Painful memories: Challenges in trauma-focused therapy for torture survivors with PTSD and chronic pain
– a narrative review
Keywords:Torture survivors, Chronic pain', PTSD, comorbidity, exposure therapy
Introduction: PTSD and chronic pain are disorders that researchers increasingly acknowledge to be risk factors that overlap and their comorbidity is associated with poorer treatment outcomes. This review focuses on torture survivors due to the high prevalence of comorbidity in this group, as well as how PTSD and chronic pain might develop, interact and mutually maintain each other.
Methods: A narrative review of empirical studies and theoretical models regarding chronic pain and PTSD in torture survivors, informed by studies conducted in other contexts.
Results and discussion: An overview of PTSD and chronic pain studies of torture survivors is presented. Treatment studies for torture survivors with PTSD are scarce and have been discouraging. Studies in other patient populations and theoretical models of maintaining factors within the cognitive-behavioral paradigm are presented, and focused around how interactions between PTSD and chronic pain might mitigate treatment of both disorders. Mutually maintaining factors between chronic pain and PTSD are presented as potential barriers to healing, and clinical implications involve suggestions for clinicians with intention to overcome these barriers in trauma-focused treatment of torture survivors. The knowledge base on how chronic pain and PTSD interact within the context of torture is still very limited. Torture is a potent risk factor in itself for both chronic pain and PTSD. Studies point to complex interactions between pain and PTSD across different trauma-exposed populations, especially when the trauma includes pain. Moreover, the coping strategies that are available and might function as some form of protection during torture [e.g. dissociation, withdrawal], might conversely function to exacerbate symptoms when the survivor is in a safe rehabilitation context.
Observations combined with CPPC literature and recent developments in learning theory challenge clinical practice accordingly. Additionally, the limited knowledge base prevents us from providing clear-cut sugges- tions, particularly as the majority of scientific enquiry regarding chronic pain and PTSD has been conducted in other populations outside of the torture survivors group. Furthermore, cultural factors, specific needs and characteristics in this group, the human rights perspective and the socio-political context all need to be acknowledged. Trauma-focused treatment does not appear to specifically target all the mechanisms that are supposedly interacting in maintaining chronic pain and PTSD. Interdisciplinary rehabilitation and close collaboration between physiotherapists and trauma-focused therapists are warranted.
Afari, N., Ahumada, S. M., Wright, L. J., Mostoufi, S., Golnari, G., Reis,V., & Cuneo, J. G. (2014). Psychological trauma and functional somatic syndromes: A systematic review and meta- analysis. Psychosomatic Medicine, 76(1), 2-11. https://doi.org/10.1097/PSY.0000000000000010
Åkerblom, S., Perrin, S., Fischer, M. R., McCracken, L. M. (2018) The relationship between posttraumatic stress disorder and chronic pain in people seeking treatment for chronic pain. The mediating role of psychological flexibility. Clinical Journal of Pain, 34(6), 487-496. https://doi.org/10.1097/AJP.0000000000000561
American Psychiatric Association (2012). DSM-5: Cultural Formulation Interview. http://www.dsm5.org/proposedrevision/Documents/DSM5%20Draft%20CFI.pdf
Amnesty International (2013). Amnesty International report 2013:The state of the world's human rights. http://files.amnesty.org/air13/AmnestyInternational_AnnualReport2013_ complete_en.pdf
Amris, K., Lester, J. E. & de Williams, A. C. C. (2019). Pain from torture: Assessment and management. PAIN Reports, 4(6). https://doi/10.1097/PR9.0000000000000794
Andersen, T. E., Karstoft, K-I., Brink, O., & Elklit, A. (2016). Pain-catastrophizing and fear-avoidance beliefs as mediators between post-traumatic stress symptoms and pain following whiplash injury – A prospective cohort study. European Journal of Pain, 20,1241-1252. https://doi.org/10.1002/ejp.848
