Psychological reactions of women who have been raped. A descriptive and comparative study

Tonic Immobility as a Defensive Trauma Response to Rape: Bridging Public Health and Law

There is widespread scientific evidence that validates tonic immobility (TI) as part of the trauma response in victims of rape, and criminal justice practitioners are increasingly trained in trauma-informed approaches. Yet, legal and policy definitions of consent do not fully recognize TI during the incident as evidence of nonconsent. Using a systematic review of U.S. law and policy regarding sexual violence and consent, this paper analyzes the substantial legal reform of rape law and definitions of consent, suggesting ways to further integrate TI into existing law and legal practices to improve public health approaches and justice responses for victims.

Tonic immobility triggered by COVID-19-related trauma is associated with long-term PTSD symptoms

During the COVID-19 pandemic healthcare workers were repeatedly exposed to traumatic experiences. Facing life-threatening events and repeated exposure to traumatic duty-related situations may cause posttraumatic stress disorder (PTSD). While tonic immobility has been considered a key vulnerability factor for PTSD, little is known about this relationship in the long term. In this study, we aimed to determine whether peritraumatic tonic immobility triggered by COVID-19-related trauma predicts PTSD symptom severity six to twelve months later. We conducted an online longitudinal survey using the PTSD Checklist for the DSM-5 (PCL-5) and the Tonic Immobility Scale to assess PTSD symptoms and the tonic immobility response, respectively. Multivariate regression models revealed a significant association between tonic immobility and PTSD symptoms. Each one-unit increase in the tonic immobility score was associated with a 1.5 % increase in the average PTSD symptom score six to twelve months after the traumatic event that triggered the tonic immobility. Furthermore, participants who showed significant or extreme levels of tonic immobility were 3.5 times or 7.3 times more likely to have a probable PTSD diagnosis, respectively. Hence, peritraumatic tonic immobility seems to have a lasting deleterious effect on mental health. Psychological treatment for health care professionals is urgent, and psychoeducation about the involuntary, biological nature of tonic immobility is essential to reduce suffering.

Tonic immobility is associated with posttraumatic stress symptoms in healthcare professionals exposed to COVID-19-related trauma

The Coronavirus Disease 2019 (COVID-19) pandemic has exposed healthcare workers (HCW) to traumatic situations that might lead to the development of posttraumatic stress disorder (PTSD). An important vulnerability factor for PTSD is the peritraumatic tonic immobility (TI) reaction, an involuntary and reflexive defensive response evoked by an intense and inescapable threat. TI is largely understudied in humans and has not been investigated during trauma related to COVID-19. For HCW, the pandemic context might be experienced as an intense and potentially inescapable threat, i.e., an overwhelming situation. Here, we investigated if TI response occurred during traumatic events related to the pandemic and its association with posttraumatic stress symptoms (PTSS). An online survey of 1001 HCW investigated COVID-19-related traumatic experiences, TI and PTSS. TI was reported for all types of traumatic events, and multivariate regression models revealed that TI was significantly associated with PTSS severity. HCW who reported high TI scores exhibited an increase of 9.08 times the probability of having a probable diagnosis of PTSD. Thus, TI was evoked by pandemic-related traumatic situations and associated with PTSS severity and higher odds of a PTSD diagnosis. Tonic immobility occurrence should be screened, and psychoeducation about its reflexive biological nature should be introduced.

Risk Avoidance Strategies after Sexual Assault: A Dyadic Study of Survivors and Informal Support Providers

Interview data from 45 matched pairs of survivors disclosing sexual assaults and their primary informal support provider (friend, family, significant other) were used to explore survivor-support provider perspectives on self-protective behaviors survivors and those close to them take to protect themselves from future assaults. Strategies for reducing risk taken by survivors included behavioral changes, security measures, self-defense strategies, avoiding alcohol/drugs, and protecting others. Support providers play critical roles by encouraging survivors to pursue risk avoidance strategies, and employing these strategies themselves. Counseling and prevention implications are drawn in the context of risks facing survivors trying to avoid further sexual victimization.

