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Are Gender Differences in Post-Traumatic Stress Disorder Rates Attenuated in Substance Use Disorder Patients?

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Abstract

We review 15 studies that examined rates of post-traumatic stress disorder (PTSD) in substance use disorder (SUD) patients to determine whether the typical female-greater-than- male gender difference in PTSD rates is attenuated in SUD samples. Since the majority of studies reviewed did not find a gender difference in PTSD rates, we critically examined methodological factors that might account for this attenuation, but none appeared to completely account for the variability in detection of gender differences across studies. Several factors may contribute to making rates of PTSD among SUD males equivalent to the high rates observed in SUD females: 1) the risky lifestyle associated with men's substance abuse may increase their exposure to traumatic events, 2) a history of more severe trauma characteristics may be apparent among men with SUDs, or 3) attenuated gender differences in rates of other comorbidities that increase PTSD risk (e.g., depression) may exist. Clinical implications are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Are Gender Differences in Post-Traumatic
Stress Disorder Rates Attenuated in Substance
Use Disorder Patients?
Abstract
We review 15 studies that examined rates of post-traumatic
stress disorder (PTSD) in substance use disorder (SUD)
patients to determine whether the typical female-greater-
than-male gender difference in PTSD rates is attenuated in
SUD samples. Since the majority of studies reviewed did
not find a gender difference in PTSD rates, we critically
examined methodological factors that might account for
this attenuation, but none appeared to completely account
for the variability in detection of gender differences across
studies. Several factors may contribute to making rates of
PTSD among SUD males equivalent to the high rates
observed in SUD females: 1) the risky lifestyle associated
with men’s substance abuse may increase their exposure to
traumatic events, 2) a history of more severe trauma char-
acteristics may be apparent among men with SUDs, or 3)
attenuated gender differences in rates of other comorbidi-
ties that increase PTSD risk (e.g., depression) may exist.
Clinical implications are discussed.
According to epidemiological studies, post-traumat-
ic stress disorder (PTSD) is a highly comorbid condi-
tion among those with substance use disorders (SUDs;
see review by Stewart, 1996). In the National
Comorbidity Survey, a large-scale epidemiologic survey
conducted in the U.S., Kessler and colleagues (1997)
found that those with alcohol dependence were at 3-4
times increased risk of lifetime PTSD as compared to
those without alcohol dependence. Moreover, the
presence of comorbid PTSD among individuals being
treated for SUDs is related to poorer treatment adher-
ence (Hien, Nunes, Rudnick Levin, & Fraser, 2000)
and outcomes, including higher relapse rates (e.g.,
Ouimette, Brown, & Najavits, 1998; Ouimette, Finney,
& Moos, 1999). It has been suggested that if patients
with comorbid SUD-PTSD were to receive trauma-spe-
cific treatment, they might avoid overutilizing or mis-
using expensive inpatient SUD treatments, thereby
reducing the cost of clinical care (e.g., Brown,
Recupero, & Stout, 1995).
The delineation of gender variations in the presen-
tation of this comorbidity may identify factors that will
improve treatment outcomes (Sonne et al., 2003). A
fairly consistent finding across epidemiologic studies
on PTSD rates in the general adult population is that
women are about twice as likely to have PTSD as men
(e.g., Breslau, Chilcoat, Kessler, Peterson, & Lucia,
1999; Breslau, Davis, Andreski, & Peterson, 1991;
Breslau, Davis, Andreski, Peterson, & Schultz, 1997;
Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).
Moreover, women experience qualitatively different
traumatic life experiences than do men. These find-
ings have led to an interest in understanding gender
differences in PTSD and their implications for etiology
and treatment of the disorder (e.g., Kimerling,
Ouimette, & Weitlauf, in press).
Early research on comorbid PTSD-SUDs focused
almost exclusively on male veterans whose pathology
arose in the context of combat trauma; more recently,
a focus has emerged on women with comorbid PTSD-
SUDs (Najavits, Weiss, & Shaw, 1997). The major pur-
pose of this article is to examine gender as an impor-
tant individual difference variable with respect to trau-
ma and PTSD among patients with SUDs. This brief
review focuses on rates of trauma and PTSD among
clinical samples of male and female SUD patients.
Summaries of the methods and findings of the studies
reviewed in this article are provided in Tables 1 and 2,
for trauma exposure rates and PTSD rates, respectively.
Gender Differences in Adult Samples
Brown et al. (1995) studied the prevalence of trau-
ma histories and comorbid PTSD among 84 adults (48
male; 36 female) seeking treatment at a private hospi-
tal inpatient substance-abuse treatment program.
Participants completed self-report measures of lifetime
SHERRY H. STEWART
VALERIE V. GRANT
Dalhousie University
PAIGE OUIMETTE
Center for Integrated Healthcare,
Syracuse VA Medical Center
PAMELA J. BROWN
Private Practice
Canadian Psychology/Psychologie canadienne, 2006, 47:2, 110-124
Canadian Psychology Copyright 2006 by the Canadian Psychology Association
2006, Vol. 47, No. 2, 110-124 DOI: 10.1037/cp2006003
CP 47-2 4/21/06 9:22 PM Page 110
Gender and PTSD in SUD Patients 111
trauma exposure and PTSD symptoms. Women were
more likely than men to have been physically
abused/assaulted (31% vs. 6%), sexually abused/
assaulted (25% vs. 4%), and/or raped (25% vs. 2%) as
reported on the Life Stressor Checklist (LSC). Women
also reported having experienced a greater number of
lifetime traumas than the men (Means = 2.08 vs. 1.13,
respectively). Using a conservative cutoff, approxi-
mately 25% of the sample met criteria for PTSD.
Significantly more women than men were classified as
having lifetime PTSD (i.e., 43% vs. 12%).
Grice, Brady, Dustan, Malcolm, and Kilpatrick
(1995) investigated the relationship between sexual
and physical assault and PTSD in 100 substance-depen-
dent inpatients (50 men; 50 women) at either a uni-
versity-based substance-abuse program or a university-
affiliated private substance-abuse treatment facility. A
high proportion (66%) of the sample reported a his-
tory of sexual or physical assault. Women had signifi-
cantly higher rates of sexual assault history, serial
assault, and familial assault relative to men.
Participants who had experienced childhood assault
TABLE 1
Gender Differences in Trauma Exposure in Clinical SUD Samples
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Study Sample Trauma Measure Gender Differences
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Brown et al. 84 (36 F) inpatients LSC F > M: physical abuse;
(1995) with SUDs (Wolfe et al., 1996) sexual abuse; rape.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Grice et al. 100 (50 F) substance- clinical F > M: sexual, serial,
(1995) dependent inpatients interview and familial assault.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Najavits et al. 122 (43 F) cocaine- THQ F > M: physical and
(1998) dependent outpatients (Green, 1996) sexual abuse.
M > F: disaster; crime.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Dansky et al. 95 (61F) inpatients clinical F > M: rape. M > F:
(1996) with SUDs interview familial physical assault.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Dansky et al. 91 (33 F) cocaine- clinical F > M: physical assault
(1999)adependent patients interview by intimate partner.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Bonin et al. 91 (30 F) in- & out- trauma screen F > M: forced sex;
(2000) patients with SUDs (Stein et al., 1997) sexual pressure before age 18.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Ouimette et al. 24,959 (745 F) in- ASI (2 items) F > M: sexual abuse;
(2000) & outpatients with SUDs (McLellan et al., 1992) dual abuse (sexual + physical).
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Brown et al. 95 (51F) substance- LSC-R F > M: adult forced
(1999) dependent inpatients (Wolfe et al., 1996) sex; adult physical
abuse; types trauma.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Deykin & Buka 297 (75 F) substance- clinical F > M: rape. M > F:
(1997) dependent adolescent inpatients interview sudden injury/accident.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Coffey et al. 118 (67 F) in- & out- NWS PTSD Module F > M: rape; other
(1998) patients with substance dependence (Kilpatrick et al., 1989) sexual assault. M > F: combat.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Back et al. 91 (34 F) cocaine- Modified NWS PTSD Module F > M: sexual assault.
(2000) dependent outpatients (Kilpatrick et al., 1989)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Hien et al. 96 (49 F) opiate- modified TEQ F > M: childhood
(2000) dependent patients (Fullilove et al., 1993; Mod. sexual abuse; domestic violence.
by Hien & Scheier, 1996)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Jaycox et al. 212 (42 F) adolescent Author compiled list F > M: natural disaster; touched sexually
(2004) inpatients with SUDs of 9 traumatic events w/o consent; sexually attacked.
M > F: accident; stabbed or shot at.
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Notes. a The only trauma type examined in this study was physical assault.