Asmundson, G. J. G., Coons, M. J., Taylor, S., & Klatz, J. (2002). PTSD and the experience of pain: Research and clinical implications of shared vulnerability and mutual maintenance models. Canadian Journal of Psychiatry, 47, 903-907. https://doi.org/10.1177/070674370204701004
Asmundson, G. J. G. (2014). The emotional and physical pains of trauma: Contemporary and innovative approaches for treating co-occurring PTSD and chronic pain. Depression and Anxiety, 31(9), 717-720. https://doi.org/10.1002/da.22285
Baird, E., de Williams, A. C. C., Hearn, L., & Amris, K. (2017). Interventions for treating persistent pain in survivors of torture. Cochrane Database of Systematic Reviews (8). https://doi.org/10.1002/14651858.CD012051.pub2
Başoğlu, M., Livanou, M., & Crnobarić, C. (2007). Torture vs other cruel, inhuman, and degrading treatment: Is the distinction real or apparent? Archives of General Psychiatry, 64(3), 277-285. https://doi.org/10.1001/archpsyc.64.3.277
Beck, A. (2016). Transcultural Cognitive Behaviour Therapy for Anxiety and Depression: A Practical Guide. Taylor & Francis
Bosco, M. A., Gallinati, J. L., & Clark, M. E. (2013). Conceptualizing and Treating Comorbid Chronic Pain and PTSD. Pain Research and Treatment. https://doi.org/10.1155/2013/174728
Brennstuhl, M. J., Tarquinio, C., & Montel, S. (2014). Chronic Pain and PTSD: Evolving Views on Their Comorbidity. Perspectives on Psychiatric Care, 51(4), 295-304. https://doi.org/10.1111/ppc.12093
Brewin, C. R., Gregory, J. D., Lipton, M., & Burgess, N. (2010). Intrusive Images in Psychological Disorders: Characteristics, Neural Mechanisms, and Treatment Implications. Psychological Review, 117(1), 210-232. https://doi.org/10.1037/a0018113
Brown, L. A., LeBeau, R. T., Chat, K-Y. & Craske, M. G. (2016). Associative learning versus fear habituation as predictors of long-term extinction retention. Cognition & emotion, 31(4), 687-698. https://doi.org/10.1080/02699931.2016.1158695
Buhmann, C. (2014). Traumatized refugees: Morbidity, treatment and predictors of outcome. Danish Medical Journal, 61(8): B4871.
Carinci, A. J., Mehta, P., & Christo, P. J. (2010). Chronic Pain in Torture Victims. Current Pain and Headache Reports, 14(2), 73-79. https://doi.org/10.1007/s11916-010-0101-2
Carlsson, J. M., Mortensen, E. M., & Kastrup, M. (2006). Predictors of mental health and quality of life in male tortured refugees. Nordic Journal of Psychiatry, 60(1), 51-57. https://doi.org/10.1080/08039480500504982
Chimenti, R. L., Frey-Law, L. A., & Sluka, K. A. (2018). A mechanism-based approach to physical therapist management of pain. Physical Therapy, 98(5), 302-314, https://doi.org/10.1093/ptj/pzy030
Ciccone, D. S., Elliott, D. K., Chandler, H. K., Nayak, S., & Raphael, K. G. (2005). Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis. Clinical Journal of Pain, 21, 378-386. https://doi.org/10.1097/01.ajp.0000149796.08746.ea.
Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. (2014). Maximizing Exposure Therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23. doi: 10.1016/j.brat.2014.04.006
Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J. W., & Karoly, P. (2012). Fear-avoidance model of chronic pain: The next generation. Clinical Journal of Pain, 28(6), 475-483. https://doi.org/10.1097/AJP.0b013e3182385392
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., . . . Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141. https://doi.org/10.1016/j.cpr.2015.10.003
de Williams, A. C. C., & Baird, E. (2016). Special Considerations for the Treatment of Pain from Torture and War. Current Anesthesiology Reports, 6(4), 319-326. https://doi.org/10.1007/s40140-016-0187-0
de Williams, A. C. C. & van der Merwe, J. (2013). The psychological impact of torture. British Journal of Pain, 7(2), 101-106. https://doi.org/10.1177/2049463713483596
Defrin, R., Ginzburg, K., Solomon, Z., Polad, E., Bloch, M., Govezensky, M., & Schreiber, S. (2008). Quantitative testing of pain perception in subjects with PTSD — Implications for the mechanism of the coexistence between PTSD and chronic pain. Pain, 138(2), 450-459. https://doi.org/10.1016/j.pain.2008.05.006
