Prevalence of Victimization and Posttraumatic Stress ...

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The International Journal of the Addictions, 30(9), 1079-1099, 1995

Prevalence of Victimization and Posttraumatic Stress Disorder among Women with Substance Use Disorders: Comparison of Telephone and In-Person Assessment Samples Bonnie S. Dansky, Ph.D.,lY* Michael E. Saladin, Ph.D.,2 Kathleen T. Brady, M.D., Ph.D.,2 Dean G. Kilpatrick, Ph.D.,l and Heidi S. Resnick, Ph.D.' National Crime Victims Research and Treatment Center, Department of Psychiatv and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina 2Cenfer for Drug and Aicohol Programs, Department of Psychiatiy and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina

ABSTRACT A structured interview with behaviorally specific probes was used to assess victimization and posttraumatic stress disorder (PTSD)in a clinical and a national, epidemiologic sample of women who had received treatment for a substance use disorder. Separate clinical and epidemiologic approaches to evaluating substance use disorders were *To whom correspondence should be addressed at National Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425-0742. FAX: (803) 792-3388. 1079 Copyright 0 1995 by Marcel Dekker, Inc.


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compared. More than 80% of women in both samples had a history of sexual and/or physical assault and approximately one-quarter had current PTSD. The similarity in patterns of victimization, PTSD, and substance use across two samples suggests that telephone structured interviews are a valid method of collecting datahnformation about these important phenomena.

Key words. Victimization; Substance use disorders; Posttraumatic stress disorder

INTRODUCTION Over the past ten years numerous national or community-based studies have documented a relationship between posttraumatic stress disorder (PTSD), victimization, and substance use disorders (Burnam et al., 1988; Cottler et al., 1992; George and Winfield-Laird, 1986; Helzer et al., 1987; Kilpatrick, 1990; Kulka et al., 1990). Researchers have observed in the general population high rates of substance use disorders among individuals with comorbid PTSD in association with traumatic events such as victimization or disaster (Burnam et al., 1988; George and Winfield-Laird, 1986; Helzer et al., 1987; Kilpatrick, 1990). For instance, an epidemiologic catchment area survey (ECA study) of psychiatric illness in the general population revealed that women with PTSD were 1.4 times as likely to have drug misuse or dependence as women without PTSD (Helzer et al., 1987). Similarly, in a recent epidemiological telephone survey of female adults, a lifetime history of PTSD was found to be a major risk factor for substance use problems. As compared to women without a history of PTSD, those with PTSD were 2.3 times more likely to have used any illegal substance 3 or more times and between 4 and 5 times more likely to have nonmedically used prescription drugs (Kilpatrick, 1990). Moreover, increased rates of substance use disorders also have been observed in samples of crime victims, regardless of PTSD status (Burnam et al., 1988; George and Winfield-Laird, 1986). Prevalence rates indicated that 80% of women who reported having sought treatment for a substance use disorder at some point during their lives also reported having experienced a sexual assault, physical assault, or the death of a family member due to homicide (Kilpatrick, 1990). These studies demonstrate that crime victims, particularly those suffering from PTSD, are at risk for having substance use disorders. Although epidemiologic researchers recently have provided evidence of a relationship between crime-related posttraumatic stress disorder (CR-PTSD) and substance use disorders in women, such associations have not been well researched in clinical samples of patients with substance use disorders (Table 1). Only a few researchers have incorporated a screening instrument to systemati-

Table 1.

PTSD, Victimization, and Substance Use: Selected Parameters and Studies" Victimization history

21% PA Subst; 14% PA control

2,663 M and F; ECA; av age 43.6

9 % CSA; 10% CPA; 3% both CSA and CPA 6% CSA; 15% CPA; 5 % I + PA; 4 % I 84% CSA and/or CPA

947 M and F; IP; av age 30 500 M and F; IP; Subst; adolescents 178 M and F; Subst

73% SA or PA; 40% CSA or CPA

55 adult F; IP; Subst; av age 32.8

Substance use

Life PTSD

100% A or D

Method SCID INT

SR

100% A or D

INT

100% A or D

INT

23% A; 8% D

8.5% A

63% SA or PA

INT

100% A (Subst group)

67% CSA Subst; 28% CSA control

INT

15% A; 12% M; 5 % CiO; 6 % PIH (Subst group) 100% A or D

92% CPA; 58% SA

DIS INT

SR

100% A; 61% C; 35% 0

SCID INT


ss

27% SA or PA

118 F; corrections; av age 31.4 45 F Subst; 40 F controls; av age Subst 39.4; av age controls 31 189 F; IP; av age 35.3 30 M; IP; Subst; VA; av age 46

