Information Processing of Sexual Abuse in Elders

Ann W. Burgess; Paul T. Clements


J Foren Nurs. 2006;2(3):113-120. 

In This Article

Theoretical Analysis and Application

Sexual assault is a life-altering traumatic event and monitoring for manifestations of post-traumatic symptomology within the initial 3-6 months post-exposure is imperative (American Psychiatric Association, 2000).

The related disruptive sequelae indicate that the victim has been unsuccessful in implementing self-soothing techniques and cognitive management of the event. Typically, there is an unwanted but seemingly uncontrollable compulsion to dwell on the event which leads toward attempts, both overt and subtle, to prevent further assaults. This is most commonly seen via initial employment of defense mechanisms generally manifested in overarching individual and interpersonal response patterns of avoidance and/or aggression. The ability to successfully manage the traumatic insult will depend on a number of factors, including appraisal of the situation, previous experiences, surrounding support systems, and the capacity to intrapsychically process the event. However, for many elders, cognitive impairment, concomitant medication or medical-related issues, or underlying psychosocial issues (isolation, dependence on others, lack of awareness of resources) may interfere with such processing and integration.

In essence, these circumstances may prevent any attempts at effective interpretation of the event and subsequent actions such as reporting to the authorities, successfully navigating typically highly-charged affective states related to the trauma, establishing an anchor for safety, etc. (Brandl, 2003; Teitelman & Copolillo, 2002).

There are commonly displays of intrusive or avoidant behaviors, which are often noted as "new" or "disturbing," and are often reflective of the traumatic exposure or may be seen as the re-emergence or increased frequency and severity of previously displayed disruptive behaviors. For example, as noted in the case study of Ms. B, agency personnel noted both exaggerated cognitive and affective behaviors (increased crying, heightened anxiety, refusal to eat, depressed mood ) as well as the onset of a new disturbing behavior ("licking" and pulling the covers up to her chin when touched) that they attributed to the post-traumatic event timeline. For Ms. M, this was manifested by extreme hypervigilence and ongoing fear of a subsequent attack from the offender, believing that he sat in front of her house wearing a disguise and was watching her. These examples support the tenets that exposure to traumatic stimuli typically induces a biphasic state of hyperarousal and/or numbing, which may cause the victim to experience highly-emotional states with lower levels of thinking.

Although potentially manifested differently in the elderly, particularly those with cognitive impairment, it is conceivable that this may often be misinterpreted as advancement of any existing cognitive impairment, such as dementia, or as manipulative behavior, perhaps secondary to a previously established personality disorder, or may even be misdiagnosed as psychosis.

Instead, what is more likely to be occurring is that subsequent to the sexual assault, the victim cannot adapt to the trauma and becomes disorganized, flooded, and overwhelmed and may experience and respond to visual and motoric reliving of the event with flashbacks and other intrusive thoughts that are generally preceded with physiologic arousal and environmental cuing (Lang, Bradley, & Cuthbert, 1990; Wenzlaff & Wegner, 2000).

These disruptions may affect the sensory, perceptual, cognitive, and interpersonal performance levels with symptoms including hyperactivity, somatic complaints (particularly new onset or without seeming medical foundation), emotional withdrawal, interpersonal agitation and other displays of "social inappropriateness," hypervigilence of others and surrounding activities, and nightmares (Gibson, 2005; Weintraub & Ruskin, 1999).

Behavioral and affective disruptions may involve both internal (intrapsychic) and external (interpersonal and environmental) cues that produce intrusions of images, auditory, and kinesthetic information associated with the trauma (Miller, Litz, Greif, & Wang, 2001; Phillips, & LeDoux, 1992) and may lead to future concerns about repeated danger (Burgess et al., 1995). Again, the symptoms of interpersonal disruption typically reflect patterns of avoidance and aggression.

The avoidant pattern is characterized by either denial of the event or episodes of numbing and dissociation as a method of avoiding remembering the trauma. As such, elder sexual assault victims may display a lack of energy for day-to-day living. Avoidant patterns of behaviors, such as an excessive fear of others, may be demonstrated as worries about general safety, fear of being alone, inquiries about who is working specific shifts at an agency, repeating statements about seemingly unrelated events, and an inability to assert or protect oneself.

