Interpersonal Trauma and Posttraumatic Stress ...

Interpersonal Trauma and Posttraumatic Stress Disorder in Patients With Severe Mental Illness: Demographic, Clinical, and Health Correlates by Kim T. Mueser, Michelle P . SdLyers, Stanley D. Rosenberg, Lisa A. Qoodman, Susan M. Essock, Fred C. Osher, Marvin S. Swartz, Marian I. Butterfield, and the 5 Site Health and Risk Study Research Committee

This study's purpose was to evaluate the prevalence and correlates of posttraumatic stress disorder (PTSD) in persons with severe mental illness. Standardized assessments of interpersonal trauma and PTSD were conducted in 782 patients with severe mental illness receiving services in one of five inpatient and outpatient treatment settings. Analyses examined the prevalence of PTSD and the demographic, clinical, and health correlates of PTSD diagnosis. The overall rate of current PTSD in the sample was 34.8 percent For demographic characteristics, the prevalence of PTSD was higher in patients who were younger, white, homeless, and unemployed. For clinical and health variables, PTSD was more common in patients with major mood disorders (compared to schizophrenia or schizoaffective disorders), alcohol use disorder, more recent psychiatric hospitalizations, more health problems, more visits to doctors for health problems, and more nonpsychiatric hospitalizations over the past year. The results support prior research documenting the high rates of PTSD in patients with severe mental illness and suggest that PTSD may contribute to substance abuse, psychiatric and medical comorbidity, and psychiatric and health service utilization. Keywords: Severe mental illness, schizophrenia, trauma, posttraumatic stress disorder, PTSD, health, symptoms. Schizophrenia Bulletin, 30(l):45-57,2004. There is abundant evidence that people with severe mental illness (SMI), such as major mood disorders and schizophrenia, are prone to high rates of exposure to interpersonal trauma, including sexual and physical abuse and

Send reprint requests to Dr. K.T. Mueser, NH-Dartmouth Psychiatric Research Center, Main Building, 105 Pleasant St., Concord, NH 03301; e-mail: [email protected].

45

Downloaded from schizophreniabulletin.oxfordjournals.org at University of Portland on May 23, 2011

assault (Carmen et al. 1984; Greenfield et al. 1994; Lipschitz et al. 1996; Goodman et al. 1997, 2001; Mueser et al. 1998). Although a variety of clinical correlates of trauma in patients with SMI have been identified, such as symptom severity and substance abuse (Carmen et al. 1984; Beck and Van der Kolk 1987; Greenfield et al. 1994; Davies-Netzley et al. 1996; Briere et al. 1997; Figueroa et al. 1997), recent attention has turned to evaluating the prevalence of PTSD in this population. PTSD may be an important consequence of trauma to assess because a wealth of clinical and research information exists about this disorder in the general population and effective treatments have been established (Foa et al. 2000). Seven studies have been conducted on the prevalence of PTSD in patients with SMI. Across six of these studies, the prevalence of current PTSD was between 29 percent and 43 percent (Craine et al. 1988; Cascardi et al. 1996; Mueser et al. 1998, 2001; Switzer et al. 1999; McFarlane et al. 2001), while in the seventh study the rate of current PTSD was 14 percent (Neria et al. 2002). These rates are substantially higher than estimates of 1.2 percent to 2.7 percent of current PTSD in a community sample (Stein et al. 1997). Moreover, rates of current PTSD in the SMI population far exceed prevalence of lifetime PTSD in the general population, which ranges from 7.8 percent to 12.3 percent (Breslau et al. 1991; Resnick et al. 1993; Kessler et al. 1995). Although the evidence suggests increased rates of PTSD in patients with SMI, prior research suffers from several limitations, including small sample sizes (Craine

Abstract

Schizophrenia Bulletin, Vol. 30, No. 1, 2004

K.T. Mueser et al.

et al. 1988; Cascardi et al. 1996; Mueser et al. 2001), narrow scope of trauma assessment (Craine et al. 1988; Cascardi et al. 1996), and single-site coverage (Craine et al. 1988; Cascardi et al. 1996; McFarlane et al. 2001; Mueser et al. 2001; Neria et al. 2002). In addition, while several studies have examined demographic correlates of PTSD in the SMI population, fewer have evaluated clinical correlates, and even less research has evaluated the relationships between PTSD and either health status or psychiatric and medical service utilization. These are potentially important consequences to examine, as poorer health and more medical treatment have been associated with PTSD in other populations (Falger et al. 1992; Hidalgo and Davidson 2000). Moreover, the inherently stressful nature of PTSD may be expected to worsen the course of SMI (McFarlane 1996; Mueser et al. 2002). This study was conducted to evaluate the prevalence of PTSD in a large sample of patients with SMI in multiple treatment sites across four different states. Correlates of PTSD were examined, including demographic characteristics, clinical variables, health, and receipt of treatment.

hospitalization and assigned to mandatory outpatient treatment following discharge. Half the sample had then been randomly assigned to be released from the outpatient commitment order but received case management during followup. Procedures. Following informed consent, respondents participated in a 1-hour interview. Participants received pretest counseling for HTV/AIDS and provided blood and urine specimens (Rosenberg et al. 2001). Participants were paid $35 for participating and were provided with test results, posttest counseling, and referrals for followup testing and treatment as needed.

Methods Participants. The current study is part of a larger investigation of risk behaviors and sexually transmitted disease in patients with SMI receiving treatment through the public mental health systems of Connecticut, Maryland, New Hampshire, or North Carolina (Rosenberg et al. 2001). All patients had a diagnosis of schizophrenia or other psychotic disorder or major mood disorder (major depression or bipolar disorder) and met criteria for SMI as defined by the respective state. All patients provided informed consent and were above age 18. The proportion of participants who consented to the study was 87 percent, ranging from 72 percent to 93 percent (Rosenberg et al. 2001). In New Hampshire, an inpatient sample (n = 139) was composed of consecutive consenting admissions to the state psychiatric hospital. Outpatient participants (n = 152) were randomly selected from a list of eligible patients in community support programs at two community mental health centers. The Maryland sample (n 141) was randomly selected from patients with schizophrenia or schizoaffective disorder from three community mental health centers in Baltimore. Participants from Connecticut (n = 158) were recruited from an ongoing study of community treatment for patients with SMI and substance use disorders in two urban mental health centers. North Carolina participants (n = 192) were subjects in an ongoing study of involuntary outpatient commitment in nine contiguous rural and urban counties. All had been recruited originally during an involuntary psychiatric

