1. Introduction

Refugees, especially those subjected to torture, often experience many difficulties, including post-traumatic stress disorder (PTSD), depression, and somatic disturbances (e.g., pain) that, together, interfere with day-to-day functioning. These impairments are likely to be the result of many factors, including decline in cognitive functioning, a common finding in non-refugee populations with PTSD and depression. Studies of trauma-exposed individuals have found that severity of PTSD and depression are associated with cognitive deficits in attentional control, task-shifting, inhibition, information processing speed, and working- and long-term memory.

Additionally, cognitive impairments are also common among individuals whose traumatic exposure involved a head injury or other experiences capable of producing brain injury (e.g., suffocation, inhalation of toxic substances, rapid acceleration of the head), loss of consciousness (LOC), and/or post-traumatic amnesia. Reports of LOC and/or post-traumatic amnesia suggest that a traumatic brain injury (TBI) has occurred. TBI in refugees frequently occurs under difficult conditions before or during flight from their home countries. These injuries often result from torture, other organized violence, or war. Furthermore, TBI has been associated with an increased risk of developing PTSD, and the cognitive impairments associated with PTSD are hard to distinguish from TBI.

Studies on combat veterans find that those with PTSD/depression and a TBI have greater impairments in cognitive functioning and poorer functional outcomes than those with TBIs or PTSD/depression alone, suggesting an interactional effect between PTSD and TBI on cognition. There is preliminary evidence of a complex relationship between trauma, head injury/TBI, cognitive impairments, and PTSD in trauma-affected refugees. Several studies have described a high prevalence of self-reported TBI in refugee populations, but, to date, only three studies have examined the relationship between TBI and PTSD in refugees. The three studies find that a history of TBI is strongly associated with higher levels of depression and health complaints, including pain, with those having both TBI and PTSD showing the highest levels of overall disability. The other two studies found a history of TBI to be strongly associated with the severity of PTSD, whereas one did not. In investigating the relationship between PTSD and cognition, Kivling-Bodén et al. (2003) found that PTSD severity was associated with alterations in fluid intelligence and episodic memory in civilian refugees from the war in Yugoslavia. Yehuda et al. (2003) observed lower scores on a test of verbal learning in Holocaust survivors compared with trauma-exposed controls. In a study of over 300 Congolese refugees, PTSD severity was found to be significantly associated with reductions in working memory and executive and psychosocial functioning.

Aim of the Study

To date, no study has reported on the relationship between all three factors simultaneously: TBI, symptom severity in PTSD, and cognitive functioning in refugee populations. The present study aims to address this gap in the literature in a large sample of tortured refugees seeking treatment for post-traumatic distress. Based on the available literature, we anticipated that the refugees would show evidence of broad cognitive impairments rather than localized cognitive deficits, i.e., suggestive of an injury to specific brain regions. Thus, we chose the Symbol Digit Modality Test (SDMT), a clinician-administered test of associative working memory, visual scanning, attention, and information processing speed that can be administered in less than five minutes. We expected that that the severity of cognitive impairments, as measured with SDMT, would be significantly correlated with severity of PTSD, depression, anxiety, pain, and health-related disability. We also anticipated that refugees with a history of TBI, defined by a history of head injury with loss of consciousness, would demonstrate additional cognitive impairment and more severe PTSD, depression, anxiety, pain, and health-related disability than those without TBI.

2. Materials and Methods

2.1. Setting and Population

The Danish Institute Against Torture (DIGNITY) operates a specialist outpatient clinic in Copenhagen, providing treatment targeting PTSD, depression, and somatic complaints in refugees exposed to torture and/or other organized violence. Patients included 141 adult refugees (38% women) referred to DIGNITY 2012–2014 and who were screened with the SDMT pre-treatment. The main countries of origin included Iraq (36%), Iran (18%), Lebanon (6%), Bosnia (5%), Afghanistan (4%), Somalia (4%), and Syria (2%). The patients had been residents in Denmark between 1 and 29 years. The patients had an average age of 45.4 years (SD = 9.4) and had been in school an average of 9.7 years (SD = 4.9) (please see previous publication for more detailed description of patients at DIGNITY). A large part of the population used antidepressants and sleep medication.Inclusion criteria for the treatment were (1) 18 years or older; (2) arriving to Denmark as a refugee; (3) exposure to torture or organized violence; (4) permanent right to remain (asylum) in Denmark; (5) the ability to finance transportation to the clinic; (6) the presence of both primary psychiatric and somatic symptoms requiring treatment; (7) no current alcohol or drug-dependency; and (8) not presently suffering from psychosis.

2.2. Design and Procedures

The study was cross-sectional. At pre-treatment, all patients completed standardized self-report measures of mental/physical health and cognitive screening with the SDMT. Approximately half of the patients also completed Part 3 of the Harvard Trauma Questionnaire (HTQ), which screens for possible head traumas, at pre-treatment. Whenever possible, the self-report measures were in the participant’s preferred language, and, where necessary, an interpreter assisted in completing the measures. All self-report measures used in this study have been found to be valid for their intended purposes and for use with refugees. SDMT was chosen as a suitable screening tool to capture reductions in processing speed, attention, and working memory associated with TBI and as a measure of general cognitive impairment and decline.All patients gave informed consent to participate in the study. The Danish Data Protection Agency and the Danish Patient Safety Authority approved this research. Due to the nature of this research, the data will not be shared publicly, so supporting data are not available.

2.3. Measures

Traumatic exposure, possible brain injury, and PTSD were assessed using Parts 1, 3, and 4 of the Harvard Trauma Questionnaire (HTQ). Part 1 of the HTQ assesses (lifetime) exposure to 46 different types of traumatic events. Part 3 (5 items) measures history of possible brain injury, either through head injury or experiences that increase the risk of brain damage (e.g., suffocation, near-drowning, prolonged starvation) and loss of consciousness during a possible head trauma.

In the present study, a traumatic brain injury (TBI) was defined as the occurrence of an experience capable of producing a brain injury, as assessed by Part 3 of the HTQ, including loss of consciousness, which would be a head injury event plus associated loss of consciousness. Part 4 (16 items) assesses the symptoms of PTSD as described in the 4th Revised Edition of the Diagnostic and Statistical Manual of Mental Disorders, where patients rate how much each symptom has troubled them over the past week (1 = not at all, 4 = extremely). The recommended cut-off score for a DSM-IV PTSD diagnosis is 2.5.

Anxiety and Depression were assessed using the 25-item Hopkins Symptom Checklist (HSCL-25). Patients evaluate the extent to which each symptom bothered them during the past week (1 = not at all, 4 = extremely). A total score is computed based on the mean rating for all 25 items, as well as item means for anxiety (10 items) and depression (15 items). Suggested cut-off scores for the depression and anxiety subscales are 1.75.

Pain severity and pain-related interference were assessed using the 9-item version of the Brief Pain Inventory (BPI). A two-dimensional representation of the human body is then presented, and respondents shade in body areas where they experience pain; the total number of shaded areas is calculated. Items 3–6 assess the worst, least, average, and current pain intensity (0 = no pain, 10 = worst pain imaginable). Items 7–8 assess medication use and relief from pain when using the medication (0% = no relief, 100% = complete relief). Item 9 assesses interference from pain (0 = no interference, 10 = complete interference) in general activity, mood, mobility, work, relations with others, sleep, and enjoyment of life. Mean scores are computed for items assessing pain severity (4 items) and pain interference (7 items).

2.4. Screening Cognitive Performance

The Symbol Digit Modality Test (SDMT) was used as a measure of impairment and cognitive performance. SDMT is a widely used measure for assessing processing speed but also taps into attention, working memory, and incidental learning. Information processing speed is often referred to as a foundation necessary for learning, word retrieval, and executive functions and is commonly affected even in mild or diffuse injuries to the brain. In the written format provided, patients were given a coded key matching nine abstract symbols corresponding with numerical digits. Below the key was a random sequence of these abstract symbols, each with a blank space underneath for filling in the matching number. The score represents the number of correct substitutions within 90 s, with possible scores ranging from 0 and 110. The written format is considered relatively free from cultural bias and serves as a useful screening tool for individuals who are not fluent in the testing language. The SDMT demonstrates good psychometric properties and has proven sensitive in detecting cognitive impairments and decline across various disorders, including PTSD, and in several non-English speaking countries. Along with high validity and reliability, these studies have shown SDMT to be easily performed and carried out by non-trained healthcare staff. One advantage to more conventional screening tests is that it does not have ceiling effects but can be used to assess performance in both high- and low-functioning populations. Due to its psychometric qualities, including being correlated to employment and daily functioning, it is considered a core neuropsychological measure in neurology.

Health-Related Disability was assessed using the 36-item WHO Disability Assessment Schedule (WHODAS 2.0). The WHODAS 2.0 assesses the impact of physical and psychiatric difficulties across six domains (6 items per domain): understanding and communicating, mobility, self-care, getting along with others, life activities, and participation in society. For each item, patients rate their difficulties over the past 30 days (1 = none; 5 = extreme or cannot do). An overall disability score is then generated using an algorithm that weights individual items and converts the total to a 0–100 scale, where higher scores indicate greater impairments. While normative data are available, there are no agreed upon clinical cut-offs. A study of US combat veterans applying for PTSD-related disability benefits concluded that a scores exceeding 40 indicated clinically-significant functional impairment, placing the individual in the top 10% of those reporting health-related disability according to published norms.

2.5. Statistical Analysis

Statistical analyses were conducted using SPSS for Mac, version 23.0. The percentage of missing data at the variable level was minimal (0–2.9%) across all measures, except for WHODAS 2.0, where 10.3% and 15% of responses were missing for two items (on the self-care and getting along with people sub-scales). Little’s MCAR test revealed that the data were missing at random, permitting imputation at the item level using the expectation maximization algorithm. For all patients, the proportion scoring within the clinical range for cognitive impairments on the SDMT was calculated, along with the pairwise correlations between SDMT scores and the measures of PTSD, depression, anxiety, pain, and health-related disability. Multiple linear regression models investigated the association between dependent variable health-related disability and cognitive impairment, pain interference, PTSD, depression, and anxiety. In the subset of patients who were screened with Part 3 of the HTQ, those who reported a head injury with LOC were compared to those with a head injury without accompanied LOC on measures of cognitive performance (SDMT), PTSD (HTQ-4), anxiety and depression (HSCL-25), pain (BPI), and health-related disability (WHODAS 2.0) via one-way analysis of variance (ANOVA). SDMT raw scores were compared to age-related normative data, and cognitive impairment was defined by performances ≥ 2 standard deviations (SD) below normative means.