Defrin, R., Lahav,Y., & Solomon, Z. (2017). Dysfunctional Pain Modulation in Torture Survivors: The Mediating Effect of PTSD. Journal of Pain, 1, 1-10. https://doi.org/10.1016/j.jpain.2016.09.005
Ehlers, A., & Clark, D. (2000). A cognitive model of persistent posttraumatic stress disorder. Behaviour Research and Therapy, 15(3), 319-345. https//doi.org/10.1016/S0005-7967%2899%2900123-0
Dibaj, I., Halvorsen, J. O., Kennair, L. E. O., & Stenmark, H. I. (2017). An Evaluation of Combined Narrative Exposure Therapy and Physiotherapy for Comorbid PTSD and Chronic Pain in Torture Survivors Torture, 27(1), 13-27. https://doi.org/10.7146/torture.v27i1.26534
Ehlers, A., & Clark, D. (2000). A cognitive model of persistent posttraumatic stress disorder. Behaviour Research and Therapy, 8, 319-45
Frazier, P., Anders, S., Perera, S.,Tomich, P., Tennen, H., Park, C., & Tashiro, T. (2009). Traumatic events among undergraduate students: Prevalence and associated symptoms. Journal of Counseling Psychology, 56(3), 450–460. https://doi.org/10.1037/a0016412
Geuze, E., Westenberg, H. G., Jochims, A., de Kloet, C. S., Bohus, M.,Vermetten, E., & Schmahl, C. (2007). Altered pain processing in veterans with posttraumatic stress disorder. Archives of General Psychiatry, 64(1), 76-85. https://doi.org/10.1001/archpsyc.64.1.76
Greenhalgh, T, Thorne, S, Malterud, K. (2018). Time to challenge the spurious hierarchy of systematic over narrative reviews? European Journal of Clinical Investigation, 48. https://doi.org/10.1111/eci.12931
Giummarra, M. J., Casey, S. L., Devlin, A., Ioannou, L. J., Gibson, S. J., Georgiou-Karistianis, N., Jennings, P. A., Cameron, P. A., & Ponsford, J. (2017). Co-occurrence of posttraumatic stress symptoms, pain, and disability 12 months after traumatic injury. Pain reports, 2(5). https://doi.org/10.1097/PR9.0000000000000622
Haarbauer-Krupa, J., Taylor, C. A., Yue, J. K., Winkler, E. A., Pirracchio, R., Cooper, S. R., . . . Manley, G. T. (2017). Screening for Post-Traumatic Stress Disorder in a Civilian Emergency Department Population with Traumatic Brain Injury. Journal of Neurotrauma, 34(1), 50-58. https://doi.org/10.1089/neu.2015.4158
Hayes, S. C., & Hofmann, S. G. (2017). The third wave of cognitive behavioral therapy and the rise of process-based care. World psychiatry: Official journal of the World Psychiatric Association (WPA), 16(3), 245–246. https://doi.org/10.1002/wps.20442
Hollander, M., Jong, J., Volders, S., Goossens, M., Smeets, R. & Vlaeyen, J. (2010). Fear reduction in patients with chronic pain: A learning theory perspective. Expert review of neurotherapeutics, 10(11). https://doi.org/10.1586/ern.10.115
Horn, R., & Keefe, A. (2016). Measuring change and changing measures: The development of a torture survivor specific measure of change, Torture, 26(2), 19-40. https://doi.org/10.7146/torture.v26i2.108116
Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81(3), 394–404. https://doi.org/10.1037/a0031474
International Rehabilitation Council for Torture Victims (2017). People on the Move:Torture and Migration - Data in the Fight against Impunity Thematic Report 2017. https://irct.org/assets/uploads/pdf_20170906095246.pdf
International Rehabilitation Council for Torture Victims (2018). UNCAT Implementation Tool 2018 - Providing rehabilitation to victims of torture and other ill-treatment. https://cti2024.org/content/images/CTIRehabilitation_Tool5-ENG-final.pdf.
Jenewein, J., Wittmann, L., Moergeli, H., Creutzig, J., & Schnyder, U. (2009). Mutual influence of posttraumatic stress disorder symptoms and chronic pain among injured accident survivors: a longitudinal study. Journal of Traumatic Stress, 22(6), 540-548. https://doi.org/10.1002/jts.20453
Kale, E., Finset, A., Eikeland, H. L., & Gulbrandsen, P. (2011). Emotional cues and concerns in hospital encounters with non-Western immigrants as compared with Norwegians: An exploratory study. Patient Education and Counseling, 84(3), 325-331, https://doi.org/10.1016/j.pec.2011.05.009
Keller, A. S. (2002). Caring and advocating for victims of torture. The Lancet, 360 (Suppl), 55- 56. https://doi/10.1016/S0140-6736(02)11823-X
Kind, S., & Otis, J. D. (2019) The Interaction Between Chronic Pain and PTSD. Current Pain Headache Report, 23(12): 91. https://doi.org/10.1007/s11916-019-0828-3.