I I I

I

I

; F = female; IP = inpatient: Subst = substance misuse treatment; VA = Veteran's Administration Hospital; ECA = Epid A = Alcohol misuse; C = cocaine misuse; 0 = opiod misuse; M = marijuana misuse; P = pill misuse; H = hallucinog = childhood sexual abuse; CPA = childhood physical abuse; I = incest; ASA = sexual assault as an adult; APA = physica A = physical assault; AA = aggravated assault. Method: Int = interview; SR = self-report; SCID = structured clinical int c interview schedule. Limifarions: ITS = incomplete trauma screening; LS = limited sample; No PTSD = no PTSD screeni

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cally assess PTSD among women seeking treatment for a substance use disorder (Brady et al., 1994; Grice et al., 1992; Triffleman et al., 1993), despite the fact that several researchers have examined the prevalence of sexual and physical assault in such samples (Brown and Anderson, 1991; Cavaiola and Schiff, 1988; Cohen and Densen-Gerber, 1982; Ladwig and Andersen, 1989; Miller et al., 1987; Swett et al., 1991; Wallen, 1992; Wasnick et al., 1990; Yandow, 1989). Since untreated PTSD in those with substance use disorders may have critical repercussions regarding the efficacy of treatment for chemical dependency, empirical evidence to substantiate the high prevalence of victimization and PTSD among women in treatment for substance use disorders is important. Furthermore, assessing the extent to which prevalence rates from treatment-seeking samples correspond with what has been observed in epidemiologic samples can provide critical information regarding the representativeness of findings with clinical samples. Comparable data obtained across inperson clinical interview and more structured epidemiological approaches would support the validity of epidemiological approaches that, at times, have been criticized as lacking in sensitivity. Thus, to assess the prevalence rates of victimization and PTSD among female patients with substance use disorders and provide empirical information concerning the reliability of a screening instrument, one structured interview with behaviorally specific probes was utilized with two separate samples. The first sample, which included women who indicated that they had received treatment for a substance use disorder, was a subset of the National Women’s Study ( W S ) sample. The NWS was a longitudinal telephone survey designed to assess a number of disorders, including substance use disorders and PTSD. The second sample consisted of women evaluated with face-to-face interviews during the time they actually were receiving inpatient treatment for a substance use disorder. The central objectives of this study were to: 1) measure the prevalence rates for PTSD and victimization among women with substance use disorders by telephone survey with a national sample and by face-to-face interviews with a clinical sample, and 2) gather information concerning the reliability of the NWS PTSD module as a diagnostic instrument.

METHODS Subjects

Telephone Sample: The National Women’s Study Participants in the 1989 National Women’s Study consisted of a national household probability sample of 4,008 women age 18 or greater in the United States (Resnick et al., 1993). All 50 states were sampled within three general regions (classified by the US Census Bureau): 29% of the sample from Central Cities, 45 74 from Standard Metropolitan Statistical Area (SMSA) Remain-


PTSD AND SUBSTANCE USE DISORDERS

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ders (suburban), and 26% from Non-SMSA regions (rural). Of this total, 2,008 were a national probability household sample of female adults, whereas the remaining 2,000 were an oversample of younger women aged 18 to 34. The oversample of younger women was included because they are overrepresented among assault victims and individuals with substance use difficulties. A total of 70 participants indicated that during their lifetime they had received inpatient and/or outpatient treatment for a substance use disorder and were included in the data analysis (Table 2). The sample comprised women who had received inpatient treatment (n = 33), outpatient treatment (n = 28), and treatment not classified as “inpatient” or “outpatient” (n = 8). One woman was unsure of the type of treatment she received. Participants’ ages ranged from 17 to 73 with an average age for the sample of 31.1 (SD = 10.42). Racial, marital, employment, and educational information is presented in Table 2.

Table 2. Demographic Characteristics of the Telephone and In-Person Samples

Age

Telephone sample (N = 70) X = 31.06 (SD = 10.42)

In-Person sample (N = 73) X = 34.42 (SD = 8.25)

Race

Telephone sample (n = 70)

In-Person sample (n = 72)

Caucasian African-American Native American Hispanic Marital status Marriedcohabitating Separateddivorced Widowed Singlehever married Education (highest achieved)

Less than high school graduate High school graduate Some college College degree Employment Employed full or part time Unemployed Homemaker Student Retired/disabled

80.0% (n = 10.0% (n = 5.7% (n = 4.3% (n =

56) 7) 4) 3)

Telephone sample (n = 70) 52.9% (n = 22.9% (n = 4.3% (n = 20.0% (n =

37) 16) 3) 14)

Telephone samDle (n = 70) 27.1% (n = 40.0% (n = 25.7% (n = 7.2% (n =

19) 28) 18) 5)

Telephone sample (n = 70) 57.2% (n = 17.1% (n = 20.0% (n = 1.4% (n = 4.3% (n =

40) 12) 14) 1)

3)

47.2% (n = 34) 51.4% (n = 37) 1.4% (n = 1) -

In-Person sample (n = 48) 18.7% (n = 43.8% (n = 2.1% (n = 35.4% (n =

9) 21) 1) 17)

In-Person sample (n = 48) 41.7% (n 22.9% (n 27.1% (n 8.4% (n

= = = =

20) 11) 13) 4)

