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Journal of Traumatic Stress, Vol. 10, No. 3, 1997

Posttraumatic Stress Disorder, Self- and Interpersonal Dysfunction Among Sexually Retraumatized Women Marylene Cloitre,1,2 Polly Scarvalone,1 and JoAnn Difede1

This study assessed self and interpersonal dysfunction as well as posttraumatic stress disorder (PTSD) among three groups of women: women sexually assaulted in both childhood and adulthood, women sexually assaulted only in adulthood and women who were never assaulted. Rates of PTSD were high and equivalent in the two assault groups. However, retraumatized women were more likely to be alexithymic, show dissociation scores indicating risk for dissociative disorders, and to have attempted suicide compared to the other two groups, who did not differ from each other. Additionally, only the retraumatized women experienced clinically significant levels of interpersonal problems. The findings suggest that formulations more inclusive than PTSD are required to capture the psychological difficulties experienced by this population. Treatment implications are discussed. KEY WORDS: Posttraumatic stress disorder; sexual assault; child abuse; retraumatization.

Sexual retraumatization among women is highly prevalent and little understood. Community surveys indicate that at least 50% of adult rape victims have a history of early life sexual victimization (Russell, 1983). The converse is also evident: women abused as children are at increased risk for later sexual victimization (Fromuth, 1986; Gidycz, Coble, Latham, & Layman, 1993; Koss & Dinero, 1989; Wyatt, Guthrie, & Notgrass, 1992). Indeed, among women reporting a history of sexual assault, the majority 1Department

of Psychiatry, New York Hospital-Cornell Medical Center, New York, New York, 10021. 2To whom correspondence should be addressed at Payne Whitney Clinic, Box 147, New York Hospital-Cornell Medical Center, New York, New York 10021. 437 0894-9867/97/0700-0437$12.50/l O 1997 International Society for Traumatic Stress Studies

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(65%) report having been assaulted in both childhood and adulthood, with much smaller numbers reporting only one or the other form of assault (Wyatt et al., 1992). Despite the fact that retraumatized women make up the largest subgroup of sexually assaulted women, there is very little information about the psychological impact of experiencing assaults in both childhood and adulthood. Some studies have implicitly approached the issue by comparing the symptom profiles of women with single versus multiple sexual assaults (Gidycz et al., 1993; Marhoefer-Dvorak, Resick, Hutter, & Girelli, 1988; Sorenson, Siegal, Golding, & Stein, 1992). However, the life period in which the first assault took place (childhood or adulthood) is rarely identified. Whether an assault occurred in childhood or adulthood matters, as the impact of interpersonal violence which first occurs in childhood may be qualitatively different from that which occurs in adulthood. Various theorists have suggested that understanding the sequelae of childhood sexual violence in terms of a posttraumatic stress disorder (PTSD) model underestimates the range of negative effects (Finkelhor, 1984; Herman, 1992; Roth, Pelcovitz, van der Kolk, & Mandel, 1995). Contemporary developmental theorists posit that abuse which occurs during childhood profoundly interferes with the developmental tasks of that period, namely self-other relatedness and self-integration (Cole & Putnam, 1992; Harter, Alexander, & Neimeyer, 1988). Cole and Putnam (1992), for example, suggest that childhood sexual abuse has unique negative effects on victims' sense of self and social functioning as revealed in dissociation, difficulties with affect regulation and impulse control (e.g., suicide attempts) as well as with difficulties with trust and intimacy in relationships. Dynamic accounts have suggested that one reason abuse undermines the developmental task of selforganization and affect regulation is that the child is deprived of the healthy and much needed mediation of a caretaker to modulate physiological arousal and provide a balance between soothing and stimulation (van der Kolk, 1987). Furthermore, the abuse-laden relationship with the caretaker sets down a prototype for interpersonal relating which is fraught with difficulties around power, control, trust and intimacy (Cloitre, 1995). Most studies investigating the psychological profile of sexually retraumatized women have not assessed these aspects of functioning and have been limited to symptoms such as anxiety, depression and those associated with PTSD. The risk of this type of assessment is that it produces only a partial picture of the psychological difficulties of women who have experienced sexual assault in both childhood and adulthood, making them appear more similar to adult rape victims than they really are.

