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Tonic immobility during sexual assault – a common reaction predicting post‐traumatic stress disorder and severe depression
AOGS ORIGINAL RESEARCH ARTICLE
Tonic immobility during sexual assault – a common
eaction predicting post-traumatic stress disorder and
severe depression
ANNA M€OLLER , HANS PETER S€ONDERGAARD & LOTTI HELSTR€OM
Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
Key words
Depression, peritraumatic reactions, post-
traumatic stress disorder, rape, sexual assault,
Tonic Immobility Scale
Co
espondence
Anna M€oller, Stockholm South General
Hospital, Department of Obstetrics and
Gynecology, Sjukhusbacken 10, 118 83
Stockholm, Sweden.
E-mail: XXXXXXXXXX
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: M€oller A,
S€ondergaard HP, Helstr€om L. Tonic immobility
during sexual assault – a common reaction
predicting post-traumatic stress disorder and
severe depression. Acta Obstet Gynecol
Scand 2017; 96:932–938.
Received: 30 August 2016
Accepted: 21 May 2017
DOI: XXXXXXXXXX/aogs.13174
Abstract
Introduction. Active resistance is considered to be the ‘normal’ reaction during
ape. However, studies have indicated that similar to animals, humans exposed
to extreme threat may react with a state of involuntary, temporary moto
inhibition known as tonic immobility. The aim of the present study was to
assess the occu
ence of tonic immobility during rape and subsequent post-
traumatic stress disorder and severe depression. Material and methods. Tonic
immobility at the time of the assault was assessed using the Tonic Immobility
Scale in 298 women who had visited the Emergency clinic for raped women
within 1 month of a sexual assault. Information about the assault and the
victim characteristics were taken from the structured clinical data files. Afte
6 months, 189 women were assessed regarding the development of post-
traumatic stress disorder and depression. Results. Of the 298 women, 70%
eported significant tonic immobility and 48% reported extreme tonic
immobility during the assault. Tonic immobility was associated with the
development of post-traumatic stress disorder (OR 2.75; 95% CI 1.50–5.03,
p = XXXXXXXXXXand severe depression (OR 3.42; 95% CI 1.51–7.72, p = XXXXXXXXXXat
6 months. Further, previous trauma history (OR 2.36; 95% CI 1.48–3.77,
p < XXXXXXXXXXand psychiatric treatment history (OR 2.00; 95% CI 1.26–3.19,
p = XXXXXXXXXXwere associated with the tonic immobility response.
Conclusions. Tonic immobility during rape is a common reaction associated
with subsequent post-traumatic stress disorder and severe depression.
Knowledge of this reaction in sexual assault victims is important in legal
matters and for healthcare follow up.
A
eviations: ASD, Acute stress disorder; BDI, Beck Depression Index; DSM-
IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition; OR,
odds ratio; PDS, Post-traumatic Stress Diagnostic Scale; PTSD, post-traumatic
stress disorder; SASRQ, Stanford Acute Stress Reaction Questionnaire; SCID-I,
Structured Clinical Interview for DSM-IV; TI, tonic immobility; TIS, Tonic
Immobility Scale.
Introduction
Tonic immobility (TI) in animals has been considered an
evolutionary adaptive defensive reaction to a predatory
attack when resistance is not possible and other resources
are unavailable (1). Far less is known about TI in
humans. The legal system seeks visible signs of resistance
ecause when it is absent, it is more difficult to prove a
sexual assault (2). However, a substantial number of vic-
tims do not resist the attacker in any way (3). In humans,
TI has been described as an involuntary, temporary state
of motor inhibition in response to situations involving
intense fear. It has been further described as a catatonic-
ª 2017 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica XXXXXXXXXX–938932
http:
orcid.org/ XXXXXXXXXX
http:
orcid.org/ XXXXXXXXXX
http:
orcid.org/ XXXXXXXXXX
info:doi/10.1111/aogs.13174
info:doi/10.1111/aogs.13174
like state with muscle hyper- or hypo-tonicity, tremor,
lack of vocalization, analgesia and relative unresponsive-
ness to external stimuli. Most studies on TI in humans
have focused on sexual assault victims. This is probably
ecause there is a postulated similarity between sexual
assaults and predatory encounters (1). Sexual assault has
also been described as one of the most traumatic experi-
ences a person can be exposed to (4), and studies have
shown that TI scores are significantly higher in victims of
sexual abuse compared with other types of trauma (5).
In these studies, significant immobility has been reported
in 37% (6), 42% (7), and 52% of the sexual assault
victims (8).
Along with other peritraumatic stress reactions, TI has
een associated with the development of post-traumatic
stress disorder (PTSD) (9–11). Lima and colleagues (10)
showed that among victims of violence, TI predicted the
severity of post-traumatic stress symptoms, as well as a
poor response to treatment. Further, Bovin and collegues
(12) suggested that TI could be one path through which
victims develop PTSD. Volchan and collegues (13) sug-
gested that patients with PTSD were more likely to expe-
ience TI during subsequent stress.