Kirmayer, L.J., Ban, L., & Jaranson, J. (2018). Cultural logics of emotion: implications for understanding torture and its sequelae. Torture, 28(1), 84–100.
Koren, D., Norman, D., Cohen, A., Berman, J., & Klein, E. M. (2005). Increased PTSD Risk With Combat-Related Injury: A Matched Comparison Study of Injured and Uninjured Soldiers Experiencing the Same Combat Events. The American Journal of Psychiatry, 162(2), 276-282. https://doi.org/10.1176/appi.ajp.162.2.276
Kumpula, M., Orcutt, H., Bardeen, J. & Varkovitzky, R. (2011). Peritraumatic Dissociation and Experiential Avoidance as Prospective Predictors of Posttraumatic Stress Symptoms. Journal of Abnormal Psychology, 120(3), 617-627. https://doi.org/10.1037/a0023927.
Leung, A., Shukla, S., Fallah, A., Song, D., Lin, L., Golshan, S., Tsai, A., Jak, A., Polston, G. & Lee, R. (2016). Repetitive Transcranial Magnetic Stimulation in Managing Mild Traumatic Brain Injury Related Headaches. Neuromodulation: Technology at the Neural Interface, 19: 133-141. https://doi.org/10.1111/ner.12364
Levy-Gigi, E., Kéri, S., Myers, C. E., Lencovsky, Z., Sharvit-Benbaji, H., Orr, S. P., . . . Gluck, M.A. (2012). Individuals with posttraumatic stress disorder show a selective deficit in generalization of associative learning. Neuropsychology, 26(6), 758-767. https://doi.org/10.1037/a0029361
Liedl, A., & Knaevelsrud, C. (2008). Chronic pain and PTSD: The perpetual avoidance model and its treatment implications. Torture, 18, 69-76.
Linton, S. (2013). A Transdiagnostic Approach to Pain and Emotion. Journal of Applied Biobehavioral Research, 18(2), 82-103. https://doi.org/10.1111/jabr.12007
López-Martínez, A. E. (2015). The overlap of PTSD and chronic pain: a challenge for rehabilitation interventions. Physical Therapy Review, 20(1), 59-61. https://doi.org/10.1179/1743288X14Y.0000000159
Marx, B., & Sloan, D. (2005). Peritraumatic dissociation and experiential avoidance as predictors of traumatic stress symptomatology. Behaviour research and therapy, 43(5), 569-83. https://doi.org/10.1016/j.brat.2004.04.004
McColl, H., Higson-Smith, C., Gjerding, S., Omar, M. H., Rahman, B. A., Hamed, M., . . . Awad, Z. (2010). Rehabilitation of torture survivors in five countries: Common themes and challenges. International Journal of Mental Health Systems, 4(16), 4-16. https://doi.org/10.1186/1752-4458-4-16
Merskey, H., & Bogduk, N. (1994). Classification of Chronic Pain. (2nd ed.). IASP Press.
Mollayeva, T., Cassidy, J. D., Shapiro, C. M., Mollayeva, S., & Colantonio, A. (2017). Concussion/mild traumatic brain injury-related chronic pain in males and females: A diagnostic modelling study. Medicine (Baltimore), 96(7), https://doi.org/10.1097/MD.0000000000005917
Morville, A-L., Erlandsson, L-K., Danneskiold- Samsoe, B., Amris, K., & Eklund, M. (2015). Satisfaction with daily occupations amongst asylum seekers in Denmark. Scandinavian Journal of Occupational Therapy, 22(3), 207- 215. https://doi.org/10.3109/11038128.2014.982702
Moseley, G. L. Z., N., Birklein, F., Marinus, J., van Hilten, J. J., & Luomajoki, H. (2008). Thinking about movement hurts: The effect of motor imagery on pain and swelling in people with chronic arm pain. Arthritis Care & Research, 59(5), 623-631. https://doi.org/10.1002/art.23580
Neuner, F. (2008). Stabilisierung vor Konfrontation in der Traumatherapie –Grundregel oder Mythos? Verhaltenstherapie, 18(2), 109-118. https://doi.org/10.1159/000134006
Nickerson, A., Bryant, R. A., Silove, D., & Steel, Z. (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review, 31(3), 399- 417. https://doi.org/10.1016/j.cpr.2010.10.004
Nordin, L, Perrin, S. (2019). Pain and posttraumatic stress disorder in refugees who survived torture: The role of pain catastrophizing and trauma-related beliefs. European Journal of Pain. 2019; 23: 1497– 1506. https://doi.org/10.1002/ejp.1415
Norwegian Red Cross (2020) Torturert og glemt? Identifsering og rehabilitering av torturutsatte i Norge. Oslo: Røde Kors. https://www.rodekors.no/globalassets/globalt/rapporter-program-avtaler/humanitar-analyserapporter/torturert-og-glemt-2020.pdf.