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Retraumatization

The purpose of this study was to assess not only the diagnostic status, but also the self and interpersonal functioning of women with a history of both child and adulthood assault compared to women who were assaulted only in adulthood and to women who were never assaulted. We expected that while the rate of PTSD might be similar between the two assault groups, only the retraumatized women would show significant self and interpersonal dysfunction.

Method

Study Participants The study sample of 56 women consisted of three groups. The retraumatized (FT) group (n = 24) included women who reported a history of sexual abuse in childhood and at least one sexual assault in adulthood. The adult assault only (AAO) group (n = 16) were women who reported at least one sexual assault as an adult but no history of childhood abuse. The control or no assault (NA) group (n = 16) reported no history of childhood abuse or adult assault. Procedure Advertisements were placed in local papers announcing potential free assessment and treatment of rape-related psychological difficulties for women. Women responded to the ads by calling the service. A phone screen was completed in which the study criteria were reviewed and a description of the study given. Women who did not meet criteria for the treatment study were offered referrals to other clinics in the community. The control group was recruited through local advertisements seeking women who had never experienced rape, attempted rape or childhood neglect, physical or sexual abuse. The control group was paid $40.00 for participation. Following the phone screen, potential study participants were invited to the trauma study service for clinical assessment. All participants received identical assessments and clinical interviews. Exclusion criteria for all study participants were current or past history of schizophrenia, current or past history of organic brain syndrome, presence of eating disorder or borderline personality disorder, and acute suicidal risk. Women who reported a history of childhood sexual abuse were designated as members of the Retraumatized (RT) group, women who reported that they had not experienced abuse in childhood were designated as members of the Adult Assault Only (AAO) group.


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Clinical Interviews

Measures Structured Clinical Interview for DSM-III-R I and II (SCID I and II: Spitzer, Williams, & Gibbon, 1987; Spitzer, Williams, Gibbon, & First, 1989). These are diagnostic interviews to acquire information about DSMIII-R Axes I and II criteria, respectively. The SCID I and II have acceptable joint interview interrater reliabilities with kappas between .70 and .94 (Skre, Onstad, Torgersen, & Kringlen, 1991). The Child Maltreatment Interview Schedule. This 193-item instrument gathers information about parental emotional, physical and sexual abuse and neglect (Briere, 1992). It has successfully discriminated among the long-term effects of various types of abuse in adult survivors (Briere & Runtz, 1990). We randomly selected 10 interviews of participants reporting a history of childhood abuse during the initial screen to examine inter-rater reliability on a subset of variables. Kappas for each of the variables were as follows: sexual abuse by father figure = 1.00, extent of sexual abuse (frequency and duration) = .56, physical abuse by mother figure = .80. Sexual Assault History Initial Interview Schedule, This 167-item interview obtains information concerning history of adult sexual assault and other types of interpersonal victimization in adulthood (e.g., physical assault, robbery). It has been used in previous studies of rape victims (Resick, 1987). The same ten subject interviews identified above were assessed for interrater reliabilities on presence of at least one adult sexual assault (kappa = 1.00), designation of stranger rape (kappa = .41), designation of acquaintance rape (kappa = 1.00).

Self-Functioning Measures The Toronto Alexithymia Scale (TAS; Taylor et al., 1988). The TAS is a 26-item, psychometrically sound self-report questionnaire that assesses difficulties in recognizing and verbalizing feelings. The scale appears sensitive to chronicity of trauma, in that higher scores have been associated with frequency of traumatic events (Zeitlin, McNally, & Cassiday, 1993). Items in this scale include "When I'm upset, I don't know if I'm sad, frightened or angry." and "It is difficult for me to find the right words for my feelings." Scores can range from 26 to 130. A TAS score of 74 or higher indicates alexithymia (Taylor, et al., 1988). Internal reliability as measured by Cronbach's alpha coefficient in our sample was .69.

