AM. J. DRUG ALCOHOL ABUSE, 22(1), pp. 75-93 (1996)

Victimization and PTSD in Individuals with Substance Use Disorders: Gender and Racial Differences

Bonnie S. Dansky,*#lI2 Ph.D. Kathleen T. Brady,2 Ph.D. Michael E. Saladin,2 M.D., Ph.D. Therese Killeen,2 M.S.N. Sharon Becker,2 M.S.W. John Roitzsch,2 Ph.D. National Crime Victims Research and Treatment Center

*Center for Drug and Alcohol Programs Department of Psychiatry and Behavioral Sciences Medical University of South Carolina Charleston, South Carolina 29425-0742

ABSTRACT

There is a paucity of studies concerning the prevalence of crime-related posttraumatic stress disorder (CR-PTSD) in individuals with substance use disorders, despite documen- tation of particularly high prevalence rates of sexual and physical assault in this popu- lation. A central objective of the present investigation was to assess victimization ex- periences and CR-PTSD among individuals receiving inpatient treatment for substance use disorders and evaluate gender and racial differences in assault characteristics and CR-PTSD prevalence rates. A total of 95 inpatients (34 men and 61 women; 41 Afri- can-Americans, 52 Caucasians, and 2 other minorities) were administered a structured

*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.

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interview to assess substance abuseldependence, trauma, and PTSD. Approximately 90% of the participants had a lifetime history of sexual andor physical assault, and approxi- mately 50% had CR-PTSD. With the exception of rape, no gender differences in as- sault or CR-PTSD prevalence rates were observed. Women were more likely than men to perceive their life as endangered during a rape. Men were younger than women when they experienced their first (or only) aggravated assault and were more likely to have been assaulted by a family member. No racial differences were detected for assault or PTSD, although African-American patients were significantly more likely to identify cocaine as their primary drug than Caucasian patients. Given the strikingly high rate of comorbid CR-PTSD among substance use disordered patients, exploration of the type and timing of interventions would be of clinical interest.

INTRODUCTION

Researchers have observed high rates of substance use disorders among individuals in the general population who have posttraumatic stress disorder (PTSD) in association with traumatic events such as victimization or disas- ter (1-6). Conv'ersely, increased rates of victimization and crime-related PTSD (CR-PTSD) have been observed in national or community samples of individuals who met criteria for a substance use disorder (1,3-5). Victim- ization histories gathered from treatment-seeking samples have also substan- tiated the high prevalence rates of sexual and physical assault among patients with substance use disorders (7-17). Although these findings suggest that there is a strong association between victimization/PTSD and substance use disorders, methodological limitations preclude an examination of individual differences such as gender and race in the relationship between criminal victimization/PTSD and substance use disorders.

In addition to a lack of information concerning the role of demographic characteristics in the association between substance use disorders and victim- ization/PTSD, differences in sampling and methodology (including sample characteristics and victimization screening protocols) are likely responsible for the wide discrepancy in documented prevalence rates of sexual and physi- cal abuse in samples of substance use disordered patients. Some research- ers have obtained victimization rates from treatment-seeking samples of sub- stance use disordered patients similar to what has been observed in the general population. For instance, Rounsaville and coworkers found that trau- matic childhood events were reported by 30% of opiate addicts in treatment (15), and Ladwig and Andersen, in studying a group of chemically depen- dent women, noted that 27% reported histories of physical and/or sexual abuse (12). In contrast, other researchers have obtained much higher vic- timization rates in patients with substance use disorders. Wasnick et al. re- ported that out of 50 drug-dependent women, 46% reported being raped

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GENDER DIFFERENCES AND CR-PTSD 77

(16). Cohen and Densen-Gerber found that 84% of their sample of female inpatient substance abusers reported a history of childhood sexual or physi- cal assault (8), and Yandow estimated that approximately 75% of women in treatment for substance abuse have a history of sexual trauma (17). Finally, when a highly specific diagnostic instrument was employed to assess victim- ization history, Grice and her colleagues found, in an inpatient sample of substance abusers, that 65% of the women and 16% of the men experienced a sexual assault, and 57% of the women and 93% of the men reported a history of aggravated assault (1 1).