However, most studies on TI in humans have been ret-
ospective (7–12,14). Further, earlier studies have been
ased on small sample sizes, making assumptions on cau-
sal relationships hazardous.
In the present study, we wanted to assess TI during
ape in a large group of sexual assault victims at a follow-
up appointment shortly after the emergency visit. We
hypothesized that in screening a large clinical sample
shortly after an assault, the experience of TI would be
even greater than what has been found in earlier studies
ecause it would reduce the possibility of a recall bias.
Additionally, we wanted to explore the association
etween TI and the development of PTSD. In an earlie
study (15) we found that the major risk factors for PTSD
included having been sexually assaulted by a group, suf-
fering from Acute Stress Disorder (ASD) shortly after the
assault, having been subjected to several acts during the
assault, having been injured and having a history of ear-
lier traumatization. Therefore, we hypothesized that TI
increases the risk of PTSD development, even afte
adjusting for these other known risk factors.
Material and methods
The study was performed at the Emergency Clinic fo
Raped Women in Stockholm, Sweden. In Stockholm all
sexual assault victim care is centralized to this unit and
the clinic is open 24 h a day. The clinic offers medical
and forensic examination within 1 month of the sexual
assault and services approximately 600 patients per yea
after rape. All services are free of charge and independent
of police reporting. At the time of the study, the clinic
saw only female patients.
At a medical check-up appointment, approximately
10–14 days after the acute visit, all eligible women were
asked to participate in the study. Women were found eli-
gible if they were over the age of 18 years and were liter-
ate in Swedish. In addition, the consenting women
needed to be able to participate in an interview that
assessed PTSD symptoms and complete self-report ques-
tionnaires about their mental health. The participants
were informed of the research procedure and risks, and
they signed written consent.
Of 1047 eligible women, 317 female victims of rape o
attempted rape, who had been in contact with the clinic
etween Fe
uary 2009 and December 2011, agreed to
participate in the study. Of these, 298 women completed
the assessment regarding TI and 63% of the Post-trau-
matic came back for the 6-month visit, leading to a final
sample of 189 women who were also assessed for the pos-
sible development of PTSD (15). Consenting women
completed four self-rating questionnaires: Tonic Immobil-
ity Scale (TIS), Beck Depression Index (BDI),
Post-traumatic Stress Diagnostic Scale (PDS), and Stan-
ford Acute Stress Reaction Questionnaire (SASRQ). Infor-
mation on any history of earlier sexual assaults, sexual
assault in childhood, and the number of other earlie
traumas were taken from the PDS questionnaire. Infor-
mation regarding victim and assault characteristics were
taken from the clinic’s structured data files. Six months
after the rape, study participants were assessed regarding
PTSD using the Structured Clinical Interview for Diag-
nostic and Statistical Manual of Mental Disorders, 4th
edition (DSM-IV; SCID-I), and they completed two of
the self-rating questionnaires (BDI, SASRQ).
Measures
The Tonic Immobility Scale-Adult Form (TIS-A; 16), Part
1, is a 12-item questionnaire designed to assess the core
features and components of TI. A Swedish version of the
scale was used that had been translated using forward
Key Message
Tonic immobility during rape is a common reaction,
yet overlooked. In sexual assault victims, tonic immo-
ility is associated with an increased risk of subse-
quent post-traumatic stress disorder and severe
depression. Tonic immobility should be assessed in
all sexual assault victims.
ª 2017 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica XXXXXXXXXX–938 933
A. M€oller et al. Tonic immobility during rape
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translation and then back-translated by an independent
translator for control. The first 10 questions are answered
using a seven-point Likert scale (range 0–6). To obtain
the total score, the item scores are summed (Table 1).
Higher scores in response to items 1–10 reflect greater TI
ehaviors. The TIS-A consists of two subscales: TTI
(seven items) and Fear (three items) (7). The TI scale
includes questions that assess various aspects of TI, such
as feeling frozen or paralyzed, the inability to move
although not restrained, the inability to call out o
scream, numbness, feeling cold, fearing for one’s life, and
feeling detached from self (scores 0–42). The Fear sub-
scale includes items that assess fea
panic, trembling/shak-
ing and feelings of detachment from su
oundings (scores
0–18). Using the same cut-off scores as earlier studies
(7,8), a total score > 21 represented a significant TI and a
total score ≥ 28 represented extreme TI. Symptoms of
fear were considered clinically significant when a respon-
der’s total score on the Fear subscale was ≥ 9. In the pre-
sent study the Cronbach’s a was 0.87 for the whole
questionnaire, 0.81 for the TI factor, and 0.62 for the fea
factor.
The Beck Depression Inventory, BDI-II (17), includes 21
questions that measure depressive symptoms. The cut-off
points for the sum scores were 0–13 (no depression), 14–
19 (mild depression), 20–28 (moderate depression), and
≥ 29 (severe depression). Cronbach’s a was 0.90.