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Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986). The DES is a reliable 28-item self-report measure of subjective experiences with dissociative states. High DES scores have been associated with a history of child abuse among clinical and nonclinical samples (Chu & Dill, 1990; Sandberg & Lynn, 1992). Scores range from 0 to 100. Following the guidelines established by Steinberg, Rounsaville and Cicchetti (1991), we used a cut-off score of 20 or more to identify the percent of study participants who were at risk for a dissociative disorder. Items in this scale reflect a range of experiences such as "Sometimes people have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don't remember all or part of the trip," and "Some people find that they are approached by people that they do not know who call them by another name or insist that they have met them before." The scale demonstrated high internal consistency in our sample (alpha = .95). Suicidal behavior. This information was elicited by the clinician, using the query " Have you ever had a period of time where you felt so bad that you tried to hurt or kill yourself?" Lethality of attempts ranged from mild (e.g., took 10 aspirins and suffered mild gastritis) to severe (e.g., overdose resulting in respiratory arrest or coma). Suicide attempts were selected as the behavioral measure of self functioning as they reflect an experientially salient, clinically relevant and highly negative outcome in self-functioning. Interpersonal Functioning Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988). The IIP is a psycharaetrically sound 127-item self-report measure which examines difficulties in six dimensions of interpersonal functioning: assertiveness, sociability, intimacy, submissiveness, responsibility and control. The items for all six dimensions are organized in two ways. Some items are introduced with the phrase "It is hard for me to..." followed by a possible problem, such as "say no to other people" (assertive item), or "have someone dependent on me" (intimacy item). The second item phrasing concerns things the study participant does too much, such as "I feel competitive even when the situation does not call for it" (submissive item) or "I blame myself too much for causing other people's problems" (responsibility item). Items are rated on a scale from 0 (not at all) to 4 (extremely). Subscale measures can range from 0 to 4. In our sample, the global scale was highly reliable (alpha = .98) and internal consistency ranged from .75 to .96 for the subscales.


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Definitions of Assault and Abuse Categories Adult sexual assault was defined as completed or attempted efforts of forced sexual events (vaginal intercourse, anal intercourse, fellatio, and cunnilingus, and objects in any orifice) occurring at or after the age of 18, as reported by the study participant. Information was collected concerning whether the event was accompanied by verbal threat to life and/or presence of a weapon. Childhood sexual abuse was defined as the participant's report of at least one incident of sexual contact before the age of 18 (fondling, attempted or completed vaginal, oral or anal intercourse) initiated by a family member, caretaker or trusted adult. In order to distinguish coercive sexual experiences from voluntary sexual experimentation, in this definition, the perpetrator had to be at least 5 years older than the participant. If the age difference was less than 5 years, only incidents involving coercion or that were undesired were included. Childhood physical abuse was defined as the report of 1) at least one incident of cruel and unusual punishment by the parent or carefigure (e.g., being locked in a refrigerator, being hung upside down from the top of a stairway) or (2) at least 12 incidents within 1 year (named the "worst" year) in which the parent or carefigure physically and purposefully acted against the child (e.g., hit, punch, cut or push) and by doing so produced bruises, bleeding, scratches, broken bones or teeth.

Results Subject Characteristics Comparisons of the three groups on sociodemographic characteristics revealed that the groups did not differ significantly on any characteristic. The total sample ranged widely in age with 53% between the ages of 18 and 30 and 47% between 31 and 65. The mean age was 33.5 (SD = 10.6) for the sample as a whole. The sample was predominantly White (76%), employed (92%) and highly educated (91% with some college to graduate training). Slightly over half were currently unmarried (55%) and most (89%) did not have children.