CP 47-2 4/21/06 9:22 PM Page 111
112 Stewart, Grant, Ouimette, and Brown
TABLE 2
Gender Differences in PTSD Rates in Clinical SUD Samples
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Lifetime (Current)
PTSD Ratesb
––––––––––––––––––––––––––
Study Sample PTSD MeasureaPTSD Criteria F M
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Brown et al. 84 (36 F) inpatients C-MISS self-report DSM-III-R 43% 12%*
(1995) with SUDs (Lauterbach et al., 1997) (APA, 1987)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Brady et al. 100 (50 F) substance- SCID DSM-III-R 46% 24%
(1993) dependent inpatients (Spitzer et al., 1990) (APA, 1987)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Najavits et al. 122 (43 F) cocaine- PCL self-report DSM-III-R (30%) (15%)*
(1998) dependent outpatients (Blanchard et al., 1996) (APA, 1987)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Dansky et al. 95 (61F) inpatients NWS PTSD Module DSM-III-R 53% 53%
(1996)cwith SUDs (Kilpatrick et al., 1989) (APA, 1987) (38%) (44%)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Dansky et al. 91 (33 F) cocaine- NWS PTSD Module DSM-III-R 72% 31%*
(1999)ddependent patients (Kilpatrick et al., 1989) (APA, 1987) (38%) (16%)*
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Bonin et al. 91 (30 F) in- & out- MPSS self-report DSM-IV (40%) (36%)
(2000)epatients with SUDs (Falsetti et al., 1993) (APA, 1994)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Ouimette et al. 24,959 (745 F) SUD VA database ICD-9 18% 13%f
(2000) in- & outpatients (WHO, 1978) 23% 14%*,f,g
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Brown et al. 95 (51F) substance- CAPS interview DSM-IV (51%)h
(1999) dependent inpatients (Blake et al., 1995) (APA, 1994)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Clark et al. 133 (55 F) alcohol- Modified K-SADS DSM-III-R 24% 9%
(1997) dependent adolescents (Puig-Antich et al., 1981) (APA, 1987)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Deykin & 297 (75 F) adolescent DIS DSM-III-R 45% 24%*
Buka (1997) inpatients with (Robins et al., 1981) (APA, 1987) (40%) (12%)*
substance dependence 57% 33%*,g
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Coffey et al. 118 (67 F) in- & NWS PTSD Module DSM-III-R (37%)h
(1998) outpatients with (Kilpatrick et al., 1989) (APA, 1987)
substance dependence
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Back et al. 91 (34 F) cocaine- modified NWS PTSD module DSM-III-R 68% 28%*
(2000) dependent outpatients (Kilpatrick et al., 1989) (APA, 1987)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Hien et al. 96 (49 F) opiate- modified SCID-SAC DSM-IV (26%) (13%)
(2000) dependent patients (Nunes et al., 1996) (APA, 1994)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Kushner et al. 83 (29 F) alcohol- SCID DSM-IV (24%) (9%)
(2005) dependent inpatients (First et al., 1996) (APA, 1994)
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Jaycox et al. 212 (42 F) adolescent Self-report Children’s PTSD DSM-IV (33%) (18%)*
(2004) inpatients with SUDs Inventory (Saigh et al., 2002) (APA, 1994) (26%) (13%)g
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Notes. F = females; M = males. Significant gender difference (p< .05) indicated by asterisk (*). aAll PTSD measures are structured inter-
views unless otherwise specified. bAll reported rates of PTSD are calculated for total sample regardless of trauma exposure, unless otherwise
specified. cPTSD rates assessed in this study were specifically crime-related PTSD rates. dPTSD rates represent rates in those with physical
abuse history rather than total sample. ePTSD rates represent rates of those meeting full criteria for disorder (possible PTSD cases exclud-
ed). fRates were calculated based on proportions adjusted for important demographic differences between men and women. gRates of
PTSD among only those participants with trauma exposure.hThese figures represent current PTSD rates in the total sample; gender-specif-
ic rates were not available.
CP 47-2 4/21/06 9:22 PM Page 112
Gender and PTSD in SUD Patients 113
had an earlier age at onset of SUDs than those who
had not experienced childhood assault. Approxi-
mately half of the assault victims, but none of the non-
assault group, met criteria for lifetime PTSD as
assessed by a structured clinical interview.
Brady, Grice, Dustan, and Randall (1993) reported
on gender differences in psychiatric comorbidity in
this same mixed-gender sample of SUD patients.
There was no significant gender difference in rates of
comorbid PTSD diagnoses. The authors also noted
that the female/male ratio of PTSD in their sample of
SUD patients was lower than that found in the general
population (Brady et al., 1993). Trauma and PTSD
occurred before the onset of substance dependence
for the majority of women (78%). However, this was
also true for the majority of men (73%), and there
were no significant gender differences in relative
order of onset. These temporality data are consistent
with the self-medication hypothesis for both women
and men (Khantzian, 1985).
Najavits et al. (1998) examined exposure to trauma
and rates of PTSD in 122 treatment-seeking adult out-
patients with cocaine dependence (79 males; 43
females) who were participating in the National
Institute of Drug Abuse Cocaine Collaborative Study.
Lifetime trauma exposure and past-month PTSD were
assessed using self-report measures. In order to be
classified as having PTSD, participants had to endorse
at least one traumatic event as well as indicate suffi-
cient post-traumatic stress symptomatology. Compared
to their female counterparts, cocaine-dependent men
reported experiencing significantly more general dis-
asters (Means = 3.9 vs. 2.0 for men and women,
respectively) and crime-related traumas (Means = 1.4
vs. 0.9 for men and women, respectively). Conversely,
the women reported experiencing significantly more
physical and sexual abuse than the men (Means = 1.7
vs. 0.9 for the women and men, respectively). A signifi-
cantly higher proportion of female than male cocaine
addicts met criteria for a comorbid diagnosis of cur-
rent (past-month) PTSD (i.e., 30% vs. 15%, χ2[1, N=
122] = 3.87, p< .051).
Dansky et al. (1996) assessed criminal victimization
experiences and crime-related PTSD among 95 adult
SUD inpatients (34 male; 61 female). Gender differ-
ences in assault characteristics and crime-related PTSD
prevalence rates were evaluated. Participants were
administered structured interviews to assess lifetime
history of sexual and/or physical assault exposure,
including completed rape, sexual molestation,
attempted sexual assault, aggravated assault, and
other physical assaults (i.e., serious physical attacks in
childhood adolescence perpetrated by guardian) and
PTSD. In order to be classified as having crime-related
PTSD, participants had to report exposure to at least
one crime-related traumatic event and meet criteria
for post-traumatic stress symptomatology, but it was
not necessary for them to link their PTSD symptoms to
a specific traumatic event. Approximately 90% of the
sample reported a lifetime history of sexual and/or
physical assault. Women reported significantly higher
rates of completed rape than the men (i.e., 59% vs.
21% for women and men, respectively). Of those who
reported experiencing a completed rape, women were
also significantly more likely than men to perceive
their life as endangered during the rape (i.e., 89% vs.
57% for women and men, respectively). There were
no other significant gender differences in perception
of life threat for any of the other types of trauma sur-
veyed. Males were younger, on average, than females
when they experienced their first (or only) aggravated
assault (15 vs. 20 years old for the men and women,
respectively). Males were more likely to have been
physically assaulted by a family member than females
(73% vs. 26% for men and women, respectively). No
other gender differences in assault characteristics
were observed. Approximately 53% of the sample met
lifetime criteria for crime-related PTSD, with more
than 40% meeting criteria within the six months prior
to the study interview. Males and females did not dif-
fer significantly in terms of rates of crime-related
PTSD, however.
Dansky, Byrne, and Brady (1999) assessed exposure
to physical assault and rates of PTSD in a sample of 91
adults (33 women; 58 men; aged 20-51 years) who
were seeking treatment for cocaine dependence at a
medical centre substance-abuse clinic. Physical assault
was assessed via clinical interview and included self-
reports of exposure to aggravated assault with a
weapon, aggravated assault without a weapon, and
simple assault. The relationship of the victim to the
perpetrator was assessed for each type of physical
assault to examine potential differences in the conse-
quences of assault perpetrated by intimate partners
versus other assailants. PTSD was assessed with a struc-
tured interview. In order to meet criteria for PTSD
diagnosis, participants had to link PTSD symptoms to
traumatic event(s). Overall, about 86% (n= 78) of the
substance-dependent patients reported having been
physically assaulted at least once during their lifetime.
Slightly less than half of these 78 individuals (i.e.,
46%) reported physical assault perpetrated by an inti-
mate partner. Although women did not differ from
men in their likelihood of being physically assaulted at
1 The current authors calculated the chi-square value and corre-
sponding significance value based on information provided in the
original paper.
CP 47-2 4/21/06 9:22 PM Page 113
114 Stewart, Grant, Ouimette, and Brown
least once in their lifetime, women were significantly
more likely than men to report having been physically
assaulted by an intimate partner (76% vs. 29% for
women and men, respectively). Among those assault-
ed by an intimate partner, women were significantly
more likely than men to report having feared death or
serious injury during aggravated assault without a
weapon (94% vs. 56%), and simple assault (82% vs.
18%).
Of the 78 individuals with a history of physical
assault, close to half (46%) met lifetime criteria for a
diagnosis of PTSD (Dansky et al., 1999). It is important
to note that the index event for the diagnosis of PTSD
was not necessarily physical assault. Relative to those
assaulted by a nonintimate partner, participants
assaulted by an intimate partner were more likely to
meet current (i.e., past six months) and lifetime crite-
ria for a comorbid PTSD diagnosis. When intimate ver-
sus nonintimate assaults were analyzed separately for
gender, the data indicated that men physically assault-
ed by an intimate partner (vs. those physically assault-
ed by someone else) were significantly more likely to
meet criteria for current (but not lifetime) PTSD.
Although this pattern was also observed for women, it
was not statistically significant, perhaps due to inade-
quate power associated with small sample size (i.e.,
only four women with histories of assault had only
been assaulted by a perpetrator who was not an inti-
mate partner). Women with histories of assault were
significantly more likely than men with such histories
to meet criteria for a current (38% vs. 16%, respec-
tively) or lifetime (72% vs. 31%, respectively) diagno-
sis of PTSD.
Bonin, Norton, Asmundson, Dicurzio, and
Pidlubny (2000) investigated the prevalence and char-
acteristics of comorbid PTSD in 91 patients (61 male;
30 female) attending one of several community-based
substance-abuse programs (including day and residen-
tial programs). Exposure to 11 specific traumatic
events (e.g., serving in combat, unwanted sexual con-
tact involving force or threat, and sexual pressure
before age 18, which includes pressure, coercion, and
nonphysical or physical threats designed to encourage
sexual contact) was assessed using a self-report trauma
screen. Participants were classified, according to the
procedure of Asmundson, Norton, Allerdings,
Norton, and Larsen (1998), as currently having PTSD,
possible PTSD, or no PTSD based on a self-report mea-
sure. To be classified as having PTSD, participants had
to report having experienced symptoms for at least
two months (which is longer than the one-month
duration criterion specified in DSM-IV and thus is a
conservative estimate of current PTSD rates). Across
the 11 traumatic events on the trauma screen, signifi-
cant gender differences were obtained for two types of
events: More women than men reported unwanted
sexual contact involving force or threat (53% vs. 8%)
and sexual pressure before age 18 (53% vs. 21%).
About 52% of the sample had either PTSD (37%) or
possible PTSD (15%). However, the proportion of
male and female SUD patients with comorbid PTSD
did not differ significantly. Gender-specific rates were
obtained from the authors (G. R. Norton, personal
communication, March 14, 2000).
