Acute Panic Reactions Among Rape Victims: Implications For Prevention Of Post-Rape Psychopathology
By Heidi Resnick, Ph.D.
NCP Clinical Quarterly 7(3): Summer 1997
Over the past 8 years I have been studying acute post-rape physiological and psychological responses and concerns of recent female rape victims in order to identify factors related to differential recovery patterns. Rape victims who report the crime to police represent a unique population of trauma victims because they are typically seen within hours of the assault for necessary medico-legal evaluation. Unlike a majority of the clinical population seeking psychological services post-trauma, the acute reactions of recent rape victims can be studied with relatively little distortion due to retrospective reporting. In addition, data on the acute responses and concerns of victims can be used to develop interventions that might be implemented in the acute post-rape time frame. Given the routine treatment of these rape victims shortly after an assault in both medical and rape crisis center settings, such early interventions may be feasible and may actually serve to prevent longer term problems typically seen in more chronic treatment seeking groups. Foa and colleagues (1) have demonstrated the utility of applying a brief 4 session preventive treatment program with rape victims seen within 14 days of assault. Women who recieved a cognitive behavioral intervention targeting PTSD symptoms had a much lower rate of PTSD at two months post-rape than women who received no treatment (10% vs 70%). In the current article, data related to panic symptoms as an early pattern of response to traumatic events are reviewed along with suggestions for tailoring preventive interventions to reduce the risk of panic and PTSD among rape victims.
Data from longitudinal studies of recent rape victims indicate that degree of initial psychological distress, including fear and anxiety and intrusive symptoms are significant predictors of longer term psychological distress and anxiety (2) as well as posttraumatic stress disorder (3). These studies assessed early symptom distress within the first few weeks post-rape and used these measures to predict clinically significant psychological distress or PTSD that persisted for at least 3 months post-rape. Additionally, data also indicate that retrospective reports of reactions occurring during the incident are significant predictors of chronic distress. Accordingly, Girelli et al. (4) found that reported degree of emotional distress during rape significantly predicted current intrusive, phobic avoidance, and fear symptoms among women who had been raped at least 3 months prior to study. Similarly, the reported perception of threat to one's life during a crime incident has been identified as a significant predictor of PTSD (5,6).
A major component of the recently conducted DSM-IV PTSD Field Trial was to gain an understanding of typical initial post-trauma subjective distress reactions and evaluate the relationship between initial subjective distress and longer term PTSD (7). To accomplish this, the 25 item Initial Subjective Reactions (ISR) Scale was developed to assess specific cognitive, emotional, and physiological reactions that may have occurred during a stressor event. This scale included panic attack symptom items as well as other emotions or cognitions that might characterize the initial distress response. The physical reaction subscale is presented in Table 1.
Table 1. Physical Reaction Subscale (Initial Subjective Reactions Scale).
For each of the following bodily sensations would you say you experienced it: Not at all, a little bit, a moderate amount, or an extreme amount during the incident or when you first learned about it (or during the worst point or incident if it was a series of events that happened).
Degree of Physical Reaction
Not At All (1), A Little Bit (2), A Moderate Amount (3), An Extreme Amount (4)
Physical Reaction
|
A. Shortness of breath |
1 2 3 4 |
|
B. Dizziness or feeling faint |
1 2 3 4 |
|
C. Rapid heart rate |
1 2 3 4 |
|
D. Trembling or shaking |
1 2 3 4 |
|
E. Sweating |
1 2 3 4 |
|
F. Nausea or abdominal distress |
1 2 3 4 |
|
G. Body numbness or tingling sensations |
1 2 3 4 |
|
H. Hot flashes or chills |
1 2 3 4 |
|
I. Choking |
1 2 3 4 |
|
J. Chest pain or discomfort |
1 2 3 4 |
Fifteen other items assess emotional and cognitive reactions. Phrasing in the instructions is designed to be applicable to a variety of stressor events including direct assaults as well as homicide or other death or injury of a family member or close friend. Responses obtained from a subset of 373 respondents in reference to the experience of a first or only Criterion A stressor event were factor analyzed using a principle components analysis with varimax rotation (7,8) that yielded a five factor solution that accounted for 61.5% of the variance in responses.
The largest factor, entitled "Panic/Physiological Arousal"accounted for 38.5% of the variance and included items describing: dizziness, chest pain, shortness of breath, hot flashes, physical numbing, nausea/gastrointestinal upset, choking, sweating, and fear of going crazy or losing control of emotions. A second factor entitled "Cognitive/Fear" accounting for 7.9% of the variance included panic symptoms of feeling fearful, trembling or shaking, and rapid heart rate, as well as fear of death or serious injury and reactions of helplessness, confusion, and surprise. The remaining 3 factors, each accounting for 6% or less of total variance included: an "Interpersonal" factor (embarrassment, guilt, violated trust); a "Dysphoria" factor (anger, disgust, and sadness); and a "Numbing/Unreality" factor (unreality, emotional numbing, detached as if in a dream). It should be noted that the latter factor contains items that define panic attack symptoms and that are also considered to reflect dissociative responses to traumatic events. In addition, as noted by Falsetti et al. (9) the perception of fear that one may be killed or seriously injured during an incident and the fear of losing control or going crazy may actually be parts of an initial reaction to a realistically dangerous/out of control/crazy incident that become conditioned responses that later may be experienced as more general panic attack representations of these cognitions (e.g. not subjectively tied to the particular event experienced) that may either cue off or be cued by situational or physiological arousal factors. Data indicated that panic and fear factor scores were higher in association with assault and combat experiences than with other Criterion A events and that each mean factor score summed across up to three "high magnitude" stressors was significantly associated with meeting criteria for lifetime and current PTSD. The ISR, which was part of the Potential Stressful Events Interview (PSEI) developed as part of the Field Trial study, is an example of a measure that can be used to assess Criterion A2 (subjective distress) of the PTSD diagnosis (10).
A study of the reactions of recent rape victims is consistent with the prominence of panic attack symptoms in characterizing the acute response (11). In this study, Resnick et al. administered the ISR scale to two groups of rape victims: a) 32 women who were assessed at 2 weeks post-rape; and b) 29 women who completed the assessment within 72 hours post-rape at the emergency room post-rape exam. Women rated the degree to which each response was experienced during the rape. Responses were dichotomized as present or absent based on a rating that the reaction was experienced a "moderate" or "extreme amount" versus "not at all" or "a little bit". Reported rates of panic attack symptoms did not differ across the two samples. In each group, all symptoms were reported by over one-third of women. Almost all (90%) of women seen at the emergency room met criteria for a panic attack (four or more symptoms) at the time of the rape experience.
Longitudinal data indicated that physiological symptoms of panic were predictive of longer term intrusion, depressive, and somatic symptoms at a three month follow-up. These data are consistent with an earlier study of retrospectively reported symptoms occurring during a rape incident (12). In that study of 25 women, over 90% reported feeling terrified, and the majority reported heart racing, rapid breathing, shaking or trembling, and tight muscles. We are currently evaluating, in an ongoing study, the association between panic attack prevalence at 6 weeks post-rape and presence of PTSD at 3 months post-rape within a larger sample of rape victims. Other anxiety response patterns may also be important in characterizing the initial response to rape. For example, Galliano et al. (13) reported that 37% of women retrospectively reported responses during rape that were consistent with a tonic immobility reaction that was characterized by freezing or feeling immobilized despite absence of physical constraints. Thus, there is likely to be heterogeneity in patterns of responding among victims of rape or other traumatic events. Incorporation of knowledge of such heterogeneity and range of responding is important to include within interventions with rape victims.
Results of these studies indicate that panic attack responses are typical of the acute response to rape, and that this pattern of acute distress is associated with longer term PTSD. Thus, it has been hypothesized (9) that the acute physiological panic response constitutes a "true" alarm reaction that may become part of a network of conditioned cues that persists as longer term physiological symptoms of PTSD. Trauma related cognitions may also persist and their trauma related origins may be missed among some samples of panic patients who may not have received adequate assessment for histories of traumatic events. Data from the National PTSD Prevalence and Comorbidity Study (14) are consistent with proposed associations between PTSD and panic. Among the 3,065 women studied, all other anxiety disorders occurred at significantly higher rates in association with PTSD. Rates of agoraphobia (22.4% vs 7.8%) and panic disorder (12.4% vs 4.3%) were associated with greatest increased odds in association with presence versus absence of PTSD.
Currently I, along with my co-investigators Ron Acierno and Dean Kilpatrick at the National Crime Victims Research and Treatment Center, am conducting a brief preventive intervention with recent rape victims funded by the Interagency consortium on Violence Against Women and Violence Within the Family. Rationale for the treatment is partly based on the data reviewed here about acute panic reactions occurring post-assault and the hypothesized role of acute panic distress in development of post-assault PTSD and panic symptoms. If the onset of panic symptoms occurs in many cases at the time of exposure to a traumatic event, early post-trauma intervention might serve to prevent both panic and PTSD. Given the hypothesized role of anticipatory anxiety in the development/maintenance of panic disorder (15), early treatment might serve to prevent the onset of panic disorder if implemented prior to a subsequent "false" alarm. Reduced fear of physiological sensations might lead to reduced intensity of such sensations and a reduction in avoidance of situations, thoughts, and feelings that might bring these sensations about. In addition, given the findings that early distress predicts longer term PTSD, reduced post-trauma panic symptoms prevent chronic PTSD via a reduction in initial distress level post-rape. The intervention will be implemented as quickly after an assault as possible and is designed to reduce post-rape rates of panic and PTSD. Similar to an effective intervention conducted by Swinson and colleagues (16) to reduce panic within an emergency room patient population, the treatment strategy includes psychoeducation about panic as well as instructions for therapeutic exposure to realistically nondangerous situations. In addition, we include information about PTSD as well as panic and the hypothesized interrelationships between the two. Thus, education about panic symptoms presents the view that such physiological, cognitive, and behavioral reactions are a normal part of the body's survival response that may be triggered later on by other stimuli within the assault situation (or that may be similar), or related thoughts or feelings. In addition, physiological sensations of panic are presented as important cues stemming from the initial assault situation that may trigger other assault related cognitions, emotions, and behavioral avoidance even in the absence of identifiable situational cues. Similarly, instructions for exposure are presented with regard to both PTSD and somatic panic cues. Additional components of the treatment address victims' post-rape health and other concerns. The feasibility of implementing early post-assault interventions and determination of optimal post-assault time frames for treatment delivery need to be evaluated along with the efficacy of such treatments in preventing longer term mental health problems post-assault.
