Self-harming behaviour and dissociation in complex PTSD.

Introduction Self-harming behaviour has been found to be related to experiences of torture and life-threatening events among some refugee populations.1 The issue of intractable pain2, specifically associated with torture sequelae has had a central role in the identification of clusters denoting increased self-harming and risk-taking behaviour among traumatized refugees. The pathological environment of prolonged abuse such as incarceration and rape, fosters the development of a remarkable array of psychiatric symptoms. The identification of Posttraumatic Stress Disorder (PTSD) in refugee populations,3,4 and reactive dysthymia or major depression,5 associated with combat experiences,6 together with stressors related to captivity, incarceration and torture7, have suggested a focus on comorbidity issues with respect to PTSD in refugee populations. Kramer et al.6 reported that Vietnam veterans with diagnosis of PTSD plus depression exhibited more suicidal and self-harming behaviour than those with PTSD alone or depression alone. Ferrada-Noli et al.7 found that among refugee samples, 56% corresponded to subjects diagnosed with both PTSD and a depressive disorder. There have been some, albeit limited, studies on the high prevalence of passive self-destructive behaviour8 and frequent suicidal ideations containing expressions of self-condemnation, guilt, anger or obsessive re-enactment of a torture theme. Some clear associations have been found between torture methods and the preferred suicidal methods. For example, Ferrada-Noli et al.2 found interesting associations in a sample of 65 refugees who had survived torture. They found that out of 18 of the cases who had been subjected to blunt violence to the head and body, 14 reported jumping from a height or in front of a train as the content of suicidal ideation, of the 6 cases subjected to water torture (submarino) 5 reported drowning as the content of suicidal ideation, of the 5 cases subjected to sharp force torture, 4 had attempted stabbing themselves and of the 3 cases subjected to asphyctic torture, 2 had considered hanging as a method of suicide. Repetition of harm following prolonged traumatisation has been noted to be sequelae of severe trauma.9 Many traumatized people expose themselves, seemingly compulsively, to situations reminiscent of Self-harming behaviour and dissociation in complex PTSD: