Applied Evidence

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Sinus tachycardia educational video for patients

Courtesy of: WirelessDx

Go to http://www.wirelessdx.com/sinustachycardia.htm

Narrow QRS complex tachycardias—rhythms with a rate >100 beats per minute (bpm) and a QRS duration <120 ms—are frequently encountered in both inpatient and outpatient settings. Therapeutic strategy ranges from simple reassurance to acute inpatient intervention, depending on the specific arrhythmia.

Early and accurate diagnosis is paramount to avoid unnecessary testing, ensure timely management, and prevent complications and long-term adverse outcomes. While most narrow QRS complex tachycardias are easily diagnosed, some pose a diagnostic challenge.

This review can help. We start with a summary of the various types of narrow QRS complex tachycardias, accompanied in some cases with 12-lead electrocardiogram (EKG) strips. Next, we highlight key characteristics to consider in the differential and provide an algorithm to help you zero in on the diagnosis.

Narrow QRS complex tachycardias: What you’ll find

Narrow QRS complex tachycardias fall into 2 broad categories: those that are sinus node-generated, and those that are not. Here’s a look at both.

Sinus node-generated tachycardias
Sinus node tachycardia (FIGURE 1), the most common arrhythmia,¹ is an appropriate response to physiologic or emotional stress or disease processes. It is defined as a heart rate >100 bpm with the presence of P waves of normal sinus morphology on a 12-lead EKG.

FIGURE 1
Sinus tachycardia

Inappropriate sinus tachycardia is a nonparoxysmal arrhythmia with a resting daytime heart rate >100 bpm (or an average heart rate >90 bpm over a 24-hour period), normal P wave morphology, and an exaggerated response to physical activity.^2,3 What distinguishes it from simple sinus tachycardia is the disproportionate degree of the arrhythmia to the level of physiologic stress.

Inappropriate sinus tachycardia is a diagnosis of exclusion, established only after other reversible pathologic or pharmacologic causes of tachycardia, such as hyperthyroidism, pheochromocytoma, infection, or theophylline toxicity, have been ruled out. Possible mechanisms may include autonomic dysfunction with increased cardiac sympathetic or reduced vagal output.⁴

Paroxysmal orthostatic tachycardia syndrome (POTS) is an abnormal sinus tachycardia response to an upright position.^5,6 It is diagnosed by a heart rate ≥120 bpm or an increase ≥30 bpm within 5 minutes of standing up or being on a tilt table, with simultaneous development of orthostatic symptoms, such as dizziness, light-headedness, or even syncope, without the corresponding drop in blood pressure. Symptoms usually resolve after the patient assumes a supine position. The presentation may overlap with that of inappropriate sinus tachycardia, although patients with POTS usually develop autonomic symptoms such as constipation, tremor, or heat/cold intolerance, as well.^7,8

Sinus node reentry tachycardia is a paroxysmal tachycardia with a normal P wave on a 12-lead EKG. The paroxysmal nature of the arrhythmia and a positive response to atropine and vagal maneuvers, as well as identification by electrophysiologic studies, differentiate this condition from inappropriate sinus tachycardia.⁹

Nonsinus node-generated tachycardias
Focal atrial tachycardia (FIGURE 2) is caused by an automatic, triggered, or microreentrant mechanism that can be localized to a specific area of atrial tissue.¹⁰ The diagnosis can often be made by a careful review of the EKG, which will reveal P waves that differ from those of the sinus beat.¹¹ This can be tricky, however, as a P wave on a 12-lead EKG from a focal point close to the sinoatrial node may resemble that of a normal sinus rhythm.

FIGURE 2
Focal atrial tachycardia

The atrial rate associated with this condition can vary from 120 to 300 bpm, depending on the focus, and may be associated with variable degrees of atrioventricular (AV) block. The crista terminalis in the right atrium and pulmonary vein ostia are frequent origins of focal atrial arrhythmias.^12,13

Multifocal atrial tachycardia (FIGURE 3) is a supraventricular arrhythmia with ≥3 different P wave morphologies, as well as varying PR and RR intervals on the 12-lead EKG. It is typically associated with lung disorders but may occur in patients with other conditions, such as theophylline toxicity.¹⁴

FIGURE 3
Multifocal atrial tachycardia

Atrioventricular nodal reentrant tachycardia (AVNRT), a reentrant form of narrow QRS complex tachycardia, is based on a dual (slow and fast) pathway of the compact AV node (FIGURE 4). In the typical form—constituting 90% of cases¹⁵—antegrade conduction is via the slow pathway and retrograde conduction is via the fast pathway.¹⁶ In the atypical form, it’s the other way around.

FIGURE 4
Atrioventricular nodal reentrant tachycardia

Orthodromic atrioventricular reciprocating tachycardia (AVRT), or Wolff-Parkinson-White syndrome, is a narrow QRS complex tachycardia in which antegrade conduction is via the AV node and retrograde conduction is via an accessory pathway (bundle of Kent). The accessory pathway consists of a band of muscle tissue that connects the atrium directly to the ventricles, allowing electrical impulses to bypass the AV node. Antidromic AVRT, a wide QRS complex tachycardia, is the most common supraventricular arrhythmia in patients with accessory pathways.¹⁷

Atrial fibrillation (FIGURE 5), the most common arrhythmia for which medical treatment is required,¹⁸ is an irregular rhythm with an undulating baseline.¹⁹

FIGURE 5
Atrial fibrillation

Atrial flutter is a reentrant tachycardia originating in either atrium, with regular flutter (F) waves on a 12-lead EKG (FIGURE 6). A counterclockwise propagating isthmus-dependent atrial flutter originating in the right atrium produces the typical “sawtooth” pattern of negative F waves in the inferior electrocardiographic leads.

FIGURE 6
Atrial flutter

Junctional ectopic tachycardia is a rare arrhythmia caused by increased automaticity within the bundle of His.^20,21 It is typically diagnosed in childhood and usually presents as a narrow QRS tachycardia with AV dissociation,²² but retrograde conduction to the atrium has also been found.²¹

How to approach the differential diagnosis

There are a number of characteristics to consider in the differential diagnosis of a patient with narrow QRS complex tachycardia (ALGORITHM).^1,23-29 These include:

• rhythm regularity
• P wave axis and morphology
• relative duration of RP and PR intervals
• P wave position relative to the QRS complex
• ST elevation in lead aVR
• onset and termination mode.

ALGORITHM
Narrow QRS complex tachycardia: Zeroing in on the diagnosis^1,23-29

AVNRT, atrioventricular nodal reentrant tachycardia; AVRT, atrioventricular reciprocating tachycardia; EKG, electrocardiogram; MAT, multifocal atrial tachycardia.
*Or technically poor EKG.

Rhythm regularity is a key consideration. An irregular rhythm and the absence of P waves (or the presence of fibrillatory waves) characterizes atrial fibrillation; irregularity and ≥3 different P wave morphologies is suggestive of multifocal atrial tachycardia. Other possibilities include frequent premature atrial contractions or a sinoatrial or AV nodal conduction block.

AV dissociation is rarely seen in narrow QRS complex tachycardia. Its presence raises the possibility of junctional ectopic tachycardia, ventricular tachycardia, or complete AV node block.

P wave axis and morphology can help with both the differentiation and the origin of narrow QRS complex tachycardias. A superior-to-inferior axis of P waves (positivity in leads II, III, and aVF) is seen in sinus node-generated tachycardias and sometimes in focal atrial tachycardia. An inferior-superior P wave axis (negativity in leads II, III, and aVF) is observed in AVNRT, AVRT, and a subset of focal atrial tachycardia.^23,24

The specific P wave axis and morphology in focal atrial tachycardia depends on the site of atrial automaticity. If the origin is near the sinus node region or high in the atrium, the result would be a superior-to-inferior P wave axis; if it originates lower in the atrium, the resulting atrial depolarization would be an inferior-to-superior axis.^23,24

Relative duration of RP and PR intervals can help to differentiate narrow QRS complex tachycardias based on the timing of the P wave with respect to adjacent QRS complexes. Those in which the RP interval is longer than the PR interval are called long RP tachycardias and include sinus tachycardia, intra-atrial tachycardia, atypical AVNRT, and AVRT with a slowly conducting ventriculoatrial pathway.^25,26

Short RP tachycardias are characterized by an RP interval that’s shorter than the PR interval. Only 2 arrhythmias present as short RP tachycardias: AVNRT and AVRT.²⁷ If the RP interval is <70 ms, AVNRT is the likely diagnosis.²⁸

P wave position. A careful review of the position of the P wave with respect to the QRS complex can provide additional help in distinguishing between AVNRT and AVRT. In 66% of AVNRTs, the P wave is hidden within the QRS complex;²⁹ in 30%, a retrograde P wave closely follows the QRS complex, creating a “pseudo-S” wave; and 4% of the time, the P wave precedes the QRS complex.

In AVRT, a retrograde P wave follows the QRS complex. This creates a potential dilemma in differentiating 30% of AVNRTs from AVRT. In AVNRT, the retrograde P wave typically appears very close to the QRS complex, creating a pseudo-S wave. In the orthodromic AVRT, there is usually a separation between the QRS and retrograde P wave. In general, if the RP interval is <70 ms, the arrhythmia is usually due to typical AVNRT.²⁸

ST segment elevation in lead aVR on a 12-lead EKG in a supraventricular tachycardia is about 70% sensitive and 70% to 83% specific for a diagnosis of AVRT.^30,31 ST depression of more than 2 mm or T wave inversion is more common in AVRT than in AVNRT.³² QRS alternans, which refers to variations in QRS amplitude or direction with every other beat, has been reported to be indicative of AVRT, ^33,34 but may in fact be a rate-dependent phenomenon that has little to do with the mechanism of tachycardias.³⁵

Onset and termination and other indicators. Still uncertain? Patterns of arrhythmias and modes of onset and termination may provide additional help with the differential diagnosis.

Sinus tachycardias and atrial tachycardias frequently demonstrate a “warm up” in rate, for instance, while AVNRT and AVRT are often triggered by premature atrial contractions. A positive response to the Valsalva maneuver or to adenosine is typically characteristic of reentrant tachycardias using the AV node, such as AVNRT and AVRT.

Comparing a baseline 12-lead EKG with an EKG taken during an episode of tachycardia often provides further information about the mechanism of the arrhythmia. The presence of pre-excitation, the morphology of P waves, and the lack of retrograde P waves on a baseline EKG can be useful in narrowing the differential diagnosis.

Figures courtesy of: University of Buffalo and Buffalo General Hospital.

CORRESPONDENCE Vipul Gupta, MD, MPH, State University of New York at Buffalo, 131 Biomedical Education Building, Buffalo, NY 14214;

WATCH THE VIDEO

Sinus tachycardia educational video for patients

Courtesy of: WirelessDx

Go to http://www.wirelessdx.com/sinustachycardia.htm

Narrow QRS complex tachycardias—rhythms with a rate >100 beats per minute (bpm) and a QRS duration <120 ms—are frequently encountered in both inpatient and outpatient settings. Therapeutic strategy ranges from simple reassurance to acute inpatient intervention, depending on the specific arrhythmia.

Early and accurate diagnosis is paramount to avoid unnecessary testing, ensure timely management, and prevent complications and long-term adverse outcomes. While most narrow QRS complex tachycardias are easily diagnosed, some pose a diagnostic challenge.

This review can help. We start with a summary of the various types of narrow QRS complex tachycardias, accompanied in some cases with 12-lead electrocardiogram (EKG) strips. Next, we highlight key characteristics to consider in the differential and provide an algorithm to help you zero in on the diagnosis.

Narrow QRS complex tachycardias: What you’ll find

Narrow QRS complex tachycardias fall into 2 broad categories: those that are sinus node-generated, and those that are not. Here’s a look at both.

Sinus node-generated tachycardias
Sinus node tachycardia (FIGURE 1), the most common arrhythmia,¹ is an appropriate response to physiologic or emotional stress or disease processes. It is defined as a heart rate >100 bpm with the presence of P waves of normal sinus morphology on a 12-lead EKG.

FIGURE 1
Sinus tachycardia

Inappropriate sinus tachycardia is a nonparoxysmal arrhythmia with a resting daytime heart rate >100 bpm (or an average heart rate >90 bpm over a 24-hour period), normal P wave morphology, and an exaggerated response to physical activity.^2,3 What distinguishes it from simple sinus tachycardia is the disproportionate degree of the arrhythmia to the level of physiologic stress.