References
1. Foa, E.B., Hearst-Ikeda, D., & Perry, K.J. (1995). Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology, 63, 948-955.
2. Kilpatrick, D.G., Veronen, L.J., & Best, C.L. (1985). Factors predicting psychological distress among rape victims. In C.R. Figley (Ed.), Trauma and its wake (pp.133-141). New York: Bruner/Mazel.
3. Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T., & Walsh, W. (1992). A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5, 455-475.
4. Girelli, S.A., Resick, P.A., Marhoefer-Dvorak, S., & Hutter, C.K. (1986). Subjective distress and violence during rape: Their effects on long-term fear. Victims and Violence, 1, 35-46.
5. Kilpatrick, D., Saunders, B., Amick-McMullan, A., Best, C., Veronen, L., & Resnick, H. (1989). Victim and crime factors associated with development of crime-related post-traumatic stress disorder. Behavior Therapy, 20, 199-214.
6. Weaver, T.L., & Clum, G.A. (1995). Psychological distress associated with interpersonal violence: A meta-analysis. Clinical Psychology Review, 15, 115-140.
7. Kilpatrick, D.G., Resnick, H.S., Freedy, J.R., Pelcovitz, D., Resick, P., Roth, S., & van der Kolk, B. (In press). The posttraumatic stress disorder field trial: Evaluation of the PTSD construct: Criteria A though E. In T.A. Widiger, A.J. Frances, H.A. Pincus, M.B. First, R. Ross, & W. Davis (Eds.), DSM-IV sourcebook, Vol. IV. Washington, DC: American Psychiatric Press.
8. Resnick, H.S., Kilpatrick, D.G., Dansky, B.S., & Freedy, J.R. (1992). Emotional and physiological responses during a variety of traumatic events. Paper presented at the Association for the Advancement of Behavior Therapy meeting. Boston, MA.
9. Falsetti, S.A., Resnick, H.S., Dansky, B.S., Lydiard, R.B., & Kilpatrick, D.G. (1995). The relationship of stress to panic disorder: Cause or effect? In C.M. Mazure (Ed.), Does stress cause psychiatric illness? (pp.111-147). Washington, DC: American Psychiatric Press.
10. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, (4th ed.) Washington, DC: Author.
11. Resnick, H.S., Falsetti, S.A., Kilpatrick, D.G., & Foy, D.W. (1994). Associations between panic attacks and dissociative responses to rape. Paper presented at the International Society for Traumatic Stress Studies. Chicago, IL.
12. Veronen, L.J., Kilpatrick, D.G., & Resick, P.A. (1979). Treating fear and anxiety in rape victims. In W.H. Parsonage (Ed.), Perspectives on victimology (pp. 148-159). Beverly Hills, CA: Sage.
13. Galliano, G., Noble, L.M., Travis, L.A., & Puechl, C. (1993). Victim reactions during rape/sexual assault. A preliminary study of the immobility response and its correlates. Journal of Interpersonal Violence, 8, 109-114.
14. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1996). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060.
15. Barlow, D.H. (1988). Anxiety and its disorders. New York: Guilford.
16. Swinson, R.P., Soulios, C., Cox, B.J., Kuch, K. (1992). Brief treatment of emergency room patients with panic attacks. American Journal of Psychiatry, 149, 944-946.
Heidi Resnick is an Associate Professor of Clinical Psychology at the National Crime Victims Research and Treatment Center at the Medical University of South Carolina in Charleston, SC. She is currently principal investigator on NIH Interagency Consortium on Violence Against Women and Violence Within the Family Grant DA11158 to evaluate a preventive intervention post-rape as well as on a CDC funded cooperative agreement study of rape victims' health related concerns and behaviors (U64/CCU409683).
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