In-Person sample (n = 48) 14.6% (n = 66.7% (n = 14.6% (n = 2.1% (n = 2.1% (n =

7) 32) 7) 1)

1)

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In-Person Sample: Center for Drug and Alcohol Programs Victimization study

All patients admitted between 1993 and 1994 to the adult inpatient chemical dependency treatment program at a tertiary care training hospital in Charleston, South Carolina, were screened by trained clinicians for trauma history and PTSD within 1 week following alcohol or drug detoxification. Outpatient substance use disordered patients who were being considered for participation in various research protocols were also screened for PTSD and victimization. The Center for Drug and Alcohol Programs (CDAP) chemical dependency treatment program is staffed by a multidisciplinary treatment team consisting of a psychiatrist, a psychologist, psychiatry residents, nurses, a social worker, a recreational therapist, and an occupational therapist. All staff were trained in substance use disorders or were in the process of receiving specialized training. The basic treatment provided included substance use education, group therapy, pharmacotherapy, relapse prevention, and vocational rehabilitation. The following are the demographic characteristics of all patients who received inpatient or outpatient treatment at CDAP between January 1993 and January 1994.Approximately 50% of the patients in the chemical dependency treatment program were men, and the average age was 35 years old. About 40% of the patients were hospitalized for treatment of alcohol dependency, about 35% were in treatment for cocaine dependency, and about one-quarter were in treatment for misuse of prescription medication, hallucinogens/psychodelics, heroin, marijuana, or other illicit drugs. Participants’ ages ranged from 16 to 68 with an average age for the sample of 34.6 (SD = 8.2). Racial, marital, employment, and educational information is displayed in Table 2. It should be noted that information concerning marital status, employment, and education was obtained from a self-report inventory that a majority, but not all, of the participants completed. It also is important to note that the racial composition of Charleston, South Carolina (where the In-Person sample was drawn), is 67.8% Caucasian, 30.2% African-American, 1.9% all other minorities (Charleston City Chamber of Commerce, 1994). Men were excluded from the current investigation since the comparison population (National Women’s Study) was limited to female participants. Female patients were included in the study if they (a) completed inpatient or outpatient treatment, (b) were cognitively intact enough to complete a l-hour interview about trauma history and PTSD and a half-hour interview about their substance use history, and (c) were literate, The treatment-seeking sample comprised 73 women (61 inpatients and 12 outpatients). Inpatient-Outpatient Comparisons. Chi-square analyses were calculated within each sample to test for differences between participants who were in-



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volved in inpatient chemical dependency treatment compared with those who only received outpatient services. Among the In-Person sample, no significant differences were found between the inpatient and outpatient groups. Slightly different results were obtained from comparisons with the Telephone sample. Although no significant group differences were detected for each type of sexual or physical assault, significantly higher rates of victimization in general were 1 )3.89, p < .05]. No obtained for the inpatient group [90.9 vs. 71.4%; ~ ~ ( = significant differences were found between the inpatient and outpatient groups in the prevalence of Lifetime PTSD or Current PTSD.Since there was only one significant difference detected between the inpatient and outpatient samples, the groups (inpatient and outpatient) were combined to create two samples: one treatment-seeking In-Person sample and one treatment-seeking Telephone sample. Instruments

Telephone Sample: The National Women’s Study The h W S Wave 1 structured telephone interview was developed specifically to accurately assess the prevalence of substance use disorders and victimization in United States women. The entire interview protocol has been described in detail elsewhere (Resnick et al., 1993).

Victimization and Posttraumatic Stress Disorder (PTSD) Screening. PTSD was assessed using the National Women’s Study ( W S ) PTSD module (Kilpatrick et al., 1989). The h W S PTSD module was modified from the Diagnostic Interview Schedule (DIS)used in the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990). Participants were screened for symptoms of PTSD (using DSM-III-R criteria), regardless of whether they had experienced an event which met PTSD Criterion A (an event outside of the range of usual human experience that would produce marked distress in almost anyone). Subjects were classified as meeting Criterion A, the necessary stressor criterion for PTSD, if they reported the occurrence of at least one traumatic event such as indirect victimization due to homicide of a significant other or direct sexual or physical assault at some time during their lives. The remaining symptom criteria were obtained via a structured interview schedule to assess intrusive symptoms, symptoms of avoidance, and symptoms of increased arousal. Respondents were not required to link their symptoms to a specific traumatic event which would necessitate a level of insight concerning symptom-event correspondence that most respondents likely did not possess. The PTSD measure was prefaced with a nonevent-specific probe as follows: “People experience a variety of moods and feelings from time to time. In your case, has there ever been a period of a month of more during


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which. . . .” Statements following this probe were specifically phrased to assess symptom presence such as “you had repeated bad dreams or nightmares.” Lifetime PTSD was assigned if a respondent met the DSM-III-R criteria by having the necessary number of Criterion B (one reexperiencing), C (three avoidance), and D (two increased arousal) symptoms. Concurrent validity obtained from a slightly modified version of the PTSD interview with the SCIDPTSD module was good with a kappa of 0.71 for Lifetime PTSD. Reliability of the PTSD diagnostic interview also was acceptable (see Resnick et al., 1993).