Inappropriate sinus tachycardia is a diagnosis of exclusion, established only after other reversible pathologic or pharmacologic causes of tachycardia, such as hyperthyroidism, pheochromocytoma, infection, or theophylline toxicity, have been ruled out. Possible mechanisms may include autonomic dysfunction with increased cardiac sympathetic or reduced vagal output.⁴

Paroxysmal orthostatic tachycardia syndrome (POTS) is an abnormal sinus tachycardia response to an upright position.^5,6 It is diagnosed by a heart rate ≥120 bpm or an increase ≥30 bpm within 5 minutes of standing up or being on a tilt table, with simultaneous development of orthostatic symptoms, such as dizziness, light-headedness, or even syncope, without the corresponding drop in blood pressure. Symptoms usually resolve after the patient assumes a supine position. The presentation may overlap with that of inappropriate sinus tachycardia, although patients with POTS usually develop autonomic symptoms such as constipation, tremor, or heat/cold intolerance, as well.^7,8

Sinus node reentry tachycardia is a paroxysmal tachycardia with a normal P wave on a 12-lead EKG. The paroxysmal nature of the arrhythmia and a positive response to atropine and vagal maneuvers, as well as identification by electrophysiologic studies, differentiate this condition from inappropriate sinus tachycardia.⁹

Nonsinus node-generated tachycardias
Focal atrial tachycardia (FIGURE 2) is caused by an automatic, triggered, or microreentrant mechanism that can be localized to a specific area of atrial tissue.¹⁰ The diagnosis can often be made by a careful review of the EKG, which will reveal P waves that differ from those of the sinus beat.¹¹ This can be tricky, however, as a P wave on a 12-lead EKG from a focal point close to the sinoatrial node may resemble that of a normal sinus rhythm.

FIGURE 2
Focal atrial tachycardia

The atrial rate associated with this condition can vary from 120 to 300 bpm, depending on the focus, and may be associated with variable degrees of atrioventricular (AV) block. The crista terminalis in the right atrium and pulmonary vein ostia are frequent origins of focal atrial arrhythmias.^12,13

Multifocal atrial tachycardia (FIGURE 3) is a supraventricular arrhythmia with ≥3 different P wave morphologies, as well as varying PR and RR intervals on the 12-lead EKG. It is typically associated with lung disorders but may occur in patients with other conditions, such as theophylline toxicity.¹⁴

FIGURE 3
Multifocal atrial tachycardia

Atrioventricular nodal reentrant tachycardia (AVNRT), a reentrant form of narrow QRS complex tachycardia, is based on a dual (slow and fast) pathway of the compact AV node (FIGURE 4). In the typical form—constituting 90% of cases¹⁵—antegrade conduction is via the slow pathway and retrograde conduction is via the fast pathway.¹⁶ In the atypical form, it’s the other way around.

FIGURE 4
Atrioventricular nodal reentrant tachycardia

Orthodromic atrioventricular reciprocating tachycardia (AVRT), or Wolff-Parkinson-White syndrome, is a narrow QRS complex tachycardia in which antegrade conduction is via the AV node and retrograde conduction is via an accessory pathway (bundle of Kent). The accessory pathway consists of a band of muscle tissue that connects the atrium directly to the ventricles, allowing electrical impulses to bypass the AV node. Antidromic AVRT, a wide QRS complex tachycardia, is the most common supraventricular arrhythmia in patients with accessory pathways.¹⁷

Atrial fibrillation (FIGURE 5), the most common arrhythmia for which medical treatment is required,¹⁸ is an irregular rhythm with an undulating baseline.¹⁹

FIGURE 5
Atrial fibrillation

Atrial flutter is a reentrant tachycardia originating in either atrium, with regular flutter (F) waves on a 12-lead EKG (FIGURE 6). A counterclockwise propagating isthmus-dependent atrial flutter originating in the right atrium produces the typical “sawtooth” pattern of negative F waves in the inferior electrocardiographic leads.

FIGURE 6
Atrial flutter

Junctional ectopic tachycardia is a rare arrhythmia caused by increased automaticity within the bundle of His.^20,21 It is typically diagnosed in childhood and usually presents as a narrow QRS tachycardia with AV dissociation,²² but retrograde conduction to the atrium has also been found.²¹

How to approach the differential diagnosis

There are a number of characteristics to consider in the differential diagnosis of a patient with narrow QRS complex tachycardia (ALGORITHM).^1,23-29 These include:

• rhythm regularity
• P wave axis and morphology
• relative duration of RP and PR intervals
• P wave position relative to the QRS complex
• ST elevation in lead aVR
• onset and termination mode.

ALGORITHM
Narrow QRS complex tachycardia: Zeroing in on the diagnosis^1,23-29

AVNRT, atrioventricular nodal reentrant tachycardia; AVRT, atrioventricular reciprocating tachycardia; EKG, electrocardiogram; MAT, multifocal atrial tachycardia.
*Or technically poor EKG.

Rhythm regularity is a key consideration. An irregular rhythm and the absence of P waves (or the presence of fibrillatory waves) characterizes atrial fibrillation; irregularity and ≥3 different P wave morphologies is suggestive of multifocal atrial tachycardia. Other possibilities include frequent premature atrial contractions or a sinoatrial or AV nodal conduction block.

AV dissociation is rarely seen in narrow QRS complex tachycardia. Its presence raises the possibility of junctional ectopic tachycardia, ventricular tachycardia, or complete AV node block.

P wave axis and morphology can help with both the differentiation and the origin of narrow QRS complex tachycardias. A superior-to-inferior axis of P waves (positivity in leads II, III, and aVF) is seen in sinus node-generated tachycardias and sometimes in focal atrial tachycardia. An inferior-superior P wave axis (negativity in leads II, III, and aVF) is observed in AVNRT, AVRT, and a subset of focal atrial tachycardia.^23,24

The specific P wave axis and morphology in focal atrial tachycardia depends on the site of atrial automaticity. If the origin is near the sinus node region or high in the atrium, the result would be a superior-to-inferior P wave axis; if it originates lower in the atrium, the resulting atrial depolarization would be an inferior-to-superior axis.^23,24

Relative duration of RP and PR intervals can help to differentiate narrow QRS complex tachycardias based on the timing of the P wave with respect to adjacent QRS complexes. Those in which the RP interval is longer than the PR interval are called long RP tachycardias and include sinus tachycardia, intra-atrial tachycardia, atypical AVNRT, and AVRT with a slowly conducting ventriculoatrial pathway.^25,26

Short RP tachycardias are characterized by an RP interval that’s shorter than the PR interval. Only 2 arrhythmias present as short RP tachycardias: AVNRT and AVRT.²⁷ If the RP interval is <70 ms, AVNRT is the likely diagnosis.²⁸

P wave position. A careful review of the position of the P wave with respect to the QRS complex can provide additional help in distinguishing between AVNRT and AVRT. In 66% of AVNRTs, the P wave is hidden within the QRS complex;²⁹ in 30%, a retrograde P wave closely follows the QRS complex, creating a “pseudo-S” wave; and 4% of the time, the P wave precedes the QRS complex.

In AVRT, a retrograde P wave follows the QRS complex. This creates a potential dilemma in differentiating 30% of AVNRTs from AVRT. In AVNRT, the retrograde P wave typically appears very close to the QRS complex, creating a pseudo-S wave. In the orthodromic AVRT, there is usually a separation between the QRS and retrograde P wave. In general, if the RP interval is <70 ms, the arrhythmia is usually due to typical AVNRT.²⁸

ST segment elevation in lead aVR on a 12-lead EKG in a supraventricular tachycardia is about 70% sensitive and 70% to 83% specific for a diagnosis of AVRT.^30,31 ST depression of more than 2 mm or T wave inversion is more common in AVRT than in AVNRT.³² QRS alternans, which refers to variations in QRS amplitude or direction with every other beat, has been reported to be indicative of AVRT, ^33,34 but may in fact be a rate-dependent phenomenon that has little to do with the mechanism of tachycardias.³⁵

Onset and termination and other indicators. Still uncertain? Patterns of arrhythmias and modes of onset and termination may provide additional help with the differential diagnosis.

Sinus tachycardias and atrial tachycardias frequently demonstrate a “warm up” in rate, for instance, while AVNRT and AVRT are often triggered by premature atrial contractions. A positive response to the Valsalva maneuver or to adenosine is typically characteristic of reentrant tachycardias using the AV node, such as AVNRT and AVRT.

Comparing a baseline 12-lead EKG with an EKG taken during an episode of tachycardia often provides further information about the mechanism of the arrhythmia. The presence of pre-excitation, the morphology of P waves, and the lack of retrograde P waves on a baseline EKG can be useful in narrowing the differential diagnosis.

Figures courtesy of: University of Buffalo and Buffalo General Hospital.

CORRESPONDENCE Vipul Gupta, MD, MPH, State University of New York at Buffalo, 131 Biomedical Education Building, Buffalo, NY 14214;

WATCH THE VIDEO

Sinus tachycardia educational video for patients

Courtesy of: WirelessDx

Go to http://www.wirelessdx.com/sinustachycardia.htm

Narrow QRS complex tachycardias—rhythms with a rate >100 beats per minute (bpm) and a QRS duration <120 ms—are frequently encountered in both inpatient and outpatient settings. Therapeutic strategy ranges from simple reassurance to acute inpatient intervention, depending on the specific arrhythmia.

Early and accurate diagnosis is paramount to avoid unnecessary testing, ensure timely management, and prevent complications and long-term adverse outcomes. While most narrow QRS complex tachycardias are easily diagnosed, some pose a diagnostic challenge.

This review can help. We start with a summary of the various types of narrow QRS complex tachycardias, accompanied in some cases with 12-lead electrocardiogram (EKG) strips. Next, we highlight key characteristics to consider in the differential and provide an algorithm to help you zero in on the diagnosis.

Narrow QRS complex tachycardias: What you’ll find

Narrow QRS complex tachycardias fall into 2 broad categories: those that are sinus node-generated, and those that are not. Here’s a look at both.

Sinus node-generated tachycardias
Sinus node tachycardia (FIGURE 1), the most common arrhythmia,¹ is an appropriate response to physiologic or emotional stress or disease processes. It is defined as a heart rate >100 bpm with the presence of P waves of normal sinus morphology on a 12-lead EKG.

FIGURE 1
Sinus tachycardia

Inappropriate sinus tachycardia is a nonparoxysmal arrhythmia with a resting daytime heart rate >100 bpm (or an average heart rate >90 bpm over a 24-hour period), normal P wave morphology, and an exaggerated response to physical activity.^2,3 What distinguishes it from simple sinus tachycardia is the disproportionate degree of the arrhythmia to the level of physiologic stress.

Inappropriate sinus tachycardia is a diagnosis of exclusion, established only after other reversible pathologic or pharmacologic causes of tachycardia, such as hyperthyroidism, pheochromocytoma, infection, or theophylline toxicity, have been ruled out. Possible mechanisms may include autonomic dysfunction with increased cardiac sympathetic or reduced vagal output.⁴

Paroxysmal orthostatic tachycardia syndrome (POTS) is an abnormal sinus tachycardia response to an upright position.^5,6 It is diagnosed by a heart rate ≥120 bpm or an increase ≥30 bpm within 5 minutes of standing up or being on a tilt table, with simultaneous development of orthostatic symptoms, such as dizziness, light-headedness, or even syncope, without the corresponding drop in blood pressure. Symptoms usually resolve after the patient assumes a supine position. The presentation may overlap with that of inappropriate sinus tachycardia, although patients with POTS usually develop autonomic symptoms such as constipation, tremor, or heat/cold intolerance, as well.^7,8

Sinus node reentry tachycardia is a paroxysmal tachycardia with a normal P wave on a 12-lead EKG. The paroxysmal nature of the arrhythmia and a positive response to atropine and vagal maneuvers, as well as identification by electrophysiologic studies, differentiate this condition from inappropriate sinus tachycardia.⁹

Nonsinus node-generated tachycardias
Focal atrial tachycardia (FIGURE 2) is caused by an automatic, triggered, or microreentrant mechanism that can be localized to a specific area of atrial tissue.¹⁰ The diagnosis can often be made by a careful review of the EKG, which will reveal P waves that differ from those of the sinus beat.¹¹ This can be tricky, however, as a P wave on a 12-lead EKG from a focal point close to the sinoatrial node may resemble that of a normal sinus rhythm.

FIGURE 2
Focal atrial tachycardia

The atrial rate associated with this condition can vary from 120 to 300 bpm, depending on the focus, and may be associated with variable degrees of atrioventricular (AV) block. The crista terminalis in the right atrium and pulmonary vein ostia are frequent origins of focal atrial arrhythmias.^12,13

Multifocal atrial tachycardia (FIGURE 3) is a supraventricular arrhythmia with ≥3 different P wave morphologies, as well as varying PR and RR intervals on the 12-lead EKG. It is typically associated with lung disorders but may occur in patients with other conditions, such as theophylline toxicity.¹⁴

FIGURE 3
Multifocal atrial tachycardia

Atrioventricular nodal reentrant tachycardia (AVNRT), a reentrant form of narrow QRS complex tachycardia, is based on a dual (slow and fast) pathway of the compact AV node (FIGURE 4). In the typical form—constituting 90% of cases¹⁵—antegrade conduction is via the slow pathway and retrograde conduction is via the fast pathway.¹⁶ In the atypical form, it’s the other way around.