Rape Characteristics The two assault groups did not differ in length of tune since most recent sexual assault (M = 10.2 years, SD = 8.4) nor in the type of threat

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used during the assault (50% reported no verbal or physical threat). However, compared to the AAO group, the RT group was more likely to have been raped by an acquaintance (36% vs. 81% respectively), x2 (1, N = 35) = 7.36, p = .007, and to have been raped more than once in adulthood (21% vs. 71% respectively), x2 (1, N = 35) = 8.41, p = .004 (see Table 1).

Other Interpersonal Violence Events The three groups differed on the presence of physical assaults in adulthood, x2 (2, N = 50) = 7.75, p = .02, with 70% of the RT group experiencing at least one physical assault not related to the rape event(s) in comparison to 29% of the AAO group and 31% of the NA group. There were no differences among the three groups in rates of other types of interpersonal violence such as robbery, burglary, and purse snatching (see Table 1). Table 1. Characteristics of Most Recent Rape and Other Types of Interpersonal Violence Group RT NA AAO (n=24) (n = 16) (n = 16) % % % X2 p Value Rape Months since last rape (mean) Number of times raped in adulthood (more than once) Offender of last rape Stranger Acquaintance Type of Threat Weapon only Verbal threat to life only Weapon and verbal threat Neither weapon nor verbal threat Other interpersonal violence Physical assault Robbery Burglary Auto theft Purse snatching a,bDifferent

114 71a

103 21*

19a 81

64b 36

10 26 11 53

15 23 15 46

— — — —

70a 35 35 6 47

29b 14 21 0 57

31b 19 38 0 38

— —

8.41

ns .004

7.36

.007

— —

ns

7.75

.02 ns ns ns ns

superscripts indicate significant differences between or among the groups.


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Table 2. Rate of Current Axis I Disorders by Assault History Group RT AAO NA ( n = 2 4 ) (n = 16) (n = 16) % % % X2 p Value Posttraumatic stress disorder Affective disorders Major depression Dysthymia

Other anxiety disorders General anxiety disorder Simple phobia Social phobia Panic disorder (with and without agoraphobia) abDifferent

75

70

6

18.85 .0001

40 25

30 0

0 0

8.07 .02 7.29 .03

40 50 35

20 10 10

6 0 0

ns 13.57 .001 8.07 .02

25

20

6

ns

superscripts indicate significant differences between or among the groups.

Characteristics of Childhood Abuse Of the 24 women in the RT group, 47% had been sexually abused by a father figure; 14% by a mother figure, 14% by a male sibling or other relative (e.g., uncle, cousin) and 23% by a trusted adult (e.g., family friend). In addition, 75% had been physically abused by a mother figure and 28% by a father figure. Age of onset of abuse ranged from ages 3 to 16 (M = 72 years, SD = 3.8). Posttraumatic Stress and other Axis I Diagnoses The two assault groups did not differ in rates of PTSD; 75% of the RT group and 70% of the AAO group met criteria for the disorder (see Table 2). One participant in the NA group met criteria for PTSD related to witnessing her parents' physical abuse of each other. Compared to the NA group, the RT group had higher rates of PTSD, x2 (1, N = 36) = 17.01, p < .001 and major depressive disorder, x2 = (1,N = 36) = 8.22, p = < .004. Similarly, when compared to the NA group, the AAO group was also more likely to have higher rates of PTSD, x2 (1, N = 26) = 11.74, p = < .001, and of major depression, x2 (1, N = 26) = 5.43, p < .002. Table 2 presents the rate of current disorders for the three groups as well

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Table 3. Interpersonal Functioning by Assault History Group

RT (n = 24)

(n = 16)

NA (n = 16)

AAO

M

(SD)

M

(SD)

M

(SD)

F

P Value

Inventory of Interpersonal Problems

1.71a

(.63)

1.12*

(.54)

.76*

(.41)

14.66

.0001

Subscales Assertive Sociable Submissive Intimacy Responsible Control

2.02a 2.23a 1,40a 1.18a 2.14a .93"

(.76) (.93) (.78) (.68) (.83) (.55)

1.35* 1.25* .91b .70b

(.74) (.92) (.53) (.53) (.61) (.30)