It should be noted that no men were included in the majority of the stud- ies of sexual assault (10,12,13,16,17) and that racial differences were not evaluated in any of the studies cited. Evidence from a general population sample suggests that some racial and gender differences in assault prevalence may exist (18). Specifically, women were less likely than men to be vic- tims of violent crime, although the rate of violent crime for men but not women has decreased between 1973 and 1991. Women were significantly more likely than men to be victimized by intimates. Additionally, African- American and Hispanic women were more likely to experience a violent crime than Caucasian women. Whether these types of gender and racial differences in assault prevalence exist among patients seeking treatment for a substance use disorder is unknown. Further investigation of victimization rates is necessary to evaluate comorbidity with substance use disorders and to increase understanding of the role of demographic characteristics in this relationship.

Prevalence rates and demographic differences regarding comorbid PTSD and substance use disorders also have not been adequately studied. Despite increased attention to victimization, there is a paucity of studies concerning the prevalence of CR-PTSD among treatment-seeking samples of individu- als with substance use disorders. A central objective of the present investi- gation was to assess victimization experiences and the prevalence of CR- PTSD among inpatients obtaining treatment for alcohol, cocaine, or polysubstance abuse or dependence. Gender and racial differences in assault characteristics, PTSD prevalence, and drug choice were examined.

METHODS

Subjects

All patients admitted to the adult inpatient substance abuse treatment pro- gram at a large, tertiary care training hospital were screened by trained

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clinicians for trauma history and PTSD within one week following alcohol or drug detoxification. A total of 95 inpatients (34 male and 61 female patients; 41 African-Americans, 52 Caucasian patients, and 2 other minori- ties) were screened for substance abuseldependence, trauma, and PTSD. Ap- proximately 30 potential participants were not screened for a variety of rea- sons [too psychotic to be interviewed (n = 7), AMA discharge (n = 2), transfer to another hospital or discharged too quickly (n = 6), not coher- ent or too physically or mentally fragile (n = 4), illiteracy (n = l), and interview refusal (n = lo)].

Instruments

Victimization and posttraumatic stress disorder (PTSD) screening. PTSD was assessed using the National Women’s Study (NWS) PTSD module (19). The NWS PTSD module was modified from the Diagnostic Interview Sched- ule (DIS) used in the National Vietnam Veterans Readjustment Study (NVVRS; 6). Participants were screened for symptoms of PTSD (using DSM-111-R criteria), regardless of whether they had experienced an event that met PTSD Criterion A (an event outside of range of usual human experi- ence that would produce marked distress in almost anyone).

Behaviorally specific questions were employed to gather information about victimization experiences and other Criterion A events. “Completed Rape” was defined as unwanted sexual contact that involved penetration of the vagina or anus with a finger, tongue, penis, or other object by a person who used force or threats of force. “Sexual Molestation” was defined as unwanted sexual contact with the breasts or genital area without penetration that oc- curred due to force or threat of force. “Attempted Sexual Assault” included an experience in which unwanted sexual contact was attempted but no ac- tual physical contact occurred in the breast or genital area. “Aggravated Assault” included attacks or threats with a weapon or physical attacks or threats made without a weapon but an intent to kill or seriously injure. “Other Physical Assaults” included physical attacks occurring before the age of 18 that were perpetrated by a guardian (including parent) that left a mark or a bruise or led the individual to miss a day of school or work, or physical attacks that occurred during adulthood that were not of an aggravated na- ture. Other Criterion A events probed were natural disasters, serious acci- dents, homicide of a loved one, exposure to dead bodies, and witnessing the violent death of a person.