FIGURE 4
Atrioventricular nodal reentrant tachycardia

Orthodromic atrioventricular reciprocating tachycardia (AVRT), or Wolff-Parkinson-White syndrome, is a narrow QRS complex tachycardia in which antegrade conduction is via the AV node and retrograde conduction is via an accessory pathway (bundle of Kent). The accessory pathway consists of a band of muscle tissue that connects the atrium directly to the ventricles, allowing electrical impulses to bypass the AV node. Antidromic AVRT, a wide QRS complex tachycardia, is the most common supraventricular arrhythmia in patients with accessory pathways.¹⁷

Atrial fibrillation (FIGURE 5), the most common arrhythmia for which medical treatment is required,¹⁸ is an irregular rhythm with an undulating baseline.¹⁹

FIGURE 5
Atrial fibrillation

Atrial flutter is a reentrant tachycardia originating in either atrium, with regular flutter (F) waves on a 12-lead EKG (FIGURE 6). A counterclockwise propagating isthmus-dependent atrial flutter originating in the right atrium produces the typical “sawtooth” pattern of negative F waves in the inferior electrocardiographic leads.

FIGURE 6
Atrial flutter

Junctional ectopic tachycardia is a rare arrhythmia caused by increased automaticity within the bundle of His.^20,21 It is typically diagnosed in childhood and usually presents as a narrow QRS tachycardia with AV dissociation,²² but retrograde conduction to the atrium has also been found.²¹

How to approach the differential diagnosis

There are a number of characteristics to consider in the differential diagnosis of a patient with narrow QRS complex tachycardia (ALGORITHM).^1,23-29 These include:

• rhythm regularity
• P wave axis and morphology
• relative duration of RP and PR intervals
• P wave position relative to the QRS complex
• ST elevation in lead aVR
• onset and termination mode.

ALGORITHM
Narrow QRS complex tachycardia: Zeroing in on the diagnosis^1,23-29

AVNRT, atrioventricular nodal reentrant tachycardia; AVRT, atrioventricular reciprocating tachycardia; EKG, electrocardiogram; MAT, multifocal atrial tachycardia.
*Or technically poor EKG.

Rhythm regularity is a key consideration. An irregular rhythm and the absence of P waves (or the presence of fibrillatory waves) characterizes atrial fibrillation; irregularity and ≥3 different P wave morphologies is suggestive of multifocal atrial tachycardia. Other possibilities include frequent premature atrial contractions or a sinoatrial or AV nodal conduction block.

AV dissociation is rarely seen in narrow QRS complex tachycardia. Its presence raises the possibility of junctional ectopic tachycardia, ventricular tachycardia, or complete AV node block.

P wave axis and morphology can help with both the differentiation and the origin of narrow QRS complex tachycardias. A superior-to-inferior axis of P waves (positivity in leads II, III, and aVF) is seen in sinus node-generated tachycardias and sometimes in focal atrial tachycardia. An inferior-superior P wave axis (negativity in leads II, III, and aVF) is observed in AVNRT, AVRT, and a subset of focal atrial tachycardia.^23,24

The specific P wave axis and morphology in focal atrial tachycardia depends on the site of atrial automaticity. If the origin is near the sinus node region or high in the atrium, the result would be a superior-to-inferior P wave axis; if it originates lower in the atrium, the resulting atrial depolarization would be an inferior-to-superior axis.^23,24

Relative duration of RP and PR intervals can help to differentiate narrow QRS complex tachycardias based on the timing of the P wave with respect to adjacent QRS complexes. Those in which the RP interval is longer than the PR interval are called long RP tachycardias and include sinus tachycardia, intra-atrial tachycardia, atypical AVNRT, and AVRT with a slowly conducting ventriculoatrial pathway.^25,26

Short RP tachycardias are characterized by an RP interval that’s shorter than the PR interval. Only 2 arrhythmias present as short RP tachycardias: AVNRT and AVRT.²⁷ If the RP interval is <70 ms, AVNRT is the likely diagnosis.²⁸

P wave position. A careful review of the position of the P wave with respect to the QRS complex can provide additional help in distinguishing between AVNRT and AVRT. In 66% of AVNRTs, the P wave is hidden within the QRS complex;²⁹ in 30%, a retrograde P wave closely follows the QRS complex, creating a “pseudo-S” wave; and 4% of the time, the P wave precedes the QRS complex.

In AVRT, a retrograde P wave follows the QRS complex. This creates a potential dilemma in differentiating 30% of AVNRTs from AVRT. In AVNRT, the retrograde P wave typically appears very close to the QRS complex, creating a pseudo-S wave. In the orthodromic AVRT, there is usually a separation between the QRS and retrograde P wave. In general, if the RP interval is <70 ms, the arrhythmia is usually due to typical AVNRT.²⁸

ST segment elevation in lead aVR on a 12-lead EKG in a supraventricular tachycardia is about 70% sensitive and 70% to 83% specific for a diagnosis of AVRT.^30,31 ST depression of more than 2 mm or T wave inversion is more common in AVRT than in AVNRT.³² QRS alternans, which refers to variations in QRS amplitude or direction with every other beat, has been reported to be indicative of AVRT, ^33,34 but may in fact be a rate-dependent phenomenon that has little to do with the mechanism of tachycardias.³⁵

Onset and termination and other indicators. Still uncertain? Patterns of arrhythmias and modes of onset and termination may provide additional help with the differential diagnosis.

Sinus tachycardias and atrial tachycardias frequently demonstrate a “warm up” in rate, for instance, while AVNRT and AVRT are often triggered by premature atrial contractions. A positive response to the Valsalva maneuver or to adenosine is typically characteristic of reentrant tachycardias using the AV node, such as AVNRT and AVRT.

Comparing a baseline 12-lead EKG with an EKG taken during an episode of tachycardia often provides further information about the mechanism of the arrhythmia. The presence of pre-excitation, the morphology of P waves, and the lack of retrograde P waves on a baseline EKG can be useful in narrowing the differential diagnosis.

Figures courtesy of: University of Buffalo and Buffalo General Hospital.

CORRESPONDENCE Vipul Gupta, MD, MPH, State University of New York at Buffalo, 131 Biomedical Education Building, Buffalo, NY 14214;

Late last year, news outlets nationwide confirmed what many had long suspected: America’s middle class is shrinking. The latest data from the US Census Bureau found that nearly half (48%) of Americans are poor or low income.^1,2

That means 46.2 million people—more than 15% of US citizens—are living below the federal poverty level (FPL), which is $23,050 for a family of 4. Another 97.3 million (about 33%) meet the criterion for low income—earning between $23,050 and $45,869 for a family of 4.^1,2 These numbers are based on the Census Bureau’s new supplemental poverty measure, which considers costs like medical and housing and benefits such as food stamps in calculating poverty.³

The way that census data are analyzed is a key consideration for policy makers and legislators. For primary care physicians, the findings simply serve as a critical reminder that millions of Americans—including some of your patients—are struggling to stay afloat.

In some cases, the problems patients face will be so severe that there won’t be much you can do about them. In others, there are steps you can take to lend a helping hand (TABLE).

TABLE
Help the poor and uninsured: 9 things you can do

Death by poverty?

That’s the title of a summary of a recent study, posted on the Web site of Columbia University’s Mailman School of Public Health.⁴ The researchers found that poverty, low levels of education, and a lack of social support, among other “social” factors, account for as many deaths as heart attack, stroke, and lung cancer.⁵

A related study, also by researchers at Columbia, attempted to quantify the health impact of some leading medical and nonmedical factors. Their findings: The detrimental effects of poverty, smoking, and being a high school dropout exceed those of binge drinking, being overweight or obese, and being uninsured.⁶ The average low-income individual loses 8.2 years of good health simply because of his or her economic status, the lead researcher reported. In contrast, the average loss associated with obesity is 4.2 years and 6.6 years with smoking. The overall health of the US population won’t improve until poverty rates are reduced and educational deficits are addressed, the lead researcher concluded.⁷

That’s not to negate the importance of health coverage, however: A Kaiser Family Foundation study of low-income adults found that fully half (51%) of those who lacked health insurance had not gone to a doctor or clinic in the previous 12 months—and 69% had received no preventive care in the course of the year.⁸

Another survey, completed in 2007, asked adults younger than 65 about their use of medication. About 1 in 7 (13.9%) said they had failed to fill a prescription in the previous year because they couldn’t afford it. Four years earlier, 10.3% had done so.⁹

Recently, however, the situation appears to have gotten even worse. In a 2011 Consumer Reports survey, just under half of adults taking prescription medication reported that they had cut costs by engaging in what the surveyors described as “risky health care tradeoffs”—eg, not filling a prescription, skipping doses, or taking an expired medication.¹⁰

Poverty in childhood has long-lasting effects
Children may be less likely than adults to require prescription drugs, but they are typically the hardest hit by poverty—both in numbers and long-term effects. The poverty rate for those younger than 18 is 22%, according to the National Center for Children in Poverty.¹¹ For kids under the age of 5, it’s more than 25%.¹²

Children of poor, uneducated parents have worse health and die earlier than those whose families are wealthier and better educated, research suggests.^13-16 Even kids from middle class families fall short on measures of health and well-being compared with children whose families are more affluent. What’s more, being poor in early childhood appears to have lasting effects. Regardless of social or economic status or individual behavior later in life, studies suggest that the stress of poverty in the early years is associated with chronic illness and disability in adulthood.^13-16

The bottom line, according to the Robert Wood Johnson Commission to Build a Healthier America: “For the first time in our history, the United States is raising a generation of children who may live sicker, shorter lives than their parents.”¹³ Hunger, or the lack of an adequate supply of nutritious food, is a key factor.¹⁷

Hunger hits home

In an op-ed in the San Francisco Chronicle, family physician Laura Gottlieb told the story of an 8-year-old boy whose family she’d known for years. Brought to her office because of abdominal pain, the boy underwent multiple tests, including urine and stool examinations, blood work, and imaging studies. As soon as one test came back, Dr. Gottlieb ordered another. All were negative, and no cause for GI distress was found.¹⁸

Only later did she discover that hunger was the source of the pain. “It had never even occurred to me to ask his mother about how much food there was in the house,” Dr. Gottlieb wrote.¹⁸

In a similar vein, CBS News recently ran a story about a high school football team that seemed to be down on its luck. Besides being on a losing streak, many of the players were lethargic. Eventually, an astute coach realized that a mental pickup wasn’t what the team members needed—nutrition was. In this impoverished Burke County, Georgia school, about 85% of the student body qualify for in-school breakfast and lunch. But for many kids, those 2 meals were all they had to eat.¹⁹

With the help of a school nutritionist and the federal Healthy Hunger-Free Kids Act, hundreds of students now receive dinner, too. And last season, in late 2011, the properly fueled team members went on to win the state championship.¹⁹

Who is “food insecure”? In 2010, the latest year for which figures are available, 14.5% of US households (representing a total of 48.8 million people) were “food insecure,” as the problem of having too little to eat is officially known.²⁰ Most of these families managed without substantially disrupting their normal eating patterns or reducing their intake, the US Department of Agriculture reports. This was accomplished by cutting back on the variety of foods they ate, getting federal food assistance, or getting food from food banks, among other coping strategies. But for 6.4 million households, the problem was severe enough to disrupt normal eating patterns and cause those affected to eat less than usual at least part of the time in the course of the year.²⁰

Here, too, the toll on children is especially high. Twenty percent of households with children face food insecurity, nearly twice the rate of childless households.²⁰ In a child’s earliest years, too little energy, protein, and other nutrients can result in long-lasting deficits in social, cognitive, and emotional development; malnutrition and deficiencies in vitamins and minerals may even result in brain impairment.¹⁸ In addition, school-age children who don’t have enough to eat have more behavioral problems and are more likely than those who are not struggling with hunger to be in special education classes.¹⁷

The hunger and obesity link
Ironically, hunger is also associated with obesity. High calorie, high carbohydrate foods like pasta and bread typically cost considerably less than nutrient-rich low-carb foods like cheese, fruit, fish, and vegetables, and are more filling. And in poor neighborhoods, food that is high in carbohydrates and low in protein and other nutrients tends to be more available than fresh, healthy—and more perishable—food.²¹

What’s more, people living in poverty may find it especially difficult to exercise. In many neighborhoods, exercising outdoors can be dangerous, gyms are unaffordable, and safe parks and playgrounds may be few and far between.²¹

Identifying poor and hungry patients

In a survey conducted by the Childhood Hunger Initiative of Oregon, most of the nearly 200 physicians and nurse practitioners who responded expressed a desire to learn more about the consequences of hunger and how to address them. Besides being uncomfortable broaching the subject of hunger and other poverty-related issues, the providers cited time constraints as a barrier to doing so.²²

Ask this question
Citing similar obstacles, Canadian researchers conducted a pilot study in search of an easy-to-use, evidence-based “case-finding” tool. They offered questionnaires to patients at 4 clinics in British Columbia to determine which questions had the highest likelihood of determining whether an individual was struggling with hunger, poverty, or homelessness. Participants, which included patients above (n=94) and below (n=51) the poverty line, were also asked how they felt about being asked such questions.²³

One particular question—“Do you (ever) have difficulty making ends meet at the end of the month?”—proved to be the best predictor of poverty. Although 2 additional questions about food and housing were identified as suitable for a 3-item screening tool, this single question alone had 98% sensitivity and 60% specificity (odds ratio, 32.3; 95% confidence interval, 5.4-191.5). Equally important, 85% of study participants with income below the poverty level thought that poverty screening was important, and 67% said they felt comfortable talking to their family physician about it.²³

Take this course
In response to the results of the provider survey conducted by the Childhood Hunger Initiative of Oregon, a team at the Oregon State University Extension Service developed an online training program. The free 5-module course, available at http://oregonstate.edu/instruct/dce/chi/modules.html, addresses the impact of childhood hunger and provides screening and intervention tips.²⁴

A recommended strategy is to incorporate a question related to hunger and food insecurity into the medical history or physical assessment. Noting that you’ll learn more by asking whether a family has sufficient resources to provide a healthy diet than by simply inquiring about a balanced diet, a narrator uses this wording:

“In the past month, was there any day when you or anyone in your family went hungry because you didn’t have enough money for food?”²⁴

What you can do to help needy patients

Some patients who are out of work, uninsured, and barely able to pay for food and shelter will simply put off doctor visits—or come in only after their condition is so dire that you have no recourse but to send them to the emergency department (ED). The result, of course, is just the opposite of what they had hoped for. They end up with a much larger bill—or, if they have coverage, with a much bigger copay—not to mention a far more serious condition than they would likely have had if they’d come in sooner.