Substance Use Disorders Screening. A majority of the questions used to assess substance use disorders were taken from the 1986 Survey of Drug and Alcohol Use in New York State, which was conducted jointly for the New York State Division of Substance Abuse Services and the New York State Division of Alcoholism and Alcohol Abuse by Louis Harris and Associates. The 1986 survey was conducted by telephone and measured the following types of substances: 1) non-medically prescribed use of tranquilizers, barbiturates, sedatives, or stimulants; 2) alcoholic beverages; 3) marijuana; 4) inhalants; 5 ) cocaine; and 6) opiates and combinations of substances. Additionally, information was collected regarding indicators of problem usage such as: 1) problems with family or friends; 2) problems with work or school; 3) injuries or accidents other than motor vehicles; 4) problems with health; and 5 ) problems with the law. Data were also gathered about driving while intoxicated, signs of alcohol addiction, whether treatment for substance use was ever sought, and which type of substance misuse treatment was received. Demographic Characteristics. Respondents provided details about their age, racial/ethnic background, educational and vocational status, marital status, and their annual family income. In-Person Sample: Center for Drug and Alcohol Programs Victimization study

Victimization and Posttraumatic Stress Disorder (PTSD) Screening. The instrument employed for the trauma history and PTSD screening was the same, with two exceptions, as the instrument utilized for the National Women’s Study. One exception pertained to the method of evaluating the I-month duration criterion for PTSD. In the In-Person interviews the l-month criterion was evaluated by a probe at the end of the interview to determine whether the symptoms lasted at least 1 month. This is in contrast to the method employed with the Telephone interviews wherein the l-month duration was assessed with each symptom. The second exception was the inclusion of two additional behaviorally-specific questions pertaining to physical assault, which may have


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given respondents in the In-Person sample extra opportunities to report assaults of an aggravated nature.

Substance Use Disorders Screening. All participants in the In-Person sample were receiving treatment for a substance use disorder. Assessment of the substance use disorder was accomplished by clinical interview, urine drug screen, and/or the Addiction Severity Index (ASI; McLellan et al., 1990). Information necessary to make a substance use disorder classification by substance of choice was available for 59 of the 73 respondents. Demographic Characteristics. Respondents provided details about their age and racial/ethnic background during the interview. As mentioned above, information about their marital status, education, and current employment was obtained from a self-report questionnaire. Procedure

Telephone Sample: The National Women’s Study The original sample of 4,008 female adults (Wave 1 sample) was generated by multistage geographic sampling procedures, wherein stratified samples of counties in four regions of the country were generated as primary sampling units during the first of a two-stage sampling procedure. The second stage of the sampling procedure involved systematic selection of residential telephone exchanges within the primary sampling units. Random digit dialing was used to target households within each strata. To insure random selection within a household, the female adult with the most recent birthday was interviewed (for further details see Resnick et al., 1993). All women who were cognitively intact enough to respond to the interview questions were included in the sample. The structured telephone interviews were of approximately 40 minutes duration. In terms of reliability of administration of interviews, a highly structured procedure was followed. A computer-assisted telephone interview (CATI) procedure was conducted in which the interviewer was prompted on a computer screen with each consecutive question. Respondents’ answers to questions were entered into the computer program by the interviewer, and the program automatically moved to each subsequent probe or followed an appropriate skip pattern based on the entered response. This procedure was monitored by random checks of survey and data entry performance several times per interviewer shift. These checks were conducted by monitors who simultaneously listened to ongoing telephone interviews while also watching data entry on a separate computer monitor that tapped into the particular CATI program. Finally, reliability of diagnostic assignment was ensured by use of a computer algorithm

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for positive or negative diagnosis of substance use disorders. The use of a highly structured interview, careful monitoring of interviewers’ behavior, and computerized diagnostic assignment ensured that the methods of administration and scoring were as reliable as possible. The interviews were conducted by Schulman, Ronca, and Bucuvalas (SRBI), a New-York-based survey research firm. Only well-trained, experienced female SRBI interviewers were used. As mentioned above, a weighting program was used to ensure that the sample was representative of women in the United States population.

In-Person Sample: Center for Drug and Alcohol Programs Victimization Study Participants were interviewed in their rooms on the inpatient psychiatric unit by clinical psychology interns who received intensive training in the administration of structured interviews. The interviews were approximately 1 hour in length. Participants were given a brief self-report questionnaire, which included background questions, to complete on their own. Diagnostic information from the screening interviews was provided to participants’ treatment team to aid in the provision of clinical services.