46


Measures. Standardized interviews assessed demographic characteristics, substance use, risk behaviors for HTV, trauma history, health care utilization, and other illness-related variables. In the analyses presented below, we focus on background characteristics, sexual and physical assault, PTSD, and indexes of physical and mental health and service utilization. Background characteristics. Background characteristics included sex, age, race, marital status, poverty level, employment status, recent homelessness, and diagnosis. We defined "homelessness" as having no regular residence, or living in a shelter or on the street at some point in the last 6 months. To determine the poverty status, we used the 1999 poverty guidelines of the Department of Health and Human Services (based on the 1998 census; Federal Register 1999), which take into account income, marital status, and number of children. Most psychiatric diagnoses (80.7%) were obtained from chart review and available clinical data, and 19.3 percent were based on the Structured Clinical Interview for DSM-IV (SCID) (First et al. 1996). Four of the sites used SCTD diagnoses on some of their participants to validate the chart reviews. The North Carolina site evaluated agreement between specific Axis I diagnoses based on the SCID and chart reviews on 155 patients and found acceptable levels of reliability (kappa = 0.72). At the Connecticut site, agreement between general SCID diagnosis ("psychotic disorder," including schizophrenia, schizoaffective disorder, bipolar disorder, or major depression with psychotic features vs. no psychotic disorder) and chart reviews was examined for 65 patients and found to be high (kappa = 1.0). Concordance rates between SCID and chart diagnoses were informally examined at the New Hampshire and Maryland sites and found to be acceptable (i.e., agreement in > 70% of patients), but because of the smaller sample sizes kappas were not computed. Current alcohol and drug use (cocaine, cannabis) disorders were identified with the Dartmouth Assessment of Lifestyle Instrument


Interpersonal Trauma and PTSD

diagnoses based on the Clinician Administered PTSD Scale (CAPS) in accident and sexual assault victims (Blanchard et al. 1996) and were moderately associated in one study of patients with SMI (Mueser et al. 2001). However, in a larger study of computerized versus interviewer-based assessment of patients with SMI (Wolford 1999), PCL scores showed high test-retest and internal reliability and correlated highly (> 0.75) with expert CAPS ratings. Depending on cutoff scores used, diagnostic agreement between CAPS and PCL was approximately 0.80 (Rosenberg et al. 2002). Clinical, health, and service utilization variables. These variables were assessed in several ways. The Medical Outcomes Study Short Form 12-Item Health Survey (SF-12) (Ware et al. 1996) was verbally administered to assess health-related quality of life. The SF-12 consists of 12 items assessing physical and mental health and yields two summary scores: the Mental Component Summary and Physical Component Summary. Scoring is norm-based with a mean of 50 (standard deviation = 10); higher scores indicate better health. The SF-12 includes items on overall health; on physical health limitations on moderate activities or on work; and on the degree to which pain interferes with activities. Other items assess the impact of emotional problems on performance of tasks, including work-related tasks, and mood. These general items on symptoms and limitations due to physical and/or mental health problems do not overlap with the PCL. The SF-12 is reliable and valid in general and medical populations (Ware et al. 19%, 1998; Jenkinson et al. 1997; Gandek et al. 1998) and people with SMI (Salyers et al. 2000). Other clinical and physical health indexes included self-reported number of psychiatric hospitalizations in the past year, age of first psychiatric hospitalization, chronic health problems, doctor visits for physical health problems, and days hospitalized for physical health. During the interview, participants were asked if they had ever been told by a doctor that they had any of the following chronic medical problems: asthma, diabetes, heart trouble, hypertension, arthritis, cancer, lung disease, ulcers, stroke, epilepsy, head injury, or infectious diseases (e.g., hepatitis, chlamydia). We summed the number of items endorsed. Participants were asked to report for the past 6 months the number of times they had received care for a physical health problem and the number of days hospitalized for physical health problems. Data Analyses. First, we examined the prevalence of physical and sexual assault, comparing rates by gender in childhood and adulthood. Next, we examined rates of PTSD. We examined the relationship between assault and PTSD by calculating odds ratios of PTSD, given exposure to different types of assault separately for men and

47


(Rosenberg et al. 1998), an 18-item screening tool for substance use disorder (abuse or dependence) specifically developed and validated for patients with SMI. Childhood assault. We used the Sexual Abuse Exposure Questionnaire (SAEQ; Rodriguez et al. 1997) to assess childhood sexual assault. The SAEQ identifies 10 categories of increasingly invasive unwanted sexual experiences. Participants were asked if they had experienced each of these events before age 16. We defined "childhood sexual assault" as an affirmative response to any of the six items involving unwanted sexual contact from a parent, a caregiver, or someone else in authority. This scale has been shown to have good test-retest reliability in patients with SMI (Goodman et al. 1999). To assess child physical assault, we developed three questions by combining the most severe items from the violence subscale of the Conflict Tactics Scales (CTS; Straus 1989a, 1989ft). The CTS violence subscale presents an ordered series of aggressive actions by an adult caregiver or parent and asks respondents to report the number of times each of the acts occurred. We defined child physical assault as any form of beating, choking, kicking, burning, or weapon use by a parent or other caregiver before the participant turned 16. Adult and recent assault. To measure assault in adulthood and over the past year, we used the physical assault and sexual assault subscales of the Revised Conflict Tactics Scales (CTS2; Straus et al. 19%). Both subscales ask about a range of acts, ordered from least to most severe. For each item, violence by an intimate partner, acquaintances, or strangers was evaluated, and whether the assault had occurred in adulthood (since age 16) and in the last year. We defined adult physical assault as any assault, ranging from grabbing, pushing, or shoving to using a knife or gun, that was perpetrated against a person who is an adult. Adult sexual assault was defined as oral, anal, or vaginal intercourse achieved through either physical force or threat. PTSD. PTSD was assessed with the PTSD Checklist (PCL; Blanchard et al. 1996), a self-report screening measure of PTSD. The PCL includes 17 questions, one for each DSM-FV PTSD symptom, requiring the respondent to rate the severity of each symptom over the past month on a 5-point (1-5) Likert scale. PTSD diagnoses are derived by using a cutpoint of 3 ("moderate severity") to identify the presence of a symptom. Thus, based on DSM-IV, patients were classified as meeting criteria for PTSD if at least 1 criterion B (intrusive) symptom, 3 criterion C (avoidant) symptoms, and 2 criterion D (hyperarousal) symptoms were rated at 3 or above. The PCL has strong test-retest reliability and internal consistency in combat veterans (Blanchard et al. 1996) and people with SMI (Goodman et al. 1999; Mueser et al. 2001). PTSD diagnoses based on the PCL are strongly related to PTSD


K.T. Muescr et al.

women. Finally, we examined rates of PTSD across background characteristics and clinical and health variables, comparing subgroups on the prevalence of PTSD using chi-square tests both within the overall sample as well as within gender (male, female) and diagnostic group (schizophrenia-schizoaffective, major mood disorder). Continuous variables were transformed into categorical variables based on median split of the sample.