Here are some ways you can help.

Discuss costs with uninsured patients. To encourage uninsured patients to come in before their condition worsens, make them aware of the comparatively low cost of a visit to your office vs that of, say, imaging studies, specialist visits, and lab tests, as well as ED costs. That’s one of the interventions recommended by Robert A. Forester, MD, and Richard J. Heck, MD, the authors of “What You Can Do to Help Your Uninsured Patients.”²⁵ Consider offering discounts to low-income patients (within the bounds of Medicare and other insurance provisions), they also suggest.

Use fewer diagnostic tests. Ordering a battery of tests when a diagnosis is not readily apparent is a “cost-insensitive” way to practice medicine, authors Forester and Heck observe. Spending additional time with such patients, using your cognitive and diagnostic skills and performing a complete history and physical, frequently results in a diagnosis and treatment plan, they note.²⁵ If patients are aware that you’re trying to minimize costs, they’ll often consent to a step-by-step diagnostic work-up that can be stopped at any time it is appropriate.

Do it yourself. Expand your practice to include a variety of minor procedures, such as removal or biopsy of common skin lesions, colposcopy, or setting simple fractures. These measures can help keep costs down to better serve poor and low-income patients. The American Academy of Family Physicians offers courses and training in various procedures that family physicians can competently perform in their own offices.

Request a courtesy consult. On occasion, you may be able to avoid a costly referral by calling a colleague and asking for a courtesy consult. The specialist will often tell you how he or she would handle a clinical presentation like the one you describe and suggest you try a similar approach, suggests Doug Campos-Outcalt, MD, MPA. Dr. Campos-Outcalt, a faculty member at the University of Arizona College of Medicine and the author of JFP’s bimonthly Practice Alert column, has extensive experience working with underserved communities.

Connect patients with community services. Poor patients typically have many social and psychological needs, as well as the need for medical care, and integrated care is particularly important for those facing hunger, homelessness, and chronic illness, says Jonathan Cartsonis, MD, medical director of Healthcare for the Homeless in Phoenix. Maintain contact with hospital social services and emergency psychiatric services, and have information—and handouts—about local food banks, homeless shelters, and community clinics, among other resources. (See the resources listed in the box.)

In Seattle, for example, “Project Access” is an organization that helps give the underserved access to specialists. And in many parts of the country, local Rotary clubs sponsor free clinics staffed with volunteer and retired physicians, working cooperatively with local pharmacies to provide at-cost generic drugs.

Keep drug costs down
Physicians can help to insulate their poor and low-income patients from high drug costs in a number of ways:

Reduce polypharmacy. Half of Americans take at least one prescription drug, according to the 2011 Consumer Reports survey. Among this group, people with limited income—those earning less than $40,000—take, on average, 5.7 different drugs.¹⁰ Eliminating unnecessary medications, including supplements, herbs, and any other over-the-counter products, can lead to substantial savings. To determine what can be eliminated, ask patients to bring in everything they’re taking and conduct a brown bag medication review. To learn more, see “Help your patient ‘get’ what you just said: A health literacy guide” (J Fam Pract. 2012;61:190-196).

Prescribe generics. Newer brand-name drugs may not be markedly better than older, established agents. And many generics are available at major retailers like Wal-Mart for just a few dollars for a 30-day supply or at CVS for $9.99 for a 3-month supply.²⁶ Yet some physicians routinely order newer medications, even for indigent patients.

Be upfront about drug costs. When you prescribe a new drug, whether generic or branded, it is important to discuss the cost (easily accessible online and in many electronic medical record systems) with the patient. Yet only 5% of respondents to the 2011 Consumer Reports survey said their health care providers had done so. Two-thirds of those surveyed (64%) did not discover the cost of a drug until they went to a pharmacy to pick it up.¹⁰

Think twice before handing out samples. Drug samples would appear to benefit the poor and the uninsured, but evidence suggests otherwise.^27,28 In a study that assessed out-of-pocket costs associated with the use of samples, patients who had never received samples had lower out-of-pocket costs.28 That’s partly because most samples are newer, more expensive drugs, and patients who start taking them are often unable to afford the cost of a prescription. Another study found that the use of generic drugs for uninsured patients rose (from 12% to 30%) after the clinic discontinued the use of samples.²⁷

CORRESPONDENCE Laura C. Lippman, MD, 2311 North 45th Street, No. 171, Seattle, WA 98103; lclippman@gmail.com

Late last year, news outlets nationwide confirmed what many had long suspected: America’s middle class is shrinking. The latest data from the US Census Bureau found that nearly half (48%) of Americans are poor or low income.^1,2

That means 46.2 million people—more than 15% of US citizens—are living below the federal poverty level (FPL), which is $23,050 for a family of 4. Another 97.3 million (about 33%) meet the criterion for low income—earning between $23,050 and $45,869 for a family of 4.^1,2 These numbers are based on the Census Bureau’s new supplemental poverty measure, which considers costs like medical and housing and benefits such as food stamps in calculating poverty.³

The way that census data are analyzed is a key consideration for policy makers and legislators. For primary care physicians, the findings simply serve as a critical reminder that millions of Americans—including some of your patients—are struggling to stay afloat.

In some cases, the problems patients face will be so severe that there won’t be much you can do about them. In others, there are steps you can take to lend a helping hand (TABLE).

TABLE
Help the poor and uninsured: 9 things you can do

Death by poverty?

That’s the title of a summary of a recent study, posted on the Web site of Columbia University’s Mailman School of Public Health.⁴ The researchers found that poverty, low levels of education, and a lack of social support, among other “social” factors, account for as many deaths as heart attack, stroke, and lung cancer.⁵

A related study, also by researchers at Columbia, attempted to quantify the health impact of some leading medical and nonmedical factors. Their findings: The detrimental effects of poverty, smoking, and being a high school dropout exceed those of binge drinking, being overweight or obese, and being uninsured.⁶ The average low-income individual loses 8.2 years of good health simply because of his or her economic status, the lead researcher reported. In contrast, the average loss associated with obesity is 4.2 years and 6.6 years with smoking. The overall health of the US population won’t improve until poverty rates are reduced and educational deficits are addressed, the lead researcher concluded.⁷

That’s not to negate the importance of health coverage, however: A Kaiser Family Foundation study of low-income adults found that fully half (51%) of those who lacked health insurance had not gone to a doctor or clinic in the previous 12 months—and 69% had received no preventive care in the course of the year.⁸

Another survey, completed in 2007, asked adults younger than 65 about their use of medication. About 1 in 7 (13.9%) said they had failed to fill a prescription in the previous year because they couldn’t afford it. Four years earlier, 10.3% had done so.⁹

Recently, however, the situation appears to have gotten even worse. In a 2011 Consumer Reports survey, just under half of adults taking prescription medication reported that they had cut costs by engaging in what the surveyors described as “risky health care tradeoffs”—eg, not filling a prescription, skipping doses, or taking an expired medication.¹⁰

Poverty in childhood has long-lasting effects
Children may be less likely than adults to require prescription drugs, but they are typically the hardest hit by poverty—both in numbers and long-term effects. The poverty rate for those younger than 18 is 22%, according to the National Center for Children in Poverty.¹¹ For kids under the age of 5, it’s more than 25%.¹²

Children of poor, uneducated parents have worse health and die earlier than those whose families are wealthier and better educated, research suggests.^13-16 Even kids from middle class families fall short on measures of health and well-being compared with children whose families are more affluent. What’s more, being poor in early childhood appears to have lasting effects. Regardless of social or economic status or individual behavior later in life, studies suggest that the stress of poverty in the early years is associated with chronic illness and disability in adulthood.^13-16

The bottom line, according to the Robert Wood Johnson Commission to Build a Healthier America: “For the first time in our history, the United States is raising a generation of children who may live sicker, shorter lives than their parents.”¹³ Hunger, or the lack of an adequate supply of nutritious food, is a key factor.¹⁷

Hunger hits home

In an op-ed in the San Francisco Chronicle, family physician Laura Gottlieb told the story of an 8-year-old boy whose family she’d known for years. Brought to her office because of abdominal pain, the boy underwent multiple tests, including urine and stool examinations, blood work, and imaging studies. As soon as one test came back, Dr. Gottlieb ordered another. All were negative, and no cause for GI distress was found.¹⁸

Only later did she discover that hunger was the source of the pain. “It had never even occurred to me to ask his mother about how much food there was in the house,” Dr. Gottlieb wrote.¹⁸

In a similar vein, CBS News recently ran a story about a high school football team that seemed to be down on its luck. Besides being on a losing streak, many of the players were lethargic. Eventually, an astute coach realized that a mental pickup wasn’t what the team members needed—nutrition was. In this impoverished Burke County, Georgia school, about 85% of the student body qualify for in-school breakfast and lunch. But for many kids, those 2 meals were all they had to eat.¹⁹

With the help of a school nutritionist and the federal Healthy Hunger-Free Kids Act, hundreds of students now receive dinner, too. And last season, in late 2011, the properly fueled team members went on to win the state championship.¹⁹

Who is “food insecure”? In 2010, the latest year for which figures are available, 14.5% of US households (representing a total of 48.8 million people) were “food insecure,” as the problem of having too little to eat is officially known.²⁰ Most of these families managed without substantially disrupting their normal eating patterns or reducing their intake, the US Department of Agriculture reports. This was accomplished by cutting back on the variety of foods they ate, getting federal food assistance, or getting food from food banks, among other coping strategies. But for 6.4 million households, the problem was severe enough to disrupt normal eating patterns and cause those affected to eat less than usual at least part of the time in the course of the year.²⁰

Here, too, the toll on children is especially high. Twenty percent of households with children face food insecurity, nearly twice the rate of childless households.²⁰ In a child’s earliest years, too little energy, protein, and other nutrients can result in long-lasting deficits in social, cognitive, and emotional development; malnutrition and deficiencies in vitamins and minerals may even result in brain impairment.¹⁸ In addition, school-age children who don’t have enough to eat have more behavioral problems and are more likely than those who are not struggling with hunger to be in special education classes.¹⁷

The hunger and obesity link
Ironically, hunger is also associated with obesity. High calorie, high carbohydrate foods like pasta and bread typically cost considerably less than nutrient-rich low-carb foods like cheese, fruit, fish, and vegetables, and are more filling. And in poor neighborhoods, food that is high in carbohydrates and low in protein and other nutrients tends to be more available than fresh, healthy—and more perishable—food.²¹

What’s more, people living in poverty may find it especially difficult to exercise. In many neighborhoods, exercising outdoors can be dangerous, gyms are unaffordable, and safe parks and playgrounds may be few and far between.²¹

Identifying poor and hungry patients

In a survey conducted by the Childhood Hunger Initiative of Oregon, most of the nearly 200 physicians and nurse practitioners who responded expressed a desire to learn more about the consequences of hunger and how to address them. Besides being uncomfortable broaching the subject of hunger and other poverty-related issues, the providers cited time constraints as a barrier to doing so.²²

Ask this question
Citing similar obstacles, Canadian researchers conducted a pilot study in search of an easy-to-use, evidence-based “case-finding” tool. They offered questionnaires to patients at 4 clinics in British Columbia to determine which questions had the highest likelihood of determining whether an individual was struggling with hunger, poverty, or homelessness. Participants, which included patients above (n=94) and below (n=51) the poverty line, were also asked how they felt about being asked such questions.²³

One particular question—“Do you (ever) have difficulty making ends meet at the end of the month?”—proved to be the best predictor of poverty. Although 2 additional questions about food and housing were identified as suitable for a 3-item screening tool, this single question alone had 98% sensitivity and 60% specificity (odds ratio, 32.3; 95% confidence interval, 5.4-191.5). Equally important, 85% of study participants with income below the poverty level thought that poverty screening was important, and 67% said they felt comfortable talking to their family physician about it.²³

Take this course
In response to the results of the provider survey conducted by the Childhood Hunger Initiative of Oregon, a team at the Oregon State University Extension Service developed an online training program. The free 5-module course, available at http://oregonstate.edu/instruct/dce/chi/modules.html, addresses the impact of childhood hunger and provides screening and intervention tips.²⁴

A recommended strategy is to incorporate a question related to hunger and food insecurity into the medical history or physical assessment. Noting that you’ll learn more by asking whether a family has sufficient resources to provide a healthy diet than by simply inquiring about a balanced diet, a narrator uses this wording:

“In the past month, was there any day when you or anyone in your family went hungry because you didn’t have enough money for food?”²⁴

What you can do to help needy patients

Some patients who are out of work, uninsured, and barely able to pay for food and shelter will simply put off doctor visits—or come in only after their condition is so dire that you have no recourse but to send them to the emergency department (ED). The result, of course, is just the opposite of what they had hoped for. They end up with a much larger bill—or, if they have coverage, with a much bigger copay—not to mention a far more serious condition than they would likely have had if they’d come in sooner.