3. Results

All patients scored above clinical cut-offs for either PTSD, anxiety, or depression: 90% for PTSD (HTQ-4 M = 3.15, SD = 0.48), 97% for anxiety (HSCL-anxiety M = 3.01, SD = 0.56), and 98% for depression (HSCL-depression M = 3.01, SD = 0.52).

SDMT raw scores from patients and age-relevant norms as comparative references are reported in the following: patients under 30 years of age (N = 7): M = 41 (SD = 12.06) and age-relevant norms: M = 58.2 (SD = 9.1); patients in the age range 30–55 (N = 109): M = 25.89 (SD = 12.99) and age-relevant norms: M = 53.2 (SD = 8.9); and patients over 55 years (N = 25): M = 21.24 (SD = 12.4); age-related norms M = 35.8 (SD = 9.6).Across all ages, when compared to published norm: M = 50.3 (SD = 9.0), 88% (124 of 141 patients) scored ≥ 2 SD below published normative means, i.e., in the cognitively impaired range. Education did not yield significant differences in performance when patients with ≥ 8 years of education (M = 27.2, SD = 13.4) were compared to those with ≤8 years or unreported (M = 25.2, SD = 15.4).Table 1 presents the pairwise correlations between total scores on the SDMT, HTQ-4, HSCL-25, BPI, and WHODAS 2.0. Table 2 presents a multiple linear regression showing the relationship between health-related disability and cognitive impairment, pain interference, PTSD, depression, and anxiety in three different models.

The results from Table 1 show significant negative correlations between cognitive impairment and PTSD (r = −0.44), depression (r = −0.40), anxiety (r = −0.34), pain severity (r = −0.27), pain interference (r = −0.39), and health-related disability (r = −0.46).

The multiple linear regression analysis in Table 2 shows that cognitive impairment significantly predicts health-related disability in Model 1. In Model 2, when pain interference is added, both cognitive impairment and pain interference significantly predict health-related disability. In Model 3, PTSD, depression, and anxiety are also significant predictors of health-related disability.

Of the 141 patients, 80 (56.7%) were also screened for possible head trauma using Part 3 of the HTQ. The decision to conduct the head trauma screening (HTQ) was based on the therapist allocated to the participant rather than on symptoms, criteria, or selection. Of the patients screened with HTQ-3, 78 (98%) reported a possible head trauma. Of these, 64 patients (82%) reported a possible head trauma with LOC (i.e., TBI) and 14 (18%) reported a possible head trauma without LOC (No-TBI). Reports of LOC suggest that a traumatic brain injury (TBI) has occurred. Table 3 presents the means, standard deviations, p-values, and Cohen’s d for scores on the SDMT, HTQ, HSCL-25, BPI and WHODAS 2.0 (separately) for the TBI (N = 64) and no-TBI (N = 14) groups. Compared to the no-TBI group, patients in the TBI-group had significantly poorer cognitive performances (SDMT) and health-related disability (WHODAS 2.0), with the observed differences in the moderate range. No significant between-group differences were observed for the severity of PTSD (Part 4, HTQ), depression or anxiety (HSCL-25), or for pain severity and pain-related interference (BPI).

4. Discussion

This study addresses a gap in the literature regarding the relationship between cognitive impairment, head trauma/TBI, and post-traumatic distress in clinically referred refugees exposed to torture and other organized forms of violence. Based on results from the SDMT, using a brief measure of information processing speed that is widely used to screen individuals with suspected cognitive impairment and brain disease/injury, a large majority (88%) of the refugees performed at levels suggestive of significant cognitive impairment, i.e., more than two standard deviations below population means, corresponding to ≤2nd percentile, which is generally considered in the impaired range. These results may reflect both organic impairment (TBI) and the effects of overall symptom load given the high levels of PTSD, depression, and pain in this sample. The exceptionally low levels of cognitive performance on the SDMT found here may help explain the high levels of impairment in everyday functioning found on the WHODAS 2.0. From previous research, we know that lower scores on the SDMT are associated with increased difficulties maintaining employment and carrying out everyday life-skills such as money management and even conventional use of a computer. This is one of the first studies to suggest that lower scores on the SDMT are related to functional difficulties in traumatized (and tortured) refugees.

It is important to acknowledge that cultural background can affect performance on cognitive tests, including the SDMT (a time-based test), e.g., with a cultural weighting on thoroughness rather than speed, but the extent of this effect was neither anticipated nor previously observed. Similarly, one could speculate that the present results may be explained by level of education. However, as reported previously by Nordin et al. (2019), the educational level in this population is not unusually low (M = 9.06, SD 5.28). Consequently, neither cultural differences nor degree of schooling seem to fully explain the severity of cognitive impairments found in this culturally diverse sample of traumatized refugees.

Refugees in this study with lower SDMT scores also had significantly higher levels of interference from pain and health-related disability. As expected, individuals with more severe symptoms of PTSD, depression, anxiety, and pain had the lowest performance on the SDMT. The study reveals that cognitive impairment, particularly together with PTSD, depression, anxiety, and pain, is a significant predictor of health-related disability among tortured and trauma-affected refugees. The regression analysis demonstrates that these factors, when considered together, account for a high variance (R² = 0.61) in health-related disability. Thus, the present findings add to a small body of literature, suggesting that the high levels of distress and disability observed in tortured and trauma-affected refugees with PTSD, depression, and pain may be partly owed to cognitive impairments.

Consistent with previous studies of tortured refugees, the majority of those screened for head traumas in this study reported one or more possible TBIs. Previous research has revealed that combat veterans with a history of both TBI and PTSD have greater cognitive and psychosocial impairments than those with only PTSD or TBI. No such comparisons were possible in this study, because nearly all the refugees scored above the clinical cut-off on the self-report measures of PTSD. Nevertheless, when compared to the small subset of refugees who reported a head trauma but no loss of consciousness, those reporting consequent loss of consciousness (i.e., TBI) showed significantly lower cognitive performances and higher health-related disability in this sample. Consequently, these findings align closely with studies of combat veterans where differences in information processing speed have been used to differentiate PTSD patients with and without a history of TBI, as well as individuals with a history of TBI from controls.

Contrary to expectation, patients defined with TBI did not differ from those with a history of head traumas without loss of consciousness in terms of severity of symptoms of PTSD, depression, anxiety, or pain. Still, lower scores on the SDMT were associated with greater severity in these symptom domains in the sample at large. Research on non-refugee, trauma-exposed populations indicates that a history of mild TBI, involving no or very brief loss of consciousness, is associated with greater PTSD severity, but the relationship is less clear in moderate to severe TBI. The present findings suggest a complex interaction between TBI, cognitive impairment, and post-traumatic distress in tortured and trauma-affected refugees seeking treatment for PTSD and related difficulties. The uneven groups and low number of head trauma without loss of consciousness in this analysis might have contributed to a problem with power that can lead to a false negative result regarding PTSD, depression, anxiety, and pain. Additional studies involving larger samples sizes, comparison groups, and a more fine-grained assessment of probable TBI and cognitive impairments are essential to delineate these relationships.

While the present study benefitted from the use of standardized measures of cognitive impairments, psychiatric symptoms, and health-related disability in a large sample of trauma-affected refugees, certain methodological limits must be noted. Only one neuropsychological test was used to screen for cognitive impairment, and self-report questionnaires were used for the psychiatric, pain, and TBI variables. Data for this study were also drawn from patients referred to a highly specialized outpatient mental health clinic for tortured refugees, very few of whom did not have PTSD, depression, or a history of TBI. A large part of the patients reported the use of sleep medications and antidepressants. Future studies should use a non-medicated control group to investigate effects of such medications on SDMT for this population. The SDMT has been validated as a measure of cognitive impairment in several patient groups and across nations, but further validation studies with refugee populations with regards to the heterogeneity of culture, language, and education are needed. Future studies involving cognitive impairment in this population would benefit from using SDMT alongside other cross-culturally validated screening tools for validation purposes, as well as other psychometric tests to explore the range of possible cognitive impairments. Although the SDMT was administered to all patients entering treatment during the study period, Part 3 of the HTQ (assessing head trauma/TBI) was only administered to slightly more than 50 percent of the patients.

Despite these limitations, the present study provides important data on the level of cognitive functioning in tortured refugees with a history of TBIs and the relationship of such functioning on PTSD, depression, anxiety, pain, and health-related disability. The present findings also suggest that further studies are needed to determine whether treatments for post-traumatic distress and somatic complaints can produce improvements in cognitive impairments in refugees with and without a history of TBI or vice versa. Given the detrimental consequences on everyday functioning associated with even diffuse forms of cognitive impairments such as slowed information processing, our findings raise the need to attend to this aspect of functioning for complete and improved patient management.

5. Conclusions

A majority of tortured and trauma exposed, treatment-seeking refugees scored in the cognitively impaired range on a widely used screening measure for neurological dysfunction. Lower levels of cognitive performances were associated with higher levels of posttraumatic distress, pain, and disability. Refugees with a reported history of head injury and loss of consciousness had the lowest levels of cognitive performance. Clinicians working with trauma-affected refugees should consider routine screening for head injury, loss of consciousness, and cognitive impairments. Moreover, the present findings point to the need for incorporating cognitive rehabilitation in treatment with patients exposed to torture and trauma.

Summary

Refugees who have experienced torture often face significant health challenges, including Post-Traumatic Stress Disorder (PTSD), depression, and physical pain. These issues can make daily life difficult and may be linked to a decline in cognitive abilities, which is also seen in people with PTSD and depression who are not refugees. Research on individuals exposed to trauma shows that the severity of PTSD and depression is connected to problems with attention, changing tasks, self-control, processing speed, and memory.

Additionally, cognitive problems are common in individuals whose trauma involved a head injury or other events that could harm the brain, such as suffocation or exposure to toxic substances. These injuries often occur due to torture, organized violence, or war. Traumatic Brain Injury (TBI) is linked to a higher risk of developing PTSD, and it can be hard to tell the difference between cognitive problems caused by PTSD and those caused by TBI.

