learn that emotional problems are related to a physical
injury and may become more committed to working with programs specially designed
to treat head injury patients. We hope that our documenting physical effects of
brain damage in a group of torture survivors will provide evidence leading to
improved diagnostic and treatment approaches. The next steps should be clinical
trials comparing the results of head-injury-specific treatment programs with more
traditional therapies for emotional disorders in patients with a history of both
trauma and head injury."
Mollica also notes the need to improve training for the
physicians most likely to treat such patients in the community. "Most primary
care physicians are not prepared to identify mild traumatic head injury either
in patients who may have experienced trauma or torture - including veterans or
refugees - or in survivors of assaults or even auto accidents." He is a professor
of Psychiatry at Harvard Medical School.
Co-authors of the study are James Lavelle, LICSW, HRTP
and MGH Psychiatry; In Kyoon Lyoo, M.D., Ph.D., McLean Hospital; Miriam Chernoff,
Ph.D., Harvard School of Public Health; Hoan Bui, Vietnamese-American Civic Association,
Dorchester, Mass.; Sujung Yoon, M.D., Ph.D., Catholic University Medical College,
Seoul; Jieun Kim, M.D., Seoul National University; and Perry Renshaw, M.D., Ph.D., University
of Utah.
The study was supported by grants from the U.S. National
Institute of Health and the Ministry of Education, Science and Technology of South
Korea.
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