Here are some ways you can help.

Discuss costs with uninsured patients. To encourage uninsured patients to come in before their condition worsens, make them aware of the comparatively low cost of a visit to your office vs that of, say, imaging studies, specialist visits, and lab tests, as well as ED costs. That’s one of the interventions recommended by Robert A. Forester, MD, and Richard J. Heck, MD, the authors of “What You Can Do to Help Your Uninsured Patients.”²⁵ Consider offering discounts to low-income patients (within the bounds of Medicare and other insurance provisions), they also suggest.

Use fewer diagnostic tests. Ordering a battery of tests when a diagnosis is not readily apparent is a “cost-insensitive” way to practice medicine, authors Forester and Heck observe. Spending additional time with such patients, using your cognitive and diagnostic skills and performing a complete history and physical, frequently results in a diagnosis and treatment plan, they note.²⁵ If patients are aware that you’re trying to minimize costs, they’ll often consent to a step-by-step diagnostic work-up that can be stopped at any time it is appropriate.

Do it yourself. Expand your practice to include a variety of minor procedures, such as removal or biopsy of common skin lesions, colposcopy, or setting simple fractures. These measures can help keep costs down to better serve poor and low-income patients. The American Academy of Family Physicians offers courses and training in various procedures that family physicians can competently perform in their own offices.

Request a courtesy consult. On occasion, you may be able to avoid a costly referral by calling a colleague and asking for a courtesy consult. The specialist will often tell you how he or she would handle a clinical presentation like the one you describe and suggest you try a similar approach, suggests Doug Campos-Outcalt, MD, MPA. Dr. Campos-Outcalt, a faculty member at the University of Arizona College of Medicine and the author of JFP’s bimonthly Practice Alert column, has extensive experience working with underserved communities.

Connect patients with community services. Poor patients typically have many social and psychological needs, as well as the need for medical care, and integrated care is particularly important for those facing hunger, homelessness, and chronic illness, says Jonathan Cartsonis, MD, medical director of Healthcare for the Homeless in Phoenix. Maintain contact with hospital social services and emergency psychiatric services, and have information—and handouts—about local food banks, homeless shelters, and community clinics, among other resources. (See the resources listed in the box.)

In Seattle, for example, “Project Access” is an organization that helps give the underserved access to specialists. And in many parts of the country, local Rotary clubs sponsor free clinics staffed with volunteer and retired physicians, working cooperatively with local pharmacies to provide at-cost generic drugs.

Keep drug costs down
Physicians can help to insulate their poor and low-income patients from high drug costs in a number of ways:

Reduce polypharmacy. Half of Americans take at least one prescription drug, according to the 2011 Consumer Reports survey. Among this group, people with limited income—those earning less than $40,000—take, on average, 5.7 different drugs.¹⁰ Eliminating unnecessary medications, including supplements, herbs, and any other over-the-counter products, can lead to substantial savings. To determine what can be eliminated, ask patients to bring in everything they’re taking and conduct a brown bag medication review. To learn more, see “Help your patient ‘get’ what you just said: A health literacy guide” (J Fam Pract. 2012;61:190-196).

Prescribe generics. Newer brand-name drugs may not be markedly better than older, established agents. And many generics are available at major retailers like Wal-Mart for just a few dollars for a 30-day supply or at CVS for $9.99 for a 3-month supply.²⁶ Yet some physicians routinely order newer medications, even for indigent patients.

Be upfront about drug costs. When you prescribe a new drug, whether generic or branded, it is important to discuss the cost (easily accessible online and in many electronic medical record systems) with the patient. Yet only 5% of respondents to the 2011 Consumer Reports survey said their health care providers had done so. Two-thirds of those surveyed (64%) did not discover the cost of a drug until they went to a pharmacy to pick it up.¹⁰

Think twice before handing out samples. Drug samples would appear to benefit the poor and the uninsured, but evidence suggests otherwise.^27,28 In a study that assessed out-of-pocket costs associated with the use of samples, patients who had never received samples had lower out-of-pocket costs.28 That’s partly because most samples are newer, more expensive drugs, and patients who start taking them are often unable to afford the cost of a prescription. Another study found that the use of generic drugs for uninsured patients rose (from 12% to 30%) after the clinic discontinued the use of samples.²⁷

CORRESPONDENCE Laura C. Lippman, MD, 2311 North 45th Street, No. 171, Seattle, WA 98103; lclippman@gmail.com

Late last year, news outlets nationwide confirmed what many had long suspected: America’s middle class is shrinking. The latest data from the US Census Bureau found that nearly half (48%) of Americans are poor or low income.^1,2

That means 46.2 million people—more than 15% of US citizens—are living below the federal poverty level (FPL), which is $23,050 for a family of 4. Another 97.3 million (about 33%) meet the criterion for low income—earning between $23,050 and $45,869 for a family of 4.^1,2 These numbers are based on the Census Bureau’s new supplemental poverty measure, which considers costs like medical and housing and benefits such as food stamps in calculating poverty.³

The way that census data are analyzed is a key consideration for policy makers and legislators. For primary care physicians, the findings simply serve as a critical reminder that millions of Americans—including some of your patients—are struggling to stay afloat.

In some cases, the problems patients face will be so severe that there won’t be much you can do about them. In others, there are steps you can take to lend a helping hand (TABLE).

TABLE
Help the poor and uninsured: 9 things you can do

Death by poverty?

That’s the title of a summary of a recent study, posted on the Web site of Columbia University’s Mailman School of Public Health.⁴ The researchers found that poverty, low levels of education, and a lack of social support, among other “social” factors, account for as many deaths as heart attack, stroke, and lung cancer.⁵

A related study, also by researchers at Columbia, attempted to quantify the health impact of some leading medical and nonmedical factors. Their findings: The detrimental effects of poverty, smoking, and being a high school dropout exceed those of binge drinking, being overweight or obese, and being uninsured.⁶ The average low-income individual loses 8.2 years of good health simply because of his or her economic status, the lead researcher reported. In contrast, the average loss associated with obesity is 4.2 years and 6.6 years with smoking. The overall health of the US population won’t improve until poverty rates are reduced and educational deficits are addressed, the lead researcher concluded.⁷

That’s not to negate the importance of health coverage, however: A Kaiser Family Foundation study of low-income adults found that fully half (51%) of those who lacked health insurance had not gone to a doctor or clinic in the previous 12 months—and 69% had received no preventive care in the course of the year.⁸

Another survey, completed in 2007, asked adults younger than 65 about their use of medication. About 1 in 7 (13.9%) said they had failed to fill a prescription in the previous year because they couldn’t afford it. Four years earlier, 10.3% had done so.⁹

Recently, however, the situation appears to have gotten even worse. In a 2011 Consumer Reports survey, just under half of adults taking prescription medication reported that they had cut costs by engaging in what the surveyors described as “risky health care tradeoffs”—eg, not filling a prescription, skipping doses, or taking an expired medication.¹⁰

Poverty in childhood has long-lasting effects
Children may be less likely than adults to require prescription drugs, but they are typically the hardest hit by poverty—both in numbers and long-term effects. The poverty rate for those younger than 18 is 22%, according to the National Center for Children in Poverty.¹¹ For kids under the age of 5, it’s more than 25%.¹²

Children of poor, uneducated parents have worse health and die earlier than those whose families are wealthier and better educated, research suggests.^13-16 Even kids from middle class families fall short on measures of health and well-being compared with children whose families are more affluent. What’s more, being poor in early childhood appears to have lasting effects. Regardless of social or economic status or individual behavior later in life, studies suggest that the stress of poverty in the early years is associated with chronic illness and disability in adulthood.^13-16

The bottom line, according to the Robert Wood Johnson Commission to Build a Healthier America: “For the first time in our history, the United States is raising a generation of children who may live sicker, shorter lives than their parents.”¹³ Hunger, or the lack of an adequate supply of nutritious food, is a key factor.¹⁷

Hunger hits home

In an op-ed in the San Francisco Chronicle, family physician Laura Gottlieb told the story of an 8-year-old boy whose family she’d known for years. Brought to her office because of abdominal pain, the boy underwent multiple tests, including urine and stool examinations, blood work, and imaging studies. As soon as one test came back, Dr. Gottlieb ordered another. All were negative, and no cause for GI distress was found.¹⁸

Only later did she discover that hunger was the source of the pain. “It had never even occurred to me to ask his mother about how much food there was in the house,” Dr. Gottlieb wrote.¹⁸

In a similar vein, CBS News recently ran a story about a high school football team that seemed to be down on its luck. Besides being on a losing streak, many of the players were lethargic. Eventually, an astute coach realized that a mental pickup wasn’t what the team members needed—nutrition was. In this impoverished Burke County, Georgia school, about 85% of the student body qualify for in-school breakfast and lunch. But for many kids, those 2 meals were all they had to eat.¹⁹

With the help of a school nutritionist and the federal Healthy Hunger-Free Kids Act, hundreds of students now receive dinner, too. And last season, in late 2011, the properly fueled team members went on to win the state championship.¹⁹

Who is “food insecure”? In 2010, the latest year for which figures are available, 14.5% of US households (representing a total of 48.8 million people) were “food insecure,” as the problem of having too little to eat is officially known.²⁰ Most of these families managed without substantially disrupting their normal eating patterns or reducing their intake, the US Department of Agriculture reports. This was accomplished by cutting back on the variety of foods they ate, getting federal food assistance, or getting food from food banks, among other coping strategies. But for 6.4 million households, the problem was severe enough to disrupt normal eating patterns and cause those affected to eat less than usual at least part of the time in the course of the year.²⁰

Here, too, the toll on children is especially high. Twenty percent of households with children face food insecurity, nearly twice the rate of childless households.²⁰ In a child’s earliest years, too little energy, protein, and other nutrients can result in long-lasting deficits in social, cognitive, and emotional development; malnutrition and deficiencies in vitamins and minerals may even result in brain impairment.¹⁸ In addition, school-age children who don’t have enough to eat have more behavioral problems and are more likely than those who are not struggling with hunger to be in special education classes.¹⁷

The hunger and obesity link
Ironically, hunger is also associated with obesity. High calorie, high carbohydrate foods like pasta and bread typically cost considerably less than nutrient-rich low-carb foods like cheese, fruit, fish, and vegetables, and are more filling. And in poor neighborhoods, food that is high in carbohydrates and low in protein and other nutrients tends to be more available than fresh, healthy—and more perishable—food.²¹

What’s more, people living in poverty may find it especially difficult to exercise. In many neighborhoods, exercising outdoors can be dangerous, gyms are unaffordable, and safe parks and playgrounds may be few and far between.²¹

Identifying poor and hungry patients

In a survey conducted by the Childhood Hunger Initiative of Oregon, most of the nearly 200 physicians and nurse practitioners who responded expressed a desire to learn more about the consequences of hunger and how to address them. Besides being uncomfortable broaching the subject of hunger and other poverty-related issues, the providers cited time constraints as a barrier to doing so.²²

Ask this question
Citing similar obstacles, Canadian researchers conducted a pilot study in search of an easy-to-use, evidence-based “case-finding” tool. They offered questionnaires to patients at 4 clinics in British Columbia to determine which questions had the highest likelihood of determining whether an individual was struggling with hunger, poverty, or homelessness. Participants, which included patients above (n=94) and below (n=51) the poverty line, were also asked how they felt about being asked such questions.²³

One particular question—“Do you (ever) have difficulty making ends meet at the end of the month?”—proved to be the best predictor of poverty. Although 2 additional questions about food and housing were identified as suitable for a 3-item screening tool, this single question alone had 98% sensitivity and 60% specificity (odds ratio, 32.3; 95% confidence interval, 5.4-191.5). Equally important, 85% of study participants with income below the poverty level thought that poverty screening was important, and 67% said they felt comfortable talking to their family physician about it.²³

Take this course
In response to the results of the provider survey conducted by the Childhood Hunger Initiative of Oregon, a team at the Oregon State University Extension Service developed an online training program. The free 5-module course, available at http://oregonstate.edu/instruct/dce/chi/modules.html, addresses the impact of childhood hunger and provides screening and intervention tips.²⁴

A recommended strategy is to incorporate a question related to hunger and food insecurity into the medical history or physical assessment. Noting that you’ll learn more by asking whether a family has sufficient resources to provide a healthy diet than by simply inquiring about a balanced diet, a narrator uses this wording:

“In the past month, was there any day when you or anyone in your family went hungry because you didn’t have enough money for food?”²⁴

What you can do to help needy patients

Some patients who are out of work, uninsured, and barely able to pay for food and shelter will simply put off doctor visits—or come in only after their condition is so dire that you have no recourse but to send them to the emergency department (ED). The result, of course, is just the opposite of what they had hoped for. They end up with a much larger bill—or, if they have coverage, with a much bigger copay—not to mention a far more serious condition than they would likely have had if they’d come in sooner.

