Rape-Related PTSD: Issues and Interventions
By Dean G. Kilpatrick, PhD, Ananda B. Amstadter, MS, Heidi S. Resnick, PhD, and Kenneth J. Ruggiero, PhD |
June 1, 2007
Dr Kilpatrick is a distinguished university professor, Ananda Amstadter is a predoctoral fellow, Dr Resnick is professor, and Dr Ruggiero is assistant professor in the department of psychiatry and behavioral sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina in Charleston. They report no conflicts of interest concerning the subject matter of this article.
Pharmacological early interventions
The release of stress hormones, such as epinephrine(Drug information on epinephrine), following a traumatic event assists in memory consolidation and learning,31 and therefore ß-adrenergic antagonists, such as propranolol(Drug information on propranolol), may attenuate these effects. A randomized placebo-controlled 10-day trial of propranolol beginning 6 hours after a traumatic event (trauma types were not detailed in this report) was conducted.32 One month rates of PTSD were 30% in the placebo group and 18% in the propranolol group. Furthermore, the propranolol group was less physiologically responsive to an idiographic trauma script than the placebo group.
A subsequent nonrandomized controlled trial of propranolol with survivors of motor vehicle accidents or victims of physical assault yielded similar results,33 suggesting that propranolol may successfully prevent PTSD. Propranolol has also been found to be efficacious in an open trial with pediatric burn patients.34 These results are promising; however, the findings need replication with larger RCTs.
Treatment modalities for PTSD Psychosocial interventions
Guideline recommendations for the treatment of PTSD are provided by Foa and colleagues,35,36 as well as by the International Society of Traumatic Stress Studies.37 Generally 4 psychosocial intervention techniques are endorsed for adults: exposure therapy, cognitive therapy, anxiety management training, and psychoeducation. These techniques are rarely used alone and are more frequently part of a multicomponent treatment program whose efficacy in RCTs is shown in the Table and detailed below.
Prolonged exposure (PE)38 has received substantial empirical support in the treatment of assault-related PTSD. PE typically consists of 8 to 12 sessions in which both imaginal and in vivo exposure is used. During imaginal exposure, the patient visualizes the traumatic event and describes the event in detail while being encouraged by the therapist to focus on the most emotional aspects of the event. Eleven RCTs supporting the efficacy of PE have been conducted,39-49 and 9 of these included rape victims. Cognitive processing therapy (CPT), a treatment program supplementing exposure-based techniques with psychoeducation and cognitive restructuring, was first studied in a group format and compared with a waitlist control in a sample of rape victims, with results indicating its efficacy in reducing PTSD symptoms.50
More recently, CPT and PE were found to be equally effective over a minimal attention control for rape- related PTSD.44 General CBT programs have also been supported in numerous RCTs for PTSD.51-54 Existing data also provide support for the ability of stress inoculation therapy (SIT)55 to reduce symptoms of PTSD. SIT has been found to be as effective as PE, and 2 trials have found SIT to reduce symptoms compared with controls.40,41 Although the aforementioned studies support the efficacy of these interventions, it should be noted that a substantial percentage of those treated do not improve, underscoring the need for continued treatment development and evaluation.
In comparison to the adult literature, the treatment outcome literature for child sexual abuse is scarce. Although other RCTs of treatment for PTSD of child sexual abuse have been conducted56 the treatment program that received the most support is trauma-focused CBT (TF-CBT).57 Five RCTs of TR-CBT have been undertaken,57-61 all of which included child sexual abuse. These trials support the superiority of TF-CBT over play therapy and SC. A review by Cohen62 provides detailed information for treating children with PTSD, and the reader is referred to that article for more information. (Clinicians seeking additional information on TF-CBT can visit the Web site, http://tfcbt.musc.edu, which provides an innovative training program that follows the organization of the TF-CBT model.)
SSRIs have received the most empirical attention in the treatment of PTSD, and in fact sertraline(Drug information on sertraline) and paroxetine(Drug information on paroxetine), both SSRIs, are the only medications that have received FDA approval for treatment of PTSD.63 The expert consensus guidelines for PTSD36 endorse SSRIs as the most desirable pharmacological treatment for PTSD. In a recent article, Davidson64 reports on alternative pharmacological treatments and the reader is referred to that source for an in-depth review of alternative treatments.