Patel, N., Kellezi, B., & de Williams, A. C. C. (2014). Psychological, social and welfare interventions for psychological health and well-being of torture survivors. Cochrane Database Systematic Reviews. https://doi.org/10.1002/14651858.CD009317.pub2.
Patel, N., de Williams, A. C. C., & Kellezi, B.(2016). Reviewing outcomes of psychological interventions with torture survivors: Conceptual, methodological and ethical Issues. Torture, 26(1), 2-16. https://doi.org/10.7146/torture.v26i1.108060
Peacock, S., & Patel, S. (2008). Cultural Influences on Pain. Reviews in Pain, 1(2), 6–9. https://doi.org/10.1177/204946370800100203
Perez-Sales, P. (2017). Editorial: Psychotherapy for torture survivors – Suggested pathways for research. Torture, 27(1). https://doi.org/10.7146/torture.v27i1.26528
Phifer, J., Skelton, K., Weiss, T., Schwartz, A. C., Wingo, A., Gillespie, C. F., . . . Ressler, K. J. (2011). Pain symptomatology and pain medication use in civilian PTSD. Pain, 152(10), 2233-2240. https://doi.org/10.1016/j.pain.2011.04.019
Pittig, A., Treanor, M., LeBeau, R. & Craske, M. G. (2018). The role of associative fear and avoidance learning in anxiety disorders: Gaps and directions for future research. Neuroscience & Biobehavioral Reviews, 88, 117-140. https://doi.org/10.1016/j.neubiorev.2018.03.015.
Prip, K., Persson, A.L., & Sjölund, B. H. (2012). Sensory functions in the foot soles in victims of generalized torture, in victims also beaten under the feet (falanga) and in healthy controls - A blinded study using quantitative sensory testing. BMC International Health & Human Rights, 39. https://doi.org/10.1186/1472-698X-12-39
Quiroga, J., & Jaranson, J. M. (2005). Politically- motivated torture and its survivors: A desk study review of the literature. Torture (Thematic Issue), 15(2-3), 1-111.
Rometsch-Ogioun El Sount, C., Windthorst, P., Denkinger, J., Ziser, K., Nikendei, C., Kindermann, D., . . . Junne, F. (2019). Chronic pain in refugees with posttraumatic stress disorder (PTSD): A systematic review on patients' characteristics and specific interventions. Journal of Psychosomatic Research, 118, 83-97. https://doi.org/10.1016/j.jpsychores.2018.07.014
Roth, R. S., Geisser, M. E., & Bates, R. (2008). The relation of post-traumatic stress symptoms to depression and pain in patients with accident-related chronic pain. The Journal of Pain, 9(7), 588-596. https://doi.org/10.1016/j.jpain.2008.01.333
Santiago, P. N., Ursano, R. J., Gray, C. L., Pynoos, R. S., Spiegel, D., Lewis-Fernandez, R., . . . Fullerton, C. S. (2013). A Systematic Review of PTSD Prevalence and Trajectories in DSM-5 Defined Trauma Exposed Populations: Intentional and Non-Intentional Traumatic Events. PLOS One, 8(4). https://doi.org/10.1371/journal.pone.0059236
Sareen, J., Cox, B., Stein, M., Afifi, T., Fleet, C., & Asmundson, G. J. G. (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine, 69, 242-248. https://doi.org/10.1097/PSY.0b013e31803146d8
Sharp, T. J., & Harvey, A. (2001). Chronic pain and post-traumatic stress disorder: Mutual maintenance? Clinical Psychology Review, 21. https://doi.org/10.1016/s0272-7358(00)00071-4
Shipherd, J. C., Keyes, M., Jovanovic, T., Ready, D. J., Baltzell, D., Worley, V., . . . Duncan, E. (2007). Veterans seeking treatment for posttraumatic stress disorder: What about comorbid chronic pain? Journal of Rehabilitation Research & Development, 44(2), 153-166. https://doi.org/10.1682/jrrd.2006.06.0065
Silove, D., Ventevogel, P., & Rees, S. (2017). The contemporary refugee crisis: An overview of mental health challenges. World Psychiatry, 16(2), 130-139. https://doi.org/10.1002/wps.20438
