Torture survivors’ symptom load compared to chronic pain and psychiatric in-patients Uwe Harlacher* Peter Polatin** *) Nunca Mas & Medicines Sans Frontiers (currently Iraq) **) George Washington University, Harvard Program in Refugee Trauma, Boston, MA, USA

Background and Introduction Pre treatment assessment data collected 2006 - 2011 at the Danish Rehabilitation and Research Center for Torture Survivors (RCT) are compared with other patient groups A Danish comparison between refugee patients with psychiatric in-patients has been re-analyzed in order to correct for a bias due to exclusion of refugee clients with substance abuse and hallucinations

Pain rehab without work ambition Pain rehab with work ambition Disability Rating Index (DRI) Scores (mean of 12 items) for Torture Survivors (RCT prior to rehabilitation) compared to mixed Chronic Pain Patients (assessment only & prior to participation in rehabilitation programs with and without ambition to increase working capability) documented in the Swedish annual report 2008 of the Swedish National Register for Pain Rehabilitation (NRS) Torture RCT n = 197 Pain assessment n = 1470 Pain rehab without work ambition n = 186 Pain rehab with work ambition n = 818 Mean 57 54 50 53 Sd = 22 21 20 18 t = 1.92 3.35 2.48 p = .056 .001 .014 Cohen's d = .15 .34 .22

Neck/Shoulder & Low Back Pain Median for Disability Rating Index (DRI) Scores for Torture Survivors prior to rehabilitation at RCT compared to scores from the DRI evaluation study (arthritis knee/hip = patients waiting for implant surgery, multiple sclerosis = wheel chair bound patients); chi² comparison of the proportion of RCT-subjects above the median of the comparison group Torture RCT Neck/ Shoulder Neck/Shoulder & Low Back Pain Arthritis Knee Hip Multiple Sclerosis n = 197 127 39 24 23 16 Median 62 27 50 65 85 chi²= 58.96 15.39 2.22 0.85 33.53 p: <.01 = .14 = .36

Hospital Anxiety and Depression Scale (HADS) sum-scores for anxiety and depression for RCT Torture survivors and pain patients documented in the annual report 2013 of the Swedish National Register for Pain Rehabilitation (NRS) Torture / RCT Chronic Pain / NRS 2013 Anxiety n = 147 Depression n = 1994 n = 1996 Median 18 16 9 8 Mean 16.5 15.5 8.9 8.3 Sd 4.29 4.15 4.86 4.46 t 20.48 20.19 p < .000 Cohen's d 1.57 1.62

Mean d without substance item .40 .57 .71 .61 .44 .08 Health of Nation Outcome Scales (HoNos) sum score (12 items) for refugee patients at intake at the Clinic for PTSD and Transcultural Psychiatry, Aarhus University Hospital (CPTP)* and psychiatric in-patients at intake at the Psychiatric Center North Zealand*. Group wise mean effect sizes (d) of differences between the refugee and all other groups for all items and for the substance abuse and hallucination items and both excluded; the effect sizes are computed based on the item-wise effect sizes provided by Palic et al. (2014). *Denmark CPTP Refugees n=448 Schizo-phrenia n=3175 Affective disorders n=3081 Anxiety disord. n=1781 Person. disord. n=1030 Addic- tion n=950 Demen- tia Sum all items 15.7 12.2 9.9 9.0 10.2 13.3 15.6 Mean d all items .32 .49 .62 .51 .17 .05 Mean d without substance item .40 .57 .71 .61 .44 .08 Mean d without hallucination item .46 .52 .67 .55 .20 .11 Mean d without both critical items .56 .77 .50 .15

Conclusions Pain related dysfunction of TOV is higher than that of pain patients receiving about 120 h multidisciplinary pain rehabilitation without ambition to improve/restore working ability The dysfunction is comparable to about 70 year old patients receiving artificial knees and hips The degree of anxiety and depression is much higher than that of pain patients Refugees (including ca. 30% TOV) have more general symptoms than psychiatric in-patients and are most similar to Dementia patients and most dissimilar to Anxiety Disorder patients

Discussion and comments The findings contradict: Danish political propaganda like “all immigrants have to (implicitly are able to) work” The assumption that all symptoms of TOV are secondary to PTSD or depression That minimal treatment, e.g. 5 h (taking translation into account) psychotherapy as applied in a Danish state based treatment program, could have a noteworthy beneficial effect That the right of rehabilitation for TOV makes sense as far as the given amount of treatment lacks way behind that offered to other patient groups with comparable symptom load That Danish state-financed organizations declaring to work in the interest of TOV engage in adequate advocacy