Here are some ways you can help.

Discuss costs with uninsured patients. To encourage uninsured patients to come in before their condition worsens, make them aware of the comparatively low cost of a visit to your office vs that of, say, imaging studies, specialist visits, and lab tests, as well as ED costs. That’s one of the interventions recommended by Robert A. Forester, MD, and Richard J. Heck, MD, the authors of “What You Can Do to Help Your Uninsured Patients.”²⁵ Consider offering discounts to low-income patients (within the bounds of Medicare and other insurance provisions), they also suggest.

Use fewer diagnostic tests. Ordering a battery of tests when a diagnosis is not readily apparent is a “cost-insensitive” way to practice medicine, authors Forester and Heck observe. Spending additional time with such patients, using your cognitive and diagnostic skills and performing a complete history and physical, frequently results in a diagnosis and treatment plan, they note.²⁵ If patients are aware that you’re trying to minimize costs, they’ll often consent to a step-by-step diagnostic work-up that can be stopped at any time it is appropriate.

Do it yourself. Expand your practice to include a variety of minor procedures, such as removal or biopsy of common skin lesions, colposcopy, or setting simple fractures. These measures can help keep costs down to better serve poor and low-income patients. The American Academy of Family Physicians offers courses and training in various procedures that family physicians can competently perform in their own offices.

Request a courtesy consult. On occasion, you may be able to avoid a costly referral by calling a colleague and asking for a courtesy consult. The specialist will often tell you how he or she would handle a clinical presentation like the one you describe and suggest you try a similar approach, suggests Doug Campos-Outcalt, MD, MPA. Dr. Campos-Outcalt, a faculty member at the University of Arizona College of Medicine and the author of JFP’s bimonthly Practice Alert column, has extensive experience working with underserved communities.

Connect patients with community services. Poor patients typically have many social and psychological needs, as well as the need for medical care, and integrated care is particularly important for those facing hunger, homelessness, and chronic illness, says Jonathan Cartsonis, MD, medical director of Healthcare for the Homeless in Phoenix. Maintain contact with hospital social services and emergency psychiatric services, and have information—and handouts—about local food banks, homeless shelters, and community clinics, among other resources. (See the resources listed in the box.)

In Seattle, for example, “Project Access” is an organization that helps give the underserved access to specialists. And in many parts of the country, local Rotary clubs sponsor free clinics staffed with volunteer and retired physicians, working cooperatively with local pharmacies to provide at-cost generic drugs.

Keep drug costs down
Physicians can help to insulate their poor and low-income patients from high drug costs in a number of ways:

Reduce polypharmacy. Half of Americans take at least one prescription drug, according to the 2011 Consumer Reports survey. Among this group, people with limited income—those earning less than $40,000—take, on average, 5.7 different drugs.¹⁰ Eliminating unnecessary medications, including supplements, herbs, and any other over-the-counter products, can lead to substantial savings. To determine what can be eliminated, ask patients to bring in everything they’re taking and conduct a brown bag medication review. To learn more, see “Help your patient ‘get’ what you just said: A health literacy guide” (J Fam Pract. 2012;61:190-196).

Prescribe generics. Newer brand-name drugs may not be markedly better than older, established agents. And many generics are available at major retailers like Wal-Mart for just a few dollars for a 30-day supply or at CVS for $9.99 for a 3-month supply.²⁶ Yet some physicians routinely order newer medications, even for indigent patients.

Be upfront about drug costs. When you prescribe a new drug, whether generic or branded, it is important to discuss the cost (easily accessible online and in many electronic medical record systems) with the patient. Yet only 5% of respondents to the 2011 Consumer Reports survey said their health care providers had done so. Two-thirds of those surveyed (64%) did not discover the cost of a drug until they went to a pharmacy to pick it up.¹⁰

Think twice before handing out samples. Drug samples would appear to benefit the poor and the uninsured, but evidence suggests otherwise.^27,28 In a study that assessed out-of-pocket costs associated with the use of samples, patients who had never received samples had lower out-of-pocket costs.28 That’s partly because most samples are newer, more expensive drugs, and patients who start taking them are often unable to afford the cost of a prescription. Another study found that the use of generic drugs for uninsured patients rose (from 12% to 30%) after the clinic discontinued the use of samples.²⁷

CORRESPONDENCE Laura C. Lippman, MD, 2311 North 45th Street, No. 171, Seattle, WA 98103; lclippman@gmail.com

Nearly half of the world’s 200 nations torture their citizens.¹ Although survivors have high rates of physical and psychiatric morbidity, and in coming to this country tend to live in highly concentrated refugee groups, physicians rarely discover torture histories.^2,3

Torture survivors may avoid speaking of it because they do not understand that treatment is available for their physical, psychiatric, and pain disorders. A lack of detection delays the diagnosis and treatment of the sequelae of torture. It may also affect their future safety: Individuals seeking asylum are deprived of the medical documentation needed to support their petitions.

Your involvement in recording histories and exam findings and in referring patients for specialized care can restore lives. It can also aid in reversing the “invisibility” of torture survivors that perpetuates inadequate clinical education, research, and development of appropriate therapies.

Are you caring for a survivor—and don’t know it? Approximately 500,000 torture survivors live in the United States.⁴ This equals the number of individuals with Parkinson’s disease and outnumbers those with multiple sclerosis.^5,6 Physicians may encounter torture survivors in primary care settings, emergency departments, or while consulting with colleagues about patients who have specialized medical needs. There are no evidence-based guidelines for assessing and treating torture survivors. Most studies are from single institutions and have modest sample sizes. Most use univariate analyses, and the effect of confounding variables is often unexamined. Moreover, the diversity of torture survivors’ cultures limits the generalizability of findings from particular groups.

In this article, we propose an approach—based on studies that address cross-cultural issues or use multicenter, multivariate, meta-analytic methods—that can enable you to better identify survivors of torture, assess and document consequent morbidities, and refer them to appropriate treatment programs. We focus on individuals who were tortured months or years earlier rather than on recently traumatized patients.

Facts that justify targeted screening

Although the number of torture survivors is not so high as to warrant population-wide screening, the prevalence of such victims in easily identified refugee groups does justify screening in this setting. Tortured individuals are more likely to emigrate than are their unmolested fellow nationals.⁷ Six percent to 12% of immigrants from countries where torture is practiced say they have been tortured.^2,3 Torture rates are highest in people seeking political asylum. Twenty percent to 40% of asylum-seeking refugees from Somalia, Ethiopia, Eritrea, Senegal, Sierra Leone, Tibet, and Bhutan report being tortured.^7-9 In this context, the lack of data on refugees from countries such as Zimbabwe or Myanmar is not reassuring.

The plight of children. About 4% of torture survivors are children.^10,11 Some are street children brutalized by police; some are tortured to terrorize family members; some belonged to “enemy” communities. Investigation is warranted if an immigrant child comes from a country where torture is common and if the child was old enough to be imprisoned or forced to serve as a child soldier before entering a safe refugee camp prior to immigration.¹² It is more appropriate to screen such children for post-traumatic stress disorder (PTSD) than torture. A meta-analysis found that 11% of refugee children (vs 9% of adults) have PTSD, regardless of whether they were tortured or experienced war or pandemic political violence.¹⁰ The American Academy of Child and Adolescent Psychiatry provides a summary of findings typically seen in children with PTSD.¹³

How to broach the subject with adults. Screening for torture survivors is reliable and takes little time. You might want to ask a question that mentions torture specifically. For example, you might say: “Some people in your situation have experienced torture. Has that ever happened to you?”² Other questions could be less direct and follow the legal definition of torture from the Convention Against Torture: “While in captivity, did you ever experience physical or mental suffering that was deliberately and systematically inflicted by a soldier, policeman, or militant, or other person acting with government approval?”^14,15 The sensitivity and specificity of screening questions are estimated at 80% and 90%, respectively.⁸ Patient factors that can dampen sensitivity are shame and stigmatization (especially for survivors of sexual torture) and the trauma-amnestic component of PTSD. Secondary gain with regard to immigration appeals, however, rarely causes overreporting.³

If a patient answers Yes to a screening question, your responsibility is 2-fold. First, begin compiling a medical record that accurately reflects the patient’s description of torture and the medical findings relevant to those statements. Accurate documentation is important because medical records are used as evidence in hearings to rule on petitions for asylum. Second, refer the patient for proper treatment that can reduce disability, pain, and psychiatric distress.

Assess physical morbidity

Torture survivors’ physical symptoms and signs are as varied^16-18 as the methods by which they have been abused.^19-21 Let a patient’s complaints and report of the techniques used guide your examination.^{9,14,15,22,23}

Concussive trauma is nearly universally reported. This includes beatings with fists, clubs, and batons. Caning causes horizontal lesions typically on the buttocks and back or sometimes on the backs of the legs. Whipping is typically applied to the back, where it produces downsloping lesions that curl laterally off the trunk.¹⁸ Torturers sometimes place layers of cloth over the skin before beatings to minimize incriminating cuts and scars. In men, genital beatings are so common that researchers include them with general beatings rather than categorizing them as sexual torture.²⁴ A third to half of survivors report beatings on the feet, a technique that produces chronic neuralgias and disability from fascial injuries, which can be evaluated by MRI.^25-27 Prolonged pain and disability from foot beatings is associated with PTSD. Concussive trauma to ears can produce hearing loss. Deformities or healed fractures may be signs of blunt force trauma. Gunfire into joints leaves bony injuries and metallic fragments.

Suspension, hyperflexion. Many survivors report being suspended by an extremity or digit or forced into positions of extreme hyperflexion, hyperextension, or rotation. A variant of suspension is the use of stress positions such as confinement in a tight box. These techniques often tear ligaments, tendons, nerves, neural plexi, or other soft tissues, or cause subluxations, dislocations (eg, reverse rotation of the shoulder), fractures, or even amputating avulsions.^16,28 Careful examination and imaging of joints can detect such bone and soft tissue injuries.

Ligatures, binding, and compression to extremities or genitalia are used to restrain or to cause pain or injury. The long-term sequelae include scars, neuropathies, ligamentous injuries, muscle trauma, and ischemic injuries. Thumbscrews—small vises clamped on fingers, thumbs, or toes—produce destructive compressive fractures and deformities in the distal bones and joints of the fingers or toes.¹⁶

Burns, electrical shock, and mutilation by cutting are widely inflicted. Shock is applied to the skin, genitalia, or within body cavities with wires, cattle prods, or electrified grids such as bedsprings. Muscle spasms caused by intra-oral cattle prods can cause jaw dislocations. Intense shocks on the back can cause muscle spasms that result in vertebral compression fractures.¹⁶ Although nontherapeutic, biopsies of electrical scars have evidentiary value.¹⁸ Teeth are often extracted as a form of mutilation.

Sexual torture is substantially under-reported. Five percent to 15% of male torture survivors report being sexually abused.^24,29 Of these, 50% report threats of castration or rape, 33% are raped or forced to perform sex on, or in view of, others, and 10% report genital shocks or mutilation.^24,29 Although fewer women than men are tortured, about half of women survivors report sexual torture, usually rape, sometimes in front of family members.^30,31 Given the prevalence of rape among female torture survivors, case finding during or before prenatal care may enable a practitioner to desensitize or sedate a woman before using gynecological instruments or techniques like paracervical injections that can trigger PTSD arousal reactions.

Injurious environments. Nearly all torture survivors report being subjected to extremes of heat or cold, a lack of water or food or sanitation or medical care, or crowding, filth, and extreme noise. Some survivors report asphyxia with a dry or wet cloth over the face or by being immersed in water. A few report being given substances that cause dystonia, diarrhea, or loss of consciousness.

Assess psychological morbidity

The distinction between physical and psychological torture is imperfect. Fear of physical violence is a psychological stressor. Psychological torture has physical sequelae such as sexual dysfunction. Psychological torture uses various methods to humiliate, degrade, or cause extreme fear (sham executions, being forced to watch torture), or to isolate or disorient (blindfolding, sleep deprivation) a prisoner.^9,15,21 The combination of physical and psychological torture causes severe, chronic psychological morbidity.⁷ The nature and severity of this morbidity is shaped by the nature of the torture, personal resilience, social supports, stressors in life after torture, and therapy.

