Subjective Sleep Disturbances in Sexual Assault Survivors: Associations With Trauma and Posttraumatic Stress Disorder Symptom Severity

Prior work implicates sleep disturbance in the development and maintenance of posttraumatic stress disorder (PTSD). However, the majority of this literature has focused on combat veteran men, and limited work has examined links between sleep disturbance and PTSD symptoms in sexual assault survivors. This is a notable gap in the literature, as sexual trauma is disproportionately likely to result in PTSD and is more common in women. We sought to examine the relations between subjective sleep disturbance, sexual assault severity, and PTSD symptoms in a sample of sexual assault survivors with PTSD (PTSD+), without PTSD (PTSD-), and healthy controls. The sample (N = 60) completed the Insomnia Severity Index and prospectively monitored their sleep for 1 week using the Consensus Sleep Diary. The sexual assault survivors also completed the Sexual Experiences Survey and PTSD Checklist-5. Results of group comparisons found that the PTSD+ group reported significantly higher insomnia symptoms, longer sleep onset latency, more nocturnal awakenings, and lower sleep quality compared to the healthy control group and higher insomnia symptoms compared to the PTSD- group. Results of regression analyses in the sexual assault survivors found that insomnia symptoms and number of nocturnal awakenings were significantly associated with higher PTSD symptoms, and sexual assault severity was significantly associated with higher insomnia symptoms, longer sleep onset latency, and lower sleep quality. These findings highlight specific features of sleep disturbance that are linked to trauma and PTSD symptom severity among sexual assault survivors.     

The Role Of Attributions and Perceived Control In Recovery From Rape

Abstract

It is fitting that a volume on post-traumatic stress includes chapters on sexual assault given both the prevalence of sexual assault and its effects. Specifically, in terms of prevalence, approximately one woman in five in the United States will be raped in her lifetime (Koss, 1993).¹ In terms of the effects of sexual assault, victims experience heightened fear, anxiety, and depression for several months, and sometimes years, following an assault (see Frazier & Borgida, 1997, and Resick, 1993, for reviews). Sexual victimization affects physical health as well and is a more powerful predictor of physician visits and outpatient medical costs than other factors (e.g., age, smoking, alcohol use) known to be related to health problems (Koss, Koss, & Woodruff, 1991). Finally, sexual assault is one of the traumatic events that is most likely to lead to posttraumatic stress disorder (PTSD) (Breslau, Davis, Andreski, & Peterson, 1991; Norris, 1992; Ullman & Siegel, 1994). In a recent national study of trauma exposure and PTSD by Kessler and his colleagues (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995), almost half of the women who said that a rape was their worst trauma met lifetime criteria for PTSD. This is in comparison, for example, with a PTSD prevalence rate of 5% for those whose worst event was a natural disaster.     

Victim Ambiguity: Bystander Intervention and Sexual Assault in the College Drinking Scene

Alcohol-related sexual assault is the most common form of sexual victimization on college campuses. Bystander intervention has been suggested as effective in preventing sexual assault, but its usefulness in sexual assaults that involve alcohol in particular has not yet been examined. The current study draws from intensive interviews with 30 undergraduates at a large Midwestern university to understand how students’ perceptions about sexual victimization and alcohol use affect their bystander behavior. Findings suggest that in alcohol-involved situations, the ambiguity of whether the woman is at risk and her perceived worthiness are significant barriers to intervention. Policy implications are discussed.     

Emotional and Cognitive Processing in Sexual Assault Survivors' Narratives

Sexual assault sequelae include posttraumatic stress disorder (PTSD), depression, and substance use. Seminal treatment models have been developed based on emotional (Foa & Kozak, 1986) and cognitive (Resick & Schnicke, 1992) theories, and determined to be efficacious. Studies also have documented the utility of Pennebaker and Beall's (1986) narrative writing paradigm for trauma- related depressive and PTSD symptoms. Recently investigations have sought to explicate its benefit, focusing on mechanisms of action. This study aimed to examine the emotional activation and cognitive processing across narrative writing sessions with undergraduate sexual assault survivors. Results revealed statistically significant reductions in depressive symptoms and alcohol use, but not PTSD symptoms. Clinically meaningful and statistically significant emotional activation and habituation occurred within and across sessions. Implications and limitations are discussed.     