Siqveland, J., Ruud, T., & Hauff, E. (2017). Post-traumatic stress disorder moderates the relationship between trauma exposure and chronic pain. European Journal of Psychotraumatology, 8(1). https://doi.org/10.1080/20008198.2017.1375337
Smith, E., Patel, N. & MacMillan, L. (2010). A remedy for torture survivors in international law: Interpreting rehabilitation. Discussion Paper. London: Medical Foundation for the Care of Victims of Torture. https://www.yumpu.com/en/document/read/38899857/a-remedy-for-torture- survivors-in-international-law-freedom-from-
Stam, R. (2007). PTSD and stress sensitisation: A tale of brain and body Part 1: Human studies. Neuroscience and Biobehavioral Reviews, 31(4), 530-557. https://doi.org/10.1016/jneubiorev.2006.11.010
Strigo, I.A., Simmons, A.N., Matthews, S.C., Grimes, E.M., Allard, C.B., Reinhardt, L.E., . . . Stein, M.B., (2010). Neural correlates of altered pain response in women with posttraumatic stress disorder from intimate partner violence. Biological Psychiatry, 68(5), 442-450. https://doi.org10.1016/j.biopsych.2010.03.034.
Sueki, D. G., Dunleavy, K., Puentedura, E. J., Spielholz, N. I., & Cheng, M. S. (2014). The role of associative learning and fear in the development of chronic pain – a comparison of chronic pain and post-traumatic stress disorder. Physical Therapy Reviews, 19(5), 352-366. https://doi.org/10.1179/1743288X14Y.0000000154
Sullivan, J. L. M., & Adams, H. (2010). Psychosocial Treatment Techniques to Augment the Impact of Physiotherapy Interventions for Low Back Pain. Physiotherapy Canada, 62(3), 180-189. https://doi.org/10.3138/physio.62.3.180
Teodorescu, D. S., Heir, T., Siqveland, J., Hauff, E., Wentzel-Larsen, T,. & Lien, L. (2015). Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross- sectional study. BMC Psychology, 3(7). https://doi.org/10.1186/s40359-015-0064-5
Thomsen, A. B., Eriksen, J., & Smidt-Nielsen, K. (2000). Chronic pain in torture survivors. Forensic Science International, 108(3), 155-163. https://doi.org/10.1016/s0379-0738(99)00209-1
Treede, R.-D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., . . . Wangw, S.-J. (2015). A classification of chronic pain for ICD-11. Pain, 156(6), 1003-1007. https://doi.org/10.1097/j.pain.0000000000000160
UN General Assembly, Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 10 December 1984, United Nations, Treaty Series, vol. 1465, p. 85. https://www.refworld.org/docid/3ae6b3a94.html
Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85, 317-332. https://doi.org/10.1016/s0304-3959(99)00242-0
Wald, J. (2008). Interoceptive Exposure as a Prelude to Trauma-Related Exposure Therapy in a Case of Posttraumatic Stress Disorder With Substantial Comorbidity. Journal of Cognitive Psychotherapy, 22(4), 331-345. https://doi.org/10.1891/0889-83126.96.36.1991
Wang, S-J., Bytyçi, A., Izeti, S., Kallaba, M., Rushiti, F., Montgomery, E., Modvig, J. (2017). A novel bio-psycho-social approach for rehabilitation of traumaticed victims of torture and war in the post-conflict context: A pilot randomized controlled trial in Kosovo. BMC Conflict and Health, 10: 34. https://doi.org/10.1186/s13031-016-0100-y
Weiss, W., Ugueto, A., Mahmooth, Z., Murray, L., Hall, B., Nadison, M., . . . Bolton, P. (2016). Mental health interventions and priorities for research for adult survivors of torture and systematic violence: A review of the literature. Torture Journal, 26(1), 17-44. https://doi.org/10.7146/torture.v26i1.108061
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