RESULTS Comparisons of Demographic Characteristics between Telephone and In-Person Samples As can be seen in Table 2, the Telephone and In-Person samples differ on a number of demographic characteristics. First, there was a significantly greater proportion of African-American participants in the In-Person sample (5 1.4%) than in the Telephone sample [10.0%;~ ~ ( 1= )25.44, p < .001]. Women in the In-Person sample also were significantly more likely than women in the 1 9.38, ) Telephone sample to be singlehever married C34.0 vs 20.0%;~ ~ ( = p < .01] or separatedldivorced [44.7 vs 22.9%;~’(1) = 12.29, p C .001]. Finally, women in the In-Person sample were significantly more likely to be unemployed (66.7%) than women in the Telephone sample [17.1%; ~ ~ ( = 1 ) 31.04, p C .OOlJ. No differences in educational background were observed. Prevalence of victimization and PTSD

The prevalence rates for sexual and physical assault are presented in Figs. 1 and 2. The prevalence rate for each type of victimization was high, particularly for the two most violent types of assault, namely rape and aggravated


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Percent

loo[ 80

60

40

20

0 Rape

Molestation

Attempted SA

Assault Type In-Person (n.73)

Tele h ne (n=90?

Fig. 1. hevalence of sexual assault in female substance misusers.

assault. Participants were classified as having experienced a “Direct Assault” if they had a history of rape, other sexual assault, or aggravated assault. Chisquare analyses conducted to compare prevalence rates for victimization among respondents in the In-Person and Telephone samples revealed no significant differences, except for aggravated assault. Women in the In-Person sample reported a significantly higher lifetime prevalence of aggravated assault (67.1 %) than women in the Telephone sample [45.7%; x2(1) = 5.83, p < .01]. In general, the rates of PTSD among women who sought treatment for a substance use disorder were remarkably high. As can be seen in Fig. 3, more than 50% of the women met criteria for Lifetime PTSD, and more than onequarter met criteria for Current PTSD. No difference in the prevalence of Lifetime PTSD was revealed by comparisons between the In-Person and Telephone samples, although the prevalence of Current PTSD was significantly higher among women in the In-Person sample (42.5%) than the Telephone sample [15.7%; ~ ~ ( = 1 )11.07, p < .001].

DANSKY ET AL.

1OW Percent


100

’

80 -

67.1

(WAS.)60

-

40

-

20 -

/

0 1 4ggravated Assault

Direct Crime

Assault Type in-Person

(11-73)

M T e i e h ne (n=?O?

Chi-square (1)-5.83, p < 0.01 Fig. 2. Prevalence of other assault in female substance misusers.

PTSD, Victimization, and Substance Misused

It is important to note that in contrast to the assessment instrument utilized to screen for victimization history and PTSD, the method of assessing substance use differed between the In-Person and Telephone samples. However, respondents in both the In-Person and Telephone samples were classified by their substance of misuse in a manner similar to that used by Cottler et al. (1992; Table 3). Respondents who misused cocaine or other “heavy” drugs, regardless of whether they also misused alcohol or marijuana, were placed in the “Heavy Drug” category. Respondents who never misused any of the Heavy Drugs, but did misuse marijuana, regardless of whether they also misused alcohol, were classified in the “Marijuana” group. Finally, respondents who never misused any Heavy Drug or Marijuana but did misuse alcohol or who reported past year daily intake of two or more drinks were classified in the “Alcohol” group.


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Percent


100

80 56 2 (n-41)

60

n

4 2.5 (n.31) 7 - 7 7

40

20

0 Current PTSD

Lifetime PTSD

In-Person (n.73) Chi-Square(l)=ll.O7, p

R!l

Tele h ne

(“.YO7

0.001

Fig. 3. Lifetime and current PTSD in female substance misusers.

Only one of 59 respondents in the In-Person sample was classified as a Marijuana user, in contrast to 11 of 70 in the Telephone sample. Since such a low cell size in the In-Person sample precluded any meaningful statistical comparisons, the Marijuana users were excluded from the analyses. Chi-square Table 3. Substance MisuselDependence Classifications

Substance category Alcohol Marijuana Heavy Drugsa

In-Person sample (n = 59)

Telephone sample (n = 70)

26.0% 1.4% 53.5%

17.1% 15.7% 60.0%

‘Heavy Drugs include cocaine, heroin, hallucinogens/psychodelics,amphetamines, barbiturates, and misuse of other prescription medications.

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analyses failed to identify any significant differences between the two samples regarding the proportion of respondents classified as Heavy Drug users as opposed to Alcohol users. No differences were identified between Alcohol and Heavy Drug users in the In-Person sample for assault history or PTSD prevalence rate. One difference was detected in the Telephone sample in that women in the Heavy Drug category were significantly more likely to have a history of completed rape (66.7%) than women in the Alcohol group [33.3%; x2(1) = 4.30, p < .05]. No other group differences were observed.