The Post-traumatic Stress Diagnostic Scale, PDS (18)
was used at baseline to assess the PTSD symptom score
(0–51), a probable pre-existing PTSD diagnosis (using the
DSM-IV criteria) and lifetime experience of traumatic
events. PTSD was diagnosed at baseline when the
espondent in PDS part 1 reported having been exposed
to or witnessing a traumatic event that, according to PDS
part 2, involved a threat to life or physical integrity;
according to PDS part 3, having at least one re-experien-
cing symptom, at least three avoidance symptoms, and at
least two arousal symptoms; that symptoms lasted fo
over 1 month; and according to PDS part 4, also caused
impairment in the respondents’ daily life in at least one
area. Cronbach’s a was 0.85.
The Stanford Acute Stress Reaction Questionnaire, SASRQ
(19), was used at baseline and at the 6-month visit. The
SASRQ is a 30-item self-report instrument with three addi-
tional questions relevant to the diagnosis of ASD. The
instrument can be used as a Likert scale (0–5), where highe
scores reflect greater symptoms, or dichotomously (0–2: 0,
3–5: 1), where 0 means absence and 1 means presence of a
symptom. According to the DSM-IV, a diagnosis of ASD
equires at least three of the five types of dissociative symp-
toms, one re-experiencing symptom, one avoidance symp-
tom, one marked anxiety/increased arousal symptom, and
impairment in at least one important area of functioning.
We also used the SASRQ total score to measure the self-
eported PTSD symptom severity over time. Cronbach’s a
was 0.90 for the whole questionnaire, which was good, and
was 0.87 for the dissociation part.
The PTSD Module of the Structured Clinical Interview
for DSM-IV (SCID-I) was used to establish cu
ent PTSD
6 months post-rape (20). The SCID-I is a widely used
structured clinical interview. A diagnosis of full PTSD
was made using the DSM-IV-TR (i.e. when clusters A
and F were fulfilled).
Statistical analyses
Because most data were not normally distributed, com-
parisons between groups (TI vs. without TI) were per-
formed using Mann–Whitney U test for continuous
variables (age, dissociation score, depression symptom
score, and PTSD symptoms score). Chi-square tests were
used for categorical/dichotomized variables (marital sta-
tus, relationship to assailant, earlier trauma, psychiatric
treatment history, pre-existing PTSD, and assault charac-
teristics). Risk factors for PTSD at 6 months were
assessed as categorical variables using logistic regression.
Variables were considered significant if the Wald test
esulted in a p-value < 0.05. All statistical analyses were
conducted using the statistical software version SPSS 22.0
(IBM Corp., Armonk, NY, USA).
Ethical approval
The study was approved by the regional medical ethics
committee in Stockholm (2008/759-31).
Table 1. Tonic Immobility Scale, items used to compute the total
score.
Rate the degree to which you/your: Mean SD
(1) Froze or felt paralyzed during
your most recent experience.
XXXXXXXXXX
(2) Were unable to move even
though not restrained.
XXXXXXXXXX
(3) Body was trembling/shaking
during the event.
3
Answered 2 days After May 26, 2023

Solution

Bidusha answered on May 28 2023
25 Votes
Critical Thinking Analysis        2
CRITICAL THINKING ANALYSIS
Table of Contents
Analysis    3
References    6
Analysis
Animals' tonic immobility (TI), which occurs when resistance to a predatory assault is impossible and alternative resources are not accessible, has been considered an evolutionarily adaptive protective response. Much little is understood about TI in individuals. The legal system looks for outward indications of resistance since laying out a sexual assault in the absence of such evidence is seriously difficult (Möller, Söndergaard & Helström, 2017). Be that as it may, a sizable portion of victims give little resistance to the assailant. In humans, TI has been characterized as a wild, transient condition of engine inhibition in reaction to profoundly stressful events. A catatonic-like condition with hyper-or hypotonicity of the muscles, quake, absence of vocalization, analgesia, and relative insensitivity to outside stimuli have also been recorded (Möller, Söndergaard & Helström, 2017). Most of human studies on TI have been on sexual assault victims. This is most reasonable a result of the suggested similarities between sexual assaults and predatory contacts. Quite possibly of the most traumatic occasion a person might have is sexual assault, and research has shown that victims of sexual abuse have a lot higher TI ratings than those who have encountered different forms of trauma. In these investigations, 37%, 42%, and 52% of sexual assault victims were viewed as significantly immobile (Rubin & Bell, 2023).
One essential diagnostic requirement for PTSD is the capacity to remember the distressing occu
ence. Because consciousness is continued during TI, it could gain traumatic experiences more distinctive and make it easier to review peritraumatic details, which would raise the severity of PTSD symptoms (Coim
a et al., 2023). It's interesting to take note of that...
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