The victims may appear distant and alienated and have a preoccupied daydreaming quality to their behavior. Phobic mannerisms may also be present via avoidance of cues or situations that trigger unpleasant sensations or memories. They may resfuse to participate in otherwise typical daily activities, be fearful of leaving their residence, and avoid participating in therapeutic programs or other social activities without obvious reasons.

The aggressive pattern is characterized by acting out aggressive behavior toward self, other patients/persons, and caregivers. The acting out may be new onset, re-emergence, or worsening of previous aggressive behavior.

Due to the natural progressive facets related to aging, co-morbid psychiatric diagnoses, or cognitive impairment, these traumatic response patterns may be misunderstood (Aarts & Op den Velde, 1996). There is often increased agitation, striking out against caregivers, and potentially self-injurious behavior including suicide attempts.

These patterns may be mistaken for onset of dementia as victims may display significant alterations in thinking and behavior, however, assessing for differential diagnosis, including assessing for sexual assault and other forms of interpersonal violence, is imperative at this juncture.

The brain and behavior correlates of PTSD can physically and psychologically overwhelm the body and mind, and subsequently, the victim may no longer be able to successfully manage the impact that it has upon daily life. In this trajectory of trauma learning, several presentations may be observed. These include re-enacting the trauma, repeating the trauma as either victim/victimizer, and displacing the aggression (Burgess & Hartman, 1988; Burgess, et al., 1995; van der Kolk, 1989).

Re-enactment is experienced as recollections of the traumatic event. This may occur as flashbacks that often contain fragmented detail and an intense sensory experience. In elders there may be repetitive themes and aspects of the traumatic event expressed via interactions with others, including the onset of previously unobserved behaviors or re-emergence or exacerbation of previously observed disturbing behaviors. Frightening dreams may occur with unrecognizable content. The person may fear that the perpetrator may return for re-enactment of the assault. Fear surrounding the safety of family and home environment might also be heightened (Friedman & Schnurr, 1995). Knowing the details of the abuse will help distinguish the origin of the behavior. The elder will need self-soothing techniques and other interventions to establish a sense of safety and decrease the hypervigilance.

During this stage of the trauma learning process, behavior patterns generally are noted in interactions with others. The behavioral repetition of the trauma may be played out in either the role of the trauma victim or the role of the victimizer (van der Kolk, 1989). Repetition of the trauma in the role of the victimizer is a major cause of aggression and violence. It can be suggested that the sexually assaulted elder will attempt to act out the power and control dynamics of the event on others in an attempt to gain a sense of control or mastery over the trauma that originally happened. They may also have fantasies of injuring or even killing the perpetrator, especially if the offender was someone considered personally "close" or someone they inherently trusted (such as a family member or agency caretaker). Additionally, suicidal ideation must be considered and assessed as it may be seen as a method of escape from fear of subsequent assaults.

During the displacement stage, behaviors and thoughts of the trauma are elaborated symbolically. The elaboration may manifest as symbolic representations of the sexual assault which may lead to psychotic reactions that have patterns of the original trauma embedded in them. This can be further exacerbated by any pre-existing cognitive impairment (Cook, Ruzek, & Cassidy, 2003).

Special attention needs to be paid to the sexually abused elder with dementia. Talking about the abuse may be impossible as noted in Case 1. But the need for safety and security and trust remain paramount. A routine therapeutic visit becomes the mode of treatment with the use of basic and clear interventions that promote safety and maximize on previous activities that have been successful for relaxation. For example, music therapy may be indicated. Favorite music can be played for the elder during a therapeutic visit while the counselor sits quietly with him or her. The time of the visit needs to be consistent each day and of a duration tolerated by the elder based on the clinician's judgement. Cassette music played each evening helps provide a soothing prelude to sleep.

For the noncognitively impaired elder, victims will benefit from concrete and clear explanations of the sexual assault as is done with younger victims. Practitioners can encourage the elder to talk about what happened. This in turn will promote adaptive coping and will provide assistance in achieving a sense of safety, well-being, and connection to the world. Other interventions include physical health assessment and care, as well as stress reduction/stress management techniques, each of which promotes the opportunity to reinvest in lasting relationships and encourages meaningful use of the day. These interventions, coupled with the opportunity to tell the trauma story safely with acceptance, will help to rebuild a sense of self.


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