DISCUSSION More than 80% of women who sought treatment for chemical dependency reported that they had experienced a sexual and/or physical assault during their lifetime. The rates of victimization found in the present samples of substance use disordered patients are consistent with those obtained by other researchers such as Miller et al. (1987) and Yandow (1989), who have found rates of sexual victimization in 67 and 75% of female substance use disordered patients. The rates obtained in the current investigation also are similar to those observed by Bryer et al. (1987), who found an overall victimization rate of 72% among female psychiatric inpatients, and by Jacobson (1989), who documented that 68% of his sample of psychiatric outpatients had a victimization history. Regarding PTSD prevalence, between 15% and one-half of women who had sought treatment for a substance use disorder had comorbid Current PTSD, and between 44 and 56% had a lifetime history of PTSD. The Lifetime PTSD rate of 56.2% in the In-Person sample is almost identical to the Lifetime PTSD rate of 54.5% obtained utilizing the Structured Clinical Interview for DSM-IIIR (SCID; Spitzer et al., 1990) in another sample at our site of female inpatients with substance use disorders (Grice et al., 1992). In addition, the Lifetime PTSD prevalence rates obtained in the In-Person and Telephone samples are consistent with the prevalence rate of 50% documented by Triffleman and her colleagues (1993). The finding in the Telephone sample that the proportion of completed rape victims was higher among women categorized as Heavy Drug users, as compared with women in the Alcohol use category, is consistent with other findings documented in the literature (e.g., Cottler et al., 1992; Elliot et al., 1989). In addition, when associations between substance use disorders and PTSD were explored in samples not limited to those who sought treatment (as in the current study), a significant relationship between type of substance misused and the prevalence of PTSD was noted with individuals who used more “serious” drugs evidencing high rates of PTSD (Cottler et al., 1992; Elliot et al., 1989; Kilpatrick et al., 1994). It is conceivable that similar results were not observed in the current samples due to: (a) demographic features of the In-Person



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sample, (b) the possibility that individuals who seek treatment for a substance use disorder differ from those with a substance use disorder in the general population, or (c) the fact that a number of women categorized in the Alcohol group in the In-Person sample may have misused cocaine or other "heavy drugs" in the past but at the time of the interview were seeking treatment for primary alcohol misuseldependence. Nonetheless, the results demonstrate that screening for victimization and PTSD is particularly important in women who misuse drugs such as cocaine, heroin, barbiturates, hallucinogens, etc. Overall, the similar victimization and PTSD prevalence rates obtained with different samples, consisting of women with disparate demographic backgrounds, provide important information regarding the NWS PTSD Module. It is likely that the higher rate of aggravated assault found in the In-Person sample was due to the fact that the slightly modified version of the NWS trauma screening used for the In-Person study contained additional probes for physical assault. In addition, the higher rate of Current PTSD observed in the In-Person sample was anticipated, since the women in the In-Person sample were receiving treatment at the time they participated in the study. In contrast, the women in the Telephone sample indicated that they had received treatment for substance misuse at some point during their life and not necessarily within 6 months of the time they were interviewed. In general, it appears that this diagnostic screening instrument can accurately detect victimization and PTSD with face-to-face and telephone interviews. Furthermore, the similarity in patterns of substance use across the two samples, despite different methods of assessing such phenomena, supports the validity of telephone structured interviews to obtain information for these classifications. Treatment lmplicatlons

The strikingly high rates of the victimization and PTSD among women who have received treatment for substance use disorders clearly support the assessment and treatment of these phenomena in this population. At this point in time, empirical evidence concerning the appropriate time during alcohol/drug detoxification to assess symptoms of other psychiatric disorders such as PTSD is lacking. In light of a paucity of empirical information, the following treatment recommendations are based upon clinical observations/clinic protocol and should be considered somewhat speculative. All patients entering treatment for substance misuse should undergo a complete screening for trauma history and PTSD, The results of the current investigation attest to the feasibility of conducting such screenings with people who misuse substances. The NWS PTSD Module, described above, appears to be a useful instrument to evaluate trauma history, and the Clinician Adminis-

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tered PTSD Scale (CAPS-1; Blake et al., 1990) is recommended to assess PTSD Criteria B, C, and D. The CAPS-1 is a 30-item structured interview designed to measure: (a) the frequency and intensity of symptoms of Criterion B, C, and D symptoms of PTSD and (b) the influence of PTSD symptoms on social and occupational functioning. In circumstances where self-report questionnaires are necessary, the following two measures are recommended: (a) the Modijied PTSD Symptom Scale (MPSS; Falsetti et al., 1993) to evaluate frequency and intensity of symptoms of PTSD and (b) the Impact of Event Scale (IES; Horowitz et al., 1979) to measure the extent to which a given stressful life event produces subjective distress. In addition to a lack of empirical information regarding diagnostic considerations in patients with comorbid PTSD and substance misuse, no studies have been conducted to determine the most appropriate treatment for crime victims with substance use disorders. Preliminary data obtained from five women who received concurrent treatment for substance misuse and CR-PTSD indicate that such concurrent treatment can lead to a significant reduction in symptoms of PTSD and chemical dependency (Dansky et al., 1994). There were no indications in any of the five patients that the cognitive-behavioral (CB) treatment for CR-PTSD interferred with the patients’ recovery from chemical dependency. The CB treatment for CR-PTSD was based on the Stress Inoculation f Prolonged Exposure treatment designed by Foa (Foa et al., 1991), and selfreport outcome measures included: the Rape Aftermath Symptom Test (a measure of fear; Kilpatrick, 1988), SCL-90 GSI (a measure of general distress; Derogatis, 1983), SCL-90-R PTSD scale (Saunders et al., 1990), and the Modified Posttraumatic Stress Symptom Scale (a measure of frequency and intensity of PTSD symptoms; Falsetti et al., 1993). These preliminary ftndings are promising, but more large-scale research concerning treatment interventions for comorbid substance use disorder and crime-related PTSD is essential.