The main psychological sequelae of torture are PTSD, depression, anxiety disorders, and chronic pain syndromes. Of torture survivors seeking treatment, 50% to 67% have PTSD, 33% have depression, 10% have generalized anxiety disorders, and another 10% have other psychiatric diagnoses.^32,33 Forty percent to 70% of torture survivors have chronic pain or somatoform disorders,^7,22,31,34 making it critical that physicians screen for a history of torture with any refugee presenting with recurrent, complex, or unexplained pain.

Many tortured refugees have experienced multiple traumas, including political terror, war, and dislocation. A complex meta-analysis involving 82,000 refugees found that torture is especially correlated with PTSD, whereas stressors such as exposure to conflict and displacement were more strongly associated with depression.^35,36

Researchers have not found correlations between the types, severity, or duration of torture (including physical vs psychological techniques) and the severity of post-torture PTSD or depression.^7,37 Head trauma received during torture may lead to frontal and temporal cortical thinning that is highly associated with post-torture depression.³⁸ Rape during torture is associated with high levels of chronic distress and sexual dysfunction.^30,39,40 Psychological resilience may be somewhat more robust in individuals who expected to be tortured.²¹

The social situation of resettled refugees affects the severity of psychiatric distress in torture survivors. Two large studies found that refugees were more distressed if they were institutionalized (in camps or compounds as opposed to homes), feared repatriation, were underemployed, or lacked economic opportunities in their new homeland.^35,41 Persistent pain or physical disability related to tissue damage or a superimposed somatoform disorder correlates strongly with persistent psychiatric morbidity.⁴² Although the intensity of PTSD decreases over years, the core symptom complex often endures and may be disabling.^32,37,43

How to connect patients with resources

The International Rehabilitation Council for Torture Victims (www.IRCT.org) and the Center for Victims of Torture (www.CVT.org) offer links to many torture survivor treatment programs. Other torture treatment centers can be found with Web searches or through international clinics or community organizations serving specific ethnic groups. Treatment programs help clients—many of whom are uninsured and, as non-US nationals, ineligible for public entitlement programs—navigate barriers to getting help. Treatment centers must address language barriers between therapists and clients. One caution: In small ethnic communities, translators may know clients and thereby raise fears of lack

of confidentiality. Treatment options. Standard interventions recommended for torture survivors include physical therapy and cognitive behavioral therapy, especially for flashbacks and disabling social avoidance behaviors that are part of PTSD.⁷ Narrative exposure therapy, a brief psychotherapy in which the patient repeatedly retells and re-experiences painful events, shows promise.^44,45 Psychological care for depression and anxiety, interdisciplinary pain desensitization, psychosocial supports, and assistance with asylum petitions are also important. The lack of validated torture survivor treatments reflects a paucity of research on this issue. It does not mean that standard effective therapies for PTSD or depression are ineffective.^32,46 It is reasonable to assume that inadequate treatment of PTSD, depression, and pain disorders magnifies and prolongs the personal, familial, and social cost of torture sequelae.

Following through on medical documentation. About 41,000 people, nearly all from countries where torture is common, sought asylum from persecution in the United States in 2011.⁴⁷ The United States grants asylum if an otherwise eligible immigrant can establish a “significant possibility” of future persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.⁴⁸ This is a government determination, not a medical certification. A study of 2400 asylum seekers found that 90% who had medical documentation of past torture were granted asylum, compared with just 37% of those lacking such medical support.⁴⁹

CORRESPONDENCE Steven H. Miles, MD, Center for Bioethics, N504 Boynton, 410 Church Street SE, Minneapolis, MN 55455; Miles001@umn.edu

Nearly half of the world’s 200 nations torture their citizens.¹ Although survivors have high rates of physical and psychiatric morbidity, and in coming to this country tend to live in highly concentrated refugee groups, physicians rarely discover torture histories.^2,3

Torture survivors may avoid speaking of it because they do not understand that treatment is available for their physical, psychiatric, and pain disorders. A lack of detection delays the diagnosis and treatment of the sequelae of torture. It may also affect their future safety: Individuals seeking asylum are deprived of the medical documentation needed to support their petitions.

Your involvement in recording histories and exam findings and in referring patients for specialized care can restore lives. It can also aid in reversing the “invisibility” of torture survivors that perpetuates inadequate clinical education, research, and development of appropriate therapies.

Are you caring for a survivor—and don’t know it? Approximately 500,000 torture survivors live in the United States.⁴ This equals the number of individuals with Parkinson’s disease and outnumbers those with multiple sclerosis.^5,6 Physicians may encounter torture survivors in primary care settings, emergency departments, or while consulting with colleagues about patients who have specialized medical needs. There are no evidence-based guidelines for assessing and treating torture survivors. Most studies are from single institutions and have modest sample sizes. Most use univariate analyses, and the effect of confounding variables is often unexamined. Moreover, the diversity of torture survivors’ cultures limits the generalizability of findings from particular groups.

In this article, we propose an approach—based on studies that address cross-cultural issues or use multicenter, multivariate, meta-analytic methods—that can enable you to better identify survivors of torture, assess and document consequent morbidities, and refer them to appropriate treatment programs. We focus on individuals who were tortured months or years earlier rather than on recently traumatized patients.

Facts that justify targeted screening

Although the number of torture survivors is not so high as to warrant population-wide screening, the prevalence of such victims in easily identified refugee groups does justify screening in this setting. Tortured individuals are more likely to emigrate than are their unmolested fellow nationals.⁷ Six percent to 12% of immigrants from countries where torture is practiced say they have been tortured.^2,3 Torture rates are highest in people seeking political asylum. Twenty percent to 40% of asylum-seeking refugees from Somalia, Ethiopia, Eritrea, Senegal, Sierra Leone, Tibet, and Bhutan report being tortured.^7-9 In this context, the lack of data on refugees from countries such as Zimbabwe or Myanmar is not reassuring.

The plight of children. About 4% of torture survivors are children.^10,11 Some are street children brutalized by police; some are tortured to terrorize family members; some belonged to “enemy” communities. Investigation is warranted if an immigrant child comes from a country where torture is common and if the child was old enough to be imprisoned or forced to serve as a child soldier before entering a safe refugee camp prior to immigration.¹² It is more appropriate to screen such children for post-traumatic stress disorder (PTSD) than torture. A meta-analysis found that 11% of refugee children (vs 9% of adults) have PTSD, regardless of whether they were tortured or experienced war or pandemic political violence.¹⁰ The American Academy of Child and Adolescent Psychiatry provides a summary of findings typically seen in children with PTSD.¹³

How to broach the subject with adults. Screening for torture survivors is reliable and takes little time. You might want to ask a question that mentions torture specifically. For example, you might say: “Some people in your situation have experienced torture. Has that ever happened to you?”² Other questions could be less direct and follow the legal definition of torture from the Convention Against Torture: “While in captivity, did you ever experience physical or mental suffering that was deliberately and systematically inflicted by a soldier, policeman, or militant, or other person acting with government approval?”^14,15 The sensitivity and specificity of screening questions are estimated at 80% and 90%, respectively.⁸ Patient factors that can dampen sensitivity are shame and stigmatization (especially for survivors of sexual torture) and the trauma-amnestic component of PTSD. Secondary gain with regard to immigration appeals, however, rarely causes overreporting.³

If a patient answers Yes to a screening question, your responsibility is 2-fold. First, begin compiling a medical record that accurately reflects the patient’s description of torture and the medical findings relevant to those statements. Accurate documentation is important because medical records are used as evidence in hearings to rule on petitions for asylum. Second, refer the patient for proper treatment that can reduce disability, pain, and psychiatric distress.

Assess physical morbidity

Torture survivors’ physical symptoms and signs are as varied^16-18 as the methods by which they have been abused.^19-21 Let a patient’s complaints and report of the techniques used guide your examination.^{9,14,15,22,23}

Concussive trauma is nearly universally reported. This includes beatings with fists, clubs, and batons. Caning causes horizontal lesions typically on the buttocks and back or sometimes on the backs of the legs. Whipping is typically applied to the back, where it produces downsloping lesions that curl laterally off the trunk.¹⁸ Torturers sometimes place layers of cloth over the skin before beatings to minimize incriminating cuts and scars. In men, genital beatings are so common that researchers include them with general beatings rather than categorizing them as sexual torture.²⁴ A third to half of survivors report beatings on the feet, a technique that produces chronic neuralgias and disability from fascial injuries, which can be evaluated by MRI.^25-27 Prolonged pain and disability from foot beatings is associated with PTSD. Concussive trauma to ears can produce hearing loss. Deformities or healed fractures may be signs of blunt force trauma. Gunfire into joints leaves bony injuries and metallic fragments.

Suspension, hyperflexion. Many survivors report being suspended by an extremity or digit or forced into positions of extreme hyperflexion, hyperextension, or rotation. A variant of suspension is the use of stress positions such as confinement in a tight box. These techniques often tear ligaments, tendons, nerves, neural plexi, or other soft tissues, or cause subluxations, dislocations (eg, reverse rotation of the shoulder), fractures, or even amputating avulsions.^16,28 Careful examination and imaging of joints can detect such bone and soft tissue injuries.

Ligatures, binding, and compression to extremities or genitalia are used to restrain or to cause pain or injury. The long-term sequelae include scars, neuropathies, ligamentous injuries, muscle trauma, and ischemic injuries. Thumbscrews—small vises clamped on fingers, thumbs, or toes—produce destructive compressive fractures and deformities in the distal bones and joints of the fingers or toes.¹⁶

Burns, electrical shock, and mutilation by cutting are widely inflicted. Shock is applied to the skin, genitalia, or within body cavities with wires, cattle prods, or electrified grids such as bedsprings. Muscle spasms caused by intra-oral cattle prods can cause jaw dislocations. Intense shocks on the back can cause muscle spasms that result in vertebral compression fractures.¹⁶ Although nontherapeutic, biopsies of electrical scars have evidentiary value.¹⁸ Teeth are often extracted as a form of mutilation.

Sexual torture is substantially under-reported. Five percent to 15% of male torture survivors report being sexually abused.^24,29 Of these, 50% report threats of castration or rape, 33% are raped or forced to perform sex on, or in view of, others, and 10% report genital shocks or mutilation.^24,29 Although fewer women than men are tortured, about half of women survivors report sexual torture, usually rape, sometimes in front of family members.^30,31 Given the prevalence of rape among female torture survivors, case finding during or before prenatal care may enable a practitioner to desensitize or sedate a woman before using gynecological instruments or techniques like paracervical injections that can trigger PTSD arousal reactions.

Injurious environments. Nearly all torture survivors report being subjected to extremes of heat or cold, a lack of water or food or sanitation or medical care, or crowding, filth, and extreme noise. Some survivors report asphyxia with a dry or wet cloth over the face or by being immersed in water. A few report being given substances that cause dystonia, diarrhea, or loss of consciousness.

Assess psychological morbidity

The distinction between physical and psychological torture is imperfect. Fear of physical violence is a psychological stressor. Psychological torture has physical sequelae such as sexual dysfunction. Psychological torture uses various methods to humiliate, degrade, or cause extreme fear (sham executions, being forced to watch torture), or to isolate or disorient (blindfolding, sleep deprivation) a prisoner.^9,15,21 The combination of physical and psychological torture causes severe, chronic psychological morbidity.⁷ The nature and severity of this morbidity is shaped by the nature of the torture, personal resilience, social supports, stressors in life after torture, and therapy.

The main psychological sequelae of torture are PTSD, depression, anxiety disorders, and chronic pain syndromes. Of torture survivors seeking treatment, 50% to 67% have PTSD, 33% have depression, 10% have generalized anxiety disorders, and another 10% have other psychiatric diagnoses.^32,33 Forty percent to 70% of torture survivors have chronic pain or somatoform disorders,^7,22,31,34 making it critical that physicians screen for a history of torture with any refugee presenting with recurrent, complex, or unexplained pain.

Many tortured refugees have experienced multiple traumas, including political terror, war, and dislocation. A complex meta-analysis involving 82,000 refugees found that torture is especially correlated with PTSD, whereas stressors such as exposure to conflict and displacement were more strongly associated with depression.^35,36

Researchers have not found correlations between the types, severity, or duration of torture (including physical vs psychological techniques) and the severity of post-torture PTSD or depression.^7,37 Head trauma received during torture may lead to frontal and temporal cortical thinning that is highly associated with post-torture depression.³⁸ Rape during torture is associated with high levels of chronic distress and sexual dysfunction.^30,39,40 Psychological resilience may be somewhat more robust in individuals who expected to be tortured.²¹

The social situation of resettled refugees affects the severity of psychiatric distress in torture survivors. Two large studies found that refugees were more distressed if they were institutionalized (in camps or compounds as opposed to homes), feared repatriation, were underemployed, or lacked economic opportunities in their new homeland.^35,41 Persistent pain or physical disability related to tissue damage or a superimposed somatoform disorder correlates strongly with persistent psychiatric morbidity.⁴² Although the intensity of PTSD decreases over years, the core symptom complex often endures and may be disabling.^32,37,43

How to connect patients with resources

The International Rehabilitation Council for Torture Victims (www.IRCT.org) and the Center for Victims of Torture (www.CVT.org) offer links to many torture survivor treatment programs. Other torture treatment centers can be found with Web searches or through international clinics or community organizations serving specific ethnic groups. Treatment programs help clients—many of whom are uninsured and, as non-US nationals, ineligible for public entitlement programs—navigate barriers to getting help. Treatment centers must address language barriers between therapists and clients. One caution: In small ethnic communities, translators may know clients and thereby raise fears of lack

of confidentiality. Treatment options. Standard interventions recommended for torture survivors include physical therapy and cognitive behavioral therapy, especially for flashbacks and disabling social avoidance behaviors that are part of PTSD.⁷ Narrative exposure therapy, a brief psychotherapy in which the patient repeatedly retells and re-experiences painful events, shows promise.^44,45 Psychological care for depression and anxiety, interdisciplinary pain desensitization, psychosocial supports, and assistance with asylum petitions are also important. The lack of validated torture survivor treatments reflects a paucity of research on this issue. It does not mean that standard effective therapies for PTSD or depression are ineffective.^32,46 It is reasonable to assume that inadequate treatment of PTSD, depression, and pain disorders magnifies and prolongs the personal, familial, and social cost of torture sequelae.