Post-traumatic stress disorder in female survivors of rape attending a genitourinary medicine clinic: a pilot study

This study describes psychological symptomatology including post-traumatic stress disorder (PTSD) in 19 women attending a specialist sexual assault service within a genitourinary medicine (GUM) clinic. Women were interviewed within one year post-rape (mean=12 weeks) using standardized questionnaires for PTSD and other psychological symptomatology. Seventeen (89.5%) of 19 women met full criteria for a diagnosis of PTSD. Anxiety predominated amongst other psychological symptomatology. Suicidal ideation was reported by 8 women and one made a suicide attempt following the rape. Although it is acknowledged this is a small, select sample, the high level of psychological trauma found suggests that genitourinary medicine clinics providing for sexual assault require access to mental health professionals.

I Said No: The Impact of Voicing Non-Consent on Women's Perceptions of and Responses to Rape

The current study explored the impact of voicing non-consent in relation to rape. Aims of the study included determining (a) the prevalence of voicing non-consent, (b) the relationship of voicing non-consent to verbal and physical resistance, and (c) whether voicing non-consent predicts distress and rape acknowledgment. Out of 262 college women who experienced rape, 81% voiced non-consent. Voicing non-consent was related to verbal and physical resistance, but was distinct in prevalence and prediction of distress. Voicing non-consent was associated with trauma-related symptoms in multivariate models. Women who voiced non-consent were more likely to acknowledge their experience as rape or sexual assault. Implications are discussed.

Women's Situational Coping With Acquaintance Sexual Assault: Applying an Appraisal-Based Model

Drawing on theories of appraisal-based coping, the present study applied structural modeling to examine relationships among personal goal orientations, primary and secondary appraisals of acquaintance sexual assault, and women's emotional and behavioral responses to it. Based on 415 college women's reports of a sexual assault experience, the model shows both direct and indirect effects. Assertive, diplomatic, and immobilized responding were each predicted by a unique profile of appraisals and orientations; personal goal orientations and primary appraisals were completely mediated by secondary appraisals. Ways that these findings can facilitate self-protective coping in an acquaintance sexual assault situation, leading to the development of effective, well-tailored self-defense and resistance programs, are discussed.

Does guilt mediate the association between tonic immobility and posttraumatic stress disorder symptoms in female trauma survivors?

Tonic immobility (TI) is an involuntary freezing response that can occur during a traumatic event. TI has been identified as a risk factor for posttraumatic stress disorder (PTSD), although the mechanism for this relationship remains unclear. This study evaluated a particular possible mechanism for the relationship between TI and PTSD symptoms: posttraumatic guilt. To examine this possibility, we assessed 63 female trauma survivors for TI, posttraumatic guilt, and PTSD symptom severity. As expected, the role of guilt in the association between TI and PTSD symptom severity was consistent with mediation (B = 0.35; p < .05). Thus, guilt may be an important mechanism by which trauma survivors who experience TI later develop PTSD symptoms. We discuss the clinical implications, including the importance of educating those who experienced TI during their trauma about the involuntary nature of this experience.

Tonic immobility in childhood sexual abuse survivors and its relationship to posttraumatic stress symptomatology

Past research has shown that 37% to 52% of sexual assault survivors report experiencing a set of peritraumatic responses, which include gross motor inhibition, analgesia, and fixed or unfocused staring. This response set closely resembles a set of unconditioned responses, collectively known as Tonic Immobility (TI). This study examined TI among childhood sexual abuse (CSA) survivors and its relation to PTSD symptomatology. Participants were 131 female college undergraduates who completed questionnaires assessing sexual abuse history, TI, and PTSD symptom severity. Results showed that TI partially mediated the relation between peritraumatic fear and overall PTSD symptom severity and completely mediated the relation between fear and the PTSD reexperiencing symptoms. Although peritraumatic fear is associated with TI, the mediation findings provide evidence for the notion that these responses are separate from one another. These results suggest that TI during CSA may play an important role in the subsequent PTSD symptomatology in adulthood.