For each type of victimization participants were asked to provide their relationship with the perpetrator. Participants were then classified as victim

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GENDER DIFFERENCES AND CR-PTSD 79

of an assault by a “blood” relative (includes father, mother, brother, sis- ter, son, or other relative) or by a nonrelative (includes husband, wife, boyfriend, girlfriend, friend, acquaintance, or stranger). Those who were victimized by both a relative and a nonrelative were classified in the “rela- tive” category. In addition, for each event participants were asked their age at the time they experienced the event and whether they had perceived the event as a threat to their life and/or sustained any physical injuries during the event. Measurement of perceived life threat and physical injury is im- portant, because such Occurrences have been found to be risk factors for CR- PTSD (20,21).

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 sched- ule 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 con- cerning symptom-event correspondence that most respondents likely did not possess (20).

The PTSD measure was prefaced with a non-event-specific probe as fol- lows: “People experience a variety of moods and feelings from time to time. In your case, has there ever been a period of a month or more during which. . . .” Statements following this probe were specifically phrased to as- sess symptom presence such as “you had repeated bad dreams or night- mares.” Criterion E was evaluated by a probe at the end of the interview to determine whether the symptoms lasted at least one month. Lifetime CR- PTSD was assigned if respondents met the DSM-111-R symptom criteria at any time in their life to any crime vicfimizafion experience. Current CR- PTSD was assigned if respondents met criteria for CR-PTSD within the 6 months prior to the interview. Concurrent validity obtained from a slightly modified version of the PTSD interview with the SCID-PTSD module was good with a kappa of 0.71 for Lifetime PTSD. Reliability of the PTSD di- agnostic interview also was acceptable (20).

Substance use disorders screening. Substance use history was obtained by clinical interview and Addiction Severity Inventory (ASI; 22) upon pa- tients’ admission to the inpatient unit, and was modified, if necessary, over the course of the patients’ hospital stay.

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Participants’ primary drug of choice was identified by their response to this question on the AS1 or, if such information was not available, from their hospital discharge summary.

Demographic characteristics. Respondents provided details about their age and racial/ethnic background during the interview. In addition, informa- tion regarding participants’ education and employment history was obtained from a self-report measure. This measure was completed by 56 of the 95 participants.

Procedure

Substance use diagnoses were assessed using the AS1 within one week of admission to the unit. Approximately four days postadmission, trauma and PTSD screenings were conducted in the patients’ rooms on the inpatient psychiatric unit. The interviews were approximately one hour in length. Diagnostic information from the screening interviews was provided to par- ticipants’ treatment team to aid in the team’s provision of services. Students’ t-tests and chi-square analyses were used to test for differences between groups.

RESULTS

Demographic Characteristics

Overall, the participants’ ages ranged from 18 to 68 with an average age for the sample of 35.34 (SD = 9.02). The racial makeup of the sample was as follows: 70.6% of the male participants were Caucasian; 26.5% of the male participants were African-American; 45.9 % ofthe female participants were Caucasian; and 52.5% of the female participants were African-Ameri- can. Chi-square analyses were conducted to test for gender differences in age and race.

Students’ t-test failed to detect a significant difference in age between male and female participants. Chi-square analysis revealed that the prevalence of African-American participants was significantly higher among women than men [53.3% v. 27.3%; Xz(l) = 5.86, p < 0.051.

As mentioned above, participants’ educational level and employment sta- tus were evaluated as part of a self-report questionnaire. Approximately 35%

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GENDER DIFFERENCES AND CR-PTSD 81

of the participants did not graduate high school, 34% were high school graduates, 27% had at least some college education, and 4% were gradu- ates of four-year colleges. About two-thirds (65.5%) of the participants were unemployed, 2% were students, 13% were homemakers or retired, and 20% were employed. Participants were categorized in the following way: “low education” for those with a high school diploma or less school (n = 39) or “high education” for those with at least some college (n = 17); and “unemployed” for those who did not work outside the home (n = 44) or “employed” for those who worked at least part-time outside the home (n = 11).