Results As shown in table 1, the prevalence of trauma in this sample was high. Overall, 84 percent reported lifetime physical assault and 52 percent reported lifetime sexual assault Furthermore, both physical and sexual assault in childhood were associated with higher rates in adulthood. Among the 336 patients who were not physically abused in childhood, 215 (64%) had been physically assaulted as adults. In contrast, among the 438 patients who had been physically abused in childhood, 384 (88%) had also been physically assaulted as adults. Even more striking, among the 486 patients who were not sexually abused in childhood, 110 (23%) had been sexually assaulted as adults, whereas among the 288 patients who had been sexually abused as children, 182 (63%) had also been sexually assaulted in adulthood. As expected, women experienced significantly more sexual assault than did men. However, regarding physical assault, men and women differed only on past year assault, with more men reporting assault Men and women reported similar levels of physical assault in childhood, adulthood, and lifetime. Odds ratios for PTSD given exposure to trauma are shown in table 2. Overall, physical and sexual assault were both associated with significantly increased odds of PTSD. For the total sample, odds ratios ranged from 2.29 Table 1. Prevalence of trauma exposure Men (n = 461)

Women (n = 321)

Total (n = 782)

Physical assault, n (%) Childhood Adulthood Pastyr Lifetime

265(58.1) 364 (79.3) 156(34.1) 395(86.1)

174(54.4) 238 (74.6) 81 (25.6) 262(82.1)

439 602 237 657

Sexual assault, n (%) Childhood Adulthood Pastyr Lifetime

134(29.2) 112(24.5) 35 (7.6) 183(40.0)

155(48.7) 181 (57.1) 64 (20.3) 217(68.2)

289 (37.2) 293 (37.8) 99 (12.8) 400(51.5)

Note.—For men, rfs range from 456 to 459; for women, rfs range from 316 to 320. ** p < 0.01; *** p < 0.001

48

(56.6) (77.4) (30.6) (84.4)

X2

1.07 2.37 6.39" 2.21 30.73"* 84.90"* 26.66*** 60.11"*


(past year physical assault) to 3.52 (childhood sexual assault). In all but one case (past year sexual assault), odds ratios were higher for women than men. Overall, 34.8 percent of the sample met criteria for PTSD. In addition to examining the demographic, clinical, and health correlates of PTSD in the entire sample, we evaluated these correlates separately within men and women, and separately within the schizophrenia-schizoaffective group and the mood disorder group. To facilitate the interpretation of these within-gender and within-diagnostic-group analyses, we first evaluated whether gender was related to diagnosis by computing a chi-square test. This chi-square test was significant (chi-square = 15.03, p < 0.001) and indicated that the schizophrenia-schizoaffective disorder group had a higher proportion of males (63.5%) than the mood disorder group (48.2%). Differences in rates of PTSD across demographic groups for the total sample, as well as within subgroups of men or women and schizophrenia-schizoaffective disorder or major mood disorder, are shown in table 3. In the overall sample, the rate of PTSD was higher in patients who were under the age of 40, white, homeless in the past 6 months, and currently unemployed. Analyses within each gender indicated the pattern of differences was similar between women and men. However, effects were stronger for women for three demographic variables (age, race, homelessness) and stronger for men than women for one variable (employment). Analyses within diagnostic groups largely paralleled analyses within gender. Stronger effects were found for the major mood disorder group, compared to the schizophrenia-schizoaffective group, on three demographic variables: age, race, and homelessness. Stronger effects were found for the schizophrenia-schizoaffective disorder group on one variable, employment. The clinical correlates of PTSD for the total sample, as well as within subgroups of men or women and schizo-



Table 2. Odds ratios for PTSD given exposure to trauma Men

Women

Total sample

Physical assault Childhood Adulthood Past yr Lifetime

2.22*** 2.24" 1.99"* 2.81"

3.07*" 2.95*" 2.98*" 4.64*"

2.53"* 2.51"* 2.29"* 3.48"*

Sexual assault Childhood Adulthood Past yr Lifetime

3.49*** 2.59"* 3.20*** 2.94***

4.05"* 2.79"* 2.80"* 3.77***

3.52*" 2.40*** 2.85*" 2.93"*

Note.—PTSD = posttraumatic stress disorder. " p < 0.01; * " p < 0.001

phrenia-schizoaffective disorder or major mood disorder, are shown in table 4. In the total sample, PTSD was more common in patients with mood disorders (compared to schizophrenia or schizoaffective disorder), current alcohol use disorder, more psychiatric hospitalizations in the past year, and a worse SF-12 Mental Component Summary score. PTSD was not related to current drug use disorder or to age of first hospitalization. In general, the associations between PTSD and clinical variables did not differ as a function of gender or diagnosis. Health correlates of PTSD for the total sample, as well as within subgroups of men or women and schizophrenia-schizoaffective disorder or major mood disorder, are shown in table 5. Each of the physical health indexes was related to PTSD. PTSD was more common in patients with chronic health problems, more health visits to a doctor, hospitalization for health reasons in the past 6 months, and worse SF-12 Physical Component Summary scores. Within-group gender and diagnostic analyses indicated similar effects across groups for number of visits to doctors for health problems and SF-12 Physical Component score, but not for health problems or hospitalization for medical reasons. For health problems, there were similar effects for PTSD between males and females, whereas the association was significant for patients with schizophrenia or schizoaffective disorder but not for those with major mood disorders. PTSD was related to nonpsychiatric hospitalizations among women and patients with major mood disorders but not for men and patients with schizophrenia or schizoaffective disorder.

Discussion Similar to prior research on trauma in patients with SMI (Greenfield et al. 1994; Lipschitz et al. 1996; Mueser et al. 1998), these findings document high rates of interpersonal trauma in childhood and adulthood, with women

49


more likely to have been sexually assaulted, and men more likely to have been physically assaulted (see Goodman et al. 2001, for an analysis of the correlates of trauma exposure in this same sample of patients). While women with SMI are clearly at increased risk for sexual victimization in childhood and adulthood, the relatively increased rate of sexual assault in men is noteworthy, with 29.2 percent reporting childhood sexual abuse, 24.5 percent reporting sexual assault in adulthood, and 7.6 percent reporting sexual assault in the past year. These rates of sexual assault throughout the lifetime of men with SMI are clearly higher than in the general population, where reported rates range between 7.3 percent and 16.0 percent (Finkelhor 1979; Kercher and McShane 1984; Baker and Duncan 1985; Risin and Koss 1987; Finkelhor et al. 1990; Priest 1992). The high rate of PTSD in this sample is consistent with other reports of PTSD in patients with SMI (Craine et al. 1988; Cascardi et al. 1996; Mueser et al. 1998, 2001; Switzer et al. 1999; McFarlane et al. 2001). The sharply elevated rate of current PTSD is a sobering demonstration of the vulnerability of people with SMI in the United States. As with the population as a whole, PTSD is one of the most potentially important clinical correlates of trauma exposure and one of the most common comorbid conditions for people with SMI. Last, the increased vulnerability for women with SMI to develop PTSD when exposed to interpersonal trauma (table 2) is similar to that reported in the general population (Kessler et al. 1995; Breslau et al. 1997). Results of this study are also consistent with earlier findings that overall rates of PTSD do not differ between men and women with SMI (Cascardi et al. 1996; Mueser et al. 1998, 2001; Switzer et al. 1999; McFarlane et al. 2001). The lack of gender differences in PTSD among patients with SMI may be partly due to the overall high rates of trauma exposure in this population. PTSD was associated with several demographic characteristics, including age (younger), race (white), homelessness, and current employment status (unemployed). Considering the high rate of childhood sexual and physical abuse in this sample of SMI, the association of PTSD with age may be due to the natural remission of PTSD over time in some people with PTSD (Kessler et al. 1995). The finding that African-American patients were less likely to have PTSD was in contrast to research on race and PTSD in the general population, in which minority status is weakly (effect size = 0.05) associated with higher rates of PTSD (Brewin et al. 2000). The race effects observed here could be related to differences in sampling strategy across the sites, as described in the Methods section. The higher rates of PTSD in unemployed, homeless patients are consistent with other studies indicating that

