Mental disorders, clinical evidence and memory problems

relevant to IRB proceedings

Janet Cleveland, LL.L, M.Sc.,Ph.D.Psychologist and researcher

McGill University

Relevance of psych reports for IRBAll divisions

1. Inability to understand proceedings - DR2. Impaired ability to present one’s case –

procedural acccommodations3. Ability to testify coherently (credibility)

RPD4. Plausibility of alleged trauma5. Mentally ill persons: members of particular

social group?6. State protection/IFA

ID & IAD – release & stay of removal7. Danger to the public

- e.g., schizophrenics no more violent than general population

- drug or alcohol abuse increases risk of violence

8. Conditions of release/stay of removal- compliance difficulties inherent to certain

mental disorders- need for case management & support

Clinical assessment process

Signs observed by clinician- nonverbal signs, tone of voice, incoherence,

agitation, tears, facial expressions, etc.Self-reported symptoms

- appearance & evolution of symptoms- relevant personal & family antecedents- current psychosocial stressors

Assessment vs. treatmentInvestigation and analysis vs. support

Psychological tests

• Limited relevance for IRB proceedings• Objective test = structured self report• Cross-cultural validation: rare

Examples of differences: persecutory beliefs

• Detecting malingeringNo specific test for veracity of PTSD or

depression claimsMMPI-2: not cross-culturally validated

Detecting malingering

• Veracity of person’s story Clinicians monitor consistency with clinical

indicatorsNot truth of alleged events

• Deception detection: psychiatrists,psychologists, judges, police, customs officers,general public…Scarcely better than chance!

PTSD and depression - prevalence

• PTSD prevalence- Conflict zones: 13-25%- Western, non-conflict: 1-4%

• Depression prevalence- Conflict zones: 13-36%- Canada: 4-6%

• High comorbidity, esp. asylum seekersFunctional impairment +++

PTSD predictors

• Cumulative exposure to trauma• Interpersonal violence– Torture and rape +++

• Current stressors (e.g., exile, uncertainty, lack of status, isolation, separation from family)

• Also predictors of depression (+ loss of loved ones, loss of self-esteem, loss of

status)• Individual vulnerability/resilience

PTSD – evolution over time

• Normal response to abnormal event• Recovery rates (no treatment)

- By 12 months: 1/3 have recovered- By 3 years: 2/3 have recovered

• Interpersonal violence (especially sexual assault and torture) + repeated trauma Higher initial PTSD rateMore likely to remain chronic Greater impairment

PTSD & depression - impairment

Impairment relevant to IRB proceedingsAbility to tell a coherent/consistent storyMemoryReluctance to talk about traumaEmotional incongruence (e.g., apparent

lack of emotion)Nonverbal behavior Vulnerability (disorganization, suicidal

reactions, etc.)

Memory – general principles

Not a video recording!Encoding

• Limited attentionMost information not encoded Focus on what is most important in the

moment • Interpretation

Expectations, stereotypes, knowledgeE.g., young man with pistol/cell phone

Encoding (cont.)

• Poor memory for time (dates, etc.) AbstractInferred, not perceived

• Intense emotions: ‘tunnel vision’Narrowing of focus on central featuresFewer secondary features encoded‘Weapon focus’

• Violence, fear, horrorDecreased memory for preceding events

Storage – recall - narrative• Memory is dynamic • Gist of events retained, secondary details fade– Even for traumatic memories

• Recounting events transforms them into a coherent narrative

• Filling in gaps – ‘scripts’ and inferences• Incorporating new information – source

confusion• Repeated events – consolidation• Hypermnesia – increased recall

Context of recall – impact on memory

Intense anxiety at time of recallIncreases confusion, omissions, incoherenceEspecially for individuals who are anxious,

depressed or have other psychological difficulties

PTSD effects: intrusive memories

Intrusive memories, nightmares, flashbacks - Involuntary, vivid, distressing- Physical symptoms (e.g., fast heartbeat)- Suppression/avoidance of traumatic memories

and triggers- Negative impact on concentration - IRB hearing may trigger traumatic memories

PTSD effects: memory for events

• Amnesia? - Traumatic Brain Injury or HIV/AIDS

Effect of PTSD on memorySchool 1. More incoherent, more inconsistencies

vs.School 2. No negative impact on memory

UNLESS significant dissociative symptoms Determining factor: stress at time of recall

Consensus on PTSD & recall

Factors that negatively impact attention, concentration & memory:- Recall in a high-stress context- Insomnia- Depression - Avoidance of ‘triggers’- Reluctance to trust following interpersonal

violence- Dissociative symptoms

Depression – effects on recall

• Moderate/severe depressionConcentration and attention problemsSlowed response (may be mistaken for

dishonesty)Insomnia – negative impact on memory Despair, self-punitive tendencies

Guideline 8 – Vulnerable persons

Why limit to “the more severe ” cases?Procedural accommodations Foster more accurate credibility assessmentDecrease interference of stress Questioning vulnerable persons

IRB Training Manual on Victims of Torture