Studies of combat veterans indicate that those with both PTSD/depression and a TBI experience more severe cognitive and functional impairments than those with either condition alone. This suggests that PTSD and TBI can interact to worsen cognitive issues. There is growing evidence of a complex link between trauma, head injury/TBI, cognitive problems, and PTSD in refugees affected by trauma. While some studies show a high rate of self-reported TBI in refugee populations, few have directly examined the relationship between TBI and PTSD in this group. Existing research suggests that a history of TBI is strongly connected to higher levels of depression, health complaints, and overall disability, especially when combined with PTSD. Some studies have also found a strong link between TBI and PTSD severity, though not all studies agree. Other research shows that PTSD severity is associated with changes in fluid intelligence, episodic memory, and reductions in working memory and executive functioning in refugees.

This study aims to investigate the relationship between TBI, PTSD symptom severity, and cognitive functioning in a large group of tortured refugees seeking treatment. Researchers expected that refugees would show widespread cognitive difficulties rather than issues in specific brain areas. The Symbol Digit Modality Test (SDMT) was used to measure associative working memory, visual scanning, attention, and information processing speed. It was anticipated that more severe cognitive problems, as measured by the SDMT, would be linked to more severe PTSD, depression, anxiety, pain, and health-related disability. It was also expected that refugees with a history of TBI (defined as a head injury with loss of consciousness) would have additional cognitive impairment and more severe psychological and physical symptoms compared to those without TBI.

Materials and Methods

Setting and Population

The Danish Institute Against Torture (DIGNITY) in Copenhagen provides specialized outpatient treatment for refugees who have experienced torture or organized violence. This study included 141 adult refugees (38% women) referred to DIGNITY between 2012 and 2014, all of whom underwent SDMT screening before treatment. The majority of patients originated from Iraq (36%), Iran (18%), Lebanon (6%), Bosnia (5%), Afghanistan (4%), Somalia (4%), and Syria (2%). Patients had resided in Denmark for an average of 1 to 29 years, with an average age of 45.4 years and an average of 9.7 years of schooling. Many patients were taking antidepressants and sleep medication. To be included in treatment, patients needed to be at least 18 years old, have arrived in Denmark as a refugee, experienced torture or organized violence, hold permanent asylum in Denmark, be able to afford transportation to the clinic, have both psychiatric and physical symptoms requiring treatment, not have current alcohol or drug dependency, and not be currently suffering from psychosis.

Design and Procedures

This study used a cross-sectional design. Before treatment, all patients completed standardized self-report surveys about their mental and physical health, along with a cognitive screening using the SDMT. Approximately half of the patients also completed Part 3 of the Harvard Trauma Questionnaire (HTQ), which screens for potential head traumas. Self-report measures were provided in the participant's preferred language whenever possible, and interpreters were available when needed. All self-report measures used in this study have been shown to be reliable and suitable for use with refugees. The SDMT was selected as a suitable screening tool to detect reductions in processing speed, attention, and working memory, which are often associated with TBI, and as a measure of overall cognitive impairment. All patients provided informed consent to participate, and the research was approved by the Danish Data Protection Agency and the Danish Patient Safety Authority. Due to the nature of the research, the data will not be made public.

Measures

Traumatic exposure, potential brain injury, and PTSD were evaluated using Parts 1, 3, and 4 of the Harvard Trauma Questionnaire (HTQ). Part 1 of the HTQ assesses a person's lifetime exposure to 46 different types of traumatic events. Part 3, consisting of five items, measures a history of potential brain injury from head injuries or experiences that increase the risk of brain damage (such as suffocation, near-drowning, or prolonged starvation), including any loss of consciousness during a potential head trauma.

In this study, a traumatic brain injury (TBI) was defined as experiencing an event capable of causing a brain injury, as assessed by Part 3 of the HTQ, specifically including loss of consciousness during a head injury event. Part 4, with 16 items, assesses PTSD symptoms based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Revised Edition. Patients rated how much each symptom affected them in the past week (1 = not at all, 4 = extremely). A score of 2.5 or higher is typically considered indicative of a DSM-IV PTSD diagnosis.

Anxiety and depression were assessed using the 25-item Hopkins Symptom Checklist (HSCL-25). Patients rated how much each symptom bothered them in the past week (1 = not at all, 4 = extremely). A total score was calculated based on the average rating of all 25 items, as well as average scores for anxiety (10 items) and depression (15 items). Suggested cut-off scores for the depression and anxiety subscales are 1.75.

Pain severity and how much pain interfered with daily life were assessed using the 9-item Brief Pain Inventory (BPI). Patients marked areas on a body diagram where they experienced pain, and the total number of shaded areas was counted. Items 3–6 assessed the worst, least, average, and current pain intensity (0 = no pain, 10 = worst pain imaginable). Items 7–8 measured medication use and the level of pain relief from medication (0% = no relief, 100% = complete relief). Item 9 assessed how much pain interfered with general activity, mood, mobility, work, relationships, sleep, and enjoyment of life (0 = no interference, 10 = complete interference). Average scores were calculated for pain severity (4 items) and pain interference (7 items).

Screening Cognitive Performance

The Symbol Digit Modality Test (SDMT) was used to measure cognitive performance and impairment. The SDMT is a widely used test for assessing processing speed, and it also evaluates attention, working memory, and incidental learning. Information processing speed is crucial for learning, word retrieval, and executive functions, and it is commonly affected even by mild or widespread brain injuries. In the written version of the test, patients were given a key matching nine abstract symbols to numerical digits. Below this key, there was a random sequence of these symbols, each with a blank space underneath for the matching number. The score represents the number of correct substitutions made within 90 seconds, with possible scores ranging from 0 to 110. The written format is considered relatively free from cultural bias and is a useful screening tool for individuals who are not fluent in the testing language. The SDMT has good psychometric properties and has been effective in detecting cognitive impairments and decline in various conditions, including PTSD, and in several non-English speaking countries. It is easy to administer by non-trained healthcare staff, highly valid and reliable, and does not have ceiling effects, meaning it can assess performance in both high- and low-functioning populations. Given its psychometric qualities, including its correlation with employment and daily functioning, it is considered a core neuropsychological measure in neurology.

Health-Related Disability was assessed using the 36-item WHO Disability Assessment Schedule (WHODAS 2.0). The WHODAS 2.0 evaluates how physical and psychiatric difficulties impact six areas of life: understanding and communicating, mobility, self-care, getting along with others, life activities, and participation in society (6 items per area). For each item, patients rated their difficulties over the past 30 days (1 = none; 5 = extreme or cannot do). An overall disability score was then calculated using an algorithm that weights individual items and converts the total to a 0–100 scale, where higher scores indicate greater impairment. While normative data are available, there are no agreed-upon clinical cut-off scores. A study of US combat veterans applying for PTSD-related disability benefits suggested that scores above 40 indicate clinically significant functional impairment, placing individuals in the top 10% of those reporting health-related disability according to published norms.

Statistical Analysis

Statistical analyses were performed using SPSS for Mac, version 23.0. The amount of missing data for most variables was very small (0–2.9%), except for WHODAS 2.0, where 10.3% and 15% of responses were missing for two items related to self-care and getting along with people. Little’s MCAR test showed that the data were missing randomly, which allowed for imputation at the item level using the expectation maximization algorithm. For all patients, the percentage who scored within the clinical range for cognitive impairments on the SDMT was calculated, along with the correlations between SDMT scores and measures of PTSD, depression, anxiety, pain, and health-related disability. Multiple linear regression models were used to examine the relationship between health-related disability (dependent variable) and cognitive impairment, pain interference, PTSD, depression, and anxiety. In the subset of patients who completed Part 3 of the HTQ, those who reported a head injury with loss of consciousness (LOC) were compared to those with a head injury without LOC. This comparison was made on measures of cognitive performance (SDMT), PTSD (HTQ-4), anxiety and depression (HSCL-25), pain (BPI), and health-related disability (WHODAS 2.0) using one-way analysis of variance (ANOVA). SDMT raw scores were compared to age-related normative data, and cognitive impairment was defined as performance at least two standard deviations (SD) below normative means.

Results

All patients scored above the clinical cut-off points for at least one of the conditions: 90% for PTSD (HTQ-4 average = 3.15, SD = 0.48), 97% for anxiety (HSCL-anxiety average = 3.01, SD = 0.56), and 98% for depression (HSCL-depression average = 3.01, SD = 0.52).

SDMT scores for patients and age-matched norms were reported as follows: patients under 30 years old (N = 7) had an average score of 41 (SD = 12.06), compared to age-matched norms of 58.2 (SD = 9.1). Patients aged 30–55 (N = 109) had an average score of 25.89 (SD = 12.99), compared to norms of 53.2 (SD = 8.9). Patients over 55 years old (N = 25) had an average score of 21.24 (SD = 12.4), compared to norms of 35.8 (SD = 9.6). Across all age groups, when compared to the published norm (average = 50.3, SD = 9.0), 88% (124 out of 141 patients) scored at least two standard deviations below the normative mean, indicating cognitive impairment. Education level did not show significant differences in performance when comparing patients with at least 8 years of education (average = 27.2, SD = 13.4) to those with 8 years or less, or unreported education (average = 25.2, SD = 15.4).

Table 1 displays the correlations between total scores on the SDMT, HTQ-4, HSCL-25, BPI, and WHODAS 2.0. Table 2 presents a multiple linear regression analysis showing the relationship between health-related disability and cognitive impairment, pain interference, PTSD, depression, and anxiety in three different models.

The results from Table 1 indicate significant negative correlations between cognitive impairment and PTSD (r = −0.44), depression (r = −0.40), anxiety (r = −0.34), pain severity (r = −0.27), pain interference (r = −0.39), and health-related disability (r = −0.46).

The multiple linear regression analysis in Table 2 shows that cognitive impairment is a significant predictor of health-related disability in Model 1. In Model 2, with the addition of pain interference, both cognitive impairment and pain interference significantly predict health-related disability. In Model 3, PTSD, depression, and anxiety are also significant predictors of health-related disability.