Ouimette, Kimerling, Shaw, and Moos (2000)
focused on the association of physical and sexual
abuse with comorbid psychological disorders among
SUD patients and whether patient gender moderates
these associations. The sample was obtained from the
U.S. Department of Veterans Affairs (VA) Outcomes
Monitoring Project (Moos, Finney, Federman, &
Suchinsky, 2000) and consisted of a total of 24,959
adult patients (745 females; 24,206 males) with SUDs
seeking inpatient or outpatient treatment in a variety
of VA settings (i.e., substance abuse, psychiatric, or
medical programs). Psychiatric diagnoses (including
PTSD and alcohol and drug use disorders) were
gleaned from clinical diagnoses in VA databases.
Physical and sexual abuse histories were assessed with
two items during a clinical interview. Specifically,
using the Addiction Severity Index (ASI; McLellan et
al., 1992), respondents were queried about any “seri-
ous problems getting along with mother, father, broth-
ers/sisters, sexual partner/spouse, children, other sig-
nificant family, neighbours, co-workers.” This was fol-
lowed by the following questions: “Did any of these
people abuse you: 1) physically (cause you physical
harm)? or, 2) sexually (force sexual advances or sexu-
al acts)?”
A high proportion of the SUD patients in the
Ouimette et al. (2000) study reported abuse histories
(29%). Women (vs. men) experienced significantly
more sexual victimization (8% vs. 2%, respectively)
and dual abuse (both physical and sexual abuse; 42%
vs. 6%, respectively). Abuse history was related to
PTSD comorbidity (although diagnosis of PTSD was
not necessarily linked to the abuse reported on the
ASI). Although rates of comorbid lifetime PTSD adjust-
ed for important demographic differences across
groups did not differ significantly by patient gender
(see Table 2), gender emerged as a moderator of the
abuse history effect in moderated multiple regression
analyses (Baron & Kenny, 1986). Specifically, the rela-
tionship between abuse and PTSD diagnosis was
stronger for female than for male SUD patients.
Among women, 23% of those with abuse histories, as
compared to only 7% of those without abuse histories,
met criteria for PTSD. Among men, 14% of those with
CP 47-2 4/21/06 9:22 PM Page 114
Gender and PTSD in SUD Patients 115
abuse histories, and 12% of those without, met criteria
for PTSD. Although gender differences in PTSD rates
were not observed in the sample as a whole, when
only those with abuse histories were examined, signifi-
cantly more women than men exhibited PTSD (χ2[1,
N= 7225] = 31.35, p< .001, see footnote 1).
Brown, Stout, and Mueller (1999) examined a
mixed-gender sample of adult SUD patients to address
whether gender differences exist in trauma exposure
and/or rates of PTSD among SUD patients. The sam-
ple was obtained from a private hospital setting and
consisted of 51 women and 44 men who were receiv-
ing inpatient treatment for an SUD. The largest pro-
portion of patients (i.e., 41%) had alcohol depen-
dence only, and 28% had drug dependence only. The
remaining 31% were dependent on both alcohol and
other drugs. Trauma history was assessed using a self-
report measure and current PTSD diagnoses were
established using a structured clinical interview.
To determine whether trauma exposure and/or
PTSD diagnoses varied by gender, females and males
were directly compared (Brown et al., 1999).
Significantly more women than men with substance
dependence reported physical abuse in adulthood
(59% vs. 14%) and forced sex in adulthood (31% vs.
5%). Women were also exposed to significantly more
traumas than the men (M= 4.0 vs. M= 2.8). Despite
these generally greater trauma histories among the
females, males and females failed to differ significant-
ly in terms of rates of current PTSD (51% in the total
sample).
Coffey, Dansky, Falsetti, Saladin, and Brady (1998)
investigated 118 (51 men; 67 women) inpatients and
outpatients at a tertiary hospital-based chemical (alco-
hol and/or drug) dependency treatment program. To
assess lifetime exposure to traumatic events (i.e., com-
bat, natural disaster, serious accidents, rape, sexual
molestation, attempted sexual assault, aggravated
assault, other physical assault, witnessing a violent
death, or having someone close be murdered) and
PTSD (in the past six months), a structured clinical
interview was used. There were no gender differences
in trauma history, except that women reported a sig-
nificantly higher prevalence than men of rape (37%
vs. 6%) and of other sexual assault (25% vs. 11%).
Also, significantly more men (10%) than women (0%)
had been exposed to combat (χ2[1, N= 118] = 6.86, p
< .01). Overall, 37% of the participants met criteria
for current (past six months) PTSD, with no significant
gender differences in prevalence.
Back and colleagues (2000) examined trauma his-
tory and current (past six months) and lifetime PTSD
in 91 adult outpatients (57 men; 34 women) with
cocaine dependence, using structured clinical inter-
views. The authors did not systematically explore gen-
der differences in trauma history, and explicitly
reported only one gender difference in trauma expo-
sure: Women were significantly more likely to report a
history of sexual assault than men (percentages not
reported). Overall, 43% and 22% of the participants
met criteria for lifetime and current PTSD, respective-
ly. A significantly higher proportion of women (68%)
than men (28%) had lifetime PTSD. It was not possible
to glean the gender breakdown of current PTSD rates
from the information provided in the original article.
Hien and colleagues (2000) investigated gender
differences in 96 (47 men; 49 women) consecutively
admitted patients seeking methadone treatment for
opiate dependence. Trauma history was assessed
through a self-report measure and PTSD through a
structured clinical interview. Women were significantly
more likely than men to have experienced childhood
sexual abuse (29% vs. 4%) and domestic violence (as
a victim of partner violence; 41% vs. 11%). Men and
women did not differ in the rates of exposure to child-
hood physical abuse or adult interpersonal violence
(as a victim or witness). Overall, the rate of current
PTSD in this sample was 20%. There was no significant
gender difference in current PTSD rates, χ2(1, N= 96)
= 2.86, ns (see footnote 1).
Kushner et al. (2005) examined rates of PTSD
among 83 adults (54 males; 29 females) seeking inpa-
tient treatment for alcohol-use disorders at a universi-
ty-affiliated medical centre. The women were not sig-
nificantly more likely than the men to have a current
(past four months) diagnosis of PTSD (24% vs. 9%; χ2
[1, N= 83] = 2.282, ns (see footnote 1); M. G.
Kushner, personal communication, August 8, 2005)
based on structured clinical interviews. This study did
not examine rates of trauma exposure in the sample
of SUD patients.
Gender Differences in Adolescent Samples
All of the above studies on gender differences in
trauma exposure and/or PTSD in SUD patients have
been conducted with adult samples. A potential limita-
tion pertains to the accuracy of reports of childhood
abuse that occurred in the distant past for adult
research participants and the degree to which chronic
substance abuse might be interfering with memory
accuracy (see Stewart, 1997). Research with adoles-
cent samples of SUD patients can overcome this limita-
tion to some degree through data on childhood trau-
ma histories relatively closer in time to event occur-
rence and before substance abuse becomes chronic
2 The Yates continuity correction was applied since one cell in
the 2 x 2 table had an expected count less than 5.
CP 47-2 4/21/06 9:22 PM Page 115
116 Stewart, Grant, Ouimette, and Brown
(see reviews by Stewart, 1996, 1997). Before beginning
to review relevant studies conducted with adolescent
SUD samples, it is important to consider that “sub-
stance dependence” as reported in studies with ado-
lescents may not be equivalent to “substance depen-
dence” in adult samples because tolerance and with-
drawal present differently in adolescents than in
adults (Martin, Kaczynski, Maisto, Bukstein, & Moss,
1995). Specifically, withdrawal symptoms may be less
likely among substance users who have not been using
heavily for many years (i.e., adolescents). Moreover,
the criterion of tolerance, which is defined as a need
for increased amounts of a substance to reach intoxi-
cation, may be less relevant to adolescents (vs. adults).
For adolescents, who are still developing physically, it
might be a normal phenomenon to require greater
quantities of a substance as they age. With this caveat
in mind, three studies that have examined rates of
exposure to trauma and of PTSD in mixed-gender ado-
lescent samples of SUD patients are discussed below.
A study by Clark et al. (1997) examined gender dif-
ferences in comorbid psychiatric disorder diagnoses
in 133 alcohol-dependent adolescents (55 female; 78
male). A majority of the adolescents with alcohol
dependence also had other SUDs (females, 76% and
males, 83%). The alcohol-dependent teens were com-
pared with an age-matched community control sam-
ple of 86 adolescents (44 female; 42 male) without
lifetime histories of SUD. Rates of PTSD, as assessed by
structured clinical interview, were significantly higher
in the alcohol dependence group compared to com-
munity controls (i.e., 24% of alcohol-dependent
females; 9% of alcohol-dependent males; 0% of con-
trols). Among those alcohol-dependent adolescents
with comorbid PTSD, the most common traumatic
experience was sexual abuse (70% of those with
PTSD). Clark et al. (1997) did not report gender dif-
ferences in exposure to various traumatic events.
Females and males did not differ significantly in rates
of PTSD diagnoses overall. However, consistent with
predictions of theoretical models suggesting that anxi-
ety disorders are more relevant to the etiology of alco-
hol use disorders among females than among males
(e.g., Cloninger, 1987), PTSD symptom levels (i.e., life-
time symptom counts) were more strongly associated
with alcohol dependence in females than in males.
The authors concluded that PTSD appears to be more
relevant for understanding adolescent alcohol depen-
dence in females than in males (Clark et al., 1997).
Deykin and Buka (1997) examined the prevalence
of PTSD among 297 adolescents (75 female; 222 male)
who were receiving treatment for chemical dependen-
cy at public residential treatment centres. As assessed
by structured clinical interview, trauma exposure was
reported by about 75% of the sample with no signifi-
cant difference between the girls and the boys in
reported trauma exposure (i.e., 80% vs. 73%, respec-
tively; χ2[1, N = 297] = 1.47, ns (see footnote 1)). The
most common traumatic events for the girls were
rape, seeing someone hurt or killed, physical assault,
and threat of injury. The most common traumatic
events for the boys were seeing someone hurt or
killed, threat of injury, and sudden injury or accident.