36.4% 26.7% x 2 ° 0.05 34.0% 35.0% x 2 = 2.70 32.3% 41.7% x 2 = 6.54* 36.8% 22.5%

33.6% 31.3% X2 ° 0.44 33.2% 35.7% x 2 = 8.69** 32.3% 46.2% x 2 = 6.92** 36.6% 25.3%

Poverty level At/below poverty level (n = 253) Above poverty level (n = 454)

Homeless past 6 mos No (n - 657) Yes (n= 119)

Currently employed No(n = 618) Yes (n= 154)

36.3% 29.2%

X2 = 6.11" 34.0% 21.2%

X2 = 3.22 30.1% 40.5%

28.6% 33.8%

X2 = 0.59 32.0% 36.5% X2 - 8.47" 32.3% 57.1%

29.3% 21.6%

31.1% 34.0%

X2 = 2.47 33.2%

X2 o 8.47** 38.0% 25.6%

X2-14.36* 43.8% 22.7% X 2 =1-81 38.9%

^ = 2.72 34.8% 28.1%

X = 0.04 31.1% 32.1%

2

X2 = 5.87* 42.7% 29.6%

NA

Females

2

X 2 =1.00 42.4% 34.6%

X2 = 5.36* 37.6% 57.9%

X2 = 0.07 41.7% 39.8%

41.1% 36.8%

X2 = 0.33 42.4%

X2 = 3.09 45.0% 30.4%

= 4.87* 49.5% 34.7% x

X = 0.26 42.9% 39.5%

2

Rate of PTSD In Each Subgroup, Broken out by Diagnosis Schizophrenia Mood spectrum disorders

* p < 0.05; " p < 0.01; '** p < 0.001

Note.—NA = not applicable; PTSD = posttraumatic stress disorder. Chi-square statistic tests whether patients with (vs. wfthout) PTSD differ significantty on demographic variable (e.g., gender). Among the 24 Hispanic clients, 11 (45.8%) had PTSD and among the 19 American Indian clients, 6 (31.6%) had PTSD.

X2 = 1 07 33.3%

X2 = 0.48 35.0%

Marital status Never married (n = 437) Divorced, widowed, separated (n = 256) Married (n = 80)

2

= 3.86* 38.3% 29.0%

x

= 15.61*" 40.6% 26.4%

Race White (n = 384) Black (n= 318)

2

X2 = 141 36.3% 31.0%

X2 = 5.73* 38.5% 30.3%

Age S 40.3 (n = 387) > 40.3 (n = 389) x

NA

-)C = 0.09 34.0% 35.0%

Males

Rate of PTSD in Each Subgroup, Broken out by Gender

Gender Male (n - 459) Female (n = 317)

Rate of PTSD In Each Subgroup for Total Sample

Table 3. Rates of PTSD across demographic characteristics


H

Z o

£

CO

s

25.6% 35.3% 49.6% X2 = 0.55 36.1% 32.7% X2 = 84.58*** 55.3% 14.0%

25.9% 36.7% 52.6% X2 = 1.07 36.8% 33.2% X 2 " 134.95*** 54.8% 14.6%

Age first hospitalization Early onset (< 22 yrs) Later onset (£ 22 yrs)

SF-12 Mental Component score Low score (< 43.6) High score (£ 43.6)

2

= 101.07*** 54.3% 12.7% x

X 2 =1.97 34.8% 29.0%

25.6% 34.7% 46.9%

X2 = 29.52*** 56.2% 18.8%

X2 = 0.02 42.5% 41.5%

26.8% 44.9% 59.7%

X 2 " 18.03***

X2 = 0.01 41.3% 40.4%

X2 = 0.66 39.4% 45.3%

NA

* p< 0.05; "p< 0.01;'" p< 0.001

Note.—NA - not applicable; PTSD » posttraumatic stress disorder; SF = Medical Outcomes Study Short Form 12-ltem Hearth Survey. Chi-square statistic tests whether patients with (vs. without) PTSD differ significantly on clinical variable (e.g., primary diagnosis).

X2 = 50.48*** 54.0% 15.4%

X2 = 0.61 38.1% 33.7%

26.2% 39.3% 58.1%

2

X 2 - 16.43***

)? = 19.75***

X2 = 39.87***

No. of psychiatric hospitalizations prior yr None(n = 429) One(n= 158) Two or more (n = 175)

X

X2 = 21.50***

X2 = 0.02 33.8% 34.5%

X^O.51 33.7% 36.5%

Current drug use disorder No (n = 573) Yes (n = 203)

X2 = 2.63 30.0% 38.4% X2 = 0.79 30.4% 34.5%

X2 = 3.63 33.0% 47.7%

X2 = 2.71 31.7% 39.8%

X2 ° 5.44* 32.3% 41.9%

Current alcohol use disorder No (n = 604) Yes (n= 172)

NA

Rate of PTSD In Each Subgroup, Broken out by Diagnosis Mood Schizophrenia disorders spectrum

=1.26 33.6% 41.4%

X2 = 3.44 29.3% 36.5% 37.1% 43.2% 27.3%

2

= 8.18 28.7% 38.2% 40.8% 47.1% 26.7% X

X2 = 11.26* 28.9% 37.4% 39.0% 44.9% 26.9%

Females

Males

Rate of PTSD In Each Subgroup, Broken out by Gender

Primary diagnosis Schizophrenia (n = 363) Schizoaffective (n = 163) Bipolar disorder (n = 141) Major depression (n = 78) Other (n = 26)

Rate of PTSD In Each Subgroup for Total Sample

Table 4. Clinical correlates of PTSD Downloaded from schizophreniabulletin.oxfordjournals.org at University of Portland on May 23, 2011

o

to

i

I

to

2

28.0% 31.2% 36.6% X2 - 0.36

29.9% 26.6% 40.7% X2 = 10.70*** 31.9% 60.6% X 2 = 12.64*" 44.0% 24.6%

X2 = 0.20 33.7% 37.0% X 2 " 12.07*** 42.6% 27.0%

X2 = 6.06* 32.9% 46.8% X2 - 24.60*** 43.3% 26.1%

No. of nonpsychiatric hospitalizations prior yr None (n = 692) One or more (n = 79)

SF-12 Physical Component score Low score (< 50.4) High score (£ 50.4)


X2 = 5.64 48.4% 32.3%

37.5% 58.8%

X2 = 5.40*

35.0% 42.2% 43.4%

X 2 " 1-18

X2 = 0.38 37.7% 40.8% 42.7%

* p< 0.05; "p< 0.01; * " p < 0.001

Note.—PTSD - posttraumatic stress disorder; SF - Medical Outcomes Study Short Form 12-ltem Health Survey. Chi-square statistic tests whether patients with (vs. without) PTSD differ significantly on health variable (e.g., health problems).