Out of 141 patients, 80 (56.7%) were also screened for potential head trauma using Part 3 of the HTQ. The decision to conduct this screening was based on the assigned therapist, not on symptoms or specific criteria. Among the patients screened with HTQ-3, 78 (98%) reported a possible head trauma. Of these, 64 patients (82%) reported a possible head trauma with loss of consciousness (LOC), which indicates a traumatic brain injury (TBI), while 14 (18%) reported a possible head trauma without LOC (No-TBI). Reports of LOC suggest that a traumatic brain injury (TBI) has occurred. Table 3 presents the averages, standard deviations, p-values, and Cohen’s d for scores on the SDMT, HTQ, HSCL-25, BPI, and WHODAS 2.0 separately for the TBI group (N = 64) and the no-TBI group (N = 14). Compared to the no-TBI group, patients in the TBI group had significantly poorer cognitive performance (SDMT) and higher health-related disability (WHODAS 2.0), with these differences being moderate in extent. No significant differences were observed between the groups for the severity of PTSD (Part 4, HTQ), depression or anxiety (HSCL-25), or for pain severity and pain-related interference (BPI).

Discussion

This study addresses a gap in the existing literature by examining the relationship between cognitive impairment, head trauma/TBI, and post-traumatic distress in refugees referred for clinical treatment after exposure to torture and organized violence. Based on the Symbol Digit Modality Test (SDMT), a brief and widely used measure for screening cognitive impairment and brain injury, a large majority (88%) of the refugees demonstrated significant cognitive impairment. Their performance levels were more than two standard deviations below population averages, placing them at or below the 2nd percentile, which is generally considered within the impaired range. These findings likely reflect both organic brain damage (TBI) and the cumulative effects of high levels of PTSD, depression, and pain observed in this sample. The exceptionally low SDMT scores may help explain the high levels of daily functional impairment reported on the WHODAS 2.0. Previous research indicates that lower SDMT scores are linked to greater difficulties in maintaining employment and performing daily life skills, such as managing finances or using a computer. This study is among the first to suggest that lower SDMT scores are related to functional difficulties in traumatized and tortured refugees.

It is important to acknowledge that cultural background can influence performance on cognitive tests, including the time-sensitive SDMT, where some cultures may prioritize thoroughness over speed. However, the extent of the observed effect was not anticipated and had not been previously reported. Similarly, one might hypothesize that the results could be explained by educational level. However, as noted in prior research, the educational attainment in this population is not unusually low. Therefore, neither cultural differences nor educational background appear to fully account for the severe cognitive impairments found in this diverse sample of traumatized refugees.

Refugees in this study with lower SDMT scores also reported significantly higher levels of pain interference and health-related disability. As expected, individuals with more severe symptoms of PTSD, depression, anxiety, and pain showed the poorest performance on the SDMT. The study reveals that cognitive impairment, particularly in combination with PTSD, depression, anxiety, and pain, is a significant predictor of health-related disability among tortured and trauma-affected refugees. The regression analysis demonstrates that these factors, when considered together, explain a substantial portion (R2 = 0.61) of the variance in health-related disability. These findings contribute to a growing body of literature suggesting that the high levels of distress and disability observed in tortured and trauma-affected refugees with PTSD, depression, and pain may be partly attributable to cognitive impairments.

Consistent with previous studies of tortured refugees, most of those screened for head traumas in this study reported one or more potential TBIs. Earlier research has shown that combat veterans with a history of both TBI and PTSD experience greater cognitive and psychosocial impairments than those with only PTSD or TBI. Such direct comparisons were not feasible in this study because nearly all refugees scored above the clinical threshold for PTSD on self-report measures. Nevertheless, when compared to the small subgroup of refugees who reported a head trauma without loss of consciousness, those who reported loss of consciousness (indicating TBI) showed significantly poorer cognitive performance and higher health-related disability in this sample. Consequently, these findings align with studies of combat veterans, where differences in information processing speed have been used to distinguish PTSD patients with and without a history of TBI, as well as individuals with TBI from control groups.

Contrary to expectations, patients defined as having TBI did not differ from those with a history of head traumas without loss of consciousness in terms of the severity of PTSD, depression, anxiety, or pain symptoms. However, lower SDMT scores were associated with greater severity across these symptom domains in the overall sample. Research on non-refugee, trauma-exposed populations suggests that a history of mild TBI, involving no or very brief loss of consciousness, is linked to greater PTSD severity, but the relationship is less clear in cases of moderate to severe TBI. The current findings point to a complex interaction between TBI, cognitive impairment, and post-traumatic distress in tortured and trauma-affected refugees seeking treatment for PTSD and related difficulties. The unequal group sizes and the small number of head trauma cases without loss of consciousness in this analysis might have contributed to a lack of statistical power, potentially leading to a false negative result regarding PTSD, depression, anxiety, and pain. Further studies with larger sample sizes, comparison groups, and more precise assessments of probable TBI and cognitive impairments are essential to clarify these relationships.

While this study benefited from using standardized measures for cognitive impairments, psychiatric symptoms, and health-related disability in a large sample of trauma-affected refugees, certain methodological limitations should be acknowledged. Only one neuropsychological test was used to screen for cognitive impairment, and self-report questionnaires were used for psychiatric, pain, and TBI variables. The data for this study were drawn from patients referred to a highly specialized outpatient mental health clinic for tortured refugees, with very few individuals not having PTSD, depression, or a history of TBI. A significant portion of the patients reported using sleep medications and antidepressants. Future studies should include a non-medicated control group to investigate the effects of such medications on SDMT performance in this population. Although the SDMT has been validated for assessing cognitive impairment in several patient groups and countries, further validation studies are needed for refugee populations, considering their diverse cultural backgrounds, languages, and educational levels. Future studies investigating cognitive impairment in this population would benefit from using the SDMT alongside other culturally validated screening tools for validation purposes, as well as other psychometric tests to explore the full range of possible cognitive impairments. Although the SDMT was administered to all patients entering treatment during the study period, Part 3 of the HTQ (assessing head trauma/TBI) was only administered to slightly more than 50 percent of the patients.

Despite these limitations, this study provides important data on the level of cognitive functioning in tortured refugees with a history of TBIs and how such functioning relates to PTSD, depression, anxiety, pain, and health-related disability. The current findings also suggest a need for further research to determine whether treatments for post-traumatic distress and physical complaints can improve cognitive impairments in refugees with and without a history of TBI, or vice versa. Given the harmful impact of even subtle cognitive impairments, such as slowed information processing, on daily functioning, these findings emphasize the importance of addressing this aspect of functioning for comprehensive and improved patient care.

Conclusions

A majority of tortured and trauma-exposed refugees seeking treatment showed scores indicative of cognitive impairment on a widely used screening tool for neurological dysfunction. Lower cognitive performance levels were linked to higher levels of post-traumatic distress, pain, and disability. Refugees who reported a history of head injury with loss of consciousness had the lowest cognitive performance. Clinicians working with trauma-affected refugees should consider routinely screening for head injury, loss of consciousness, and cognitive impairments. Furthermore, these findings highlight the need to incorporate cognitive rehabilitation into the treatment of patients exposed to torture and trauma.

Introduction

Refugees who have experienced torture often face challenges such as post-traumatic stress disorder (PTSD), depression, and physical pain. These issues can make it hard to function in daily life. Reduced thinking abilities may contribute to these problems, a common observation in people with PTSD and depression who are not refugees. Research on individuals exposed to trauma shows that the seriousness of PTSD and depression is linked to difficulties with attention, shifting between tasks, self-control, processing information quickly, and memory.

Additionally, problems with thinking skills are common in individuals whose traumatic experiences involved a head injury or other events that could harm the brain. Examples include suffocation, breathing in toxic substances, or rapid head movement, as well as losing consciousness or experiencing memory loss after the event. Losing consciousness or having memory loss after an injury often indicates a traumatic brain injury (TBI). For refugees, TBIs frequently occur under harsh conditions before or during their escape from their home countries. These injuries often result from torture, organized violence, or war. Furthermore, TBI has been linked to a higher chance of developing PTSD, and the thinking problems associated with PTSD are hard to tell apart from those caused by TBI.

Studies on combat veterans indicate that individuals with both PTSD/depression and a TBI have greater challenges with thinking abilities and poorer daily functioning compared to those with only TBI or only PTSD/depression. This suggests that PTSD and TBI may affect thinking skills in an interactive way. Early evidence points to a complex connection between trauma, head injury/TBI, thinking problems, and PTSD in refugees affected by trauma. Several studies have reported that refugees often say they have had a TBI, but only three studies have specifically looked at the link between TBI and PTSD in this population. These three studies found that a history of TBI is strongly connected to higher levels of depression and health complaints, including pain. Those with both TBI and PTSD showed the highest levels of overall disability. Two of these studies found a strong link between TBI history and the severity of PTSD, while one did not. In research on PTSD and thinking abilities, one study found that the severity of PTSD was related to changes in general problem-solving skills and memory for events in civilian refugees from the war in Yugoslavia. Another study observed lower scores on a verbal learning test in Holocaust survivors compared to control groups who also experienced trauma. A study of over 300 Congolese refugees found that PTSD severity was significantly linked to reduced working memory and executive and social functioning.

Aim of the Study

Currently, no study has simultaneously investigated the relationship between TBI, the severity of PTSD symptoms, and thinking abilities in refugee populations. This study aims to fill this gap using a large group of tortured refugees seeking treatment for post-traumatic distress. Based on existing research, researchers expected that the refugees would show widespread thinking problems rather than specific deficits that might suggest injury to particular brain areas. For this reason, the Symbol Digit Modality Test (SDMT) was chosen. This test is given by a clinician and measures associative working memory, visual scanning, attention, and how fast information is processed. It takes less than five minutes to complete. Researchers anticipated that the severity of thinking problems, as measured by the SDMT, would be significantly linked to the severity of PTSD, depression, anxiety, pain, and health-related disability. It was also expected that refugees with a history of TBI, defined as a head injury involving loss of consciousness, would show additional thinking problems and more severe PTSD, depression, anxiety, pain, and health-related disability compared to those without a TBI history.