ACKNOWLEDGMENTS Preparation of this paper was supported by NIDA Grant RO1-DA05520 awarded to Dr. Dean G. Kilpatrick (Principal Investigator). Information in this paper has been presented at the 1993 annual meeting of the International Society of Traumatic Stress Studies, San Antonio, Texas, and at the 1994 annual meeting of the Southeastern Psychological Association, New Orleans, Louisiana.

REFERENCES AMERICAN PSYCHIATRIC ASSOCIATION, COMMITTEE ON NOMENCLATURE AND STATISTICS (1987). Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised. Washington, D.C.: American Psychiatric Association.



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B W ( E , D. D., WEATHERS, F. W., NAGY, L. M., KALOUPEK, D. G., KLAUMINZER, G., CHARNEY, D. S., and KEANE, T. M. (1990). A clinician rating scale for assessing current and lifetime PTSD. Behav. Therapist 13: 187-188. BRGDY, K. T., KILLEEN, T., SALADIN, M., DANSKY, B. S., and BECKER, S. (1994). Comorbid substance abuse and PTSD: Characteristics of women in treatment. Am. J. A a c t . 3: 160-164. BROWN, G. R., and ANDERSON, B. (1991). Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse. Am. J. Psychiatry 148: 55-61. BRYER, J., NELSON, B., MILLER, J. B., and KROL. P. (1987). Childhood physical and sexual abuse as factors in adult psychiatric illness. Am. J. Psychiatry 144: 1426-1430. BURNAM, M. A., STEIN, J. A., GOLDING, J. M., et al. (1988). Sexual assault and mental disorders in a community population. J. Consult. Clin. Psychol. 56: 843-850. CAVAIOLA, A. A., and SCHIFF, M. (1988). Behavioral sequelae of physical andor sexual abuse in adolescents. Child Abuse Negl. 12: 181-188. CHARLESTON CHAMBER OF COMMERCE (1994). Personal communication. COHEN, F. S., and DENSEN-GERBER, J. D. (1982). A study of the relationship between child abuse and drug addition in 178 patients: Preliminary results. Child Abuse Negl. 6: 383-387. COTTLER, L. B., COMPTON, W. M., MAGER, D., et al. (1992). Posttraumatic stress disorder among substance users from the general population. Am. J. Psychiatry 149: 664-670. DANSKY, B. S., SALADIN, M. E., BRADY, K. T., KILLEEN, T., BECKER, S., and ROITZSCH, J. C. (1994). Concurrent Treatment of PTSD and Substance Abuse in Women. Presentation at the annual meeting of the International Society of Traumatic Stress Studies, Chicago. DEROGATIS, L. R. (1983). SCL-WR: Manual II. Towson, Maryland: Clinical Psychometric Research. ELLIOT, D., HUIZANGA, D., and MENARD, S. (Eds.) (1989). Mulriple Problem Youth: Delinquency, Substance Use, and Mental Health Problems. New York: Springer-Verlag. FALSETTI, S. A., RESNICK, H. S.,RESICK, P. A., et al. (1993). The modified PTSD symptom scale: A brief self-report measure of posttraumatic stress disorder. Behav. Therapist 16: 161-162. FOA, E. B., ROTHBAUM, B. O., RIGGS, D. S., and MURDOCK, T. B. (1991). Treatment of posstraumatic stress disorder in rape victims: A comparison between cognitive behavioral procedures and counseling. f. Consult. Clin. Psychol. 59: 715-723. GEORGE, L. K., and WINFIELD-LAIRD, I. (1986). Sexual Assault: Prevalence and Mental Health Consequences (Final report, Duke University Epidemiological Catchment Area Program). Rockville, Maryland: National Institute of Mental Health. GRICE, D. E., DUSTAN, L. R., BRADY, K. T., et al. (1992). Assault, substance abuse, and Axis I comorbidity. In Proceedings of the 145th American Psychiatric Association, p. 91. HELZER, J. E., ROBINS, L. N., and McEVOY, L. (1987). Posttraumatic stress disorder in the general population: Findings from the Epidemiological Catchment Area Survey. New Engl. J. Med. 387: 1630-1634. HOROWITZ, M., WILNER, N., and ALVAREZ, W. (1979). Impact of event scale: Measure of subjective stress. Psychosom. Med. 41: 209-218. JACOBSON, A. (1989). Physical and sexual assault histories among psychiatric outpatients. Am. f. Psychiatry 146: 755-758. KILPATRICK, D. G. (1988). Rape aftermath symptom test. In M. Hersen and A. S. Bellack (Eds.), Dictionary of Behavioral Assessment Techniques. New York: Pergamon Press, pp. 366-367. KILPATRICK, D. G. (1990). Violence as a Precursor of Women's Substance Abuse: The Rest of the Drugs-Violence Story. Paper presented at the annual meeting of the American Psychological Association, Boston, Massachusetts.