X2 = 13.92"* 39.9% 24.5%

31.3% 35.7%

X2 = 3.45

29.7% 37.9% 38.1%

= 5.36

29.8% 33.3% 39.5%

2 X

X2 = 3.50

X2 = 6.53*

= 19.93*" 22.0% 24.2% 41.3% x

No. of doctor visits for health problems None (n = 309) One (n= 159) Two or more (n = 301)

X2 = 6.03* 23.3% 32.1% 40.2%

2

= 13.60*** 26.9% 27.4% 43.7% x

Rate of PTSD in Each Subgroup, Broken out by Diagnosis Schizophrenia Mood spectrum disorders

X 2 - 18.50"* 25.8% 29.1% 42.0%

Females

Males

Rate of PTSD in Each Subgroup, Broken out by Gender

Hearth problems None (n= 194) One (n = 213) Two or more (n = 369)

Rate of PTSD in Each Subgroup for Total Sample

Table 5. Health correlates of PTSD

eS"

•?'

§•

w

3 K-

1" a-

2

.H

N>

o

.30



health on die SF-12, number of recent psychiatric hospitalizations, and alcohol use disorder. As found in several other reports (Mueser et al. 1998; Switzer et al. 1999; Neria et al. 2002), PTSD was more common in patients with a major mood disorder, especially major depression, than in patients with schizophrenia or schizoaffective disorder. This finding is in line with research from the general population indicating a high comorbidity between PTSD and major depression (Breslau et al. 1991; Kessler et al. 1995; Bleich et al. 1997; North et al. 1997) and suggests tiiat some of die patients in our sample may have major depression secondary to PTSD. Patients with PTSD reported significantly more mental health problems on the SF-12, as well as higher rates of alcohol use disorder. While trauma in patients with SMI has been found to be related to more severe psychiatric symptoms (Carmen et al. 1984; Beck and Van der Kolk 1987; Craine et al. 1988; Davies-Netzley et al. 1996; Briere et al. 1997), only one previous study has linked these problems to PTSD (McFarlane et al. 2001). Similarly, in the general population, substance use disorders have a high comorbidity with PTSD (Triffleman et al. 1995; Deering et al. 1996; Duncan et al. 1996; Kessler et al. 1997; Jacobson et al. 2001), and trauma is related to higher rates of substance abuse in patients with SMI (Goff et al. 1991; Rose et al. 1991). However, prior research has not documented die relationship between PTSD and alcohol abuse in patients with SMI. The presence of more severe mental health problems and alcohol abuse in patients with PTSD may account, in part, for their more frequent psychiatric hospitalizations. Theoretically, PTSD can be conceptualized as a general stressor, which, according to stress-vulnerability models of SMI, impinges on biological vulnerability to provoke symptom relapses (Falconer 1965; Liberman et al. 1986). In addition, it is well established that alcohol abuse leads to symptom relapses and rehospitalizations in patients with SMI (Drake et al. 1989, 19%; Linszen et al. 1994; Kozaric-Kovacic et al. 1995). Switzer et al. (1999) also found higher rates of psychiatric service utilization in their patients with SMI and comorbid PTSD. Aside from increased clinical problems, the patients with PTSD also reported more health problems, worse scores on the SF-12 Physical Component Summary, more doctor visits for health problems, and more nonpsychiatric hospitalizations over the past year (table 5). Odier studies of PTSD in patients with SMI have not examined health correlates, although poorer health is related to PTSD in die general population (Schnurr and Spiro 1999; Hidalgo and Davidson 2000; Kimerling et al. 2000; Zayfert et al. 2002). Health problems may be related to the chronic stress associated with PTSD, although it is also possible that medical problems exac-

53


PTSD is higher in persons with lower socioeconomic standing (Brewin et al. 2000). Interestingly, Zayfert et al. (2002) reported lower rates of employment for individuals with PTSD seeking treatment in an anxiety disorders clinic. Several other studies have documented high rates of trauma in homeless persons with SMI (Goodman et al. 1995; Davies-Netzley et al. 1996), and the high rates of PTSD in the homeless patients in this sample replicate this finding. This association also appears consistent with other research on the general population indicating that lower levels of social support are associated with higher vulnerability to PTSD (Brewin et al. 2000; Golding et al. 2002). The directionality of the relationship between homelessness and PTSD is unclear and may go both ways; patients witii PTSD may be more likely to become homeless because of fewer social supports and avoidance of trauma-related stimuli, but homelessness may also increase exposure to trauma, leading to or worsening PTSD. For age, race, and homelessness, the associations with PTSD were stronger among women than among men and, to a somewhat lesser extent, stronger among patients with mood disorders than among patients with schizophrenia spectrum disorders. However, in all subgroups the direction of the association between PTSD and the demographic variable was similar. For employment status, the opposite pattern was found, with associations strongest for men and for patients with schizophrenia spectrum disorders. The relationship between PTSD and demographic characteristics appears to be influenced more by gender than by diagnosis in this sample. That is, gender was significantly related to diagnosis, and the differences in the associations with PTSD were stronger between men and women than between schizophrenia-schizoaffective disorder and major mood disorders. However, it is unclear why the demographic correlates of PTSD were so strongly influenced by gender. In a comprehensive meta-analysis of 77 studies of risk factors for the development of PTSD, Brewin et al. (2000) found high heterogeneity across studies for most of the risk factors studied, including gender, age, race, and socioeconomic status. Furthermore, Brewin et al. found that a variety of factors moderated the associations between risk factors and PTSD, such as method of PTSD assessment (interview vs. questionnaire), gender composition of the sample, military versus civilian sample, prospective versus retrospective design, and inclusion of trauma over the lifespan versus focus on traumas in adulthood. As the present study focused on patients with SMI, in contrast to other studies of risk factors for PTSD, it is possible that the role of gender as a moderator of demographic risk factors is unique to the SMI population. PTSD was correlated with a range of different clinical measures, including psychiatric diagnosis, mental


K.T. Mueser ct al.