As shown in the Table, 10 RCTs have examined SSRIs for adults with PTSD; generally, findings showed efficacy over placebo (9 positive trials, 1 negative trial). On average, trials of SSRIs resulted in a minimum of a 30% reduction in PTSD symptoms, which is less of a reduction than was seen in CBT treatment trials. Results of fluoxetine(Drug information on fluoxetine) trials of 5 and 12 weeks' duration with civilian and combat traumas indicated that the medication group had greater decreases in PTSD symptoms than the placebo group.64-67 In large-scale 12-week RCTs, efficacy for paroxetine treatment was found over placebo.68,69 Notably, both of these trials included victims of rape. Two trials of sertraline also reported positive results for paroxetine compared with placebo.70,71 A recent trial of patients with PTSD found both sertraline and venlafaxine more effective than placebo in treating PTSD.72
Although SSRIs are the first-line pharmacological treatment of PTSD, other classes of drugs have been investigated in mixed trauma samples that included rape victims. Mirtazapine(Drug information on mirtazapine), a noradrenergic and specific serotonergic antidepressant, was effective over placebo.73 Lamotrigine(Drug information on lamotrigine), an anticonvulsant, has also shown preliminary efficacy in a small double-blind controlled study.74 In a small open-label trial of prazosin(Drug information on prazosin), an α1-adrenergic antagonist, sleep disturbances and nightmares were found to improve.75 Many other agents, such as antipsychotics and mood stabilizers, have been used in the treatment of combat-related PTSD; however, these medications have not been studied in the treatment of rape-related PTSD.64
Of note is a recent trial that first treated all patients, including rape victims, with sertraline for 10 weeks, showing significant improvement.76 Following this 10-week trial, 5 additional weeks of sertraline treatment were administered, with half of the patients also receiving 10 sessions of PE. Results indicate that 5 additional weeks of treatment with sertraline alone did not reduce symptoms past their level at week 10 of the trial, while the addition of PE did reduce symptoms significantly. This novel study combining psychosocial and pharmacological treatments highlights the potential importance of adjunctive therapy.
Pharmacological interventions are often used to treat children with PTSD, yet very few studies have evaluated the efficacy of these agents.36 To date, there are no double-blind RCTs for children with PTSD; however, a few small open-label trials exist. For example, clonidine(Drug information on clonidine), an adrenergic blocking agent, has been evaluated in an open trial for preschool children exposed to sexual or physical abuse or neglect. Results from this trial indicate that clonidine may be effective in symptom reduction.77
Rape and sexual assault are prevalent forms of victimization and often precipitate PTSD. Although promising early interventions and treatment for chronic psychopathology exist, the treatment response rate is not 100%, thereby demonstrating the need for further research on treatment development and efficacy.
- Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry. 2001;58:485-492.
- Foa EB, Hembree EA, Cahill SP, et al. Randomized trial of
prolonged exposure for posttraumatic stress disorder
with and without cognitive restructuring: outcome at academic
and community clinics. J Consult Clin Psychol.
1. Kilpatrick DG. What is violence against women? Defining and measuring the problem. J Interpers Violence. 2004;19:1209-1234.
2. Kilpatrick DG, Saunders BE, Smith DW. Youth Victimization: Prevalence and Implications. Washington, DC: US Department of Justice, Office of Justice Programs, National Institute of Justice;2003.
3. Kilpatrick DG, Edmunds CN, Seymour AK. Rape in America: a report to a nation. Arlington, Va: National Victim Center; April 23, 1992.
4. Kilpatrick DG, Resnick HS, Ruggiero KJ, et al. Drug- facilitated, incapacitated, and forcible rape: a national study. Final report submitted to the National Institute of Justice; 2007.
5. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences of Violence Against women: Findings From the National Violence Against Women Survey. Washington, DC: National Institute of Justice, US Department of Justice; 2000. NCJ 183781.