Chi-square analyses were conducted to test for group differences in as- sault or CR-PTSD prevalence rates. There were no significant differences between participants in the low and high education groups for the prevalence of rape, other types of sexual assault, aggravated assault, other types of physical assault, direct assault (any type of sexual or physical assault), life- time CR-PTSD, or current CR-PTSD. Similarly nonsignificant results were obtained with comparisons between employed and unemployed participants. Thus, the rates of victimization and PTSD observed in the present sample of individuals with substance use disorders cannot be attributed to partici- pants’ socioeconomic level.

Racial Comparisons for Assault Characteristics

Chi-square analyses were conducted to examine assault prevalence rates and characteristics among all Caucasian and African-American participants and among Caucasian and African-American participants of each gender. The prevalence rates for sexual and physical assault are depicted in Figure 1. No racial differences were revealed in the prevalence of completed rape, other unwanted sexual contact (sexual molestation and attempted sexual assault), aggravated assault, other physical assault (simple assault and childhood physi- cal assault by an adult), or direct assault (any type of sexual or physical assault). In addition, no racial differences were detected in participants’ ages at the time they first experienced a rape (x = 18.09 years for African- American participants and x = 14.41 years for Caucasian participants), other sexual assault (x = 16.94 years for African-American participants and x = 12.33 years for Caucasian participants), aggravated assault (x = 20.18 years for African-American participants and x = 17.37 years for Caucasian participants), or other physical assault (x = 13.36 years for African-Ameri-

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Percent

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53.7

Rape Other S.A. Aggr. Asslt Other P.A.

Type of Assault

African-American Caucasian

Fig. 1. Prevalence of sexual and physical assault by race.

can participants and x = 14.84 years for Caucasian participants). Further- more, no differences were found between African-American and Caucasian participants for whether they perceived their life to have been endangered during each type of assault. Finally, differences in victims’ relationship with the perpetrator (family versus nonfamily member) were not observed between Caucasian and African-American participants. Since no racial differences were detected for these assault characteristics, African-American and Cau- casian participants were treated as a single group for the gender compari- sons.

Gender Comparisons for Assault Characteristics

Figure 2 illustrates the prevalence rates for male and female participants for completed rape and any other unwanted sexual contact. The prevalence

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GENDER DIFFERENCES AND CR-F’TSD

Percent

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59 60

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0 Rape Molestation Attempted SA

Type of Assault - Females Males

Fig. 2. Prevalence of sexual assault by gender.

rates for aggravated assault and any other physical assault are shown in Figure 3. When all types of sexual and physical assault were considered together (direct assault), the prevalence rates were 91.8% for women and 88.2% for men.

Chi-square analyses were conducted to test for differences in the propor- tion of women and men reporting sexual and physical assaults. The preva- lence rate of completed rape for women was significantly higher than for men [59.0% v. 20.6%; X2(1) = 13.01, p < 0.0011. No significant gen- der differences were observed for other types of sexual assaults such as sexual molestation or attempted sexual assault. There were no significant dif- ferences between male and female participants for any type of physical as- sault.

There were no significant differences between female and male partici- pants in the average age at which they experienced their first completed rape (x = 16.35 years for women and x = 15.17 years for men) or the aver- age age at which they experienced their first “other sexual assault” (x = 15.36 years for women and x = 13.1 years for men). Women were

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Percent

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n

Aggravated Assault Other Physical Asslt

Type of Physical Assault

Females Males

Fig. 3. Prevalence of physical assault by gender.

significantly older than men at the time of experiencing their first aggravated assault r20.36 years v. 14.92 years; t(63) = -2.39, p < 0.051.

Women were significantly more likely than men to have perceived life threat during a rape [88.9% v. 57.1%; X2(1)=4.33, p C 0.051. However, there were no significant gender differences for perception of life threat during incidents of sexual molestation or attempted sexual assault (40.9 % for women and 60.0% for men), incidents of aggravated assault (90.2% for women and 83.3% for men), or other types of physical assault (58.5% for women and 64.7% for men).

Chi-square analyses failed to reveal any significant gender differences in victims’ relationship to the perpetrator for completed rape, sexual molesta- tion, or attempted sexual assault. For aggravated assaults not involving a weapon, men were significantly more likely to have been victimized by a relative than women [72.7% versus 25.8%; X2(1) = 7.58, p < 0.011. No significant gender differences were observed in the relationship to perpetra- tors of other types of physical assault.

