A Yale student looks at the link between scar and symptom. Shadowing clinicians at Bellevue Hospital in New York City last summer, medical student George Lui heard questions most doctors never have to ask their patients.

“Who tortured you?”

“Where and when did it happen?”

“Can you tell me more about it?”

Lui worked in the Bellevue/NYU Program for Survivors of Torture, which offers multidisciplinary services to people who have experienced physical or psychological torture. The program provides long-term treatment to patients and their families, combining medical, psychiatric, psychological and social services provided by a variety of health professionals. Working under program director Allen S. Keller, M.D., Lui’s task was to review charts of the approximately 250 active patients in the program and look for correlations between specific forms of torture and individual symptoms. Such information could help clinicians develop more effective strategies for working with victims of torture.

His apparently straightforward review took some twists and turns, Lui said. Cultural and religious habits and beliefs often dictated how people responded to torture. Tibetan torture survivors, he noted, do not often meet formal criteria developed in the west for a diagnosis of post-traumatic stress disorder because they don’t avoid thoughts or activities associated with the trauma. Avoidance, however, is one of the three pillars of PTSD diagnosis.

Clinicians often were unable to distinguish between symptoms that resulted from torture and psychosomatic symptoms resulting from psychological distress. Lui cited the case of a 57-year-old woman from Sierra Leone. Trapped in her village during a battle, she watched as rebels burned her house and murdered her relatives. After receiving death threats, she came to the United States. “Once this summer she came to the clinic complaining of abdominal pain,” Lui said, recalling the medical consultation he observed. “Is this a sequela of her trauma history or an unrelated medical manifestation?”

In his report, funded by the David E. Rogers Student Research Fellowship from the New York Academy of Medicine and the Yale School of Medicine Summer Fellowship, Lui listed forms of torture applied, countries of origin of the survivors and how the trauma was manifested. Beatings were the most common form of torture, followed by deprivation of food and water. Imprisonment was the most common psychological torture, followed by murder of relatives. Most survivors in the program, 39 percent, were from Africa, followed by Tibet, 34 percent. And most, like the woman from Sierra Leone, suffered from PTSD.

“She started to talk about her trauma history and she broke out in tears,” Lui said. “It’s really important to listen to these stories because that could greatly influence how you treat torture survivors.”