Challenges to Doing Sexual Violence Work

Sexual assault victims experience a number of effects as a result of their victimization. Sexual assault crisis workers are assigned the responsibility of trying to minimize the negative consequences of sexual assault. In their efforts to serve sexual assault victims, it is likely that certain problems make it difficult to adequately help victims. This study considers how 43 sexual assault crisis workers (27 directors of sexual assault crisis centers and 16 workers) define the challenges of serving sexual assault victims. Major challenges reported included a lack of awareness about sexual assault, victim blaming, and a lack of resources. Implications are provided.     

New Opportunities

Sexual assault is a pervasive problem in the U.S. military, especially against women. Bystander intervention is increasingly promoted as important for reducing sexual violence, and it may be particularly helpful in contexts with high rates of sexual violence. Bystander training encourages and enables people to intervene safely and stop sexual violence. In this study, we drew from an ecological model to investigate intrapersonal, microsystem, and exosystem factors that predicted Service members' assumption of personal responsibility to intervene in an alcohol‐involved sexual assault. Moreover, we examined how these predictors played a role in decisions about how to intervene: confronting the perpetrator, assisting the victim, or finding someone to help. We analyzed data from 24,610 active duty personnel collected by the Department of Defense. Several factors significantly related to Service members' bystander intentions: gender, rank, morale, attitudes about sexual assault, training, and trust in the military sexual assault system predicted the likelihood and method of bystander intervention. These findings help identify how and why people intervene (or fail to intervene) when they witness situations that could develop into sexual violence.     

The importance of distinguishing between harassment-only and assault military sexual trauma during screening

Extant research demonstrates that a history of military sexual trauma (MST) is associated with PTSD and depression diagnoses as well as heightened risk for suicidal ideation and death by suicide. Past studies of MST and its sequelae typically collapse harassment-only and assault MST screening items into a single response, recorded as positive or negative for a history of MST. It is presently unclear whether assault is associated with poorer mental health outcomes relative to harassment-only MST. Female service members/Veterans (n = 656) completed an online survey assessing history (present, absent) and type (harassment-only, assault) of MST, PTSD, depression, sexual satisfaction and function symptoms, as well as suicidal ideation. Findings revealed that those who reported a history of MST, and assault more specifically, were more likely to report higher PTSD symptoms and probable PTSD diagnosis, higher depression symptoms and probable depression diagnosis, worse sexual function and probable sexual function diagnosis, lower sexual satisfaction, and presence of suicidal ideation. Those who reported harassment-only MST also reported higher PTSD severity and probable PTSD diagnosis, but the magnitude of the association of harassment-only MST and PTSD severity relative to assault MST and PTSD severity was substantially lower. Findings suggest it is critical to distinguish between history and type of MST during screening as a combined screening item loses sensitivity to identify those at heightened risk for distress and dysfunction.     

Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder

This study examined cognitive and affective predictors of treatment dropout and treatment efficacy in Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for PTSD. Study participants were women with PTSD from a sexual assault who received at least one session of either treatment (n = 145) as part of a randomized clinical trial. Results revealed that younger age, lower intelligence, and less education were associated with higher treatment dropout, whereas higher depression and guilt at pretreatment were associated with greater improvement in PTSD symptomatology. Results by treatment condition indicated that women with higher anger at pretreatment were more likely to dropout of PE and that older women in PE and younger women in CPT had the best overall outcomes. These findings have implications for efforts to enhance treatment efficacy and retention in CBT treatment protocols.     