erbate chronic PTSD symptoms, increasing apparent comorbidity. PTSD was associated with worse functioning across all four measures of health, and the trend of associations was consistent across gender and diagnostic subgroups. Significant differences in relationships were observed for only two variables: number of health problems was strongly related to PTSD in the schizophrenia-schizoaffective disorder group but not in the mood disorders group, and PTSD was strongly related to nonpsychiatric hospitalizations in females, and moderately related among patients with mood disorders, but was not related in males or among patients with schizophrenia-schizoaffective disorder. These findings are difficult to interpret and require replication. The present findings have important implications for improving the clinical and health outcomes of patients with SMI. PTSD was correlated with both mental health and physical health problems, as well as psychiatric and medical service utilization. Although it is unclear whether PTSD actually worsens functioning in these areas, it is plausible, which suggests that the treatment of PTSD could improve psychiatric and health outcomes. Yet PTSD is rarely diagnosed in patients with SMI (Craine et al. 1988; Cascardi et al. 19%; Mueser et al. 1998; Switzer et al. 1999; McFarlane et al. 2001), and validated treatments for PTSD in this population have not been established. More rigorous research is needed to document the prevalence, correlates, and course of PTSD in patients with SMI. However, the findings of this study suggest that more attention should be directed at assessing PTSD in settings serving this population and at developing interventions to ameliorate PTSD and its attendant consequences. Several caveats of this study need to be acknowledged. First, although our sample of patients was large, patients were selected based on a combination of convenience sampling and probability sampling. Therefore, the findings may have limited generalizability to other samples of patients with SMI. Second, PTSD diagnoses were based on a screening instrument (the PCL) and not formal diagnostic interviews. Research in the general population (Blanchard et al. 1996) and among patients with SMI (Wolford 1999; Mueser et al. 2001) indicates that PTSD diagnoses based on the PCL are related to PTSD diagnoses based on structured interviews. Nevertheless, such diagnoses must be considered presumptive. These limitations notwithstanding, the present results suggest that PTSD may be an important comorbid disorder in patients with SMI that contributes to a more severe course of illness and higher service utilization. Accurate detection and treatment of PTSD may be critical to reducing distress and improving the psychiatric and health functioning of these patients.

References Baker, A.W., and Duncan, S.P. Child sexual abuse: A study of prevalence in Great Britain. Child Abuse & Neglect, 9:457^67, 1985. Beck, J.C., and Van der Kolk, B.A. Reports of childhood incest and current behavior of chronically hospitalized psychotic women. American Journal of Psychiatry, 144:1474-1476, 1987. Blanchard, E.P.; Jones-Alexander, J.; Buckley, T.C.; and Forneris, C.A. Psychometric properties of the PTSD Checklist. Behavior Therapy, 34:669-673, 1996. Bleich, A.; Koslowsky, M.; Dolev, A.; and Lerer, B. Posttraumatic stress disorder and depression. British Journal of Psychiatry, 170:479-482, 1997.

Breslau, N.; Davis, G.C.; Andreski, P.; Peterson, E.L.; and Schultz, L.R. Sex differences in posttraumatic stress disorder. Archives of General Psychiatry, 54:1044-1048, 1997. Brewin, C.R.; Andrews, B.; and Valentine, J.D. Metaanalysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68:748-766, 2000. Briere, J.; Woo, R.; McRae, B.; Foltz, J.; and Sitzman, R. Lifetime victimization history, demographics, and clinical status in female psychiatric emergency room patients. Journal of Nervous and Mental Disease, 185:95-101, 1997. Carmen, E.; Rieker, P.P.; and Mills, T. Victims of violence and psychiatric illness. American Journal of Psychiatry, 141:378-383, 1984. Cascardi, M.; Mueser, K.T.; DeGiralomo, J.; and Murrin, M. Physical aggression against psychiatric inpatients by family members and partners: A descriptive study. Psychiatric Services, 47:531-533, 19%. Craine, L.S.; Henson, C.E.; Colliver, J.A.; and MacLean, D.G. Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hospital and Community Psychiatry, 39:300-304, 1988. Davies-Netzley, S.; Hurlburt, M.S.; and Hough, R. Childhood abuse as a precursor to homelessness for homeless women in severe mental illness. Violence and Victims, 11:129-142, 1996. Deering, C.G.; Glover, S.G.; Ready, D.; Eddleman, H.C.; and Alarcon, R.D. Unique patterns of comorbidity in posttraumatic stress disorder from different sources of trauma. Comprehensive Psychiatry, 37:336-346, 1996.

54


Breslau, N.; Davis, G.C.; Andreski, P.; and Peterson, E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48:216-222, 1991.



Drake, R.E.; Mueser, K.T.; Clark, R.E.; and Wallach, M.A. The course, treatment, and outcome of substance disorder in persons with severe mental illness. American Journal of Orthopsychiatry, 66:42-51, 1996.

Golding, J.M.; Wilsnack, S.C.; and Cooper, M.L. Sexual assault history and social support: Six general population studies. Journal of Traumatic Stress, 15:187-197, 2002. Goodman, L.A.; Rosenberg, S.D.; Mueser, K.T.; and Drake, R.E. Physical and sexual assault history in women with serious mental illness: Prevalence, correlates, treatment, and future research directions. Schizophrenia Bulletin, 23(4):685-696,1997.

Duncan, R.D.; Saunders, B.E.; Kilpatrick, D.G.; Hanson, R.F.; and Resniak, H.S. Childhood physical assault as a risk factor for PTSD, depression, and substance abuse: Findings for a national survey. American Journal of Orthopsychiatry, 66:437^148, 1996.

Goodman, L.A.; Salyers, M.P.; Mueser, K.T.; Rosenberg, S.D.; Swartz, M.; Essock, S.M.; Osher, F.C.; and Butterfield, M.I. Recent victimization in women and men with severe mental illness: Prevalence and correlates. Journal of Traumatic Stress, 14:615-632, 2001.

Falconer, D.S. The inheritance of liability to certain diseases estimated from the incidence among relatives. Annals of Human Genetics, 29:51-76, 1965.

Goodman, L.A.; Thompson, K.M.; Weinfurt, K.; Corl, S.; Acker, P.; Mueser, K.T.; and Rosenberg, S.D. Reliability of reports of violent victimization and PTSD among men and women with SMI. Journal of Traumatic Stress, 12:587-599, 1999.

Falger, P.J.; Op den Velde, W.; Hovens, J.E.J.M.; Schouten, E.G.W.; de Groen, J.H.M.; and Van Duijn, H. Current posttraumatic stress disorder and cardiovascular disease risk factors in Dutch resistance veterans from World War II. Psychotherapy and Psychosomatics, 57:164-171, 1992.

Goodman, L.B.; Dutton, M.A.; and Harris, M. Physical and sexual assault prevalence among episodically homeless women with serious mental illness. American Journal of Orthopsychiatry, 65:468-478,1995.