6. Messman-Moore TL, Long PJ. Child sexual abuse and revictimization in the form of adult sexual abuse, adult physical abuse, and adult psychological maltreatment. J Interpers Violence. 2000;15:489-502.
7. Goodman LA, Salyers MP, Mueser KT, et al. Recent victimization in women and men with severe mental illness: prevalence and correlates. J Trauma Stress. 2001; 14:615-632.
8. Resnick HS, Kilpatrick DG, Dansky BS, et al. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol. 1993;61:984-991.
9. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.
10. Kilpatrick DG, Acierno R, Resnick HS, et al. A 2-year longitudinal analysis of the relationship between violent assault and substance abuse in women. J Consult Clin Psychol. 1997;65:834-847.
11. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129:52-73.
12. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol. 2000;68: 317-336.
13. Galea S, Ahern J, Resnick H, et al. Psychological sequelae of the September 11 terrorist attacks in New York City. N Engl J Med. 2002;346:982-987.
14. Lawyer SR, Ruggiero KJ, Resnick HS, et al. Mental health correlates of the victim-perpetrator relationship among interpersonally victimized adolescents. J Interpers Violence. 2006;21:1333-1353.
15. Charney DS. Psychobiological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress. Am J Psychiatry. 2004; 161:195-216.
16. Koenen KC. Genetics of posttraumatic stress disorder: review and recommendations for future studies. J Trauma Stress. In press.
17. Kitayama N, Vaccarino V, Kutner M, et al. Magnetic resonance imaging (MRI) measurement of hippocampal volume in posttraumatic stress disorder: a meta-analysis. J Affect Disord. 2005;88:79-86.
18. Smith ME. Bilateral hippocampal volume reduction in adults with post-traumatic stress disorder: a meta-analysis of structural MRI studies. Hippocampus. 2005;15: 798-807.
19. Wilson JP, Keane TM. Assessing Psychological Trauma and PTSD. New York: GuilfordPress;2004.
20. Koss MP, Gidycz CA, Wisniewski N. The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. J Consult Clin Psychol. 1987;55:162-170.
21. Resnick HS, Falsetti SA, Kilpatrick DG, Freedy JR. Assessment of rape and other civilian trauma-related PTSD: Emphasis on assessment of potentially traumatic events. In: Miller TW, ed. Theory and Assessment of Stressful Life Events. 2nd ed. Madison, Conn: International Universities Press, Inc; 1996:235-271.
22. Bryant RA, Harvey AG, Dang ST, et al. Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol. 1998;66:862-866.
23. Bryant RA, Moulds ML, Nixon RDV. Cognitive behaviour therapy of acute stress disorder: a four-year follow-up. Behav Res Ther. 2003;41:489-494.
24. Bryant RA, Sackville T, Dang ST, et al. Treating acute stress disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques. Am J Psychiatry. 1999;156:1780-1786.
25. Kilpatrick DG, Veronen LJ. Treatment for rape-related problems: crisis intervention is not enough. In: Cohen L, Claiborn W, Specter G, eds. Crisis Intervention. 2nd ed. Community-Clinical Psychology Series. New York: Human Services Press;2004.
26. Foa EB, Hearst-Ikeda D, Perry KJ. Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. J Consult Clin Psychol. 1995;63:948-955.
27. Foa EB, Zoellner LA, Feeny NC. An evaluation of three brief programs for facilitating recovery after assault. J Trauma Stress. 2006;19:29-43.
28. Resnick HS, Acierno R, Kilpatrick DG, Holmes M. Description of an early intervention to prevent substance abuse and psychopathology in recent rape victims. Behav Modif. 2005;29:156-188.
29. Acierno R, Resnick HS, Flood A, Holmes M. An acute post-rape intervention to prevent substance use and abuse. Addict Behav. 2003;28:1701-1715.
30. Resnick G, Acierno R, Holmes M, et al. Prevention of post-rape psychopathology: preliminary findings of a controlled acute rape treatment study. J Anxiety Disord. 1999;13:359-370.