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GENDER DIFFERENCES AND CR-PTSD 85

Racial and Gender Comparisons for CR-PTSD

The rates of lifetime CR-PTSD in African-American and Caucasian par- ticipants are illustrated in Figure 4. Although there appears to be a differ- ence between African-American (61 .O%) and Caucasian (46.2 %) participants for the prevalence of lifetime CR-PTSD, this difference did not reach sig- nificance [X2(1) = 20.2, p = 0.151. Similarly, the difference in prevalence of lifetime CR-PTSD between African-American male (77.8 %) and Cauca- sian male (45.8%) participants did not meet significance. No significant racial difference in the prevalence of lifetime CR-PTSD was detected for African- American female (56.3%) and Caucasian female (46.4%) participants. No racial differences were observed for the prevalence of current CR-PTSD. As with assault characteristics, since no racial differences were detected in the prevalence rates of CR-PTSD, African-American and Caucasian participants were treated as a single group for the gender comparisons.

Perc e nl

60

40

20

0 Lifetime PTSD Current PTSD

I African-American Caucasian 1 ~~ ~~

Fig. 4. Prevalence of lifetime and current CR-PTSD by race.

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Illustrated in Figure 5 are the prevalence rates for female and male partici- pants for lifetime and current CR-PTSD. More than one-half of the women and men experienced PTSD at some point during their lives, and more than 40% met criteria for CR-PTSD within 6 months of their screening interview. No significant differences between male and female participants were found for the prevalence of lifetime or current CR-PTSD.

T-tests were calculated to assess for racial and gender differences in the number of lifetime and current intrusive, avoidant, and increased arousal symptoms. When all African-American and Caucasian participants were compared, no racial differences in symptom frequency were observed. How- ever, African-American men reported a significantly higher number of in- trusive symptoms than Caucasian men [2.11 v. 1.12; (31) = 2.08, p < 0.051. No other racial or gender differences were observed in PTSD symp- tom clusters.

Perc e n I

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52.5 52.9

44.1

Lifetime PTSD Current PTSD

Females Males

Fig. 5. Prevalence of lifetime and current CR-PTSD by gender.

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GENDER DIFFERENCES AND CR-PTSD 87

Victimization, PTSD, and Substance Abuse/Dependence

Since a majority of the sample misused alcohol or cocaine (81%), poten- tial differences between these two groups were examined more closely. A higher proportion of African-American participants reported cocaine as their primary drug of choice when compared with Caucasian participants [77.1% v. 25%; X2(1) = 20.30, p < 0.0011. When this relationship was examined separately for male and female participants, African-American men were more likely to report their primary drug of choice as cocaine than Cauca- sian men [62.5% v. 15.0%; X2(1) = 6.32, p < 0.051, and African-Ameri- can women were more likely than Caucasian women to identify cocaine as their primary drug of choice [81.5% v. 35.0%; X2(1) = 10.50, p < 0.0011. However, there were no significant differences detected in drug choice be- tween Caucasian male and female participants [X2(l) = 2.13, NS] or between African-American male and female participants [X2( 1) = 1.26, NS] for their primary drug of choice. Therefore, a racial difference, rather than a gender difference, was found for primary drug of choice.

Since racial differences were detected, comparisons between drug of choice and victimization/PTSD variables were conducted separately for Cau- casian and African-American participants. No differences were detected be- tween African-American participants who misused cocaine and those who misused alcohol for prevalence rates of sexual assault, physical assault, life- time CR-PTSD, or current CR-PTSD. However, among Caucasian partici- pants the rate of completed rape was significantly higher for participants in the cocaine abuse/dependence group than for participants in the alcohol abuse/dependence group [70.0% v. 26.7%; X2(1) = 6.01, p < 0.051. No other differences were observed between Caucasian cocaine and alcohol abusers for assault or PTSD prevalence rates.