Federal Register, 64(52), March 18, 1999, 13428-13430.

Greenfield, S.F.; Strakowski, S.M.; Tohen, M.; Batson, S.C.; and Kolbrener, M.L. Childhood abuse in firstepisode psychosis. British Journal of Psychiatry, 164:831^834,1994.

Figueroa, E.F.; Silk, K.R.; Huth, A.; and Lohr, N.E. History of childhood sexual abuse and general psychopathology. Comprehensive Psychiatry, 38:23-30, 1997. Finkelhor, D. Sexually Victimized Children. New York, NY: Free Press, 1979.

Hidalgo, R.B., and Davidson, J.R.T. Posttraumatic stress disorder: Epidemiology and health-related considerations. Journal of Clinical Psychiatry, 61(Suppl 7):5-13, 2000.

Finkelhor, D.; Hotaling, G.; Lewis, I.A.; and Smith, C. Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, risk factors. Child Abuse & Neglect, 14:19-28, 1990.

Jacobson, L.K.; Southwick, S.M.; and Kosten, T.R. Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry, 158:1184-1190,2001.

First, M.B.; Spitzer, R.L.; Gibbon, M.; and Williams, J.B.W. Structured Clinical Interview for DSM-IV Axis I Disorders—Patient Edition (SCID-I/P , Version 2.0). New York, NY: Biometrics Research Department, 19%.

Jenkinson, C ; Layte, R.; Jenkinson, D.; Lawrence, K.; Petersen, S.; Pake, C ; and Stradling, J. A shorter form health survey: Can the SF-12 replicate results from the SF-36 in longitudinal studies? Journal of Public Health Medicine, 19:179-186, 1997.

Foa, E.B.; Keane, T.M.; and Friedman, M.J., eds. Effective Treatments for PTSD. New York, NY: Guilford Publications, 2000.

Kercher, G.A., and McShane, M. The prevalence of child sexual abuse victimization in an adult sample of Texas residents. Child Abuse & Neglect, 8:495-501, 1984.

Gandek, B.; Ware, J.E.; Aaronson, N.K.; Apolone, G.; Bjorner, J.B.; Brazier, J.E.; Bullinger, M.; Kaasa, S.; Leplege, A.; Prieto, L.; and Sullivan, M. Cross-validation of item selection and scoring for the SF-12 health survey in nine countries: Results from the IQOLA project. Journal of Clinical Epidemiology, 51:171-178, 1998.

Kessler, R.C.; Crum, R.M.; Warner, L.A.; Nelson, C.B.; Schulenberg, J.; and Anthony, J.C. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the national comorbidity survey. Archives of General Psychiatry, 54:313-321, 1997.

Goff, D.C.; Brotman, A.W.; Kindlon, D.; Waites, M.; and Amico, E. Self-reports of childhood abuse in chronically psychotic patients. Psychiatry Research, 37:73—80, 1991.

Kessler, R.C.; Sonnega, A.; Bromet, E.; Hughes, M.; and Nelson, C.B. Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52:1048-1060, 1995.

55


Drake, R.E.; Osher, E C ; and Wallach, M.A. Alcohol use and abuse in schizophrenia: A prospective community study. Journal of Nervous and Mental Disease, 177:408-414,1989.


K.T. Mucser ct al.

Kimerling, R.; Clum, G.; and Wolfe, J. Relationships among trauma exposure, chronic posttraumatic stress disorder symptoms, and self-reported health in women: Replication and extension. Journal of Traumatic Stress, 13:115-128,2000.

Priest, R. Child sexual abuse histories among AfricanAmerican college students: A preliminary study. American Journal of Orthopsychiatry, 62:475-476, 1992. Resnick, H.S.; Kilpatrick, D.G.; Dansky, B.S.; Saunders, B.E.; and Best, C.E. Prevalence of civilian trauma and post-traumatic stress disorder in a representative national sample of women. Journal of Consulting and Clinical Psychology, 61:984-991, 1993.

Kozaric-Kovacic, D.; Folnegovic-Smalc, V.; Folnegovic, Z.; and Marusic, A. Influence of alcoholism on the prognosis of schizophrenic patients. Journal of Studies on Alcohol, 56:622-627, 1995.

Risin, L.I., and Koss, M.P. The sexual abuse of boys: Prevalence and descriptive characteristics of childhood victimizations. Journal of Interpersonal Violence, 2:309-323,1987.

Liberman, R.P.; Mueser, K.T.; Wallace, C.J.; Jacobs, H.E.; Eckman, T; and Massel, H.K. Training skills in the psychiatrically disabled: Learning coping and competence. Schizophrenia Bulletin, 12(4):631-647, 1986.

Lipschitz, D.S.; Kaplan, M.L.; Sorkenn, J.B.; Faedda, G.L.; Chorney, P.; and Asnis, G.M. Prevalence and characteristics of physical and sexual abuse among psychiatric outpatients. Psychiatric Services, 47:189-191,19%. McFarlane, A.C. Resilience, vulnerability, and the course of posttraumatic reactions. In: van der Kolk, B.A.; McFarlane, A.C; and Weisaeth, L., eds. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: Guilford Press, 1996. pp. 155-181.

Rose, S.M.; Peabody, C.G.; and Stratigeas, B. Undetected abuse among intensive case management clients. Hospital and Community Psychiatry, 42:499-503, 1991. Rosenberg, S.D.; Drake, R.E.; Wolford, G.L.; Mueser, K.T.; Oxman, T.E.; Vidaver, R.M.; Carrieri, K.L.; and Luckoor, R. The Dartmouth Assessment of Lifestyle Instrument (DALI): A substance use disorder screen for people with severe mental illness. American Journal of Psychiatry, 155:232-238, 1998.

McFarlane, A.C; Bookless, C ; and Air, T. Posttraumatic stress disorder in a general psychiatric inpatient population. Journal of Traumatic Stress, 14:633-645, 2001.

Rosenberg, S.D.; Goodman, L.A.; Osher, F.C.; Swartz, M.; Essock, S.M.; Butterfield, M.I.; Constantine, N.T.; Wolford, G.L.; and Salyers, M.P. Prevalence of HIV, Hepatitis B and Hepatitis C in people with severe mental illness. American Journal of Public Health, 91:31-37, 2001.

Mueser, K.T.; Goodman, L.B.; Trumbetta, S.L.; Rosenberg, S.D.; Osher, F.C.; Vidaver, R.; Auciello, P.; and Foy, D.W. Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 66:493-499, 1998.

Rosenberg, S.D.; Wolford, G.I.; Jankowski, M.K.; Rosenberg, H.J.; Mueser, K.T.; and Vidaver, R. "Reliability, Validity and Diagnostic Accuracy of the PCL for Clients With Severe Mental Illness." Unpublished manuscript, 2002.