The girls were over 10 times more likely than the boys
to have been raped (40% vs. 4%; χ2[1, N= 297] =
66.56, p< .001). Boys were about twice as likely as the
girls (20% vs. 8%; χ2[1, N= 297] = 5.93, p< .05, see
footnote 1 on page 115) to have experienced a sud-
den injury or accident (an experience that carries a
low risk of PTSD). The observed lifetime prevalence of
PTSD in this sample of SUD adolescents (30%) was
about five times higher than rates seen in adolescents
in the community. Among boys, there was a signifi-
cantly higher risk for PTSD among those who had a
greater number of traumas. This relationship was not
present among girls. The authors suggested that this
gender difference might reflect the fact that boys are
exposed to more lower-risk traumas. Among the SUD
females, PTSD was the most commonly co-occurring
disorder, whereas PTSD ranked as the second most
commonly co-occurring disorder in the SUD males.
Females (vs. males) had a significantly higher lifetime
prevalence (45% vs. 24%; χ2[1, N= 297] = 11.87, p<
.01; see footnote 1 page 115) and current (past four
weeks) prevalence (40% vs. 12%; χ2[1, N= 297] =
28.01, p< .001) of PTSD. Among those with a history
of trauma, females were significantly more likely than
males to have lifetime PTSD (57% vs. 33%, χ2[1, N=
297] = 9.96, p< .01). The significantly higher rate of
PTSD among females versus males was partially due to
a greater frequency of rape in the females, which car-
ries a high risk of PTSD development (cf. Kessler et al.,
1995). Attesting to the fact that rape is a high-risk
event for PTSD development, in this sample, males
who had been raped had the same high probability of
developing PTSD as females who had been raped.
Females also had higher rates of other Axis I comor-
bidity than males, which may make them more vulner-
able to the development of PTSD (cf. Breslau et al.,
1991; Giaconia et al., 1995), irrespective of the type of
trauma exposure.
Deykin and Buka (1997) also examined the relative
order of onset of SUDs and PTSD in all comorbid
cases. Significantly more of the girls than the boys
experienced PTSD onset prior to SUD onset (59% vs.
28%; χ2[1, N= 88] = 8.40, p< .01). This suggests a
greater probability of SUDs developing secondary to
PTSD in females than in males. This temporal pattern
CP 47-2 4/21/06 9:22 PM Page 116
Gender and PTSD in SUD Patients 117
is consistent with the possibility of self-medication of
PTSD symptoms through substance misuse, at least
among females.
More recently, Jaycox, Ebener, Damesek, and
Becker (2004) studied trauma exposure and PTSD in a
sample of 212 adolescents (170 male, 42 female) who
were entering long-term residential substance abuse
treatment programs run by a private, nonprofit
agency. The investigators assessed trauma exposure
using a list of nine traumatic events (including “severe
accident, natural disaster, fire or explosion, life-threat-
ening illness, physical attack, threat with a weapon,
being stabbed or shot at, being touched sexually, and
being attacked sexually,” p. 114). Current PTSD was
assessed via a structured clinical interview. Overall,
71% of the participants reported having experienced
at least one of the surveyed traumatic events, with boys
and girls experiencing a comparable number of trau-
matic events. However, gender differences emerged
when individual traumatic events were analyzed. Girls
were significantly more likely than boys to have report-
ed experiencing a natural disaster (19% vs. 7%),
being touched sexually without consent (36% vs. 8%),
and being sexually attacked (33% vs. 4%), whereas
boys were significantly more likely than girls to have
reported experiencing an accident (38% vs. 21%) and
being stabbed or shot at (32% vs. 14%). On the
whole, 20% of all participants met diagnostic criteria
for current PTSD, while 29% of those who had experi-
enced lifetime trauma exposure met criteria for cur-
rent PTSD. Overall, girls were significantly more likely
than boys to have current PTSD (33% vs. 18%, χ2[1, N
= 212] = 5.04, p < .05). However, when only those par-
ticipants with a trauma history were considered, there
was no significant difference between girls and boys in
prevalence of current PTSD (39% vs. 26%, χ2[1, N=
152] = 2.27, ns; see footnote 1 page 115). This study is
limited in that the investigators asked only about PTSD
symptoms that were related to the trauma that the
participant considered to be most disturbing, thereby
possibly underestimating the prevalence of PTSD in
the sample.
Critical Integration
Examination of the findings reviewed in Table 2
suggest that the gender difference in PTSD rates is
attenuated in clinical SUD samples relative to the con-
sistent female-greater-than-male gender difference in
general population PTSD rates (e.g., Breslau et al.,
1991, 1997, 1999; Kessler et al., 1995). Across the 15
studies of gender differences in PTSD rates in SUD
patients (see Table 2), only 6 studies found PTSD rates
to be significantly higher among women than men
and the other 9 found no significant gender differ-
ence. The reasons for this discrepancy across studies
are not immediately apparent. Several possible expla-
nations exist, all of which require further research.
The most obvious possibility pertains to sample size
and resultant power. It is possible that studies using
larger sample sizes might be more likely to detect true
gender differences in PTSD rates than those using rela-
tively smaller sample sizes. For instance, although
Brown et al. (1999) did not find a gender difference
in PTSD rates, a later study based on a slightly expand-
ed sample of SUD patients encompassing the original
sample did find a significant gender difference in
PTSD rates (Read, Brown, & Kahler, 2004). With
respect to the studies reviewed in this paper, nine used
relatively small sample sizes (i.e., n< 100) whereas the
other six used relatively larger samples (see Table 2).
In examining Table 2 for gender differences across
studies using relatively larger or smaller sample sizes, a
pattern emerges that is consistent with a sample
size/power explanation. Specifically, of the nine stud-
ies that had a small sample size, two-thirds did not
find a gender difference in PTSD rates and of the six
studies that had a larger sample size, half did not find
a gender difference. Although it appears that adequa-
cy of overall sample size may be related to the ability
to detect gender differences in PTSD rates, this pattern
is relatively weak.
Another potential explanation pertains to the ade-
quacy of numbers of participants in each gender cell.
Adequacy of cell size is often an issue in studies of
mixed-gender clinical SUD samples. Such samples
often contain few women, given that SUDs are less
common in women (e.g., Kessler et al., 1997) and
women with SUDs are less likely to seek SUD-specific
treatment services (e.g., see review by Schober &
Annis, 1996). It is possible that studies using a suffi-
cient number of participants of each gender might be
more likely to detect true gender differences in PTSD
rates than those using relatively smaller cell sizes. Ten
of the studies reviewed in this section used samples
containing at least one relatively small cell size (i.e., <
50), whereas the other five used samples containing
larger cell sizes (i.e., > 50; see Table 2). However, no
apparent pattern emerges when examining whether
or not gender differences were observed across stud-
ies using relatively larger versus relatively smaller cell
sizes. Specifically, of the 10 studies that had at least
one small cell size, half did not find a gender differ-
ence in PTSD rates, and of the 5 studies that had larg-
er cell sizes, 80% did not find a gender difference.
Thus, there is no evidence that smaller cell sizes
account for an inability to detect gender differences
in PTSD in SUD patients.
Another possibility pertains to the method of
CP 47-2 4/21/06 9:22 PM Page 117
118 Stewart, Grant, Ouimette, and Brown
assessment of PTSD. Structured interviews correspond-
ing to established diagnostic criteria (e.g., DSM-IV)
are obviously the gold standard for establishing PTSD
rates. While some self-report methods may have good
convergence with structured interview methods, this is
not always the case. For example, the self-report
Civilian version of the Mississippi PTSD scale (C-MISS;
Norris & Perilla, 1996) used in the study by Brown et
al. (1995) has since been examined for its psychomet-
ric properties with respect to detection of “true” PTSD.
Its relationship with measures of PTSD was weaker
than its relationship with measures of depression and
anxiety, suggesting that it is best considered a general
measure of distress (Lauterbach, Vrana, King, & King,
1997). Similarly, the chart review method has limita-
tions. For example, not all patient charts are compiled
in the same way, not all clinicians record the same
type of information in charts (Stewart, 1996), and
since chart reviews use clinical diagnoses, one cannot
know whether the collection of the diagnostic data
was systematic (i.e., adhered closely to diagnostic crite-
ria). The results using the chart review method might
thus represent conservative estimates of PTSD rates
(Stewart, 1996). The studies reviewed in the present
paper varied as to whether structured interview (n=
10 studies), self-report questionnaire (n= 4 studies),
or chart review (n= 1 study) methods were used to
establish PTSD diagnoses (see Table 2). However, no
apparent pattern emerges when examining whether
or not gender differences were observed across stud-
ies that did and did not use structured interviews to
assess PTSD. In particular, of the 10 studies that used
structured interview, 70% did not find a gender differ-
ence in PTSD rates, and of the 5 studies that used
other assessment methods (i.e., self-report or chart
review), 40% did not find a gender difference. Thus,
there is no evidence that studies using structured
interviews are more likely to detect gender differences
in PTSD rates in SUD patients.
Examination of a couple of recent epidemiological
studies in the general population (Creamer et al.,
2001; Stein et al., 1997) suggests that other factors
may be germane to the detection of gender differ-
ences in PTSD rates. In their study of a Canadian com-
munity sample (N= 1002; 524 females and 478 males),
Stein et al. found that although a higher percentage
of women (2.7) than men (1.2) exhibited current
(past one month) full DSM-IV PTSD as determined by a
standardized telephone interview, this difference was
not statistically significant. Similarly, Creamer et al.
investigated a stratified Australian sample of 10,641
participants (4,705 male; 5,936 female; Andrews,
Henderson, & Hall, 2001) and found that there was
no significant gender difference in the prevalence of
DSM-IV PTSD in the past 12 months (males = 1.2%;
females = 1.4%). These two community-based studies
that did not lead to the identification of significant
gender difference in base rates of PTSD were conduct-
ed outside of the U.S., used the DSM-IV definition of
PTSD, and reported current prevalence, whereas the
studies that did lead to the identification of a substan-
tial gender difference in rates of PTSD (e.g., Breslau et
al., 1991, 1997, 1999; Kessler et al., 1995) were carried
out in the U.S., were based on earlier versions of the
DSM (except for Breslau et al., 1999), and reported
lifetime prevalence. These differences suggest that
culture (e.g., cultural differences in trauma exposure;
Creamer et al.), variation in the definition of PTSD,
and assessed time frame of PTSD may influence the
expression of gender differences in PTSD prevalence.