31. Cahill L, Prins B, Weber M, McGaugh JL. Beta-adrenergic activation and memory for emotional events. Nature. 1994;371:702-704.
32. Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry. 2002;51:189-192.
33. Vaiva G, Ducrocq F, Jezequel K, et al. Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma. Biol Psychiatry. 2003;54:947-949.
34. Famularo R, Kinscherff R, Fenton T. Propranolol treatment for childhood posttraumatic stress disorder, acute type: a pilot study. Arch Pediatr Adolesc Med. 1988; 142:1244-1247.
35. Hembree EA, Foa EB. Interventions for trauma-related emotional disturbances in adult victims of crime. J Trauma Stress. 2003;16:187-199.
36. The expert consensus guideline series: treatment of posttraumatic stress disorder. The expert consensus panels for PTSD. J Clin Psychiatry. 1999;60:3-76.
37. Foa EB, Keane TM, Friedman MJ. Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. New York: Guilford Press; 2000.
38. Foa EB, Rothbaum BO. Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. New York: Guilford Press; 1998.
39. Brom D, Kleber RJ, Defares PB. Brief psychotherapy for posttraumatic stress disorders. J Consult Clin Psychol. 1989;57:607-612.
40. Foa EB, Dancu CV, Hembree EA, et al. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol. 1999; 67:194-200.
41. Foa EB, Rothbaum BO, Riggs DS, Murdock TB. Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol. 1991;59:715-723.
42. Marks I, Lovell K, Noshirvani H, et al. Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring: a controlled study. Arch Gen Psychiatry. 1998;55:317-325.
43. Paunovic N, Öst LG. Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees. Behav Res Ther. 2001;39:1183-1197.
44. Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol. 2002;70:867-879.
45. Tarrier N, Pilgrim H, Sommerfield C, et al. A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. J Consult Clin Psychol. 1999;67:13-18.
46. Foa EB, Hembree EA, Cahill SP, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. J Consult Clin Psychol. 2005;73:953-968.
47. Neuner F, Schauer M, Klaschik C, et al. A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. J Consult Clin Psychol. 2004;72:579-587.
48. Schnurr PP, Friedman MJ, Engel CC, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. JAMA. 2007;297: 820-830.
49. Bryant RA, Moulds ML, Guthrie RM, et al. Imaginal exposure alonge and imaginal exposure with cognitive restructuring in treatment of posttraumatic stress disorder. J Consult Clin Psychol. 2003;71:706-712.
50. Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol. 1992;60:748-756.
51. Blanchard EB, Hickling EJ, Devineni T, et al. A controlled evaluation of cognitive behavioral therapy for posttraumatic stress in motor vehicle accident survivors. Behav Res Ther. 2003;41:79-96.
52. Cloitre M, Koenen KC, Cohen LR, Han H. Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse. J Consult Clin Psychol. 2002;70:1067-1074.
53. Fecteau G, Nicki R. Cognitive behavioural treatment of posttraumatic stress disorder after motor vehicle accident. Behav Cogn Psychother. 1999;27:201-214.
54. McDonagh A, Friedman M, McHugo G, et al. Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. J Consult Clin Psychol. 2005; 73:515-524.
55. Kilpatrick DG, Veronen LJ, Resick PA. Psychological sequelae to rape: assessment and treatment strategies. In: Doleys DM, Meredith RL, Ciminero AR, eds. Behavioral Medicine: Assessment and Treatment Strategies. 2nd ed. New York: Human Services Press; 1982.
56. Trowell J, Kelvin I, Weeramanthi T, et al. Psychotherapy for sexually abused girls: psychopathological outcome findings and patterns of change. Br J Psychiatry. 2002;160:234-247.57. Cohen JA, Deblinger E, Mannarino AP, Steer R. A multi-site randomized controlled trial for children with sexual abuse-related PTSD symptoms. J Am Acad Child Adolesc Psychiatry. 2004;43:393-402.
58. Cohen J, Mannarino AP. A treatment outcome study for sexually abused preschool children: initial findings. J Am Acad Child Adolesc Psychiatry. 1996;35:42-50.
