Post traumatic stress disorder

A search to prevent PTSD after sexual assault

One forensic nurse’s journey to prevent sexual assault survivors from developing post-traumatic stress disorder
April 2, 2019

Historically, post-traumatic stress disorder (PTSD) has been associated with veterans and other military personnel—it was first called “shell shock,” after all. However, PTSD is much more common throughout the population than most people think and can develop anytime a person is exposed to actual or threatened death, serious injury, accident, disaster or sexual violence.

Connection between sexual assault with PTSD

“Sexual assault is very highly recognized as a risk factor for the development of PTSD,” said Nancy Downing, PhD, RN, SANE-A, CP-SANE and associate professor in the Forensic Nursing Program at the Texas A&M College of Nursing. “After a sexual assault, roughly 82 percent of people will experience some PTSD symptoms within the first month.”

As a former psychiatric nurse, Downing quickly realized the association between sexual assault and PTSD. “Mental health outcomes after a sexual assault can be severe enough to interfere with day-to-day function, which can impede the holistic healing of the survivor,” Downing said.

After becoming a sexual assault nurse examiner in 2004, Downing has spent countless hours researching possible interventions to prevent PTSD from developing in the first month following an assault. It is only after someone has had PTSD symptoms for at least a month that they can be diagnosed with the condition, so intervening during that crucial period can help prevent it from occurring.

“The brain experiences trauma in unpredictable ways,” Downing said. “Often, survivors do not understand why their PTSD symptoms are happening, so they often have trouble explaining their feelings to themselves and others.”

Downing’s hope is to identify relationships between patient characteristics and the development of PTSD. With these results, she anticipates creating and integrating different interventions into the post-trauma sexual assault examinations to prevent or mitigate symptoms.

The role of progesterone

“Women have higher rates of PTSD, regardless the origin of the trauma,” Downing explained. “This trend hints that female hormones may play a role in the development of PTSD.”

Early research on the topic suggests women who were at the mid-luteal phase of their menstrual cycle—when progesterone levels are highest—were found to have higher rates of PTSD than women who were in the lower progesterone phase of their cycle at the time they experienced sexual assault.

“If high progesterone levels are positively correlated with a higher likelihood of PTSD, then sexual assault examiners may need to reconsider what types of emergency contraception they prescribe,” Downing said. “Most types of emergency contraception manipulate progesterone, so it may be a good tool to help prevent PTSD.”

With her current study, Downing hopes to discover more information about the relationship between hormones and the likelihood of developing symptoms of PTSD. Once confident about the relationships between the two, she can suggest interventions that can be integrated into the care during a sexual assault examination.

The role of contraception

A previous study showed women taking oral contraception before they presented for a sexual assault exam and women who were given emergency contraception during a sexual assault exam had lower levels of some common PTSD symptoms than women who did not use or declined hormonal contraception.

These findings imply progesterone—the hormone most commonly impacted by emergency contraception—does play a role in the development of PTSD. Downing’s study aims to prove these findings and to create actionable interventions to be incorporated into sexual assault examinations.

Downing’s ongoing study explores the possibility that hormonal manipulation from emergency contraception can interfere with progesterone’s potential contribution to the development of PTSD symptoms.

Background of the study

The study evaluates healthy women who have not been previously assaulted. The research tests the connections between having emergency contraception and the women’s fear conditioning, or the way women subconsciously learn to associate a neutral stimulus with an adverse event.

This study is partially funded by the Texas A&M Triads for Transformation, or T3. As a part of the President’s Excellence Fund, it is a multidisciplinary seed-grant program designed to fund transformational research projects that will help underserved populations. To conduct the study, she partnered with Annmarie MacNamara, PhD, assistant professor at the Texas A&M University Department of Psychological and Brain Sciences. MacNamara heads the MACLab—the multimethod affect and cognition lab—and is experienced in developing fear conditioning experiments. Mary Meagher, PhD, professor at the Texas A&M University Department of Psychological and Brain Sciences, completes the T3 triad. Meagher’s expertise includes understanding mechanisms of stress and its contribution to disease.

Gathering the data

In their study, women watch a computer monitor that flashes different colors across the screen. When a specific color flashes onto the screen, women in the study experience a slight electrical shock to their wrists. Eventually, the women begin to consciously and subconsciously associate that specific color on the monitor with a shock. The study uses an EEG, or electroencephalogram, to measure the amygdala’s activity in the brain. The study also measures other symptoms of fear like the amount of times the women blink and how much they begin to sweat.

After fear conditioning, the women are randomly selected to receive a placebo pill or an emergency contraceptive pill and then undergo fear extinction training, or the process to ‘forget’ their newly learned fear. In other words, they consciously and subconsciously uncoupled the previously neutral stimulus—the color on the monitor—with the adverse event—the shock on the wrist. The next day, they return to examine retention of fear extinction learning.

“The amygdala automatically associates and disassociates a stimulus with the adverse event,” Downing said. “It might help survivors of sexual assault to understand that their reactions and PTSD symptoms are automatic. They cannot control them.”

The next steps

If this study successfully connects progesterone levels with a higher likelihood of developing PTSD, then Downing and her team hope to create actionable interventions to become integrated into the standard care during an exam.

“Even though there are high rates of PTSD after sexual assault, most people spontaneously recover because the uncoupling of the fear learning will naturally occur,” said Downing. “However, about 10 percent of people develop chronic PTSD, and they will likely require professional help to unlearn the fear response. Hopefully, we can find a way to prevent PTSD from developing in the first place and save these women from the suffering PTSD brings to their lives.”

— Mary Leigh Meyer

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