Thus, we sought to examine these factors in relation
to whether or not gender differences were detected in
the studies of SUD samples reported in Table 2. We
were unable, however, to examine the influence of
culture on the variation in detected gender differ-
ences in PTSD rates because only 1 of the 15 studies
reviewed was conducted outside of the U.S.
Differences in the definition of PTSD across studies
may help explain the variability of gender difference
findings. The majority of studies of PTSD rates in SUD
samples used either DSM-III-R or DSM-IV definitions of
PTSD (see Table 2). The main difference between
DSM-III-R and DSM-IV concerns Criterion A – the defin-
ition of a traumatic event (see March, 1993). In DSM-
III-R, Criterion A specifies that the event is “outside
the range of usual human experience” and “would be
markedly distressing to almost anyone” (p. 250). In
DSM-IV, the definition changed to require that the
event involve experiencing, witnessing, or confronting
“actual or threatened death or serious injury, or a
threat to the physical integrity of self or others” (p.
427) and that the person’s response to this event
involve “intense fear, helplessness, or horror” (p. 428).
This change from DSM-III-R to DSM-IV allowed distress-
ing events within the range of normal human experi-
ence (e.g., certain crimes, sudden injuries and acci-
dents) to qualify as triggering events for PTSD. Such
events may be more common among males than
females (see Table 1), which could contribute to the
minimization of the typical female-greater-than-male
gender difference in PTSD rates found when using
DSM-IV versus DSM-III-R criteria. Of the 15 studies of
SUD samples reviewed, 9 used DSM-III-R definitions of
PTSD and 5 used DSM-IV (the other one used ICD-9).
The observed pattern is generally consistent with the
possibility that gender differences are less likely to be
observed when using DSM-IV criteria (vs. DSM-III-R), as
is suggested by the most recent epidemiological stud-
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Gender and PTSD in SUD Patients 119
ies of PTSD rates in the general population.
Specifically, 80% of the studies that used DSM-IV crite-
ria did not identify a gender difference in PTSD rates,
whereas only 44% of the studies using DSM-III-R crite-
ria did not identify a gender difference (see Table 2).
However, once again, this pattern is relatively weak.
Another potential explanation for the minimiza-
tion of gender differences in PTSD rates in SUD sam-
ples, suggested by the recent general population stud-
ies, concerns whether studies used lifetime or current
PTSD prevalence rates. There is no immediately appar-
ent reason why using lifetime (vs. current) PTSD
prevalence rates would be more likely to reveal gen-
der differences. We can only speculate that lifetime
rates are more susceptible to retrospective reporting
biases (e.g., memory biases), and that there are gen-
der differences in memory bias for PTSD. Data suggest
that given trauma exposure, women are more likely to
blame themselves for trauma, hold more negative
views of themselves, and view the world as a more dan-
gerous place than men (see review by Tolin & Foa,
2002). These established differences might make trau-
ma more salient for women than men in the longer
term. Thus, women may be more likely than men to
remember and report traumatic experiences and
adverse reactions to those experiences that occurred
in the distant past. In the current review, 3 of the 15
studies examined both lifetime and current preva-
lence rates of PTSD and the findings within each of
these studies did not vary by type of prevalence exam-
ined (see Table 2). Of the remaining 12 studies, 7
examined current prevalence rates only and 5 exam-
ined lifetime prevalence rates only. There is no evi-
dence to support the possibility suggested by the most
recent general population studies that gender differ-
ences are less likely to appear when current rates are
used. Specifically, 71.4% of studies that only examined
current prevalence of PTSD did not find a gender dif-
ference, and similarly, 60% of studies that only exam-
ined lifetime prevalence of PTSD did not find a gender
difference.
Another factor on which reviewed studies vary that
may be important in PTSD-SUD comorbidity studies is
the SUD category (e.g., alcohol vs. illicit drugs) of the
sample. For example, in a community sample of sub-
stance users, Cottler, Compton et al., (1992) found
that cocaine/opiate users were more likely to report
trauma exposure and to meet PTSD criteria than were
users of other drugs. Similarly, Najavits et al. (1998)
note that “harder” substances such as cocaine and opi-
ates show a consistently greater association with trau-
ma exposure and PTSD diagnosis than other sub-
stances such as alcohol and marijuana. Again, it is not
readily apparent why differences in the primary types
of drugs abused by the samples might account for
gender differences in PTSD prevalence rates across
studies. It is possible that gender might interact with
the type of substance abused to increase or decrease
the likelihood of PTSD. It could be that individuals
who abuse hard drugs might be more likely than those
who primarily abuse alcohol to engage in risky behav-
iours to pay for their substance of choice (Cottler et
al.). In turn, it might be that females (vs. males) who
are addicted to hard drugs are more at risk for expo-
sure to traumatic events that carry a high risk of PTSD,
thereby increasing the chance of detecting a gender
difference in PTSD rates in SUD samples abusing pri-
marily hard drugs (vs. alcohol). For example, female
hard-drug abusers might be more likely than their
male counterparts to prostitute themselves to support
their drug habit, which in turn might place them at a
higher risk for rape (Gilchrist et al., 2001). The major-
ity of studies (9/15) reviewed investigated mixed sam-
ples of patients with alcohol-use disorder and/or
other SUDs (e.g., opiate, cocaine use disorders).
Among the remaining six studies, four examined
cocaine or opiate dependent samples and the other
two examined patients with alcohol use disorders. The
pattern obtained is consistent with the possibility that
gender differences in PTSD rates are more likely to be
observed in samples including purely hard-drug
abusers (75% of studies detected a gender difference)
versus samples including purely alcohol abusers (0%
of studies detected a gender difference). Nonetheless,
this pattern was gleaned from only six studies, and
therefore the contribution of drug category to gender
differences in PTSD rates needs further exploration.
The severity of the SUD might influence the
expression of gender differences in PTSD rates in SUD
samples. If the presence of a SUD attenuates gender
differences in PTSD rates, then it is plausible that gen-
der differences would be most attenuated in the most
severe form of SUD (i.e., dependence). Of the nine
studies that examined samples including only individ-
uals with substance dependence, 55.6% did not find a
gender difference; similarly, of the six studies that
examined samples including both participants with
substance abuse and participants with substance
dependence, 66.7% did not find a gender difference.
Thus, this particular factor also does not appear to
account for the variability in the findings of the
reviewed studies. Another way of conceptualizing SUD
severity is in terms of the intensity of treatment
required. More severe SUDs presumably require more
intensive treatment (i.e., inpatient treatment). There
were nine studies that explicitly stated that they only
used patients drawn from either inpatient or outpa-
tient treatment facilities. Of the seven inpatient-only
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120 Stewart, Grant, Ouimette, and Brown
studies, 57.1% did not find a gender difference in
PTSD rates. No gender difference in PTSD rates was
evident in either of the two outpatient-only studies.
This pattern again provides no evidence to suggest
that gender differences are more likely to be detected
in samples using more severe populations.
General population studies suggest another factor
that might contribute to the variability across studies
reviewed herein. Breslau et al. (1999) concluded that
the excess risk of PTSD in females (vs. males) is most
prominent in younger age ranges (i.e., adolescence
and young adulthood). Thus, one might speculate
that gender differences in PTSD rates in SUD patients
would be most likely in adolescent samples. Across the
15 studies reviewed, 3 focused on adolescents and the
remainder focused on adults. Among the studies
examining adolescents, 33.3% did not lead to the
identification of a gender difference, whereas 66.7%
of the studies examining adults did not lead to the
identification of a gender difference. Although this
pattern is consistent with attenuated gender differ-
ences in older samples, it is important to keep in
mind that there were only three studies of adoles-
cents.
Other possibilities pertain to the nature and extent
of trauma exposure in men versus women with SUDs.
Across the studies on rates of trauma exposure in SUD
samples (see Table 1), some general patterns emerge.
First, the pattern of gender differences evident in
Table 1 tends to conform to findings reported in the
general population. For example, like women in the
general population (Kessler et al., 1995), women with
SUDs experience more sexual victimization than their
male counterparts, and like males in the general pop-
ulation (cf. Norris, 1992), males with SUDs experience
more of certain traumas (e.g., combat) than their
female counterparts. This aspect of the findings does
little to help us understand the attenuation of gender
differences in PTSD rates in SUD clinical samples.
However, the second point to note is that rates of
exposure to these various traumatic events are much
elevated in SUD samples relative to general population
estimates among both genders, placing both men and
women with SUDs at an elevated risk for PTSD.
One explanation for the gender difference in PTSD
observed in the general population is that even if men
experience more trauma, women’s trauma character-
istics are particularly severe, placing them at greater
risk for PTSD (Kimerling et al., in press). Thus, the
trauma characteristics of males and females may be
more similar in SUD samples than in the general pop-
ulation, thus increasing the relative risk for PTSD
development in SUD males. In fact, across many of the
studies that have failed to show significant gender dif-
ferences in PTSD rates in SUD samples, the males
appear to have very high rates of childhood sexual
abuse (e.g., Ouimette et al., 2000; see Table 1).
However, some studies (e.g., Bonin et al., 2000) have
led to the identification of significant gender differ-
ences in childhood sexual abuse, but still no gender
difference in PTSD rates (compare Tables 1 and 2). A
possible explanation is that, despite their lower rates
of exposure, males with SUDs may have experienced
more severe forms of childhood abuse (e.g., more
injury risk and threat involved; abuse at earlier age;
more familial perpetrators) than their female counter-
parts, thus increasing their risk for PTSD development
to a level equivalent to that seen in women. This possi-
bility is underexplored in SUD samples and is deserv-
ing of further exploration.
Another potential explanation is that men and
women in SUD patient samples are more similar to
one another in rates of other comorbid psychiatric
disorders than are men and women in the general
population. Comorbid psychiatric disorders (i.e.,
depression and anxiety) increase the likelihood of
developing PTSD (Breslau et al., 1991). Brady et al.