.76c .81* .76* .56* .91* .59*

(.74) (.50) (.43) (.41) (.68) (.49)

15.53 15.34 5.61 6.35 14.02 4.10

.0001 .0001 .006 .004 .0001

Measures

a-cDifferent

1.33b

.51b

.02

superscripts indicate significant differences among groups.

as the Chi-square and associated p-values for a three-way (i.e., three-group) comparisons. Otherwise, the adult AAO group did not differ from the NA group in the presentation of any other affective or anxiety disorder. The RT group, in contrast, had higher rates of dysthymia, x2 (1, N = 36) = 4.65, p = .03, generalized anxiety disorder, x2 (1, N = 36) = 5.4, p = .02, simple phobia, x2 (1, N = 36) = 11.08, p < .001, and social phobia, x2 (1, N = 36) = 6.95, p = .01, than the NA group. Dissociation Nearly half (46%) of the RT women scored at or above the DES cutoff of 20, compared to 13% of the AAO women and to 14% of the NA group women (see Figure 1). Fair-wise comparisons indicated that a significantly larger number of RT women were at risk for a dissociative disorder compared to the AAO women, x2 (1, N = 39) = 4.39, p = .04, and to the NA group, x2 (1, N = 38) = 3.91, p = .05. The AAO group and the NA group did not differ from each other. Alexithymia Alexithymia was operationalized as a score of 74 or more on the TAS (Taylor et al., 1988). A majority (71%) of RT women scored in this range


446

Fig. 1. Self-functioning measures across the three groups.

compared to only 7% of the AAO women and 6% of the NA group. Pairwise comparisons indicated that significantly more RT women were alexithymic compared to the AAO women, x2 (1, N = 39) = 15.29, p < .001, and the NA group, x2 (1, N = 40) = 16.18, p < .001. The AAO and NA groups did not differ from each other (see Figure 1). Suicidal Behavior A substantial number of RT women had made at least one suicide attempt in their lifetime (45%), a rate significantly higher than that for the AAO group (13%), x2 (1, N = 33) = 5.12, p = .03, and the NA group (0%), X2 (1, N = 35) = 11.80, p < .001. The AAO and NA groups did not differ from each other (see Figure 1). Sixty percent of the first suicide attempts in the RT group occurred during or after the childhood abuse but before the adult sexual assault The two suicide attempts in the AAO group occurred after the sexual assaults. Interpersonal Problems One-way analyses of variance (ANOVAs) followed by post-hoc pairwise comparisons (Student Newman-Keuls, p < .05) were performed on the

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Retraumatization

global IIP score as well as the subscales. The means and standard deviations for each group are presented in Table 3. The global IIP score indicated significant differences across the three groups, F(2, 54) = 14.66, p < .0001, with post hoc analyses revealing that the RT group scored significantly higher than the other two groups who did not differ from each other. With the exception of the assertiveness subscale, in which both assault groups scored significantly higher than the NA group, F(2,54) = 15.53, p < .0001, this pattern of differences was maintained across the subscale scores. The RT group scored higher than the other two groups on the subscales concerning sociability, F(2, 54) = 15.34, p = .0001, submissiveness, F(2, 54) = 5.61, p = .006, intimacy, F(2, 54) = 6.35, p < .004, responsibility, F(2, 54) = 14.02, p < .0001, and control, F(2, 54) = 4.11, p = .02. Although not statistically significant, the AAO group did score consistently higher on each of the IIP subscales, suggesting an elevation in interpersonal difficulties. To further assess the interpersonal difficulties of women assaulted in adulthood, we compared our sample to Horowitz's (Horowitz, 1986) normative data on psychiatric populations. Chi-squares were performed on the number of subjects within each group who scored at or above the mean for each IIP subscale. No differences emerged between the AAO and NA groups. Thus, these women did not evidence the elevation of interpersonal problems at levels found in general psychiatric populations. RT women, on the other hand, were more likely than NA group women to score above the psychiatric mean on every subscale. Effect of other adult interpersonal violence on self and interpersonal functioning among retraumatized women. We wished to determine whether the significant rates of dissociation, alexithymia, suicide attempts and interpersonal dysfunction among retraumatized women derived from the presence of additional adult traumas such as multiple rapes or physical assaults. Chisquare analyses were performed comparing retraumatized women with one versus more than one adult sexual assault on the three self-functioning measures and the global IIP scores greater than the Horowitz (1986) psychiatric sample mean. No significant differences emerged. A second set of chi-square analyses were performed comparing retraumatized women with no versus at least one physical assault on the same self and interpersonal measures. Again no differences between the two groups emerged.