59. Cohen JA, Mannarino AP. Interventions for sexually abused children: initial treatment findings. Child Maltreat. 1998;3:17-26.
60. Deblinger E, Lippmann J, Steer R. Sexually abused children suffering posttraumatic stress symptoms: initial treatment outcome findings. Child Maltreat. 1996;1:310-321.
61. Deblinger E, Stauffer LB, Steer RA. Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreat. 2001;6:332-343.
62. Cohen JA. Treating acute posttraumatic reactions in children and adolescents. Biol Psychiatry. 2003;53:827-833.
63. Seedat S, Stein DJ, Carney PD. Post-traumatic stress disorder in women: epidemiological and treatment issues. CNS Drugs. 2005;19:411-427.
64. Davidson JRT. Pharmacologic treatment of acute and chronic stress following trauma. J Clin Psychiatry. 2006; 67:34-39.
65. Connor KM, Sutherland SM, Tupler LA, et al. Fluoxetine in post-traumatic stress disorder. Randomised, double-blind study. Br J Psychiatry. 1999;175:17-22.
66. Martenyi F, Brown EB, Zhang H, et al. Fluoxetine versus placebo in posttraumatic stress disorder. J Clin Psychiatry. 2002;63:199-206.
67. van der Kolk BA, Deyfuss D, Michaels M, et al. Fluoxetine in posttraumatic stress disorder. J Clin Psychiatry. 1994;55:517-522.
68. Marshall RD, Beebe KL, Oldham M, Zaninelli R. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study. Am J Psychiatry. 2001;158:1982-1988.
69. Tucker P, Zaninelli R, Yehuda R, et al. Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebo-controlled, flexible-dosage trial. J Clin Psychiatry. 2001;62:860-868.
70. Brady K, Pearlstein T, Asnis GM, et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial. JAMA. 2000;283: 1837-1844.
71. Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry. 2001;58:485-492.
72. Davidson JRT, Rothbaum BO, Tucker P, et al. Venlafaxine extended release in posttraumatic stress disorder. a sertraline- and placebo-controlled study. J Clin Psychopharmacol. 2006;26:259-267.
73. Davidson JR, Weisler RH, Butterfield MI, et al. Mirtazapine vs placebo in posttraumatic stress disorder: a pilot trial. Biol Psychiatry. 2003;53:188-191.
74. Hertzberg MA, Butterfield MI, Feldman ME, et al. A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder. Biol Psychiatry. 1999;45: 1226-1229.
75. Taylor F, Raskind MA. The alpha-1 adrenergic antagonist prazosin improves sleep and nightmares in civilian trauma posttraumatic stress disorder. J Clin Psychopharmacol. 2002;22:82-85.
76. Rothbaum BO, Cahill SP, Foa EB, et al. Augmentation of sertraline with prolonged exposure in the treatment of posttraumatic stress disorder. J Trauma Stress. 2006;19: 625-638.
77. Harmon RJ, Riggs PD. Clonidine for posttraumatic stress disorder in preschool children. J Am Acad Child Adolesc Psychiatry. 1996;35:1247-1249.
78. Keane TM, Fairbank JA, Caddell JM, Zimmering RT. Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy. 1989; 20:245-260.
79. Falsetti SA, Resnick HS, Davis J, Gallagher NG. Treatment of posttraumatic stress disorder with comorbid panic attacks: combining cognitive processing therapy with panic control treatment techniques. Group Dynamics: Theory, Research, and Practice. 2001;5:252-260.
80. Monson CM, Schnurr PP, Resick PA, et al. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. J Consult Clin Psychol. 2006;74:898-907.
81. Hertzberg MA, Feldman ME, Beckham JC, et al. Lack of efficacy for fluoxetine in PTSD: a placebo controlled trial in combat veterans. Annals Clin Psychiatry. 2000; 2:101-105.
FROM PHYSICIANS PRACTICE
Five Steps to Improving Patient Access Judy Capko,
May 21, 2013
Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.
SearchMedica Search Result
Find peer-reviewed literature and websites for practicing medical professionals