Rape-Related PTSD: Issues and Interventions

As noted, rape and sexual assault represent one of the most common precipitating events for PTSD in women.⁸ Data from epidemiological and clinical samples show that many victims of rape also have histories of other forms of traumatic exposure, and multiple victimization is associated with increased risk of PTSD.¹¹ Other psychosocial factors found to be associated with increased risk of PTSD include family history of psychopathology, incurred injury and perceived life threat during the trauma, lower levels of perceived social support, peritraumatic emotional responses, and Hispanic ethnicity.^11-14

In addition, a number of biological factors related to PTSD risk or resilience have been identified. A recent review indicated 11 candidate neurochemical, neuropeptide, and hormonal mediators of the human stress response, including cortisol, corticotropin-releasing hormone, dehydroepiandrosterone, the locus caeruleus-norepinephrine system, neuropeptide Y, dopamine, serotonin, benzodiazepine receptors, galanin, gonadal steroids, and estrogen.¹⁵ Genetic influences on PTSD have also been reviewed, and more than half of these investigations target the dopamine system genes.¹⁶ In 2 meta-analyses, PTSD was associated with small hippocampal volume.^17,18 However, it is not yet well established whether the low hippocampal volume is a true predictor of PTSD or the outcome of having chronic PTSD.

Before starting treatment of women who have been raped, a thorough assessment must be done. A number of psychometrically sound instruments (eg, Davidson Trauma Questionnaire, Impact of Event Scale-Revised) and interviews (eg, PTSD Checklist Clinician Administered PTSD Scale, Structured Clinical Interview for DSM-IV PTSD, National Women's Study PTSD module) are available for screening for trauma history and resulting PTSD symptoms. Since PTSD is just one of many potential mental health consequences of victimization, comorbidity should also be assessed. (For the interested reader, a number of detailed books address assessment of PTSD.¹⁹)

Several factors should be taken into consideration when conducting the initial assessment of women who have been raped or sexually assaulted. First, behaviorally specific language should be used. Asking if a woman has been "raped" or "sexually assaulted" yields a lower endorsement rate than direct and behaviorally specific questions (eg, "Has a man or boy ever made you have sex by using force or threatening harm?") because of stereotypes that may be held by victims or lack of understanding about meaning of the legal terms rape or sexual assault as noted earlier.²⁰

Second, use of empathetic and orienting prefacing statements should occur before interviewing a victim in order to provide context and increase her comfort level. Examples of brief prefacing statements that help women or girls understand the context in which sexual assault can occur and that demonstrate concern on the part of the clinician are provided in the literature.²¹

Third, the clinician should conduct a thorough trauma history interview and not just assess for the referral event. In the absence of a specific referral rape incident, a thorough trauma history should be conducted as part of routine assessment, given the high prevalence of rape and other traumatic events within populations seeking mental health treatment.

Fourth, assault characteristics, such as relationship to the perpetrator, peritraumatic fear or panic, and injury incurred may be predictive of functioning and should be addressed. Fifth, the immediate needs of the victim should be assessed (eg, safety, suicidality), as well as risk factors for revictimization. Last, women who are raped or sexually assaulted may need medical care (eg, pregnancy and sexually transmitted disease testing).

Secondary prevention efforts in the wake of a traumatic event may help steer the posttrauma physical and mental health trajectory in a positive direction. Secondary prevention strategies are those implemented in short temporal proximity to the event (ie, within 4 weeks) in hopes of acting as a prophylactic for trauma-related difficulties, such as PTSD.

Early interventions that have received the most empirical support to date include brief protocols anchored in cognitive or behavioral principles. In randomized controlled trials (RCTs) of treatments for non-sexual-assault traumatic events, these interventions have produced greater improvement in functioning and decreased levels of PTSD and depression as compared with supportive counseling (SC), and showed differences that persisted through 6-month follow-up.^22-24 Kilpatrick and Veronen²⁵ found improvement among victims of rape who received 4 to 6 hours of early cognitive behavioral skills-based intervention delivered between 6 and 21 days postrape, but improvement was no greater than seen in controls.

On the other hand, Foa and colleagues²⁶ found that a brief multisession intervention that included both imaginal and in vivo exposure was effective in the short term with women who were recruited into the study less than 1 month postassault (including rape). However, no significant differences were noted in PTSD criteria at a 5.5-months assessment point.

A more recent and larger study compared functioning among sexual assault or nonsexual assault victims who, within about 4 weeks after an assault, were assigned to either 4 sessions of cognitive-behavioral therapy (CBT), assessment control, or SC.²⁷ Posttreatment results indicated that CBT was more effective than SC at reducing PTSD symptoms and led to lower general anxiety at 3-month follow-up. All groups were similar at the 9-month follow-up. Results of both studies were seen as consistent with the notion that early treatment may accelerate recovery following rape.

Another promising and cost-efficient technique aimed at decreasing acute distress in rape victims is a video intervention designed to reduce symptoms of PTSD and drug use/abuse among older-adolescent (aged 15 to 17) and adult rape victims. Resnick and colleagues²⁸ compared standard care against a video intervention (plus standard care). The video consisted of 2 components, the first aimed at stress reduction during the forensic examination and the second aimed at providing psychoeducation about adaptive coping and affect regulation techniques. The video intervention reduced intensity of PTSD symptoms among those with a history of rape and may have reduced risk for marijuana abuse.^28-30