Human tonic immobility: measurement and correlates

BACKGROUND

Tonic immobility (TI) is a temporary state of motor inhibition believed to be a response to situations involving extreme fear. Limited attention has been directed to studying TI in humans; however, the phenomenon has been well documented in the animal literature. In humans, TI is believed to occur during sexual assault, and there have been reports of fear-induced freezing in the contexts of air, naval, and other disasters.

METHODS

This study had three main purposes: (1) to assess the factor structure of a new self-report measure--the Tonic Immobility Questionnaire--designed to assess human TI in a range of traumatic events; (2) to explore associations among discovered TIQ factors and a measure of posttraumatic symptoms in the context of trauma type; and (3) to determine whether TI is related to suspected and empirically supported predictors of posttraumatic stress disorder. Participants were a subset of undergraduate students (n=78) who reported a TI experience in the context of a traumatic event.

RESULTS

No differences were found in frequency or severity of TI reported across trauma types. Exploratory factor analysis of Tonic Immobility Questionnaire item responses resulted in a three-factor solution (i.e., physical immobility, fear, and dissociation). Significant positive correlations were found between the Tonic Immobility Questionnaire and measures of posttraumatic symptoms, dissociation, anxiety sensitivity, and absorption. Regression analysis revealed that peritraumatic dissociation scores alone accounted for 51% of the variance in TI scores.

CONCLUSIONS

TI may represent an extreme behavioral expression of trauma-induced peritraumatic dissociation. Implications and directions for future research are discussed.

Exploring human freeze responses to a threat stressor

Despite the fundamental nature of tonic immobility in anxiety responses, surprisingly little empirical research has focused on the "freeze" response in humans. The present report evaluated the frequency and predictors of a freeze response in the context of a biological challenge. A nonclinical sample (N=404) underwent a 20-s inhalation of 20% CO(2)/balance O(2). Perceptions of immobility in the context of the challenge were reported in 13% of the sample, compared with 20% reporting a significant desire to flee. Subjective anxiety and panic during the challenge were associated with the freeze response, as were a number of anxiety symptom dimensions.

Tonic immobility mediates the influence of peritraumatic fear and perceived inescapability on posttraumatic stress symptom severity among sexual assault survivors

This study evaluated whether tonic immobility mediates the relations between perceived inescapability, peritraumatic fear, and posttraumatic stress disorder (PTSD) symptom severity among sexual assault survivors. Female undergraduates (N = 176) completed questionnaires assessing assault history, perceived inescapability, peritraumatic fear, tonic immobility, and PTSD symptoms. Results indicated that tonic immobility fully mediated relations between perceived inescapability and overall PTSD symptom severity, as well as reexperiencing and avoidance/numbing symptom clusters. Tonic immobility also fully mediated the relation between fear and reexperiencing symptoms, and partially mediated relations between fear and overall PTSD symptom severity, and avoidance/numbing symptoms. Results suggest that tonic immobility could be one path through which trauma survivors develop PTSD symptoms. Further study of tonic immobility may inform our ability to treat trauma victims.

Association of sexual revictimization with sexuality and psychological function

This study explores the associations of sexual revictimization (experiencing sexual abuse in childhood and adulthood) in a sample of 230 African American women who are low-income. Data indicate that women who experience sexual revictimization are more at risk for emotional stress and psychological pathology than women with no history of abuse. In addition, women who are revictimized appear to be at greater risk for emotional problems than women sexually abused only as a child or sexually assaulted only as adults. Revictimization also appears to be associated with an increased probability of engaging in prostitution, even higher than women with childhood- or adult-only victimization, who showed increased probability when compared to women never abused. Finally, women who are revictimized showed increased HIV risk, in that they were 4 times less likely than other women to consistently use condoms, but no more likely to be in monogamous relationships or less likely to have multiple partners.

Effects of rape on men: a descriptive analysis

Previous studies of the effects of rape on men have focused mainly on clinical populations. This study extended current research by investigating the effects of rape on a non-clinical sample of men recruited from the general population by media advertising. A total of 40 male rape victims were asked to provide details of their assaults, levels of psychological disturbance, long-term effects, and reporting issues. Results revealed that most assaults had been carried out using physical or violent force, in a variety of different circumstances. All of the victims reported some form of psychological disturbance as a result of being raped. Long-term effects included anxiety, depression, increased feelings of anger and vulnerability, loss of self-image, emotional distancing, self-blame, and self-harming behaviors. Findings are discussed in relation to previous research in the area and perceptions of rape.