Mueser, K.T.; Rosenberg, S.D.; Goodman, L.A.; and Trumbetta, S.L. Trauma, PTSD, and the course of schizophrenia: An interactive model. Schizophrenia Research, 53:123-143,2002.

Salyers, M.P.; Bosworth, H.B.; Swanson, J.W.; LambPagone, J.; and Osher, F.C. Reliability and validity of the SF-12 Health Survey among people with severe mental illness. Medical Care, 38:1141-1150, 2000.

Mueser, K.T.; Salyers, M.P.; Rosenberg, S.D.; Ford, J.D.; Fox, L.; and Cardy, P. A psychometric evaluation of trauma and PTSD assessments in persons with severe mental illness. Psychological Assessment, 13:110-117,2001.

Schnurr, P.P., and Spiro, A.I. Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans. Journal of Nervous and Mental Disease, 187:353-359, 1999.

Neria, Y.; Bromet, E.J.; Sievers, S.; Lavelle, J.; and Fochtmann, L.J. Trauma exposure and posttraumatic stress disorder in psychosis: Findings from a first-admission cohort. Journal of Consulting and Clinical Psychology, 70:246-251, 2002.

Stein, M.B.; Walker, J.R.; Hazen, A.L.; and Forde, D.R. Full and partial posttraumatic stress disorder: Findings from a community survey. American Journal of Psychiatry, 154:1114-1119, 1997.

North, C.S.; Smith, E.M.; and Spitznagel, E.L. One-year follow-up of survivors of a mass shooting. American Journal of Psychiatry, 154:1696-1702, 1997.

56


Rodriguez, N.; Ryan, S.W.; Van De Kemp, H.; and Foy, D.W. Posttraumatic stress disorder in adult female survivors of childhood sexual abuse: A comparison study. Journal of Consulting and Clinical Psychology, 65:53-59, 1997.

Linszen, D.; Dingemans, P.; and Lenior, M. Cannabis abuse and the course of recent onset schizophrenic disorders. Archives of General Psychiatry, 51:273-279, 1994.



Straus, M. New scoring methods for violence and new norms for the Conflict Tactics Scales. In: Straus, M., and Gelles, R., eds. Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8145 Families. New Brunswick, NJ: Transaction Books, 1989&. pp. 535-559. Straus, M.A.; Hamby, S.L.; Boney-McCoy, S.; and Sugarman, D.B. The Revised Conflict Tactics Scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17:283-316, 1996. Switzer, G.E.; Dew, M.A.; Thompson, K.; Goycoolea, J.M.; Derricott, T.; and Mullins, S.D. Posttraumatic stress disorder and service utilization among urban mental

The Authors

health center clients. Journal of Traumatic Stress, 12:25-39, 1999.

Kim T. Mueser, Ph.D., is Professor of Psychiatry and Community and Family Medicine, Dartmouth Medical School in Lebanon, NH, and New-HampshireDartmouth Psychiatric Research Center, Concord, NH. Michelle P. Salyers, Ph.D., is Assistant Scientist, CoDirector, ACT Center of Indiana, Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN. Stanley D. Rosenberg, Ph.D., is Professor of Psychiatry, Dartmouth Medical School in Lebanon, NH; Director, Dartmouth Trauma Intervention Research Center in Hanover, NH; and New Hampshire-Dartmouth Psychiatric Research Center, Lebanon, NH. Lisa A. Goodman, Ph.D., is Associate Professor, Department of Counseling and Developmental Psychology, School of Education, Boston College, Boston, MA. Susan M. Essock, Ph.D., is Professor and Director, Division of Health Services Research, Department of Psychiatry, Mount Sinai School of Medicine, New York, NY. Fred C. Osher, M.D., is Associate Professor and Director, Center for Behavioral Health, Justice, and Public Policy, Department of Psychiatry, University of Maryland, Baltimore, MD. Marvin S. Swartz, M.D., is Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC. Marian I. Butterfield, M.D., M.P.H., is Core Research Investigator, Durham Veterans Administration Institute for Clinical and Epidemiological Research, and Research Associate Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.

Triffleman, E.G.; Marmar, C.R.; Delucchi, K.L.; and Ronfeldt, H. Childhood trauma and posttraumatic stress disorder in substance abuse inpatients. Journal of Nervous and Mental Disease, 183:172-176, 1995. Ware, J.E.J.; Kosinski, M.; and Keller, S.D. SF-12: How To Score the SF-12 Physical and Mental Health Summary Scales. 3rd ed. Lincoln, RI: Quality Metric, 1998. Ware, J.J.; Kosinski, M.; and Keller, S.D. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care, 34:220-233, 1996. Wolford, G.I. "Formats for Assessing HIV Risk in Severely Mentally 111 People." National Institute of Mental Health grant RO-1 MH60073, 1999. Zayfert, C ; Dums, A.R.; Ferguson, RJ.; and Hegel, M.T. Health functioning impairments associated with posttraumatic stress disorder, anxiety disorders, and depression. Journal of Nervous and Mental Disease, 190:233-240, 2002.

Acknowledgments The 5 Site Health and Risk Study Research Committee includes from Connecticut: Jerilynn Lamb-Pagone, R.N., M.S.N.; Maryland: Lisa J. Garber, B.S., Jean S. Gearon, Ph.D., Richard W. Goldberg, Ph.D., John D. Herron, LCSW-C, Raymond S. Hoffman, M.D., and Corina L. Riismandel, B.A.; New Hampshire: Robin A. Boynton,

57


Patricia C. Carty, M.S., Robert E. Drake, M.D., Mark C. Iber, P.A., Ravindra Luckoor, M.D., Gemma R. Skillman, Ph.D., Robert M. Vidaver, M.D., and Rosemarie S. Wolfe, M.S.; North Carolina: Mary E. Becker, M.S., Hayden B. Bosworth, Ph.D., Barbara J. Burns, Ph.D., Richard Frothingham, M.D., Ronnie D. Homer, Ph.D., Lauren M. Mclntyre, Ph.D., Keith G. Meador, M.D., M.P.H., Patricia M. Spivey, B.A., Karen M. Stechuchak, M.S., and Jeffrey W. Swanson, Ph.D. This research was supported by National Institutes of Health grants R01-MH50094-03S2 (S. Rosenberg, Ph.D.), P50-MH43703 (D. Steinwachs, Ph.D.), R01-MH48103-05 (M. Swartz, M.D.), P50-MH51410-02 (M. Swartz, M.D.), R24-MH54446-05 (S. Woods, M.D.), R01-MH52872 (S. Essock, Ph.D.), and Department of Veterans Affairs, Health Services Development and Research Service, through program 824 funds and the Cooperative Studies Program (CSP706-D) (M. Butterfield, M.D.).

Straus, M. Measuring intra-family conflict and violence: The Conflict Tactics Scales. In: Straus, M., and Gelles, R., eds. Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8145 Families. New Brunswick, NJ: Transaction Books, 1989a. pp. 29-47.