Materials and Methods

Setting and Population

The Danish Institute Against Torture (DIGNITY) runs a specialized clinic in Copenhagen that provides treatment for PTSD, depression, and physical complaints in refugees who have experienced torture or other organized violence. The study included 141 adult refugees (38% women) referred to DIGNITY between 2012 and 2014. These individuals underwent an SDMT screening before treatment. The primary countries of origin included Iraq (36%), Iran (18%), Lebanon (6%), Bosnia (5%), Afghanistan (4%), Somalia (4%), and Syria (2%). Patients had lived in Denmark for 1 to 29 years. The average age of the patients was 45.4 years, and they had an average of 9.7 years of schooling. Many patients used antidepressants and sleep medication. To be included in the treatment, patients had to meet several criteria: be 18 years or older, have arrived in Denmark as a refugee, have experienced torture or organized violence, have permanent asylum in Denmark, be able to pay for transportation to the clinic, have both primary mental health and physical symptoms needing treatment, not currently be dependent on alcohol or drugs, and not currently suffer from psychosis.

Design and Procedures

This was a cross-sectional study. Before treatment, all patients completed standard self-report questionnaires about their mental and physical health, along with a cognitive screening using the SDMT. About half of the patients also completed Part 3 of the Harvard Trauma Questionnaire (HTQ), which screens for potential head traumas, before treatment. Whenever possible, self-report questionnaires were provided in the patient's preferred language, and an interpreter helped when needed. All self-report measures used in this study have been shown to be reliable and suitable for use with refugees. The SDMT was chosen as a good screening tool to detect reductions in processing speed, attention, and working memory that are linked to TBI, and as a general measure of thinking problems and decline. All patients gave informed consent to participate. The Danish Data Protection Agency and the Danish Patient Safety Authority approved this research. Due to the nature of this research, the data will not be publicly shared.

Measures

Traumatic experiences, possible brain injury, and PTSD were evaluated using Parts 1, 3, and 4 of the Harvard Trauma Questionnaire (HTQ). Part 1 of the HTQ assesses exposure to 46 different types of traumatic events throughout life. Part 3 (5 items) asks about a history of possible brain injury, either from a head injury or experiences that increase the risk of brain damage (such as suffocation, near-drowning, or prolonged starvation), and whether there was a loss of consciousness during a possible head trauma.

In this study, a traumatic brain injury (TBI) was defined as experiencing an event that could cause a brain injury, as identified by Part 3 of the HTQ, including loss of consciousness. This means a head injury event with associated loss of consciousness. Part 4 (16 items) assesses PTSD symptoms based on the 4th Revised Edition of the Diagnostic and Statistical Manual of Mental Disorders. Patients rated how much each symptom bothered them over the past week on a scale from 1 (not at all) to 4 (extremely). The recommended score for a DSM-IV PTSD diagnosis is 2.5 or higher.

Anxiety and Depression were assessed using the 25-item Hopkins Symptom Checklist (HSCL-25). Patients rated how much each symptom bothered them during the past week (1 = not at all, 4 = extremely). A total score was calculated based on the average rating for all 25 items, as well as average scores for anxiety (10 items) and depression (15 items). Suggested cut-off scores for the depression and anxiety subscales are 1.75 or higher.

Pain severity and how much pain interfered with life were assessed using the 9-item Brief Pain Inventory (BPI). Patients marked areas on a body diagram where they felt pain, and the total number of shaded areas was counted. Items 3–6 assessed the worst, least, average, and current pain intensity (0 = no pain, 10 = worst pain imaginable). Items 7–8 assessed medication use and how much relief medication provided (0% = no relief, 100% = complete relief). Item 9 assessed how much pain interfered with general activity, mood, mobility, work, relationships, sleep, and enjoyment of life (0 = no interference, 10 = complete interference). Average scores were calculated for items assessing pain severity (4 items) and pain interference (7 items).

Screening Cognitive Performance

The Symbol Digit Modality Test (SDMT) was used to measure thinking problems and cognitive performance. The SDMT is a widely used test for assessing processing speed, and it also evaluates attention, working memory, and incidental learning. Information processing speed is often considered essential for learning, finding words, and executive functions, and it is commonly affected even by mild or widespread brain injuries. In the written version of the test, patients received a key that matched nine abstract symbols with numbers. Below the key was a random sequence of these symbols, each with a blank space underneath for writing the matching number. The score was the number of correct substitutions made within 90 seconds, with possible scores ranging from 0 to 110. The written format is considered relatively free from cultural bias and is a useful screening tool for individuals who are not fluent in the testing language. The SDMT has good psychometric properties and has proven effective in detecting thinking problems and decline across various conditions, including PTSD, and in several non-English speaking countries. In addition to its high validity and reliability, these studies have shown that the SDMT is easy to administer by healthcare staff who are not highly trained. One advantage over more traditional screening tests is that it can assess performance in both high- and low-functioning populations without having a "ceiling effect" (where high performers hit the maximum score). Because of its psychological measurement qualities, including its correlation with employment and daily functioning, it is considered a key neuropsychological measure in neurology.

Health-Related Disability was assessed using the 36-item WHO Disability Assessment Schedule (WHODAS 2.0). The WHODAS 2.0 evaluates the impact of physical and mental health challenges across six areas (6 items per area): understanding and communicating, mobility, self-care, getting along with others, life activities, and participation in society. For each item, patients rated their difficulties over the past 30 days (1 = none; 5 = extreme or cannot do). An overall disability score was then generated using a calculation that weighted individual items and converted the total to a 0–100 scale, where higher scores indicate greater problems. While standard data are available, there are no universally agreed-upon clinical cut-off scores. A study of U.S. combat veterans applying for PTSD-related disability benefits concluded that scores exceeding 40 indicated clinically significant functional impairment, placing the individual in the top 10% of those reporting health-related disability according to published norms.

Statistical Analysis

Statistical analyses were performed using SPSS for Mac, version 23.0. The amount of missing data for each variable was very small (0–2.9%), except for WHODAS 2.0, where 10.3% and 15% of responses were missing for two items (in the self-care and getting along with people sections). Little’s MCAR test showed that the data were missing randomly, allowing for missing items to be estimated using a specific algorithm. For all patients, the percentage scoring within the clinical range for thinking problems on the SDMT was calculated, along with the correlations between SDMT scores and measures of PTSD, depression, anxiety, pain, and health-related disability. Multiple linear regression models were used to examine the relationship between health-related disability and thinking problems, pain interference, PTSD, depression, and anxiety. In the group of patients who completed Part 3 of the HTQ, those who reported a head injury with loss of consciousness were compared to those with a head injury without loss of consciousness. This comparison was done using a one-way analysis of variance (ANOVA) for measures of thinking performance (SDMT), PTSD (HTQ-4), anxiety and depression (HSCL-25), pain (BPI), and health-related disability (WHODAS 2.0). Raw SDMT scores were compared to age-related standard data, and thinking impairment was defined as performance at or below 2 standard deviations below the average for their age group.

Results

All patients scored above the clinical thresholds for PTSD, anxiety, or depression: 90% for PTSD, 97% for anxiety, and 98% for depression.

SDMT raw scores for patients and age-specific standard scores are reported as follows: For patients under 30 years old (N = 7), the average score was 41, while the age-specific average was 58.2. For patients aged 30–55 (N = 109), the average score was 25.89, while the age-specific average was 53.2. For patients over 55 years old (N = 25), the average score was 21.24, while the age-specific average was 35.8. Across all ages, when compared to published standards (average score of 50.3), 88% (124 out of 141 patients) scored at or below 2 standard deviations below these averages. This indicates performance in the cognitively impaired range. Educational level did not significantly affect performance when patients with 8 or more years of education were compared to those with fewer than 8 years or unreported education.

The study found significant negative correlations between thinking impairment and PTSD, depression, anxiety, pain severity, pain interference, and health-related disability. This means that as thinking impairment increased, these other factors also tended to increase.

Multiple linear regression analysis showed that thinking impairment significantly predicted health-related disability in Model 1. When pain interference was added in Model 2, both thinking impairment and pain interference were significant predictors of health-related disability. In Model 3, PTSD, depression, and anxiety were also significant predictors of health-related disability.

Out of 141 patients, 80 (56.7%) were also screened for possible head trauma using Part 3 of the HTQ. The decision to perform this screening was made by the therapist assigned to the patient, not based on symptoms or selection criteria. Of the patients screened with HTQ-3, 78 (98%) reported a possible head trauma. Among these, 64 patients (82%) reported a possible head trauma with loss of consciousness (defined as TBI), and 14 (18%) reported a possible head trauma without loss of consciousness (no-TBI). Reports of loss of consciousness suggest that a traumatic brain injury (TBI) occurred. Compared to the no-TBI group, patients in the TBI group had significantly poorer thinking performances on the SDMT and greater health-related disability, with these differences being moderately sized. No significant differences were observed between the groups for the severity of PTSD, depression, anxiety, or for pain severity and pain-related interference.

Discussion

This study addresses a gap in the research regarding the relationship between thinking problems, head trauma/TBI, and post-traumatic distress in refugees referred for clinical help after experiencing torture and other organized violence. Based on results from the SDMT, a quick test of information processing speed widely used to screen individuals for suspected thinking problems and brain injury, a large majority (88%) of the refugees performed at levels suggesting significant thinking impairment. This means their scores were more than two standard deviations below the average for the general population, placing them at or below the 2nd percentile, which is generally considered impaired. These results may be due to both actual brain damage (TBI) and the overall burden of symptoms, given the high levels of PTSD, depression, and pain in this group. The exceptionally low levels of thinking performance found in this study may help explain the high levels of problems in everyday functioning reported on the WHODAS 2.0. Previous research shows that lower scores on the SDMT are linked to increased difficulty maintaining employment and performing daily tasks such as managing money and using a computer. This is one of the first studies to suggest that lower SDMT scores are related to functional difficulties in traumatized (and tortured) refugees.

It is important to recognize that cultural background can influence performance on cognitive tests, including timed tests like the SDMT. For example, some cultures might prioritize thoroughness over speed, but the extent of this effect was not expected or previously observed to be so large. Similarly, one might guess that the current results could be explained by educational level. However, as noted in previous research, the educational level in this population is not unusually low. Therefore, neither cultural differences nor the amount of schooling seem to fully explain the severity of thinking problems found in this culturally diverse group of traumatized refugees.