The Impact of Sexual Assault on College Students’ Daily Occupations: A Phenomenological Approach

Abstract

Sexual assault is associated with a high degree of Posttraumatic Stress Disorder (PTSD) severity. Three in ten survivors of campus sexual assault develop PTSD over their lifetime. Occupational therapists treat veterans with PTSD, but limited research exists addressing college student survivors of sexual assault and occupational therapy. A phenomenological approach was used to understand meanings of sexual assault for college student survivors. Semi-structured interviews yielded rich data and themes of disruption and reduced quality of life. The author concludes there is potential for occupational therapists to play a collaborative role on college campuses.     

Treatment of a four-year-old victim of incest

Abstract

A case study describing the use of behavior techniques in the treatment of a four—year—old sexual assault victim is presented. The target behaviors included eating, phobic behaviors, self—injurious behaviors, and comments made about the father (the perpetrator) and the paternal grandmother. The child's mother served as both data collector and therapist. The study demonstrates that child victims can experience a sexual assault trauma syndrome similar to that manifested by adult victims. Additionally, the findings illustrate that a simple behavioral intervention implemented by a parent can be effective in treating young sexual assault victims.     

A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault

The effectiveness of psychological treatments for PTSD is likely to be enhanced by improved understanding of the factors involved in maintaining the disorder. Ehlers and Clark [A cognitive model of persistent posttraumatic stem disorder Behav. Res. Ther. 38 (2000) 319-345] recently proposed a cognitive model of maintenance. The current study aimed to investigate several cognitive factors highlighted in Ehlers and Clark's model using a prospective design. Fifty-seven victims of physical or sexual assault participated in the study. Cognitive factors were assessed within 4 months of assault and victims were followed-up 6 and 9 months after the assault. Cognitive variables which significantly predicted PTSD severity at both follow-ups were: cognitive processing style during assault (mental defeat, mental confusion, detachment); appraisal of assault sequelae (appraisal of symptoms, perceived negative responses of others, permanent change); negative beliefs about self and world; and maladaptive control strategies (avoidance/safety seeking). Relationships between early appraisals, control strategies, and processing styles and subsequent PTSD severity remained significant after statistically controlling for gender and perceived assault severity. These findings support the cognitive model of PTSD proposed by Ehlers and Clark and suggest that effective treatment will need to address these cognitive factors.     

Psychopathology Following Interpersonal Violence: A Comparison of Risk Factors in Older and Younger Adults

A randomly selected sample of 549 women age 55 years and older and 2,669 women age 18–34 years was interviewed via telephone to determine prevalences of physical and sexual assault, posttraumatic stress disorder (PTSD) symptomatology, and depression. Prevalences of sexual and physical assaults were lower in older compared to younger women. In addition, given a trauma, prevalences and proportionate risk of posttraumatic psychopathology and depression were also lower for older, relative to younger women. Specifically, multivariate analyses revealed that sexual assault predicted only PTSD avoidance in older adults, but all forms of PTSD symptomatology and depression in younger adult women. Similarly, physical assault predicted only PTSD re-experiencing symptoms in older women, but all forms of PTSD symptoms and depression in younger women. Self-reported health status was not associated with any increased risk of psychopathology, and low income predicted increased avoidance and depression only in younger women.     

Gay male sexual assault survivors: the relations among internalized homophobia, experiential avoidance, and psychological symptom severity

This study explored the relations among internalized homophobia (IH), experiential avoidance, and psychological symptom severity in a community sample of 74 gay male sexual assault survivors. Results indicated that IH is associated with both depressive and posttraumatic stress disorder (PTSD) symptom severity. IH accounted for more variance than assault severity in predicting both PTSD and depression symptom severity. IH and experiential avoidance similarly predicted PTSD symptom severity. In comparison with IH, however, experiential avoidance is a stronger predictor of depression symptom severity. Results also showed that experiential avoidance partially mediated the relation between IH and both depressive and PTSD symptom severity. The implications of these findings are discussed and suggestions for future research are provided.     