Discussion Rates of PTSD were high and equivalent in the retraumatized (75%) and adult sexual assault only (70%) groups. While the assault groups met criteria for other comorbid diagnoses, especially depression, the predomi-

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Cloitre, Scarvalone, and Difedc

nant current diagnosis for both groups was PTSD. Retraumatized women differed from the adult assault and control groups in that they were more likely to be alexitihymic, show DES scores indicating risk for dissociative disorders and to have attempted suicide. Retraumatized women also experienced clinically significant problems in all domains of interpersonal functioning while the other two groups did not. The results indicated that retraumatized women suffered from PTSD plus significant self- and interpersonal dysfunction. In contrast to the retraumatized women, those who were assaulted only in adulthood showed very few problems in self- and interpersonal functioning and appeared quite similar in these dimensions to women who had never been assaulted. Consistent with a developmental analysis, this pattern of results suggests that problems in self and interpersonal functioning were associated with childhood abuse and not adult sexual assault. Although retraumatized women experienced a greater number and variety of adult interpersonal trauma, these experiences were not associated with higher levels self and interpersonal dysfunction, discounting the possibility that additional adulthood traumas were the primary source of such difficulties among retraumatized women. While the negative consequences of an adult sexual assault seem adequately captured by the PTSD diagnosis, the problems of the retraumatized women are more extensive. The constellation of symptoms are much more in accord with the developing diagnostic category labeled disorders of extreme stress (DES) which describes symptoms expressive of self and interpersonal dysfunction which occur in people who have been exposed to chronic interpersonal trauma (Herman, 1992). Data from the DSM-IV field trial indicated that among individuals with PTSD, a subset also had DES and that the presence of PTSD plus DES varied as a function of age of onset of earliest trauma exposure (van der Kolk et al., 1996). Our data on the retraumatized women are consistent with this more complex diagnostic profile. Unlike rape survivors, retraumatized women experienced repeated and various forms of interpersonal violence: they were more likely to have experienced more than one sexual assault in adulthood and to have been physically attacked, independent of the rape event(s). The factors which produce and/or maintain vulnerability to multiple and frequent victimization remain unidentified. However, the symptoms empirically derived as associated with the retraumatized group, as well as our own clinical experience, may help identify some potential risk factors. First, the high level of dissociation among retraumatized women makes them not only frequently unaware of their environment and but also may make them look confused or distracted, marking them as "easy targets" to

