Rape-Related PTSD: Issues and Interventions

Rape is a crime that is defined as an unwanted sexual act that results in oral, vaginal, or anal penetration.¹ Generally speaking, there are 2 major types of rape. Forcible rape involves unwanted sexual penetration obtained by the use of force or threat of force. Drug- or alcohol-facilitated rape occurs when the victim is passed out or highly intoxicated because of voluntary or involuntary consumption of alcohol or drugs. Rape can happen to boys and men as well as to girls and women,² but this article will focus primarily on women.

Epidemiology

Before describing data on rape prevalence, it is important to address some common stereotypes so that mental health professionals will have an accurate understanding about the true nature and scope of rape.

• First, contrary to stereotype, rape is not an experience that only happens to adult women. Data from carefully conducted epidemiological studies suggest that more than half of women who have been raped were first raped before age 18.^3-5
• Second, contrary to stereotype, many women who have been raped have been raped more than once^3,5,6; women who seek treatment for a recent rape may have been raped in childhood or in adolescence.
• Third, although the stereotype is that most perpetrators are strangers, the data indicate that perpetrators are much more likely to be someone the victim knows well.^3-5
• Fourth, although many people expect victims of rape to have sustained serious physical injuries, the reality is that most rape victims sustain either minor or no physical injuries, perhaps because most of them are fearful that the perpetrator will kill or seriously injure them if they resist.^3-5

Many rape victims themselves believe these stereotypes and think of rape as something that only happens to adult women, is committed only by strangers, and that always involves excessive levels of physical force. This means that proper case finding and screening must make use of procedures that counteract these stereotypes.

There is substantial evidence that rape is a major problem for women in the United States. The best epidemiological studies indicate that the lifetime prevalence of forcible rape (ie, the proportion of women who have been raped) is between 12.6% and 16.1%.^3-5 One recent national survey⁴ found that 18% of a national probability sample of women in the United States had been victims of at least 1 forcible rape (16.1%) or drug- or alcohol-facilitated rape (5.4%). Based on 2005 US Census data, this means that an estimated 20.2 million women have been raped. This same study found that the past-year prevalence (ie, the proportion of the sample who had been raped within the past year) was 0.94%, or an estimated 1.1 million women.

Recent lifetime prevalence estimates of forcible rape are higher than those obtained in the early 1990s using similar methodology³ and suggest that the prevalence of rape in the United States has increased over the past 2 decades. Furthermore, past-year prevalence estimates for forcible rape are comparable to those reported in the early 1990s, raising doubts about claims that the annual incidence of rape is decreasing.

Of particular relevance to the topic of this article, data from a large probability sample of psychiatric patients with serious mental illnesses found that the lifetime prevalence and past-year prevalence of rape was substantially higher in female patients than the estimates just reviewed.⁷ This suggests that a history of rape victimization is not uncommon in patients with psychiatric disorders.

This article addresses 3 major topics, including screening and case finding, assessment of posttraumatic stress disorder (PTSD) and other rape-related problems, and treatment issues. With regard to treatment approaches, early intervention is briefly addressed but the main emphasis is on treatment of PTSD and other problems in women who are not recent rape victims, since those with less recent assault history are more likely to be seen by mental health practitioners.

PTSD and other consequences

Rape and other forms of sexual assault have broad-reaching effects on many levels, including basic needs, functional impairment, physical health, and mental health. Although chronic psychopathology does not develop in most rape or sexual assault victims, these forms of traumatic victimization are associated with a higher prevalence of PTSD than are other types of traumatic events. For example, the National Women's Study,⁸ an epidemiological survey of 4008 women, found the lifetime prevalence of PTSD resulting from rape and sexual assault to be 32% and 30.8%, respectively, compared with a prevalence of 9.4% caused by non- crime-related trauma (eg, motor vehicle accident).

Population-based studies indicate that about 1 in 9 women have met criteria for PTSD at some point during their lifetime.^8,9 In real population numbers, these estimates equate to about 11 million women in the United States. Other common mental health consequences of rape are major depression and alcohol or drug abuse.^8,10 In this article, we focus on PTSD because it has been the most extensively researched area of the treatment literature in this population.

Risk factors for and mediators of PTSD

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.

Screening and assessment

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).

Early interventions

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.

Psychosocial early interventions

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

Pharmacological early interventions

The release of stress hormones, such as epinephrine, following a traumatic event assists in memory consolidation and learning,³¹ and therefore ß-adrenergic antagonists, such as 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.)

Pharmacological treatment

SSRIs have received the most empirical attention in the treatment of PTSD, and in fact sertraline and 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 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, a noradrenergic and specific serotonergic antidepressant, was effective over placebo.⁷³ Lamotrigine, an anticonvulsant, has also shown preliminary efficacy in a small double-blind controlled study.⁷⁴ In a small open-label trial of 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, 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.

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