Mental disorders, clinical evidence and memory problems relevant to IRB proceedings

1. Mental disorders, clinical evidence and memory problemsrelevant to IRB proceedings Janet Cleveland, LL.L, M.Sc.,Ph.D. Psychologist and researcher McGill University

2. Relevance of psych reports for IRB All divisions 1. Inability to understand proceedings - DR 2. Impaired ability to present one’s case – procedural acccommodations 3. Ability to testify coherently (credibility) RPD 4. Plausibility of alleged trauma 5. Mentally ill persons: members of particular social group? 6. State protection/IFA

3. ID & IAD – release & stay of removal 7. 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

4. 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. treatment • Investigation and analysis vs. support

5. Psychological tests • Limited relevance for IRB proceedings • Objective test = structured self report • Cross-cultural validation: rare • Examples of differences: persecutory beliefs • Detecting malingering • No specific test for veracity of PTSD or depression claims • MMPI-2: not cross-culturally validated

6. Detecting malingering • Veracity of person’s story • Clinicians monitor consistency with clinical indicators • Not truth of alleged events • Deception detection: psychiatrists, psychologists, judges, police, customs officers, general public… • Scarcely better than chance!

7. 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 seekers • Functional impairment +++

8. 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

9. 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 rate • More likely to remain chronic • Greater impairment

10. PTSD & depression - impairment Impairment relevant to IRB proceedings • Ability to tell a coherent/consistent story • Memory • Reluctance to talk about trauma • Emotional incongruence (e.g., apparent lack of emotion) • Nonverbal behavior • Vulnerability (disorganization, suicidal reactions, etc.)

11. Memory – general principles Not a video recording! Encoding • Limited attention • Most information not encoded • Focus on what is most important in the moment • Interpretation • Expectations, stereotypes, knowledge E.g., young man with pistol/cell phone

12. Encoding (cont.) • Poor memory for time (dates, etc.) • Abstract • Inferred, not perceived • Intense emotions: ‘tunnel vision’ • Narrowing of focus on central features • Fewer secondary features encoded • ‘Weapon focus’ • Violence, fear, horror • Decreased memory for preceding events

13. 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

14. Context of recall – impact on memory Intense anxiety at time of recall • Increases confusion, omissions, incoherence • Especially for individuals who are anxious, depressed or have other psychological difficulties

15. 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

16. PTSD effects: memory for events • Amnesia? - Traumatic Brain Injury or HIV/AIDS Effect of PTSD on memory School 1. More incoherent, more inconsistencies vs. School 2. No negative impact on memory UNLESS significant dissociative symptoms Determining factor: stress at time of recall

17. 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

18. Depression – effects on recall • Moderate/severe depression • Concentration and attention problems • Slowed response (may be mistaken for dishonesty) • Insomnia – negative impact on memory • Despair, self-punitive tendencies

19. Guideline 8 – Vulnerable persons Why limit to “the more severe ” cases? Procedural accommodations • Foster more accurate credibility assessment • Decrease interference of stress Questioning vulnerable persons • IRB Training Manual on Victims of Torture