Abusive experiences and psychiatric morbidity in women primary care attenders

BACKGROUND

Abusive experiences in childhood and adulthood increase risks of psychiatric morbidity in women and independently increase risks of further abuse over the lifetime. It is unclear which experiences are most damaging.

AIMS

To measure lifetime prevalence of abusive experiences and psychiatric morbidity, and to analyse associations in women primary care attenders.

METHOD

A cross-sectional, self-report survey of 1207 women attending 13 surgeries in the London borough of Hackney, UK. Independent associations between demographic measures, abusive experiences and psychiatric outcome were established using logistic regression.

RESULTS

Childhood sexual abuse had few associations with adult mental health measures, in contrast to physical abuse. Sexual assault in adulthood was associated with substance misuse; rape with anxiety, depression and post-traumatic stress disorder but not substance misuse. Domestic violence showed strongest associations with most mental health measures, increased for experiences in the past year.

CONCLUSIONS

Abuse in childhood and adulthood have differential effects on mental health; effects are increased by recency and severity. Women should be routinely questioned about ongoing and recent experiences as well as childhood.

Sexual assaults in Singapore: a comparative study of rapists and molesters

Sexual assaults vary in terms of severity from molestation, which involves touching, stroking, fondling or grabbing of any part of the victim's body, to rape, where victims have been known to suffer severe emotional trauma. The aim of the study is to compare molesters with rapists using hypotheses that molesters and rapists commit their offences at different times of the day, at differing locations and with differing relationships with their victims. The influence of alcohol on both groups was also studied. Convicted molesters and rapists were given a semi-structured interview in prison. Demographic information and details of each offence were obtained from prison records. Comparisons were made of the demography, time, place, reasons for assault, relationship of offender to victims and the role of alcohol and drugs consumed by the perpetrators. Molesters and rapists were of similar age and ethnicity, but differed in that rapists had attained a lower educational level and were more likely to be single. Rapists were more likely to report having drunk alcohol, committing rape after midnight and in secluded places. Molesters struck in the afternoon hours and usually in crowded places. Victims of molesters tended to be relatives whereas victims of rapists were more likely to be ex-spouses or ex-lovers. Molesters tended to give other reasons for their offences. Differences between molesters and rapists could lead to intervention strategies chiefly targeting the issues of poor socialisation skills in molesters and alcohol counseling for rapists.

Psychological debriefing: controversy and challenge

OBJECTIVE

The efficacy of psychological debriefing following potentially traumatising events has become extremely controversial. This review aims to identify the issues underlying this controversy and their theoretical, social and political ramifications which are important in other areas of psychiatry and the social sciences.

METHOD

The historical background to the debriefing debate and the (largely negative) results of recent randomised controlled trials (RCTs) are reviewed.

RESULTS

Despite the negative results of recent RCTs, psychological debriefing remains the most widely used structured intervention following potentially traumatising events, designed to reduce the incidence of long-term psychiatric morbidity. The clinical relevance these trials and their applicability in vivo is questioned. There are implicit difficulties in conducting rigorous randomised controlled trials of group debriefing, and such trials may be unachievable.

CONCLUSIONS

Demonstrating the efficacy of debriefing or other preventive interventions presents major challenges to investigators and it is unlikely the controversy will be resolved in the near future.

Crime-related trauma: psychological distress in victims of bankrobbery

This study examines the relationship between the experience of a traumatic event, that is, a bankrobbery, and its psychological consequences. Two groups of employees of a major commercial bank in the Netherlands participated in this study. One group (n = 310) consisted of subjects who had experienced a bankrobbery and worked in high-frequency bankrobbery areas; the other matched control group (n = 214) consisted of nonrobbed employees from banks in the same area. Victimized subjects displayed more signs of psychological distress than the control subjects, but distress decreased over time. The main findings of this study are that a depressive/avoidant coping style, strong threat perception during the robbery, and additional life events were positively related to posttraumatic distress as assessed by the Impact of Event Scale and the Symptom Check List (SCL-90), and self-esteem was negatively associated with the SCL-90 only.