African-American patients who misused cocaine and alcohol did not dif- fer in their ages at the time they experienced their first sexual or physical assault or the degree to which they perceived life threat or experienced physical injury during their assaults. However, among the Caucasian partici- pants who experienced a rape (n = 13), it appears that participants in the cocaine group may experience their rape at a younger age than participants in the alcohol group [z = 7.5 years v. x = 16.14 years; t(l1) = 2.13, p < 0.061. Furthermore, the age of first (only) direct assault experience was significantly younger for Caucasian participants in the cocaine abuse/depen- dence group than Caucasian participants in the alcohol abuse/dependence

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group [x= 8.3 years v. 14.5 years; t (32) = 2.12, p < 0.051. No group differences were detected between Caucasian participants with primary co- caine abuse/dependence and alcohol abuseldependence for age at first physi- cal assault or the degree to which they perceived life threat or experienced physical injury during their assaults.

DISCUSSION

Almost 90% of the women and men who sought treatment for substance use disorders reported that they had experienced a sexual and/or physical assault during their lifetime. In addition, more than 40% of this treatment- seeking sample had current crime-related PTSD (CR-PTSD). These assault and PTSD prevalence rates can be contrasted with prevalence rates obtained in general population samples of 8-36% for crime victimization and 5-7% for current PTSD (20,23,24). The high rates of victimization and CR-PTSD obtained in the present sample were unrelated to the patients’ educational level or employment status and are comparable to rates observed in other treatment-seeking samples of substance use disordered patients (1 1,13, 17,25-29). Researchers such as Miller et al. (13) and Yandow (17) found rates of sexual victimization in 67% and 75% of their samples of female substance use disordered patients. Bryer et al. (28) found an overall victim- ization rate of 72% among female psychiatric inpatients, and Jacobson (29) documented that 68% of his sample of psychiatric outpatients had a victim- ization history. Furthermore, the lifetime CR-PTSD rate of 52% observed in the present sample corresponds to the lifetime PTSD rate of 54.5% ob- tained by Grice et al. (11) and the rate of 50% documented by Triffleman and her colleagues (27).

The lack of racial or gender differences for all types of direct assault except rape is a notable finding. Although there is an increased awareness of the importance of screening for sexual molestation among women, atten- tion is rarely paid to male patients’ sexual trauma history. In addition, con- trary to some evidence that African-American women are at increased risk for certain types of assaults (18), it is possible that in samples of substance- abusing patients Caucasian and African-American individuals are equally likely to have an assault history.

Regarding racial and gender differences, not only were there few racial or gender differences in the overall prevalence of assault in this sample, few differences were detected for assault characteristics. Men experienced their

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GENDER DIFFERENCES AND CR-PTSD 89

first aggravated assault at a younger age than women and were more likely to be assaulted by a family member. Women, on the other hand, perceived more life threat during a rape experience than men. As mentioned above, previous research has demonstrated that victims who perceived their lives as endangered were more likely to develop PTSD than victims who did not believe that they would be killed (20,21). One implication of the observed gender differences is that assessment of early, violent physical assault per- petrated by a family member may be particularly important when working with male patients with a substance use disorder. In addition, since men may be less likely to perceive life threat during a rape, they also may be less likely to label the assault experience as a rape or experience CR-PTSD as a result of the rape. Therefore, as has been encouraged by other research- ers (e.g., Koss), use of behaviorally specific questions, avoidance of the word rape when screening individuals for sexual assault history, and includ- ing questions about perceived life threat or physical injury may yield more accurate information.

The failure to detect any gender differences in the prevalence of CR- PTSD is somewhat discrepant with findings in the literature, where women were found to have an increased risk of PTSD (e.g., 23,24). However, the victimization prevalence rates obtained by Breslau et al. (23) and Norris (24) likely are underestimates due to a lack of sensitivity in their screening in- struments. More specifically, Breslau et al. found prevalence rates of 1.6% for rape and 8.3% for physical assault, and Norris observed sexual and physical assault prevalence rates of 4.4% and 15.0%, respectively. However, in both investigations the trauma screening instrument did not include sen- sitive, behaviorally specific questions designed to elicit information about sexual and physical assault.

