Ms. B’s prior domestic trauma predisposed her to developing post-traumatic symptom disorder (PTSD) once the gang death threats, a predisposing factor, occurred. She met the most important criteria for PTSD which is an actual threat to her physical safety. The threat was persistent for many years. She also demonstrated significant avoidance and negative cognition in her mood in support of the diagnosis of PTSD as evidence by her limited answers and hesitancy to elaborate to questions posed to her by the asylum officer.
Malingering defined as intentionally producing false or grossly exaggerated physical or psychological symptoms [4] although always a possibility was low on our differential list as the patient did not show any evidence of exaggerating her symptoms and we did not suspect embellishment. The patient also reported significant nightmares and hyperarousal requiring us to make a recommendation for an anxiolytic. The hyperarousal in PTSD is often associated with panic attacks characterized by chest pain, palpitations, shortness of breath and a “sense of impending doom.” When obtaining the psychiatric evaluation with an unknown history, symptoms of avoidance can mask the traumatic exposure which in this case was prior physical and emotional abuse [2]. Patients often avoid revisiting details of their trauma out of fear of repeated panic attacks. “Persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event” is another criterion of diagnosis per DSM-5.” When the subject is unable to recount the traumatic event history as a form of avoidance, and there are no collateral sources of information, proper diagnosis is difficult as this is solely dependent on the subject’s recounting of events and ability to verbalize her symptoms. This is especially true when there is no collateral available from another historian. Suppression of prior traumatic memories is often seen in patients with PTSD and in chronic cases smaller volume and size of bilateral hippocampi is noted in this patient population [5]. In Ms. B’s case, the lack of collateral information and significant avoidance in the retelling of her history during the asylum evaluation resulted in overlooking a diagnosis of PTSD.
Due to severe deficiency of trained mental health providers and high volume of asylum-seekers, providers may not choose to administer trauma scales, which may lead to less accurate psychological assessment [6]. This was the case with Ms. B, for the sake of evaluating more clients; we skipped administration of PTSD scales. Hence, we initially misdiagnosed her with depression which is not an uncommon mistake [7].
In evaluating such patients, where no other informants are available to provide a history of trauma, it is crucial to whenever available; administer scales, such as The Harvard Trauma Questionnaire (HTQ). The HTQ’s “cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations” [8]. The Grasso et al. study found that, “multiple informants and multiple measures improve accuracy when assessing,” and a, “knowledge of past traumatic events is a prerequisite for the survey of PTSD symptoms” [9].
Exposure to trauma is hypothesized to be an etiological factor in the emergence of panic disorder, which has a prevalence of about 35% in patients with PTSD. In those patients, panic attacks can be triggered by reminders of trauma [10].
In the case of Ms. B, the necessary questioning for asylum evaluation may have precipitated her panic attacks and hindered her ability to properly respond to the asylum officer’s interview.
The management and evaluation of asylum applicants by US Immigration and Customs Enforcement (ICE) detention centers follow the 2011 Operations Manual ICE Performance-Based National Detention Standards (PBNDS) [11]. According to this manual, a comprehensive physical examination, as well as a mental health screening by a mental health care professional, is required within 14 days of admission to an ICE detention center [11]. Thus, there is a need for a timely and accurate diagnosis and recommendations by the evaluating psychiatrist.
The asylum application of Ms. B was unsuccessful. However, there are several objectives that can be gleaned from her case. In the authors’ opinion, an accurate and timely diagnosis is essential to assist asylum officers in their own independent investigation of the case in hand. Secondly, mental health professionals should be allowed to convey their independent recommendations to the asylum officers. This may also be beneficial to the officers to rule out cases of malingering which is a credible concern. Mental health professionals in return should be aware of the legal code and evaluation provisions for asylum seekers. Ethical considerations include interview confidentiality and the need to disclose certain sensitive topics obtained during the psychiatric evaluation to asylum officers. If the asylum application is unsuccessful, consideration may be given to the asylum seekers to obtain another independent psychiatric evaluation to appeal their case.