A review of post-traumatic stress disorder. Part I: Historical development and classification

This paper describes the history of the development of understanding of psychological responses to traumatic life-events and their treatment. One major response, post-traumatic stress disorder (PTSD), is a recognized condition which has appeared relatively recently in diagnostic manuals. PTSD is a condition of major significance, not only to mental health professionals, but also to trauma surgeons and allied professionals. This paper focuses on the current definition of PTSD in the International Classification of Diseases (ICD-10, 1992, World Health Organization) and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV, 1994). PTSD first appeared as an operational diagnosis in DSM-III (1980) and was revised in DSM-III-R (1987) and DSM-IV (1994). It made its first appearance in the ICD system later, in 1992. This paper seeks to increase awareness of PTSD across the broad spectrum of trauma management professionals, to emphasize the practical value of identifying the disorder and to encourage optimism for its treatment. This paper is in two parts. The first part deals with historical development and classification. The second part (to appear in the next issue of Injury) deals with treatment.

Male rape victims referred to a forensic psychiatric service

A series of male victims of rape are presented who were identified following referral to a Forensic Psychiatric Service. In addition to being victims they were also offenders in their own right. The 22 male rape victims represent 12.5 per cent of male referrals to the service over a six-month period.

Psychological sequelae following the Gulf War. Factors associated with subsequent morbidity and the effectiveness of psychological debriefing

BACKGROUND

The aim was to study the effect of brief counselling and psychological debriefing following a trauma on subsequent morbidity.

METHOD

We investigated psychological morbidity in 62 British soldiers whose duties included the handling and identification of dead bodies of allied and enemy soldiers during the Gulf War. Of these soldiers, 69% received a psychological debriefing on completion of their duties. The subjects completed by post a demographic questionnaire, the General Health Questionnaire (GHQ-28) and the Impact of Events Scale.

RESULTS

After nine months 50% had evidence of some psychological disturbance suggestive of posttraumatic stress disorder (PTSD); 18% had sought professional help; 26% reported relationship difficulties. Neither prior training nor the psychological intervention appeared to make any difference to subsequent psychiatric morbidity. Morbidity at nine months was more likely in those with a history of psychological problems and those who believed their lives had been in danger in the Gulf.

CONCLUSIONS

These findings show that a psychological debriefing following a series of traumatic events or experiences does not appear to reduce subsequent psychiatric morbidity and highlights the need for further research in military and civilian settings.

Childhood sexual abuse and mental health in adult life

The relationship between childhood sexual abuse and mental health in adult life was investigated in a random community sample of women. There was a positive correlation between reporting abuse and greater levels of psychopathology on a range of measures. Substance abuse and suicidal behaviour were also more commonly reported by the abused group. Childhood sexual abuse was more frequent in women from disrupted homes as well as in those who had been exposed to inadequate parenting or physical abuse. While elements in the individual's childhood which increased the risks of sexual abuse were also directly associated to higher rates of adult psychopathology, abuse emerged from logistic regression as a direct contributor to adult psychopathology. Severity of abuse reported was related to the degree of adult psychopathology. The overlap between the possible effects of sexual abuse and the effects of the matrix of disadvantage from which it so often emerges were, however, so considerable as to raise doubts about how often, in practice, it operates as an independent causal element. Further, many of those reporting childhood sexual abuse did not show a measurable long-term impairment of their mental health. Abuse correlated with an increased risk for a range of mental health problems, but in most cases its effects could only be understood in relationship to the context from which it emerged.

Psychiatric morbidity in bus crews following violent assault: a follow-up study

In a prospective study 22 bus crews who were victims of physical assault were assessed using standardized psychiatric instruments, followed up for 18 months and compared to a non-assaulted control group drawn from the same bus garage. At initial assessment the assaulted group, compared to the controls showed a significant increase in psychiatric impairment and distress (as measured by the GHQ-30 and IES respectively), with 23% of assault victims developing post-traumatic stress disorder as defined by DSM-III-R. At follow-up, while high levels of both psychiatric impairment and distress persisted there was evidence that they may be separate phenomena.