Following through on medical documentation. About 41,000 people, nearly all from countries where torture is common, sought asylum from persecution in the United States in 2011.⁴⁷ The United States grants asylum if an otherwise eligible immigrant can establish a “significant possibility” of future persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.⁴⁸ This is a government determination, not a medical certification. A study of 2400 asylum seekers found that 90% who had medical documentation of past torture were granted asylum, compared with just 37% of those lacking such medical support.⁴⁹

CORRESPONDENCE Steven H. Miles, MD, Center for Bioethics, N504 Boynton, 410 Church Street SE, Minneapolis, MN 55455; Miles001@umn.edu

Nearly half of the world’s 200 nations torture their citizens.¹ Although survivors have high rates of physical and psychiatric morbidity, and in coming to this country tend to live in highly concentrated refugee groups, physicians rarely discover torture histories.^2,3

Torture survivors may avoid speaking of it because they do not understand that treatment is available for their physical, psychiatric, and pain disorders. A lack of detection delays the diagnosis and treatment of the sequelae of torture. It may also affect their future safety: Individuals seeking asylum are deprived of the medical documentation needed to support their petitions.

Your involvement in recording histories and exam findings and in referring patients for specialized care can restore lives. It can also aid in reversing the “invisibility” of torture survivors that perpetuates inadequate clinical education, research, and development of appropriate therapies.

Are you caring for a survivor—and don’t know it? Approximately 500,000 torture survivors live in the United States.⁴ This equals the number of individuals with Parkinson’s disease and outnumbers those with multiple sclerosis.^5,6 Physicians may encounter torture survivors in primary care settings, emergency departments, or while consulting with colleagues about patients who have specialized medical needs. There are no evidence-based guidelines for assessing and treating torture survivors. Most studies are from single institutions and have modest sample sizes. Most use univariate analyses, and the effect of confounding variables is often unexamined. Moreover, the diversity of torture survivors’ cultures limits the generalizability of findings from particular groups.

In this article, we propose an approach—based on studies that address cross-cultural issues or use multicenter, multivariate, meta-analytic methods—that can enable you to better identify survivors of torture, assess and document consequent morbidities, and refer them to appropriate treatment programs. We focus on individuals who were tortured months or years earlier rather than on recently traumatized patients.

Facts that justify targeted screening

Although the number of torture survivors is not so high as to warrant population-wide screening, the prevalence of such victims in easily identified refugee groups does justify screening in this setting. Tortured individuals are more likely to emigrate than are their unmolested fellow nationals.⁷ Six percent to 12% of immigrants from countries where torture is practiced say they have been tortured.^2,3 Torture rates are highest in people seeking political asylum. Twenty percent to 40% of asylum-seeking refugees from Somalia, Ethiopia, Eritrea, Senegal, Sierra Leone, Tibet, and Bhutan report being tortured.^7-9 In this context, the lack of data on refugees from countries such as Zimbabwe or Myanmar is not reassuring.

The plight of children. About 4% of torture survivors are children.^10,11 Some are street children brutalized by police; some are tortured to terrorize family members; some belonged to “enemy” communities. Investigation is warranted if an immigrant child comes from a country where torture is common and if the child was old enough to be imprisoned or forced to serve as a child soldier before entering a safe refugee camp prior to immigration.¹² It is more appropriate to screen such children for post-traumatic stress disorder (PTSD) than torture. A meta-analysis found that 11% of refugee children (vs 9% of adults) have PTSD, regardless of whether they were tortured or experienced war or pandemic political violence.¹⁰ The American Academy of Child and Adolescent Psychiatry provides a summary of findings typically seen in children with PTSD.¹³

How to broach the subject with adults. Screening for torture survivors is reliable and takes little time. You might want to ask a question that mentions torture specifically. For example, you might say: “Some people in your situation have experienced torture. Has that ever happened to you?”² Other questions could be less direct and follow the legal definition of torture from the Convention Against Torture: “While in captivity, did you ever experience physical or mental suffering that was deliberately and systematically inflicted by a soldier, policeman, or militant, or other person acting with government approval?”^14,15 The sensitivity and specificity of screening questions are estimated at 80% and 90%, respectively.⁸ Patient factors that can dampen sensitivity are shame and stigmatization (especially for survivors of sexual torture) and the trauma-amnestic component of PTSD. Secondary gain with regard to immigration appeals, however, rarely causes overreporting.³

If a patient answers Yes to a screening question, your responsibility is 2-fold. First, begin compiling a medical record that accurately reflects the patient’s description of torture and the medical findings relevant to those statements. Accurate documentation is important because medical records are used as evidence in hearings to rule on petitions for asylum. Second, refer the patient for proper treatment that can reduce disability, pain, and psychiatric distress.

Assess physical morbidity

Torture survivors’ physical symptoms and signs are as varied^16-18 as the methods by which they have been abused.^19-21 Let a patient’s complaints and report of the techniques used guide your examination.^{9,14,15,22,23}

Concussive trauma is nearly universally reported. This includes beatings with fists, clubs, and batons. Caning causes horizontal lesions typically on the buttocks and back or sometimes on the backs of the legs. Whipping is typically applied to the back, where it produces downsloping lesions that curl laterally off the trunk.¹⁸ Torturers sometimes place layers of cloth over the skin before beatings to minimize incriminating cuts and scars. In men, genital beatings are so common that researchers include them with general beatings rather than categorizing them as sexual torture.²⁴ A third to half of survivors report beatings on the feet, a technique that produces chronic neuralgias and disability from fascial injuries, which can be evaluated by MRI.^25-27 Prolonged pain and disability from foot beatings is associated with PTSD. Concussive trauma to ears can produce hearing loss. Deformities or healed fractures may be signs of blunt force trauma. Gunfire into joints leaves bony injuries and metallic fragments.

Suspension, hyperflexion. Many survivors report being suspended by an extremity or digit or forced into positions of extreme hyperflexion, hyperextension, or rotation. A variant of suspension is the use of stress positions such as confinement in a tight box. These techniques often tear ligaments, tendons, nerves, neural plexi, or other soft tissues, or cause subluxations, dislocations (eg, reverse rotation of the shoulder), fractures, or even amputating avulsions.^16,28 Careful examination and imaging of joints can detect such bone and soft tissue injuries.

Ligatures, binding, and compression to extremities or genitalia are used to restrain or to cause pain or injury. The long-term sequelae include scars, neuropathies, ligamentous injuries, muscle trauma, and ischemic injuries. Thumbscrews—small vises clamped on fingers, thumbs, or toes—produce destructive compressive fractures and deformities in the distal bones and joints of the fingers or toes.¹⁶

Burns, electrical shock, and mutilation by cutting are widely inflicted. Shock is applied to the skin, genitalia, or within body cavities with wires, cattle prods, or electrified grids such as bedsprings. Muscle spasms caused by intra-oral cattle prods can cause jaw dislocations. Intense shocks on the back can cause muscle spasms that result in vertebral compression fractures.¹⁶ Although nontherapeutic, biopsies of electrical scars have evidentiary value.¹⁸ Teeth are often extracted as a form of mutilation.

Sexual torture is substantially under-reported. Five percent to 15% of male torture survivors report being sexually abused.^24,29 Of these, 50% report threats of castration or rape, 33% are raped or forced to perform sex on, or in view of, others, and 10% report genital shocks or mutilation.^24,29 Although fewer women than men are tortured, about half of women survivors report sexual torture, usually rape, sometimes in front of family members.^30,31 Given the prevalence of rape among female torture survivors, case finding during or before prenatal care may enable a practitioner to desensitize or sedate a woman before using gynecological instruments or techniques like paracervical injections that can trigger PTSD arousal reactions.

Injurious environments. Nearly all torture survivors report being subjected to extremes of heat or cold, a lack of water or food or sanitation or medical care, or crowding, filth, and extreme noise. Some survivors report asphyxia with a dry or wet cloth over the face or by being immersed in water. A few report being given substances that cause dystonia, diarrhea, or loss of consciousness.

Assess psychological morbidity

The distinction between physical and psychological torture is imperfect. Fear of physical violence is a psychological stressor. Psychological torture has physical sequelae such as sexual dysfunction. Psychological torture uses various methods to humiliate, degrade, or cause extreme fear (sham executions, being forced to watch torture), or to isolate or disorient (blindfolding, sleep deprivation) a prisoner.^9,15,21 The combination of physical and psychological torture causes severe, chronic psychological morbidity.⁷ The nature and severity of this morbidity is shaped by the nature of the torture, personal resilience, social supports, stressors in life after torture, and therapy.

The main psychological sequelae of torture are PTSD, depression, anxiety disorders, and chronic pain syndromes. Of torture survivors seeking treatment, 50% to 67% have PTSD, 33% have depression, 10% have generalized anxiety disorders, and another 10% have other psychiatric diagnoses.^32,33 Forty percent to 70% of torture survivors have chronic pain or somatoform disorders,^7,22,31,34 making it critical that physicians screen for a history of torture with any refugee presenting with recurrent, complex, or unexplained pain.

Many tortured refugees have experienced multiple traumas, including political terror, war, and dislocation. A complex meta-analysis involving 82,000 refugees found that torture is especially correlated with PTSD, whereas stressors such as exposure to conflict and displacement were more strongly associated with depression.^35,36

Researchers have not found correlations between the types, severity, or duration of torture (including physical vs psychological techniques) and the severity of post-torture PTSD or depression.^7,37 Head trauma received during torture may lead to frontal and temporal cortical thinning that is highly associated with post-torture depression.³⁸ Rape during torture is associated with high levels of chronic distress and sexual dysfunction.^30,39,40 Psychological resilience may be somewhat more robust in individuals who expected to be tortured.²¹

The social situation of resettled refugees affects the severity of psychiatric distress in torture survivors. Two large studies found that refugees were more distressed if they were institutionalized (in camps or compounds as opposed to homes), feared repatriation, were underemployed, or lacked economic opportunities in their new homeland.^35,41 Persistent pain or physical disability related to tissue damage or a superimposed somatoform disorder correlates strongly with persistent psychiatric morbidity.⁴² Although the intensity of PTSD decreases over years, the core symptom complex often endures and may be disabling.^32,37,43

How to connect patients with resources

The International Rehabilitation Council for Torture Victims (www.IRCT.org) and the Center for Victims of Torture (www.CVT.org) offer links to many torture survivor treatment programs. Other torture treatment centers can be found with Web searches or through international clinics or community organizations serving specific ethnic groups. Treatment programs help clients—many of whom are uninsured and, as non-US nationals, ineligible for public entitlement programs—navigate barriers to getting help. Treatment centers must address language barriers between therapists and clients. One caution: In small ethnic communities, translators may know clients and thereby raise fears of lack

of confidentiality. Treatment options. Standard interventions recommended for torture survivors include physical therapy and cognitive behavioral therapy, especially for flashbacks and disabling social avoidance behaviors that are part of PTSD.⁷ Narrative exposure therapy, a brief psychotherapy in which the patient repeatedly retells and re-experiences painful events, shows promise.^44,45 Psychological care for depression and anxiety, interdisciplinary pain desensitization, psychosocial supports, and assistance with asylum petitions are also important. The lack of validated torture survivor treatments reflects a paucity of research on this issue. It does not mean that standard effective therapies for PTSD or depression are ineffective.^32,46 It is reasonable to assume that inadequate treatment of PTSD, depression, and pain disorders magnifies and prolongs the personal, familial, and social cost of torture sequelae.

Following through on medical documentation. About 41,000 people, nearly all from countries where torture is common, sought asylum from persecution in the United States in 2011.⁴⁷ The United States grants asylum if an otherwise eligible immigrant can establish a “significant possibility” of future persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.⁴⁸ This is a government determination, not a medical certification. A study of 2400 asylum seekers found that 90% who had medical documentation of past torture were granted asylum, compared with just 37% of those lacking such medical support.⁴⁹

CORRESPONDENCE Steven H. Miles, MD, Center for Bioethics, N504 Boynton, 410 Church Street SE, Minneapolis, MN 55455; Miles001@umn.edu