(1993) found that women were not more likely than
men to have affective disorders, which conflicts with
the general population finding that women (vs. men)
are at a significantly higher risk of major depressive
disorder (Kessler et al., 2003), and which may account
for their failure to observe a gender difference in
PTSD rates. Similarly, in the Hien et al. (2000) study,
almost every subject with PTSD also had a mood
(depressive) disorder, which may explain why there
was no significant gender difference in PTSD rates.
A further possibility alluded to previously in the
section on illicit drugs versus alcohol is that the
lifestyles associated with drug abuse increase trauma
exposure for SUD males, thereby increasing their risk
for PTSD development. Although research does sug-
gest that substance abuse may increase the likelihood
of being a victim of certain forms of trauma (see
reviews by Hoaken & Stewart, 2003; Kaufman Kantor
& Asdigian, 1997; Murdoch, Pihl, & Ross, 1990), little
research attention has been devoted to gender differ-
ences in PTSD development as a consequence of trau-
ma exposures secondary to alcohol/drug intoxication.
In fact, examination of the pattern of findings evident
in Table 1 suggests that male (vs. female) SUD patients
may indeed experience more of the types of traumas
theoretically most likely to occur consequential to a
drug-abusing lifestyle (e.g., exposure to certain
crimes, accidents, and injuries).
Even though overall gender differences in PTSD
rates appear to be attenuated in SUD samples, gender
nonetheless appears important in the comorbidity of
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Gender and PTSD in SUD Patients 121
PTSD and SUDs in these clinical samples. For example,
even though no overall gender differences in PTSD
prevalence was observed by Clark et al. (1997), the
association between PTSD and SUDs was stronger
among the adolescent girls than among the adoles-
cent boys. Moreover, the temporality data of Deykin
and Buka (1997) suggested that PTSD precedes the
onset of SUDs more often in girls than boys. Both of
the above findings are consistent with a self-medica-
tion explanation for the comorbidity of PTSD and SUD
in women. Nonetheless, the gender difference in tem-
porality reported by Deykin and Buka was not
observed in the adult sample studied by Brady et al.
(1993), who found that PTSD preceded SUD in the
majority of cases for both men and women.
Overall Summary and Conclusion
Comorbid PTSD-SUD is a problem for both women
and men; however, females may display a stronger
association between the symptoms of these two disor-
ders than males (e.g., Clark et al., 1997). Interestingly,
women and men with SUDs may not differ in rates of
PTSD, contrary to general population findings confer-
ring greater risk to women. Nonetheless, women’s
comorbidity may be linked more often to a history of
sexual victimization than men’s comorbidity, given the
consistently higher rates of sexual victimization
among women (vs. men). Reasons for the attenuation
in gender differences in PTSD are not readily appar-
ent, but may include the lifestyle associated with
men’s substance abuse increasing their exposure to
PTSD-inducing traumatic events, a history of more
severe trauma characteristics (e.g., repeated victimiza-
tion, earlier onset of first exposure) among men with
SUDs, or attenuated gender differences in rates of
other comorbid psychiatric disorders, such as depres-
sion, in clinical SUD samples.
We recommend that all individuals who experience
trauma, especially women who have experienced sexu-
al assault, or who have PTSD symptoms, should be edu-
cated about the risk for the development of substance
use problems. Since individuals with PTSD related to
particularly severe trauma histories appear to be at
greatest risk for SUDs, a thorough assessment of such
individuals’ substance use is warranted through multi-
ple means (self-report, interview, informant). In turn,
all SUD patients should be screened for trauma and
PTSD, and male patients may be targeted for educa-
tion about the potential consequences of the lifestyle
associated with drug use (cf. Stewart, Ouimette, &
Brown, 2002).
The first author is supported through an Investigator
Award from the Canadian Institutes of Health Research
(CIHR) and a Killam Research Professorship from the
Faculty of Science at Dalhousie University. The second
author is funded by a CIHR Canada Graduate Scholarship
Master’s Award and by a Killam Predoctoral Scholarship.
This work was supported, in part, by a grant from the U.S.
Department of Veterans Affairs Mental Health Strategic
Health Group and the Health Services Research and
Development Service to Dr. Ouimette. The views
expressed in this report are those of the authors and do
not necessarily represent the views of the U.S. Department
of Veterans Affairs.
Correspondence concerning this article should be
addressed to Sherry H. Stewart, Departments of Psychiatry
and Psychology, Dalhousie University, Halifax, Nova
Scotia, Canada B3H 4J1 (E-mail: sstewart@dal.ca).
Résumé
Nous nous penchons sur 15 études qui portent sur la
fréquence du syndrome de stress post-traumatique (SSPT)
chez les hommes et les femmes aux prises avec un trouble
d’alcoolisme et de toximanie (TAT) afin de déterminer si
la différence typique plus grande chez la femme que chez
l’homme dans la fréquence du SSPT est atténuée dans les
exemples d’hommes et de femmes aux prises avec un TAT.
Compte tenu que la majorité des études qui ont fait l’objet
de l’examen n’établissent pas de différence dans la
fréquence du SSPT chez l’homme et la femme, nous avons
examiné de façon critique les facteurs méthodologiques
qui pourraient être attribuables à une atténuation, mais
aucun ne semblait pouvoir être entièrement attribué à la
variabilité dans la détection des différences entre les sexes
entre les études. Plusieurs facteurs peuvent contribuer à
faire en sorte que la fréquence du SSPT chez les hommes
aux prises avec un TAT soit équivalente à la fréquence
élevée du syndrome observée chez les femmes aux prises
avec un TAT : 1) le style de vie à risque associé à l’abus de
l’alcool et des drogues chez les hommes peut accroître
leur exposition à des événements traumatiques; 2) les
hommes aux prises avec un TAT peuvent avoir un his-
torique de caractéristiques de traumatisme plus grave 3) il
peut se trouver des différences atténuées entre les
hommes et les femmes dans la fréquence d’autres comor-
bidités qui augmentent le risque de SSPT (p. ex. la dépres-
sion). Les conséquences cliniques de ces observations font
l’objet de la discussion.
References
American Psychiatric Association. (1994). Diagnostic and
statistical manual of mental disorders, 4th Edition (DSM-IV).
Washington, DC.
American Psychiatric Association. (1987). Diagnostic and
CP 47-2 4/21/06 9:22 PM Page 121
122 Stewart, Grant, Ouimette, and Brown
statistical manual of mental disorders, 3rd Edition Revised
(DSM-III-R). Washington, DC.
Andrews, G., Henderson, S., & Hall, W. (2001).
Prevalence, comorbidity, disability and service utiliza-
tion: Overview of the Australian National Mental
Health Survey. British Journal of Psychiatry, 178, 145-153.
Asmundson, G. J. G., Norton, G. R., Allerdings, M. D.,
Norton, P. J., & Larsen, D. K. (1998). Post-traumatic
stress disorder and work related injury. Journal of Anxiety
Disorders, 12, 57-69.
Back, S., Dansky, B. S., Coffey, S. F., Saladin, M. E., Sonne,
S., & Brady, K. T. (2000). Cocaine dependence with
and without post-traumatic stress disorder: A compari-
son of substance abuse, trauma history and psychiatric
comorbidity. The American Journal on Addictions, 9, 51-
62.
Baron, R. M., & Kenny, D. A. (1986). The moderator-medi-
ator variable distinction in social psychological
research: Conceptual, strategic, and statistical consider-
ations. Journal of Personality and Social Psychology, 51,
1173-1182.
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G.,
Gusman, F. D., Charney, D., et al. (1995). The develop-
ment of a Clinician-Administered PTSD Scale. Journal of
Traumatic Stress, 8, 75-90.
Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., &
Forneris, C. A. (1996). Psychometric properties of the
PTSD Checklist (PCL). Behaviour Research and Therapy,
34, 669-673.
Bonin, M., Norton, G. R., Asmundson, G. J. G., Dicurzio,
S., & Pidlubny, S. (2000). Drinking away the hurt: The
nature and prevalence of PTSD in substance abuse
patients. Journal of Behavior Therapy and Experimental
Psychiatry, 31, 55-66.
Brady, K. T., Grice, D. E., Dustan, L., & Randall, C. (1993).
Gender differences in substance use disorders.
American Journal of Psychiatry, 150, 1707-1711.
Breslau, N., Chilcoat, H. D., Kessler, R. C., Peterson, E. L.,
& Lucia, V. C. (1999). Vulnerability to assaultive vio-
lence: Further specification of the sex difference in
post-traumatic stress disorder. Psychological Medicine, 29,
813-821.
Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. L.
(1991). Traumatic events and posttraumatic stress dis-
order in an urban population of young adults. Archives
of General Psychiatry, 48, 216-222.
Breslau, N., Davis, G. C., Andreski, P., Peterson, E. L., &
Schultz, L. R. (1997). Sex differences in posttraumatic
stress disorder. Archives of General Psychiatry, 54, 1044-
1048.
Brown, P. J., Recupero, P. R., & Stout, R. L. (1995). PTSD
substance abuse comorbidity and treatment utilization.
Addictive Behaviors, 20, 251-254.
Brown, P. J., Stout, R. L., & Mueller, T. (1999). Substance
use disorder and posttraumatic stress disorder comor-
bidity: Addiction and psychiatric treatment rates.
Psychology of Addictive Behaviors, 13, 115-122.
Clark, D. B., Pollock, N., Bukstein, O. G., Mezzich, A. C.,
Bromberger, J. T., & Donovan, J. E. (1997). Gender and
comorbid psychopathology in adolescents with alcohol
dependence. Journal of the American Academy of Child and
Adolescent Psychiatry, 36, 1195-1203.
Cloninger, C. R. (1987). Neurogenetic adaptive mecha-
nisms in alcoholism. Science, 236, 410-416.
Coffey, S. F., Dansky, B. S., Falsetti, S. A., Saladin, M. E., &
Brady, K. T. (1998). Screening for PTSD in a substance
abuse sample: Psychometric properties of a modified
version of the PTSD Symptom Scale Self-Report. Journal
of Traumatic Stress, 11, 393-399.