Refugees in this study with lower SDMT scores also reported significantly higher levels of pain interference and health-related disability. As anticipated, individuals with more severe symptoms of PTSD, depression, anxiety, and pain performed lowest on the SDMT. The study shows that thinking problems, especially when combined with PTSD, depression, anxiety, and pain, are a significant predictor of health-related disability among tortured and trauma-affected refugees. The analysis indicates that these factors, when considered together, account for a large portion of the variation in health-related disability. Thus, these findings add to a small body of research suggesting that the high levels of distress and disability seen in tortured and trauma-affected refugees with PTSD, depression, and pain may be partly due to thinking problems.

Consistent with previous studies of tortured refugees, most of those screened for head traumas in this study reported one or more possible TBIs. Earlier research has shown that combat veterans with a history of both TBI and PTSD have greater thinking and social problems than those with only PTSD or only TBI. Such direct comparisons were not possible in this study because nearly all refugees scored above the clinical threshold for PTSD on the self-report measures. Nevertheless, when compared to the small group of refugees who reported a head trauma but no loss of consciousness, those reporting subsequent loss of consciousness (i.e., TBI) showed significantly poorer thinking performance and higher health-related disability in this sample. Consequently, these findings align closely with studies of combat veterans where differences in information processing speed have been used to distinguish PTSD patients with and without a history of TBI, as well as individuals with a history of TBI from control groups.

Contrary to expectations, patients identified with TBI did not differ from those with a history of head traumas without loss of consciousness in terms of the severity of PTSD, depression, anxiety, or pain symptoms. However, lower scores on the SDMT were associated with greater severity in these symptom areas across the entire sample. Research on non-refugee, trauma-exposed populations indicates that a history of mild TBI, involving no or very brief loss of consciousness, is linked to greater PTSD severity, but the relationship is less clear in moderate to severe TBI. The current findings suggest a complex interaction between TBI, thinking problems, and post-traumatic distress in tortured and trauma-affected refugees seeking treatment for PTSD and related difficulties. The unequal group sizes and the low number of head traumas without loss of consciousness in this analysis might have led to a problem with statistical power, potentially resulting in a false negative finding regarding PTSD, depression, anxiety, and pain. Further studies with larger samples, comparison groups, and more detailed assessments of probable TBI and thinking problems are essential to clarify these relationships.

While this study benefited from using standardized measures of thinking problems, mental health symptoms, and health-related disability in a large group of trauma-affected refugees, some methodological limitations should be noted. Only one neuropsychological test was used to screen for thinking problems, and self-report questionnaires were used for psychiatric symptoms, pain, and TBI variables. Data for this study were also collected from patients referred to a highly specialized outpatient mental health clinic for tortured refugees, very few of whom did not have PTSD, depression, or a history of TBI. A large portion of the patients reported using sleep medications and antidepressants. Future studies should include a non-medicated control group to investigate the effects of such medications on SDMT performance in this population. The SDMT has been validated as a measure of thinking problems in several patient groups and across nations, but further validation studies with refugee populations, considering the variety of cultures, languages, and educational backgrounds, are needed. Future studies investigating thinking problems in this population would benefit from using the SDMT alongside other culturally validated screening tools for validation purposes, as well as other psychometric tests to explore the full range of possible thinking problems. Although the SDMT was given to all patients entering treatment during the study period, Part 3 of the HTQ (assessing head trauma/TBI) was only administered to slightly more than 50 percent of the patients.

Despite these limitations, this study provides important data on the level of thinking function in tortured refugees with a history of TBIs and how this function relates to PTSD, depression, anxiety, pain, and health-related disability. The current findings also suggest that more studies are needed to determine whether treatments for post-traumatic distress and physical complaints can improve thinking problems in refugees with and without a history of TBI, or vice versa. Given the harmful effects on daily functioning associated with even diffuse forms of thinking problems, such as slowed information processing, these findings highlight the need to address this aspect of functioning for comprehensive and improved patient care.

Conclusions

Most tortured and trauma-exposed refugees seeking treatment scored in the range indicating thinking problems on a widely used screening test for neurological dysfunction. Lower levels of thinking performance were associated with higher levels of post-traumatic distress, pain, and disability. Refugees who reported a history of head injury with loss of consciousness showed the lowest levels of thinking performance. Clinicians working with refugees affected by trauma should consider routinely screening for head injury, loss of consciousness, and thinking problems. Furthermore, these findings suggest the need to include cognitive rehabilitation in treatment for patients exposed to torture and trauma.

Introduction

Many refugees, especially those who have been tortured, face significant challenges. These often include post-traumatic stress disorder (PTSD), depression, and physical pain, which can make daily life difficult. These problems are likely caused by several factors, including a decline in mental abilities, also known as cognitive functioning. This decline is common in people with PTSD and depression, even those who are not refugees. Studies have shown that severe PTSD and depression are linked to problems with attention, shifting between tasks, controlling impulses, processing information quickly, and both short-term and long-term memory.

Cognitive problems are also common in individuals whose trauma involved a head injury or other experiences that can harm the brain. Examples include suffocation, breathing in toxic substances, or rapid head movements. Loss of consciousness (LOC) or memory loss after an injury also suggest a traumatic brain injury (TBI) has occurred. For refugees, TBIs often happen in harsh conditions before or during their escape from home countries, often due to torture, violence, or war. Additionally, TBI has been linked to a higher risk of developing PTSD, and the cognitive issues from PTSD can be hard to tell apart from those caused by TBI.

Research on combat veterans indicates that those with both PTSD/depression and a TBI have more severe cognitive problems and worse overall functioning than those with only TBI or only PTSD/depression. This suggests that PTSD and TBI can worsen each other's effects on the brain. There is early evidence of a complex connection between trauma, head injury/TBI, cognitive problems, and PTSD in refugees affected by trauma. Several studies have reported that many refugees recall having a TBI. However, only three studies have specifically looked at the link between TBI and PTSD in refugees. These three studies found that a history of TBI is strongly linked to higher levels of depression and health complaints, including pain. Those with both TBI and PTSD showed the most severe overall disability. Two of these studies found that a history of TBI was strongly linked to how severe PTSD was, while one did not.

Aim of the Study

Currently, no study has examined the relationship between TBI, the severity of PTSD symptoms, and cognitive functioning in refugee populations all at once. This study aimed to fill this gap using a large group of tortured refugees seeking treatment for post-traumatic distress. Based on existing research, it was expected that refugees would show broad cognitive problems, rather than issues in specific brain areas. To assess this, the Symbol Digit Modality Test (SDMT) was chosen. This test, administered by a clinician, measures associative working memory, visual scanning, attention, and information processing speed in under five minutes. It was anticipated that the severity of cognitive problems, as measured by the SDMT, would be strongly connected to the severity of PTSD, depression, anxiety, pain, and disability related to health. It was also expected that refugees with a history of TBI, defined as a head injury with loss of consciousness, would have more cognitive problems and more severe PTSD, depression, anxiety, pain, and health-related disability compared to those without TBI.

Setting and Population

The Danish Institute Against Torture (DIGNITY) has a specialized clinic in Copenhagen. It provides treatment for PTSD, depression, and physical complaints in refugees who have been tortured or exposed to other organized violence. The study included 141 adult refugees (38% women) referred to DIGNITY between 2012 and 2014. These individuals were screened with the SDMT before treatment. Most patients came from Iraq (36%), Iran (18%), Lebanon (6%), Bosnia (5%), Afghanistan (4%), Somalia (4%), and Syria (2%). Patients had lived in Denmark for 1 to 29 years. The average age of patients was 45.4 years, and they had an average of 9.7 years of schooling. A significant portion of the patient group used antidepressants and sleep medication.

To be included in the treatment, patients had to meet specific criteria: (1) be 18 years or older; (2) have arrived in Denmark as a refugee; (3) have experienced torture or organized violence; (4) have permanent asylum in Denmark; (5) be able to pay for transportation to the clinic; (6) have both mental and physical symptoms needing treatment; (7) not currently be dependent on alcohol or drugs; and (8) not currently be suffering from psychosis.

Design and Procedures

This was a cross-sectional study, meaning data was collected at a single point in time. Before treatment, all patients completed standard self-report surveys about their mental and physical health. They also underwent a cognitive screening with the SDMT. About half of the patients also completed Part 3 of the Harvard Trauma Questionnaire (HTQ), which screens for possible head traumas, before treatment. Whenever possible, patients completed the self-report surveys in their preferred language. If needed, an interpreter helped them fill out the forms. All self-report measures used in this study have been shown to be reliable and suitable for use with refugees. The SDMT was chosen as a good screening tool to detect slower processing speed, attention problems, and memory issues linked to TBI. It also serves as a measure of general cognitive decline and impairment.

All patients gave their informed consent to participate in the study. The Danish Data Protection Agency and the Danish Patient Safety Authority approved this research. Due to the nature of this research, the data will not be shared publicly, so supporting data are not available.

Measures

Traumatic experiences, possible brain injury, and PTSD were assessed using Parts 1, 3, and 4 of the Harvard Trauma Questionnaire (HTQ). Part 1 asks about a person's lifetime exposure to 46 different types of traumatic events. Part 3, with 5 items, measures a history of possible brain injury. This can be from a head injury or other experiences that increase the risk of brain damage, such as suffocation, near-drowning, or prolonged starvation. It also asks about loss of consciousness during a possible head trauma.

In this study, a traumatic brain injury (TBI) was defined as an event capable of causing a brain injury, as identified by HTQ Part 3, and including a loss of consciousness. Part 4, which has 16 items, assesses PTSD symptoms based on the 4th Revised Edition of the Diagnostic and Statistical Manual of Mental Disorders. Patients rated how much each symptom bothered them in the past week (1 = not at all, 4 = extremely). A score of 2.5 is the recommended cut-off for a DSM-IV PTSD diagnosis.

Anxiety and Depression were evaluated using the 25-item Hopkins Symptom Checklist (HSCL-25). Patients rated how much each symptom bothered them during the past week (1 = not at all, 4 = extremely). A total score was calculated based on the average rating for all 25 items, as were average scores for anxiety (10 items) and depression (15 items). A score of 1.75 is suggested as a cut-off for the depression and anxiety subscales.