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THE AUTHORS Bonnie S. Dansky, Ph.D., is Assistant Professor of Clinical Psychology at the National Crime Victim’s Research and Treatment Center (NCVC) and at the National Center for Drug and Alcohol Programs in the Department of Psychiatry and Behavioral Sciences of the Medical University of South Carolina. Dr. Dansky received her B.A. from the University of Albany-State University of New York and her M.A. and Ph.D. in Clinical Psychology from Duke University. She completed a clinical internship and postdoctoral fellowship at the Medical University of South Carolina. Dr. Dansky ’s primary research interests involve examining psychological responses to criminal victimization and comorbidity of posttraumatic stress disorder with substance misuse and eating disorders. Dr. Dansky is a Principal Investigator for a NIDA-funded grant concerning victimization and PTSD in patients with substance use disorders. She has published in professional journals, made numerous presentations to local and national groups on these topics, and has an active clinical practice. Michael E. Saladin, Ph.D., is a Licensed Clinical Psychologist and Instructor of Clinical Psychology at the Center for Drug and Alcohol Programs, Medical University of South Carolina (MUSC). Dr. Saladin received his Ph.D. in Clinical Psychology at the University of Manitoba in Winnipeg, Manitoba, Canada. He completed his clinical internship at MUSC and a postdoctoral fellowship at the National Crime Victims Research and Treatment Center, MUSC. Dr. Saladin’s research interests focus on the etiology, assessment, and treatment of individuals with psychoactive substance use disorders and posttraumatic stress disorder (PTSD).


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Kathleen T. Brady is the director of the Dual Diagnosis Program in the Department of Psychiatry at the Medical University of South Carolina where she is active in research and teaching. She has over 50 publications in the area of psychiatric disorders and substance misuse. Her Ph.D. in pharmacology is from the Medical College of Virginia where she did basic science work with substances of misuse. She completed medical school, residency in psychiatry, and a fellowship in substance abuse at the Medical University of South Carolina. Her special areas of interest include anxiety disorders, affective disorders, substance misuse, and dual diagnosis.

Dean G . Kilpatrick, Ph.D., is Professor of Clinical Psychology and Director of the National Crime Victims Research and Treatment Center at the Medical University of South Carolina in Charleston. For the past 19 years he has been involved in the crime victims’ rights movement, having served as a founding member of South Carolina’s first rape crisis center in 1974 and of the South Carolina Victim Assistance Network in 1984. He was appointed by Governor Richard Riley in 1984 to the Crime Victims Advisory Board and reappointed by Governor Carroll Campbell to a second term in 1991. Dr. Kilpatrick and his colleagues have received several grants from the National Institute of Mental Health, National Institute of Justice, and the National Institute of Drug Abuse supporting their research on the scope of violent crime and its psychological impact on victims. His work has been published in scientific and professional journals, and he has made presentations to numerous state, national, and international groups. In 1985 he was given the National Organization of Victim Assistance Stephen Schafer Award for Outstanding Contributions to Victims Research. Dr. Kilpatrick serves as the Chairperson of the National Victims Center’s Research Advisory Committee. In 1990, President George Bush pre-


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sented Dr. Kilpatrick with the US Justice Department Award for Outstanding Contributions on Behalf of Victims of Crime. Dr. Kilpatrick has testified about crime victim issues at hearings held by the South Carolina General Assembly, the United States House of Representatives, and the United States Senate.

Heidi S. Resnick, Ph.D., is Associate Professor of Clinical Psychology at the National Crime Victims Research and Treatment Center (NCVC) at the Medical University of South Carolina. The NCVC is a division of the Department of Psychiatry and Behavioral Sciences at MUSC. Dr. Resnick received her B.A. from the University of Wisconsin-Madison in 1980 and Ph.D. in clinical psychology from Indiana University in 1987. Her major research interest is the study of factors involved in the etiology of posttraumatic stress following civilian trauma. Recent research has included the study of rape victims’ immediate post-rape biological and psychological response profiles in association with specific assault characteristics and as predictors of long-term PTSD outcome; ultimately this line of research may lead to strategies for prevention of PTSD as early as the initial emergency medical care contacts. In addition, she is studying rape victims’ concerns about their physical health following rape, and development of appropriate medical care and health care counseling for rape victims, including information about HIV and risk reduction.