Cottler, L. B., Compton, W. M., III, Mager, D., Spitznagel,
E. L., & Janca, A. (1992). Posttraumatic stress disorder
among substance users from the general population.
American Journal of Psychiatry, 149, 664-670.
Creamer, M., Burgess, P., & McFarlane, A. C. (2001).
Posttraumatic stress disorder: Findings from the
Australian national survey of mental health and well-
being. Psychological Medicine, 31, 1237-1247.
Dansky, B. S., Brady, K. T., Saladin, M. E., Killeen, T.,
Becker, S., & Roitzsch, J. (1996). Victimization and
PTSD in individuals with substance use disorders:
Gender and racial differences. American Journal of Drug
and Alcohol Abuse, 22, 75-93.
Dansky, B. S., Byrne, C. A., & Brady, K. T. (1999). Intimate
violence and post-traumatic stress disorder among indi-
viduals with cocaine dependence. American Journal of
Drug and Alcohol Abuse, 25, 257-268.
Deykin, E. Y., & Buka, S. L. (1997). Prevalence and risk fac-
tors for posttraumatic stress disorder among chemically
dependent adolescents. American Journal of Psychiatry,
154, 752-757.
Falsetti, S. A., Resnick, H. S., Resick, P. A., & Kilpatrick, D.
G. (1993). The modified PTSD Symptom Scale: A brief
self-report measure of posttraumatic stress disorder. The
Behavior Therapist, 16, 161-162.
First, M. B., Spitzer, R., Gibbon, M., & Williams, J. (1996).
Structured Clinical Interview for DSM-IV Axis I Disorders -
Patient Edition (SCID-I/P, version 2.0). New York:
Biometrics Research Department, New York State
Psychiatric Institute.
Fullilove, M. T., Fullilove, R. E., Smith, M., Winkler, K.,
Michael, C., Panzer, P. G., et al. (1993). Violence, trau-
ma, and posttraumatic stress disorder among women
drug users. Journal of Traumatic Stress, 6, 85-96.
Giaconia, R. M., Reinherz, H. Z., Silverman, A. B., Pakiz,
B., Frost, A. K., & Cohen, E. (1995). Truamas and post-
traumatic stress disorder in a community population of
older adolescents. Journal of the American Academy of
Child and Adolescent Psychiatry, 34, 1369-1379.
CP 47-2 4/21/06 9:22 PM Page 122
Gender and PTSD in SUD Patients 123
Gilchrist, G., Taylor, A., Goldberg, D., Mackie, C.,
Denovan, A., & Green, S. T. (2001). Behavioural and
lifestyle study of women using a drop-in centre for
female street sex workers in Glasgow, Scotland: A ten-
year comparative study. Addiction Research and Theory, 9,
43-58.
Green, B. L. (1996). Trauma History Questionnaire. In B.
H. Stamm & E. M. Varra (Eds.), Measurement of stress,
trauma, and adaptation (pp. 366-368). Lutherville, MD:
Sidron Press.
Grice, D. E., Brady, K. T., Dustan, L. R., Malcolm, R., &
Kilpatrick, D. G. (1995). Sexual and physical assault his-
tory and posttraumatic stress disorder in substance-
dependent individuals. The American Journal on
Addictions, 4, 297-305.
Hien, D. A., Nunes, E., Rudnick Levin, F., & Fraser, D.
(2000). Posttraumatic stress disorder and short-term
outcome in early methadone treatment. Journal of
Substance Abuse Treatment, 19, 31-37.
Hien, D. A., & Sheier, J. (1996). Short-term predictors of
outcome for drug-abusing women in detox: A follow-up
study. Journal of Substance Abuse Treatment, 13, 227-231.
Hoaken, P. N. S., & Stewart, S. H. (2003). Drugs of abuse
and the elicitation of human aggressive behavior.
Addictive Behaviors, 28, 1533-1554.
Jaycox, L. H., Ebener, P., Damesek, L., & Becker, K.
(2004). Trauma exposure and retention in
adolescent substance abuse treatment. Journal of
Traumatic Stress, 17, 113-121.
Kaufman Kantor, G., & Asdigian, N. (1997). When women
are under the influence: Does drinking or drug use by
women provoke beatings by men? In M. Galanter
(Ed.), Recent developments in alcoholism (Vol. 13, pp. 315-
336). New York: Plenum Press.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D.,
Merikangas, K. R., et al. (2003). The epidemiology of
major depressive disorder: Results from the National
Comorbidity Survey Replication (NCS-R). Journal of the
American Medical Association, 289, 3095-3105.
Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B.,
Schulenberg, J., & Anthony, J. C. (1997). Lifetime co-
occurrence of alcohol abuse and dependence with
other psychiatric disorders in the National Comorbidity
Survey. Archives of General Psychiatry, 54, 313-321.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., &
Nelson, C. B. (1995). Posttraumatic stress disorder in
the National Comorbidity Survey. Archives of General
Psychiatry, 52, 1048-1060.
Khantzian, E. J. (1985). The self-medication hypothesis of
addictive disorders: Focus on heroin and cocaine
dependence. The American Journal of Psychiatry, 142,
1259-1264.
Kilpatrick, D. G., Resnick, H. S., Saunders, B. E., & Best, C.
L. (1989). The National Women’s Study PTSD module.
Unpublished instrument. Charleston, SC: Crime
Victims Research and Treatment Center, Department
of Psychiatry and Behavioral Sciences, Medical
University of South Carolina.
Kimerling, R., Ouimette, P., & Weitlauf, J. (in press).
Gender and PTSD. In M. J. Friedman, T. Keane, & P. A.
Resick (Eds.), PTSD – Science and practice: A comprehensive
handbook. New York: Guilford.
Kushner, M. G., Abrams, K., Thuras, P., Hanson, K. L.,
Brekke, M., & Sletten, S. (2005). A follow-up study of
anxiety disorder and alcohol dependence in comorbid
alcoholism treatment patients. Alcoholism: Clinical and
Experimental Research, 29, 1432-1443.
Lauterbach, D., Vrana, S., King, D. W., & King, L. A.
(1997). Psychometric properties of the Civilian version
of the Mississippi PTSD scale. Journal of Traumatic Stress,
10, 499-513.
March, J. S. (1993). What constitutes a stressor? The
“Criterion A” issue. In J. R. T. Davidson & E. B. Foa
(Eds.), Posttraumatic stress disorder: DSM-IV and beyond
(pp. 37-54). Washington, DC: American Psychiatric
Press.
Martin, C. S., Kaczynski, N. A., Maisto, S. A., Bukstein,
O. M., & Moss, H. B. (1995). Patterns of DSM-IV alco-
hol abuse and dependence symptoms in adolescent
drinkers. Journal of Studies on Alcohol, 56, 672-680.
McLellan, A. T., Kushner, H., Metzger, D., Peters, R.,
Smith, I., Grison, G., et al. (1992). The fifth edition of
the Addiction Severity Index. Journal of Substance Abuse
Treatment, 9, 199-213.
Moos, R. H., Finney, J. W., Federman, E. B., & Suchinsky,
R. (2000). Specialty mental health care improves
patients’ outcomes: Findings from a nationwide pro-
gram to monitor the quality of care for patients with
substance use disorders. Journal of Studies on Alcohol, 61,
704-713.
Murdoch, D., Pihl, R. O., & Ross, D. (1990). Alcohol and
crimes of violence: Present issues. The International
Journal of the Addictions, 25, 1065-1081.
Najavits, L. M., Gastfriend, D. R., Barber, J. P., Reif, S.,
Muenz, L. R., Blaine, J., et al. (1998). Cocaine depen-
dence with and without PTSD among subjects in the
National Institute on Drug Abuse Collaborative
Cocaine Treatment Study. American Journal of Psychiatry,
155, 214-219.
Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link
between substance abuse and posttraumatic stress dis-
order in women: A research review. The American
Journal on Addictions, 6, 273-283.
Norris, F. H. (1992). Epidemiology of trauma: Frequency
and impact of different potentially traumatic events on
different demographic groups. Journal of Consulting and
Clinical Psychology, 60, 409-418.
Norris, F. H., & Perilla, J. L. (1996). The revised Civilian
CP 47-2 4/21/06 9:22 PM Page 123
124 Stewart, Grant, Ouimette, and Brown
Mississippi Scale for PTSD: Reliability, validity, and
cross-language stability. Journal of Traumatic Stress, 9,
285-298.
Nunes, E. V., Goehl, L., Seracini, A., Deliyannides, D.,
Donovan, S., Post-Koenig, T., et al. (1996). A modifica-
tion of the Structured Clinical Interview for DSM-III-R:
Test-retest reliability. American Journal of Addictions, 5,
241-248.
Ouimette, P. C., Brown, P. J., & Najavits, L. M. (1998).
Course and treatment of patients with substance use
and posttraumatic stress disorder comorbidity. Addictive
Behaviors, 23, 785-795.
Ouimette, P. C., Finney, J. W., & Moos, R. H. (1999). Two-
year post-treatment functioning and coping of sub-
stance abuse patients with post-traumatic stress disor-
der. Psychology of Addictive Behaviors, 13, 105-114.
Ouimette, P. C., Kimerling, R., Shaw, J., & Moos, R. H.
(2000). Physical and sexual abuse among women and
men with substance use disorders. Alcoholism Treatment
Quarterly, 18, 7-17.
Puig-Antich, J., Orvaschel, H., Tabrixi, M. A., & Chamberg,
W. J. (1981). The Schedule for Affective Disorders and
Schizophrenia for School-Age Children, Epidemiologic Version,
(3rd ed.). New York: Department of Child and
Adolescent Psychiatry, New York State Psychiatric
Institute.
Read, J. P., Brown, P. J., & Kahler, C. W. (2004). Substance
use and posttraumatic stress disorders: Symptom inter-
play and effects on outcome. Addictive Behaviors, 29,
1665-1672.
Robins, L. N., Helzer, J. H., Croughan, J., & Ratcliff, K. S.
(1981). The National Institute of Mental Health
Diagnostic Interview Schedule: Its history, characteris-
tics, and validity. Archives of General Psychiatry, 38, 381-
389.