Pain severity and how much pain interfered with life were assessed using the 9-item Brief Pain Inventory (BPI). A drawing of the human body was provided, and respondents shaded in areas where they felt pain; the total number of shaded areas was counted. Items 3–6 asked about the worst, least, average, and current pain intensity (0 = no pain, 10 = worst pain imaginable). Items 7–8 asked about medication use and how much relief medication provided (0% = no relief, 100% = complete relief). Item 9 assessed how much pain interfered with general activity, mood, mobility, work, relationships, sleep, and enjoyment of life (0 = no interference, 10 = complete interference). Average scores were calculated for pain severity (4 items) and pain interference (7 items).

Screening Cognitive Performance

The Symbol Digit Modality Test (SDMT) was used to measure cognitive impairment and performance. The SDMT is widely used to assess how fast a person processes information, but it also checks attention, working memory, and incidental learning. Information processing speed is considered crucial for learning, remembering words, and executive functions. This speed is often affected even by mild or widespread brain injuries. In the written version of the test, patients received a code matching nine abstract symbols to numbers. Below this key was a random series of these symbols, each with a blank space for filling in the matching number. The score was the number of correct substitutions made within 90 seconds, with possible scores ranging from 0 to 110. The written format is considered less influenced by culture and is a useful screening tool for people who are not fluent in the testing language. The SDMT has good psychometric properties and has been shown to detect cognitive problems and decline in various disorders, including PTSD, and in several non-English-speaking countries. These studies have also shown that the SDMT is easy to administer by healthcare staff without special training and is both valid and reliable. Unlike many standard screening tests, it can assess performance in both high and low-functioning populations. Because of its qualities, including its link to employment and daily functioning, it is a key neuropsychological measure in neurology.

Health-Related Disability was assessed using the 36-item WHO Disability Assessment Schedule (WHODAS 2.0). The WHODAS 2.0 looks at how physical and mental difficulties affect six areas of life: understanding and communicating, mobility, self-care, getting along with others, life activities, and participating in society (6 items per area). For each item, patients rated their difficulties over the past 30 days (1 = none; 5 = extreme or cannot do). An overall disability score was then calculated using a formula that weights individual items and converts the total to a 0–100 scale, where higher scores mean more severe problems. While standard data is available, there are no universally agreed-upon clinical cut-off scores. A study of U.S. combat veterans applying for PTSD-related disability benefits suggested that scores above 40 indicated significant functional impairment. This would place an individual in the top 10% of those reporting health-related disability based on published norms.

Statistical Analysis

Statistical analyses were performed using SPSS for Mac, version 23.0. The amount of missing data for each variable was very small (0–2.9%), except for WHODAS 2.0, where 10.3% and 15% of responses were missing for two items (on the self-care and getting along with people sub-scales). Little’s MCAR test indicated that the data were missing randomly, which allowed for missing values to be estimated at the item level using a specific statistical method. For all patients, the percentage of those scoring within the clinical range for cognitive impairments on the SDMT was calculated. Additionally, the correlations between SDMT scores and measures of PTSD, depression, anxiety, pain, and health-related disability were determined. Multiple linear regression models were used to examine how health-related disability was linked to cognitive impairment, pain interference, PTSD, depression, and anxiety. In the group of patients who were also screened with Part 3 of the HTQ, those who reported a head injury with loss of consciousness were compared to those with a head injury without loss of consciousness. This comparison focused on measures of cognitive performance (SDMT), PTSD (HTQ-4), anxiety and depression (HSCL-25), pain (BPI), and health-related disability (WHODAS 2.0) using a statistical test called one-way analysis of variance (ANOVA). Raw SDMT scores were compared to normal data for different age groups. Cognitive impairment was defined as performance that was two or more standard deviations below the average for a person's age group.

Results

All patients scored above the clinical cut-off levels for PTSD, anxiety, or depression. Specifically, 90% scored above the cut-off for PTSD, 97% for anxiety, and 98% for depression.

SDMT raw scores for patients and age-matched normal scores were as follows: Patients under 30 years old (7 participants) had an average score of 41, while the normal average for that age group is 58.2. Patients between 30 and 55 years old (109 participants) had an average score of 25.89, compared to the normal average of 53.2. Patients over 55 years old (25 participants) had an average score of 21.24, compared to the normal average of 35.8. Across all age groups, when compared to the published normal average of 50.3, 88% (124 out of 141 patients) scored two or more standard deviations below this average. This indicates they were in the cognitively impaired range. Education level did not significantly affect performance; patients with eight or more years of education had similar scores to those with fewer than eight years or unreported education.

The analysis showed significant negative connections between cognitive impairment and PTSD, depression, anxiety, pain severity, pain interference, and health-related disability. This means that as cognitive impairment increased, these other problems also tended to be more severe.

The statistical analysis further indicated that cognitive impairment was a significant predictor of health-related disability. When pain interference was added to the model, both cognitive impairment and pain interference significantly predicted health-related disability. When PTSD, depression, and anxiety were also included, they too were significant predictors of health-related disability.

Out of 141 patients, 80 (56.7%) were also screened for possible head trauma using Part 3 of the HTQ. The decision to screen for head trauma was based on the therapist assigned to the patient, not on symptoms or specific selection criteria. Of the patients screened with HTQ-3, 78 (98%) reported a possible head trauma. Among these, 64 patients (82%) reported a possible head trauma with loss of consciousness (meaning TBI), and 14 (18%) reported a possible head trauma without loss of consciousness (No-TBI). Reports of loss of consciousness suggest a traumatic brain injury (TBI) occurred. Compared to the group without TBI, patients in the TBI group showed significantly poorer cognitive performance (SDMT) and higher levels of health-related disability. These differences were of moderate size. No significant differences were found between the groups for the severity of PTSD, depression, anxiety, or for pain severity and how much pain interfered with life.

Discussion

This study explores the connection between cognitive problems, head trauma/TBI, and post-traumatic distress in refugees who have been tortured and referred for treatment. The results from the SDMT, a quick test often used to screen for cognitive issues and brain injury, showed that a large majority (88%) of the refugees performed at levels suggesting significant cognitive impairment. These scores were more than two standard deviations below the average for the general population, which typically indicates impairment. These findings may be due to actual brain damage (TBI) as well as the overall burden of symptoms, given the high levels of PTSD, depression, and pain in this group. The very low scores on the SDMT observed in this study might help explain the high levels of daily functioning problems found using the WHODAS 2.0. Previous research shows that lower SDMT scores are linked to more difficulty keeping a job and performing everyday tasks like managing money or using a computer. This is one of the first studies to suggest that lower SDMT scores are linked to functional difficulties in traumatized refugees, especially those who have been tortured.

It is important to acknowledge that cultural background can influence performance on cognitive tests, including the time-based SDMT. For example, some cultures might emphasize thoroughness over speed, but the extent of this effect was not expected or observed previously. Similarly, it could be suggested that the results are explained by education level. However, as noted in previous research, the education level in this population is not unusually low. Therefore, neither cultural differences nor educational attainment seem to fully account for the severe cognitive impairments found in this diverse group of traumatized refugees.

Refugees in this study with lower SDMT scores also reported significantly more interference from pain and higher levels of health-related disability. As expected, individuals with more severe symptoms of PTSD, depression, anxiety, and pain performed worse on the SDMT. The study shows that cognitive impairment, especially when combined with PTSD, depression, anxiety, and pain, is a major predictor of health-related disability among tortured and trauma-affected refugees. The statistical analysis demonstrates that these factors, when considered together, explain a large part of the variation in health-related disability. Thus, these findings add to the limited research suggesting that the severe distress and disability seen in tortured and trauma-affected refugees with PTSD, depression, and pain may partly stem from cognitive problems.

Consistent with earlier studies of tortured refugees, most of those screened for head traumas in this study reported one or more potential TBIs. Previous research has found that combat veterans with a history of both TBI and PTSD experience greater cognitive and social-emotional problems than those with only PTSD or TBI. Such comparisons were not possible in this study because almost all refugees scored above the clinical cut-off for PTSD on the self-report measures. Nevertheless, when compared to the small group of refugees who reported a head trauma but no loss of consciousness, those who reported loss of consciousness (i.e., TBI) showed significantly poorer cognitive performance and higher levels of health-related disability in this study group. These findings are consistent with studies of combat veterans where differences in information processing speed have been used to distinguish PTSD patients with and without a history of TBI, as well as individuals with a history of TBI from healthy controls.

Contrary to expectations, patients diagnosed with TBI did not show different levels of PTSD, depression, anxiety, or pain severity compared to those with head traumas but no loss of consciousness. However, lower SDMT scores were linked to more severe symptoms in these areas across the entire study group. Research on trauma-exposed people who are not refugees indicates that a history of mild TBI, involving little to no loss of consciousness, is linked to more severe PTSD, but the relationship is less clear for moderate to severe TBI. These findings suggest a complex interaction between TBI, cognitive impairment, and post-traumatic distress in tortured and trauma-affected refugees seeking treatment for PTSD and related issues. The uneven group sizes and the small number of head traumas without loss of consciousness in this analysis might have led to a lack of statistical power, potentially resulting in a false negative regarding PTSD, depression, anxiety, and pain. More studies with larger groups, comparison groups, and more detailed assessments of probable TBI and cognitive impairments are needed to better understand these relationships.

While this study benefited from using standardized measures for cognitive impairment, psychiatric symptoms, and health-related disability in a large group of trauma-affected refugees, some research limitations should be noted. Only one neuropsychological test was used to screen for cognitive impairment, and self-report questionnaires were used for psychiatric, pain, and TBI information. The data for this study also came from patients referred to a highly specialized mental health clinic for tortured refugees, most of whom had PTSD, depression, or a history of TBI. A significant portion of the patients reported using sleep medications and antidepressants. Future studies should include a control group not taking medication to examine the effects of such medications on SDMT performance in this population. The SDMT has been shown to be effective in measuring cognitive impairment in various patient groups and countries, but more validation studies are needed with refugee populations to account for diverse cultures, languages, and education levels. Future studies on cognitive impairment in this group would benefit from using the SDMT alongside other culturally validated screening tools for confirmation, as well as other psychological tests to explore the full range of possible cognitive problems. Although all patients entering treatment during the study period received the SDMT, Part 3 of the HTQ (which assesses head trauma/TBI) was only given to slightly more than 50 percent of the patients.