Since PTSD can only be diagnosed if a Criterion A event is identified, it is probable that the PTSD rates reported by Breslau and Norris were affected by this lack of sensitivity, particularly since PTSD prevalence rates are highly associated with victimization events (2,20). Therefore, Breslau et al.’s low PTSD prevalence rates (11.3% of women and 6% of men met criteria for lifetime PTSD to any traumatic event) and Norris’s CR-PTSD rates (12% of women and 6% of men met criteria for current CR-PTSD) are likely underestimates due to imprecise instrumentation. It is possible that with thorough screening for all types of assault, gender differences in as- sault and CR-PTSD rates obtained in general population samples would not be observed. However, it is also plausible that there is a gender difference in the CR-PTSD prevalence rate in the general population that is not present

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among substance abuse treatment-seeking samples. The implication of this, if true, is that treatment-seeking men are especially at risk for CR-PTSD compared to men in the general population. Further exploration of this is- sue is necessary.

Although there were no differences in assault prevalence or characteris- tics detected among African-American participants who misused cocaine and alcohol, a number of interesting differences were observed among Cauca- sian participants in these two groups. The higher prevalence of rape observed among Caucasian cocaine abusers is supported by findings in the literature (2,5,26). Additionally, the finding that Caucasian rape victims in the cocaine group were raped at a younger age than Caucasian rape victims in the al- cohol group is intriguing in that it suggests that rape at a younger age may be a risk factor for the use of illegal or “heavy” drugs. Further work in this area is necessary to further clarify these results.

The lack of a difference in the prevalence of CR-PTSD among patients who were primarily alcohol users versus those who were primarily cocaine users is supported by what has been observed among women in the NWS who indicated that they had received treatment for substance abuse/depen- dence (5 ) . However, when all individuals in the Nws who abused alcohol or drugs were considered (not just those who had received treatment), women who abused heavy drugs (including cocaine) reported a significantly greater number of reexperiencing, avoidant, and hyperarousal symptoms than women who abused alcohol or marijuana or nonusers. Other investigators also have noted that cocaine/heavy drug users appear to have a significantly higher rate of PTSD than individuals who misuse alcohol (2,5,26,27). Over- all, the bulk of the evidence suggests that individuals (particularly Cauca- sian individuals) who abuse cocaine/heavy drugs may be at greater risk for victimization, victimization at a younger age, and the development of PTSD.

Despite the fact that it now is common practice to evaluate patients in treatment for a substance use disorder for comorbid anxiety or depression, PTSD (one type of anxiety disorder) often is overlooked. The results from the present investigation support gathering information about victimization and CR-PTSD from male and female patients, Caucasian and African-American patients, and patients from all socioeconomic groups receiving treatment for substance use disorders. Such information can facilitate tailoring treatment to individual patient needs. None of the researchers who have collected assault histories from their patients indicated that this process was perceived to be problematic for the patients. Moreover, although there is much dis-

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cussion whether concurrent treatment for substance use disorders and other psychiatric disorders is recommended (30-32), pilot subjects from our site who received simultaneous treatment for CR-PTSD and cocaine dependence evidenced significant improvements over time in fear symptoms, PTSD symptoms, extent of general distress, and alcohol/drug-related problems (33). It also has been documented that among women involved in traditional sub- stance abuse treatment, those who had comorbid CR-PTSD were significantly more likely to be noncompliant with aftercare than those who were nega- tive for CR-PTSD, which can be seen as an indication that unchecked PTSD is associated with poorer treatment outcome (34). Therefore, early assess- ment of victimization history and CR-PTSD may be a critical part of treat- ment planning and delivery for all patients in treatment for a substance use disorder.

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 1994 American Psychological Asso- ciation’s annual conference on Psychosocial and Behavioral Factors in Women’s Health, Washington, D.C.

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