Saigh, P. A., Yasik, A. E., Oberfield, R. A., Green, B. L.,
Halamandaris, P. V., Rubenstein, H., et al. (2000). The
Children’s PTSD Inventory: Development and reliabili-
ty. Journal of Traumatic Stress, 13, 369-380.
Schober, R., & Annis, H. M. (1996). Barriers to help-seek-
ing for change in drinking: A gender focused review of
the literature. Addictive Behaviors, 21, 81-92.
Sonne, S. C., Back, S. E., Diaz Zuniga, C., Randall, C. &
Brady, K. T. (2003). Gender differences in individuals
with comorbid alcohol dependence and posttraumatic
stress disorder. American Journal on Addictions, 12, 412-
423.
Spitzer, R. L., Williams, J. B., & Gibbon, M. (1990).
Structured clinical interview for DSM-III-R. Washington,
DC: American Psychiatric Press.
Stein, M. B., Walker, J. R., Hazen, A. L., & Ford, D. R.
(1997). Full and partial posttraumatic stress disorder:
Findings from a community survey. American Journal of
Psychiatry, 154, 1114-1119.
Stewart, S. H. (1996). Alcohol abuse in individuals
exposed to trauma: A critical review. Psychological
Bulletin, 120, 83-112.
Stewart, S. H. (1997). Trauma memory and alcohol abuse:
Drinking to forget? In J. D. Read & D. S. Lindsay
(Eds.), Recollections of trauma: Scientific evidence and clini-
cal practice (pp. 461-467). New York: Plenum.
Stewart, S. H., Ouimette, P., & Brown, P. J. (2002). Gender
and the comorbidity of PTSD with substance use disor-
ders. In R. Kimerling, P. Ouimette, & J. Wolfe (Eds.),
Gender and PTSD (pp. 232-270). New York: Guilford
Press.
Tolin, D. F., & Foa, E. B. (2002). Gender and PTSD: A cog-
nitive model. In R. Kimerling & P. C. Ouimette (Eds.),
Gender and PTSD (pp. 76-97). New York: Guilford Press.
Wolfe, J., Kimerling, R., Brown, P. J., Chrestman, K. R., &
Levin, K. (1996). The Life Stressor Checklist – Revised.
In B. H. Stamm & E. M. Varra (Eds.), Measurement of
stress, trauma, and adaptation (pp. 198-200). Lutherville,
MD: Sidron Press.
World Health Organization. (1978). Mental disorders:
Glossary and guide to their classification in accordance with
the Ninth Revision of the International Classification of
Diseases (ICD-9). Geneva, Switzerland.
CP 47-2 4/21/06 9:22 PM Page 124
... A investigação do National Comorbidity Survey (NCS) encontrou nos alcoolistas um risco três a quatro vezes maior que seus controles para o desenvolvimento de TEPT como transtorno comórbido 16 . E este se mostrou como o transtorno de ansiedade mais freqüente, com prevalências de 5,6% para os que abusavam do álcool e 7,7% para os dependentes do álcool, no último ano 17 . ...
... No entanto, o transtorno por uso de substâncias psicoativas é um fator de risco para a exposição a traumas e desenvolvimento de TEPT 16 . A elaboração de diagnósticos comórbidos em dependentes químicos requer a atenção para a sobreposição de sintomas psiquiátricos e clínicos que comumente ocorrem, dificultando a avaliação 22 . ...
... Em suas primeiras entrevistas o paciente relatava visitas diárias ao pai, após as quais consumia grande quantidade de álcool, configurando a hipótese do alívio da tensão, ou seja, o consumo do álcool para aliviar sintomas de estresse 18 . Embora nem todos os estudos comprovem a associação do consumo do álcool com trauma ou TEPT 25 , há extensa literatura apontando nessa direção 19,26,16,27 . Waldrop et al. 28 , investigando 72 sujeitos com dependência do álcool ou dependência de cocaína, encontraram uma correlação positiva entre a freqüência da ingestão do álcool e a freqüência dos sintomas de TEPT. ...
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BACKGROUND: Psychiatric comorbidity is common among addicted patients. Post-traumatic stress disorder (PTSD) is a highly symptomatic anxiety disorder of acute onset after a major distressing life-event. OBJECTIVES: In clinical practice, patients suffering from drug addiction invariably report the occurrence of psychologically stressful episodes, with frequencies of PTSD ranging from 30% to 60%. Among patients suffering from alcohol dependence, the prevalence of PTSD is estimated to range between 10% and 40%. METHODS: We report the case of a 40-year old alcoholic man presenting with comorbid bipolar disorder and long-lasting symptoms of PTSD. The subject was an outpatient at the Institute for Prevention and Research on Alcohol and Other Addictions (Instituto de Prevenção e Pesquisa em Álcool e Outras Dependências - IPPAD), being assessed for the occurrence of PTSD with the aid of several psychometric instruments. RESULTS: Data derived from clinical sessions and research interviews include the Davidson Trauma Scale (DTS), which was administered at baseline and after one year of follow-up, yielding scores of 75 and 40 respectively. Global response to treatment was achieved after the recognition and appropriate treatment of the latter condition, along with the combined approach to other comorbid disorders. DISCUSSION: The investigation of traumatic events should be encouraged in the clinical management of alcoholic patients.
... A investigação do National Comorbidity Survey (NCS) encontrou nos alcoolistas um risco três a quatro vezes maior que seus controles para o desenvolvimento de TEPT como transtorno comórbido 16 . E este se mostrou como o transtorno de ansiedade mais freqüente, com prevalências de 5,6% para os que abusavam do álcool e 7,7% para os dependentes do álcool, no último ano 17 . ...
... No entanto, o transtorno por uso de substâncias psicoativas é um fator de risco para a exposição a traumas e desenvolvimento de TEPT 16 . A elaboração de diagnósticos comórbidos em dependentes químicos requer a atenção para a sobreposição de sintomas psiquiátricos e clínicos que comumente ocorrem, dificultando a avaliação 22 . ...
... Em suas primeiras entrevistas o paciente relatava visitas diárias ao pai, após as quais consumia grande quantidade de álcool, configurando a hipótese do alívio da tensão, ou seja, o consumo do álcool para aliviar sintomas de estresse 18 . Embora nem todos os estudos comprovem a associação do consumo do álcool com trauma ou TEPT 25 , há extensa literatura apontando nessa direção 19,26,16,27 . Waldrop et al. 28 , investigando 72 sujeitos com dependência do álcool ou dependência de cocaína, encontraram uma correlação positiva entre a freqüência da ingestão do álcool e a freqüência dos sintomas de TEPT. ...
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CONTEXTO: Os transtornos comórbidos entre dependentes químicos têm se mostrado a regra e não a exceção. O transtorno de estresse pós-traumático (TEPT) é um transtorno de ansiedade que se desenvolve após evento traumático, com importante sintomatologia. Quase 100% dos dependentes químicos que procuram tratamento relatam história de traumas, e as prevalências de TEPT têm variado entre 30% e 60%. Entre os alcoolistas, as prevalências de TEPT variam de 10% a 40%. Apesar das altas prevalências, tais transtornos carecem de investigação pelos clínicos. OBJETIVOS: Tem-se como objetivo relatar o caso de um alcoolista com transtorno bipolar e sintomas de TEPT há alguns anos, cujo resultado de tratamento deveu-se ao reconhecimento da última comorbidade e abordagem conjunta das patologias. MÉTODOS: Paciente masculino, 40 anos, participou em uma pesquisa do Instituto de Prevenção e Pesquisa em Álcool e outras Dependências (IPPAD), que investiga a exposição a eventos traumáticos e TEPT em dependentes químicos, respondendo a vários instrumentos. Realizou entrevistas com uma das pesquisadoras visando a este relato de caso. Os resultados foram avaliados por entrevistas com o paciente e aplicação da Davidson Trauma Scale (DTS). RESULTADOS: A DTS foi respondida por ocasião da participação na pesquisa e um ano após, para avaliar resultados de tratamento. No primeiro momento, o paciente pontuou um escore total de 75 pontos e, no segundo, de 40 pontos. A melhora deveu-se ao reconhecimento do TEPT e seu tratamento com psicoterapia psicodinâmica, terapia cognitivo-comportamental e abordagem familiar como estratégias terapêuticas utilizadas. Para o tratamento psicofarmacológico foram utilizados carbonato de lítio, sertralina e clonazepan. CONCLUSÕES: A investigação de traumas e TEPT deve ser rotina no atendimento de alcoolistas. O reconhecimento precoce desta comorbidade pode prevenir sua cronicidade, favorecer a aderência e promover o tratamento adequado.
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... Studies on PTSD report different findings based on populations and environment, including various types of traumatic events, life styles, psychological factors and methodological differences (Stewart et al., 2006). Accurate prevalence of depression and PTSD are unknown In Iranian population with SUDs. ...
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... Com quadros sintomáticos de redução do desempenho e sono prejudicado, a qualidade do serviço desses profissionais decai, assim como há maior tendência para desenvolver o TEPT (Calhoun & Resick, 1999;APA, 2002;Milet e Sougey, 2010). Também deve-se caracterizar a possibilidade do desenvolvimento de comorbidade, comum de acontecer em conjunto com o desenvolvimento de TEPT (Kessler e outros, 1995;Kristensen, Parente & Kaszniak, 2005;Stewart, Grant, Ouimette, & Brown, 2006). ...
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The article which follows this introduction was originally published as a Special (Cover) Article in the American Journal of Psychiatry in the November, 1985 issue, the same month in which the First International Drug Symposium, sponsored by The Bahamas Ministry of Health and The Embassy of the United States of America, was convened to discuss the rock-cocaine epidemic in the Bahamas and other Caribbean Islands. Based on my article, I was invited to participate in the Symposium and to speak about some of my views on the psychological predispositions for drug dependence in general, and in particular, on the psychological predisposition for cocaine dependence. At first, I did not grasp the seriousness and scope of the cocaine problem, but I accepted the invitation, believing I might make a contribution to the Symposium. I was not long in attendance at the Symposium before I realized that the Bahamian citizens, professionals, and health care leaders were facing a major crisis as a consequence of the cocaine epidemic.
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