Despite these limitations, this study provides important data on the cognitive functioning of tortured refugees with a history of TBIs and how this functioning relates to PTSD, depression, anxiety, pain, and health-related disability. The findings also suggest that more research is needed to determine whether treatments for post-traumatic distress and physical complaints can improve cognitive problems in refugees with and without a history of TBI, or vice versa. Given the harmful impact of even mild cognitive problems, such as slower information processing, on daily life, these findings highlight the need to address this aspect of functioning for comprehensive and improved patient care.

Conclusions

Most tortured and trauma-exposed refugees seeking treatment showed signs of cognitive impairment on a widely used screening test for neurological problems. This means they scored in the impaired range. Lower levels of cognitive ability were linked to higher levels of post-traumatic distress, pain, and disability. Refugees who reported a history of head injury with loss of consciousness had the lowest cognitive performance. Clinicians working with trauma-affected refugees should consider routinely screening for head injury, loss of consciousness, and cognitive problems. Furthermore, these findings suggest the need to include cognitive rehabilitation in treatment for patients exposed to torture and trauma.

Summary

Refugees who have been tortured often face many problems. These include feeling very stressed or sad, and having body aches. These issues can make it hard to do daily tasks. They may also cause problems with thinking clearly. Studies show that people with stress and sadness often have trouble with memory, paying attention, and thinking quickly.

Some people who have gone through trauma have also had a head injury. This can happen from being hit on the head, not getting enough air, or other harmful events. A head injury can also lead to issues with thinking and memory. It can be hard to tell if these thinking problems come from a head injury or from stress and sadness.

Studies with soldiers show that those with both a head injury and stress or sadness have more trouble with thinking than those with only one of these problems. It seems that trauma, head injuries, thinking problems, and stress are all linked for refugees. Many refugees report having a head injury, and some studies show a link between head injuries and higher levels of sadness and health problems.

Aim of the Study

No study has looked at head injuries, stress, and thinking problems all together in refugees. This study wanted to do that with a large group of refugees who were getting help for their trauma. It was thought that refugees would have many different thinking problems, not just problems with one part of the brain. So, a quick test was used to check memory, attention, and how fast someone thinks. It was expected that worse scores on this test would be linked to more stress, sadness, worry, pain, and trouble with daily life. It was also thought that refugees with a head injury that caused them to pass out would have more thinking problems and worse stress, sadness, worry, pain, and trouble with daily life.

Setting and Population

The study took place at a clinic in Denmark that helps refugees who have been tortured. The patients were 141 adults. Most were from Iraq, Iran, and Lebanon. They had lived in Denmark for 1 to 29 years. Their average age was about 45, and they had about 10 years of schooling. Many of them were taking medicine for sadness or to help them sleep. To be in the study, patients had to be 18 or older, be a refugee in Denmark, have been tortured, have the right to stay in Denmark, be able to get to the clinic, have mental and physical problems that needed help, not be using drugs or alcohol, and not have a serious mental illness like psychosis.

Design and Procedures

This was a one-time study. Before treatment, all patients took tests about their mental and physical health. They also took a short test to check their thinking skills. About half of the patients also answered questions about past head injuries. When possible, patients took the tests in their own language, and some had an interpreter help them. The tests used are known to work well for refugees. The thinking test was chosen because it can show problems with how fast someone thinks, pays attention, and remembers things, which can be affected by head injuries. All patients agreed to be in the study. The study followed rules from Danish agencies. The study data will not be shared publicly.

Measures

Information about past trauma, possible brain injury, and stress was gathered using parts of a special questionnaire. One part asked about 46 different types of traumatic events. Another part asked about past head injuries or other things that could hurt the brain, like not being able to breathe, and if they passed out during a head injury.

In this study, a brain injury was defined as a head injury that caused a person to pass out. A third part of the questionnaire asked about stress symptoms. Patients rated how much each symptom bothered them in the past week. A score of 2.5 or higher suggested a diagnosis of stress.

Sadness and worry were checked using another test. Patients rated how much each symptom bothered them in the past week. Higher scores meant more sadness and worry.

Pain level and how much pain got in the way of daily life were checked using a pain survey. Patients colored in areas on a body where they felt pain. They also rated their pain levels, how much pain medicine helped, and how much pain affected their daily activities like mood, work, and sleep.

Screening Cognitive Performance

The Symbol Digit Modality Test (SDMT) was used to check thinking skills. This test shows how fast someone processes information, pays attention, and remembers. Fast thinking is important for learning and daily tasks. It can be affected even by small brain injuries. In the test, patients saw a key that matched symbols to numbers. Then, they had to write down the matching numbers for a list of symbols as fast as they could for 90 seconds. The score was the number of correct answers. This test is considered fair for different cultures and useful for people who don't speak the testing language well. It works for many different groups and can show problems with thinking. It is also linked to being able to keep a job and do daily tasks.

Trouble with daily life was checked using a 36-item survey. This survey looked at how much physical and mental problems affected six areas of life: understanding, moving, self-care, getting along with others, daily activities, and being part of society. Patients rated their difficulties over the past month. A higher score meant more trouble with daily life. A score over 40 suggested a lot of trouble with daily life.

Statistical Analysis

Computers were used to look at the study information. Only a small amount of information was missing. For the patients in the study, the number of people with low scores on the thinking test was counted. Also, how thinking scores related to stress, sadness, worry, pain, and trouble with daily life was checked. Computer models were used to see how thinking problems, pain, stress, sadness, and worry were linked to trouble with daily life. For the patients who were asked about head injuries, those who passed out from a head injury were compared to those who didn't. They were compared on their thinking scores, stress, sadness, worry, pain, and trouble with daily life. Low thinking scores were defined as being much lower than what is normal for a person's age.

Results

All patients had high scores for stress, worry, or sadness. About 90% had high stress, 97% had high worry, and 98% had high sadness.

The thinking test scores were much lower for the patients than for people of the same age in the general public. For example, patients under 30 had an average score of 41, while people their age usually score around 58. For patients aged 30-55, the average score was 25.89, while people their age usually score around 53. Across all ages, 88% of the patients had very low thinking scores, meaning they were likely having thinking problems. Education level did not seem to make a big difference in these scores.

A table showed that lower thinking scores were strongly linked to more stress, sadness, worry, pain, and trouble with daily life.

Another table showed that thinking problems were linked to trouble with daily life. When pain was added to the picture, both thinking problems and pain were linked to trouble with daily life. When stress, sadness, and worry were also added, all these factors together were linked to trouble with daily life.

Out of 141 patients, 80 were also asked about head injuries. Of these, 78 (98%) reported a possible head injury. Most of these (64 patients, or 82%) said they had passed out from a head injury. Passing out after a head injury means a traumatic brain injury (TBI) likely happened. Another table showed that patients who had a head injury and passed out had much worse thinking skills and more trouble with daily life compared to those who had a head injury but did not pass out. The amount of stress, sadness, worry, or pain was similar between these two groups.

Discussion

This study looked at how thinking problems, head injuries, and trauma-related stress are connected in refugees who have been tortured. The results from the thinking test showed that most refugees (88%) had serious thinking problems, scoring very low compared to the general public. These results could be from head injuries or from the high levels of stress, sadness, and pain these refugees experience. The very low thinking scores found in this study might help explain why refugees have so much trouble with daily life. Past studies show that low scores on this thinking test are linked to difficulties keeping jobs and doing daily tasks like managing money. This study is one of the first to suggest that lower thinking scores are linked to daily life problems in traumatized refugees.

It is known that cultural background can affect how people perform on thinking tests. For example, some cultures value being thorough over being fast. However, the severe thinking problems found in this study were not expected to be fully explained by cultural differences or education levels, which were not unusually low in this group.

Refugees in this study with worse thinking scores also had more pain getting in the way of their life and more trouble with daily activities. As expected, people with more severe stress, sadness, worry, and pain had the lowest scores on the thinking test. This study shows that thinking problems, especially when combined with stress, sadness, worry, and pain, can strongly predict how much trouble tortured refugees have with daily life. These factors together explain a large part of why refugees struggle with daily life. So, these findings suggest that the high levels of distress and disability seen in tortured refugees might partly be due to thinking problems.

Many refugees in this study who were screened for head injuries reported having one or more brain injuries. Past research shows that soldiers with both a brain injury and stress have more problems with thinking and daily life than those with only one of these issues. In this study, refugees who reported a head injury where they passed out had much worse thinking skills and more trouble with daily life compared to those who had a head injury but did not pass out. These findings are similar to studies of soldiers.

However, against expectations, patients with a brain injury did not show different levels of stress, sadness, worry, or pain compared to those who had a head injury but did not pass out. Still, lower thinking scores were linked to more severe symptoms in general. This suggests that the link between brain injury, thinking problems, and trauma-related stress in tortured refugees is complex. The small number of refugees who had a head injury but did not pass out might have made it hard to see differences in stress, sadness, worry, and pain between the groups. More studies with larger groups are needed to fully understand these connections.

This study used standard ways to measure thinking problems, mental health symptoms, and trouble with daily life in many traumatized refugees. However, there were some limits. Only one thinking test was used, and patients reported their own symptoms and head injuries. The study only included patients getting help at a special clinic, so most already had stress, sadness, or a head injury. Many patients were also taking medicine for sleep or sadness. Future studies should include groups not taking these medicines to see how they affect thinking. The thinking test used has been shown to work well in many groups, but more studies are needed for different refugee groups with varied cultures, languages, and education. It would be good to use this test with other screening tools to check different kinds of thinking problems. Also, the head injury screening was only done for about half of the patients.

Even with these limits, this study gives important information about the thinking skills of tortured refugees with head injuries and how this affects their stress, sadness, worry, pain, and trouble with daily life. The findings also suggest that more studies are needed to see if treating trauma can improve thinking problems, or if improving thinking problems can help with trauma. Since even small thinking problems can greatly affect daily life, it is important for healthcare providers to pay attention to thinking skills to better help these patients.

Conclusions

Most tortured refugees seeking help showed signs of thinking problems on a common test for brain issues. Worse thinking skills were linked to more trauma-related stress, pain, and trouble with daily life. Refugees who reported a head injury with loss of consciousness had the worst thinking skills. Doctors and therapists working with traumatized refugees should regularly check for head injuries, loss of consciousness, and thinking problems. Also, it is important to include ways to improve thinking skills in the treatment for patients who have been tortured and traumatized.