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sexual and other predators. Second, their difficulty in identifying and labeling emotional states (alexithymia), impairs their ability to fully experience and recognize internally generated "danger" signals when confronted with threats to self such as unsafe environments or potentially dangerous individuals. The presence of a high rate of acquaintance rape among retraumatized women is notable. Problems with labeling feeling states may also play a role in these events. For example, difficulty in labeling feeling states results in a diminished emotional vocabulary and affectively out-of-synch self-presentation which may lead others to more easily minimize or actively disregard their "no." Perhaps equally important, retraumatized women may be less able to accurately read others' emotional cues, e.g., distinguish between anger that is appropriate versus dangerous, thus diminishing their capacity to respond effectively in interpersonally threatening situations. Last, among women with child abuse histories, boundary violations are "normative" and intricately bound up with their expectations of close, intimate relationships. The presence of repeated boundary violations in childhood may produce the acceptance of or confusion about such behaviors in adult intimate relationships. Specific problems in interpersonal functioning may contribute further to the risk of retraumatization. First, as reflected in the IIP data, retraumatized women reported significant difficulties with sociability. The sociability subscale actually represents a strong component of difficulty with trust, a central problem among childhood abuse survivors, and one which can undermine appropriate judgement about with whom to engage in initial acts of intimacy (e.g., going into someone's apartment). In addition, retraumatized women reported difficulties not only with being assertive but also with being too controlling and responsible. This indicates confusion about power dynamics in interpersonal relationships, such as when it is appropriate to be assertive or, conversely, mistaking scenarios in which they believe themselves responsible and in control of events when, in fact, they are not. Last, the high rate of suicide attempts (45%) among retraumatized women is alarming. Sixty percent of these attempts occurred during or after the abuse but before the adult assault. At the tune of the suicide attempts, the women frequently recalled feeling deep despair, disgust with themselves, alienation from the larger social environment and an inability to imagine how to escape from or change their life condition. Based on our experience in pretreatment interviews, many of these feelings persist to some degree to the current day, indicating the need for the development of effective treatments for these women. Systematic treatment outcome studies with sexual assault survivors have largely focused on the treatment of PTSD (Foa, Rothbaum, Riggs, &

450


Murdock, 1991; Resick & Schnicke, 1992). Clearly, therapies need to be developed which target the broader range of symptoms experienced by retraumatized women. This is imperative as they represent the majority of sexually victimized women. Treatment should include a focus on difficulties in self- regulation and interpersonal functioning, which are central problems for these women. It has been our experience that absence of direct attention to these issues makes successful implementation of symptom (PTSD) focused treatment much more difficult (Cloitre, 1994). Preliminary data from our own treatment investigation indicate that a short-term interpersonal process group therapy is efficacious for retraumatized women (Scarvalone, Goitre, & Difede, 1995). The treatment focused primarily on identifying, labeling and interpreting feelings among group members, including the therapists, and did not directly refer to posttraumatic stress symptoms. Interestingly, the treatment was successful in reducing rates of PTSD by 50%. These data are notable because they indicate that problems in self and interpersonal functioning may underlie and/or maintain PTSD symptoms. Limitations of the study should be noted to guard against overgeneralization of the results. Fust, the women with assault histories assessed in this study were a self-selected group of women seeking treatment. While rates of retraumatization in the community are similar to those found in our clinical population (Wyatt et al., 1992), the clinical sample may suffer from more frequent and diverse forms of traumatization as well as more numerous diagnoses and perhaps a different set of difficulties in interpersonal and self-functioning. For example, both of the retraumatized and adult assault only groups had very high rates of major depression, the presence of which may have propelled the women into treatment and created vulnerability to a greater number or types of adulthood assaults compared to non-treatment-seeking women in the community. Second, the role of other types of trauma (e.g., natural or man-made disasters) on self- and interpersonal functioning needs to be more closely examined and will require study of larger numbers of women. Last, the study focused exclusively on women. The role of childhood abuse in creating risk for revictimization or revictimizing behavior among men remains to be addressed. In a recent study of 354 psychiatrically hospitalized men, it was found that men who reported having been abused as children were at five times greater risk of being both a victim and perpetrator of violence compared to those without childhood abuse (Cloitre, Tardiff, Marzuk, Leon, & Portera, 1996). These results suggest that a different kind of risk for violence, one which includes roles as both a victim and a perpetrator, may exist for men. Future community and outpatient sample studies are required to assess the generalizability of these findings.

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In summary, this study has found that women who reported being assaulted in both childhood and adulthood not only have PTSD but also significant difficulties in self and interpersonal functioning which appear to derive from childhood abuse. These difficulties may be mediators contributing to their increased risk of retraumatization in adulthood. Clearly, a large, community-based longitudinal study, following women for 10 to 15 years, will be required to confirm the presence of child abuse as a risk factor for adult assault and to identify the variables which mediate retraumatization. The results of this study suggest that further research on both the assessment and treatment of this understudied and under-served population is warranted.

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