A critical review of field studies on the link of alcohol and adult sexual assault in women

This article reviews field studies examining two central questions regarding the link between alcohol and sexual assault. First, evidence is reviewed to evaluate whether there is a distal relationship between alcohol and risk of sexual assault victimization. Specifically, studies are examined to determine whether drinking may affect the risk of being victimized and how victimization may contribute to subsequent drinking. Second, evidence for a proximal role of drinking prior to a sexual assault victimization incident (by either victim and/or offender) is examined to determine alcohol's role in rape and injury outcomes to victims. Critical theoretical and methodological issues in these two types of studies are discussed with regard to the extant literature. Paralleling the two areas of research reviewed, two theoretical models are proposed to guide future research on (1) the global associations of drinking and sexual assault risk across the life span (macrolevel model) and (2) the role of drinking in the outcomes of actual sexual assault incidents (microlevel model). Suggestions are made for future research and intervention in this area.     

Treatment choice for PTSD

The impetus for seeking help for assault-related difficulties often rests upon the victims themselves. Yet, we know very little about what factors influence a woman's decision to seek a particular kind of help after an assault. To learn more about these factors, data from 273 women with varying degrees of trauma history and subsequent PTSD symptoms were collected. All participants read a standard, "if this happened to you, what would you do" scenario describing a traumatic event and subsequent trauma-related psychiatric symptoms. Participants were given the same trauma scenario (i.e., sexual assault) and three treatment options to choose from: sertraline (SER), prolonged exposure (PE), or no treatment. Ratings of treatment credibility, personal reactions to treatment options, and treatment choice were examined. Women were more likely to choose PE than SER for the treatment of chronic PTSD. Perceived credibility of the treatment and personal reactions coincided with women's choices. By better understanding who would choose which treatments for PTSD and why, we will improve our ability to tailor how we approach discussing treatment options with these women.     

Sexual assault: Myths and stereotypes among Australian adolescents

Myths and stereotypes about sexual assault reflect a society which excuses perpetrators of assault and blames victims for failing to control men's sexuality. Such views are well-established by early adulthood, but there is little research with adolescents. This study surveyed two hundred forty-four 14–16 year old Australian high school students (105 male, 139 female), of Anglo-European descent. Males were significantly more likely to endorse sexual assault myths, to agree that forced sex was acceptable in some situations, and to hold false stereotypes about sexual assault. Males also held more restrictive attitudes toward women's roles and endorsed a greater level of sexism in dating relationships. This suggests that male and female adolescents have differing expectations of dating relationships, which may underlie sexual assault within relationships. Assault-supportive attitudes are apparent at a young age, supporting the need for educational and social interventions targeting young people.     

Exploring Correlates of Alcohol-Specific Social Reactions in Alcohol-Involved Sexual Assaults

This exploratory study examined demographic, assault, and disclosure factors as predictors of survivors’ decisions to disclose preassault alcohol use and social reactions to their preassault alcohol use. Of survivors drinking prior to assault, those with more education and greater alcohol impairment or resistance during assault were more likely to disclose preassault drinking. Of women disclosing preassault drinking, those with more education and more violent assaults received more negative social reactions specific to their preassault drinking. Such negative reactions were more common for those telling parents, police, or medical professionals. Women with less education received more positive and negative social reactions specific to their preassault drinking. Disclosing preassault drinking in greater detail was related to positive social reactions specific to preassault drinking and greater alcohol impairment during assault was associated with both positive and negative social reactions specific to preassault drinking. Implications for research and intervention are provided for survivors disclosing alcohol-related sexual assaults.     

Sexual assault history and suicidal behavior in a national sample of women

This study examined demographic and psychosocial correlates of suicidal ideation and suicide attempts in women with histories of sexual assault in childhood and/or adulthood identified from a national sample of women. Multivariate analyses showed that women with histories of sexual assault in both childhood and adulthood reported significantly greater odds of lifetime suicide attempts, controlling for demographic factors and other psychosocial characteristics. As predicted, younger age (marginal), stressful life events (marginal), depression, PTSD, and alcohol dependence symptoms were also significantly associated with suicidal ideation. Furthermore, number of lifetime traumatic events and depression were each associated with lifetime odds of suicide attempts. Implications for studying the role of sexual trauma and other psychosocial factors in relation to women's suicidal behavior are discussed.