Helping victims of violence in Uganda

We report on a project to assist victims of war and violence in Uganda. The original aim of this project, set up by the Medical Foundation for the Care of Victims of Torture, was to establish a centre for the assessment and treatment of torture victims who had suffered during previous regimes in that country. We found, however, that a specialist centre was not the most appropriate response in a country like Uganda. We argue for the need to respect local initiatives and systems of support and against the notion that there is a single model of care which is universally relevant. Following much investigation and involvement with local personnel, we have developed a programme of training and discussion for health workers, and a service to reach the many women who have suffered rape, and whose suffering has continued, largely ignored.

Staff strain and social support in a psychiatric hospital following assault by a patient

Attacks by patients are acknowledged as an important source of stress for psychiatric staff which has ramifications for patients and the nurses' employers as well. Twenty-three psychiatric nurses and one doctor who had been assaulted by a patient at work were interviewed within 72 hours of the incident and twice more within 2 weeks. The levels of strain they experienced and the amount of support provided for them in the time between interviews were measured and correlated. Some subjects reported high levels of strain which persisted well beyond the incident. Support was usually provided on an informal basis and was concentrated in the period immediately after the incident.

Strategies for the study of long-term sequelae of oral and facial injuries

Measurement of morbidity after orofacial trauma is necessary to monitor progress and to enable decisions to be made concerning surgical intervention, compensation awards, and psychological support. Although some measurements are routinely made in the assessment of recovery after trauma, many are still in a developmental phase or have only been used in research work. There is a need for a rational, comprehensive, quantitative means of assessing morbidity after orofacial trauma. Such assessments need to include measures of social and psychological distress, as well as physical abnormalities. This article reviews available methods of measuring morbidity and identifies areas in which new methods and developments are necessary. This quantitative approach to the assessment of trauma patients is consistent with developments in traumatology and psychology, which include injury severity scoring and the use of psychomatic tests. A scoring system for assessing orofacial deformity and disability and the attendant psychosocial distress appears to be an attainable objective.

Sexual Relationships between Doctors and Patients

‘In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional illdoing and seduction, and especially from the pleasures of love with women or with men be they free or with slaves.’

Hippocratic Oath

Women as torture victims

This paper reports a retrospective study of the frequency, severity, modalities and mental health consequences of torture in 28 Latin American refugee women in Toronto. The data on these women and a comparison group of male torture victims were retrieved from case records in a hospital outpatient clinic. The results support the hypotheses implicit in the scanty literature available that the frequency and effects of torture in women differ from those found in men. In female victims, as in their male counterparts, the severity of the torture was related to the degree of their political involvement. However, torture was more frequently sexual, and its consequences more often affected the women's sexual adaptation.

Invited review: post-traumatic stress disorder; a new clinical entity?

Recently a spate of large scale disasters has caught public attention. Survivors of unexpected catastrophes find their lives radically changed. They may develop a characteristic pattern of symptoms in response to their exposure to overwhelming stress. Ten years ago, American psychiatrists introduced a new diagnostic category, post-traumatic stress disorder (PTSD), referring to the range of psychological symptoms survivors demonstrate after extreme trauma (Diagnostic and Statistical Manual of Mental Disorders, APA, Washington D.C.). Although the validity of this syndrome remains debatable, the term PTSD is increasingly in use, a practice likely to continue given its inclusion in the draft edition of ICD 10 (WHO, Geneva). This review looks at the evidence that PTSD describes a specific clinical entity. The historical background to the belief that individuals respond to stress is summarized. The criteria that must be fulfilled and methods of establishing a diagnosis are described. A discussion of aetiological factors and the natural history of the psychological response to stress follows, with reference to clinical management, including the provision of effective intervention for survivors to prevent a full blown stress reaction emerging.

The effects of sexual assault on men: a survey of 22 victims

Twenty-two men, who had been forcibly sexually assaulted, participated in a study to determine the circumstances of the attacks and the effects on the victims. The immediate and long-term responses were very similar to those described in female victims of rape.