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Victimization, Posttraumatic

Stress Disorder, and Substance

Use and Abuse Among Women

Dean G. Kilpatrick, Ph.D.; Heidi S. Resnick, Ph.D.;

Benjamin E. Saunders, Ph.D.; and Connie L. Best, Ph.D.

INTRODUCTION

Data from the Epidemiologic Catchment Area (ECA) Survey

(Helzer et al. 1987) indicate a lifetime prevalence rate of 13.8 percent

for alcohol abuse or dependence. Rates for women are substantially

lower than those observed for men: 4.57 percent v. 23.83 percent

lifetime and 2.16 percent v. 11.90 percent past year. Large differences

in rates for men and women are likely to reflect both biological and

social factors (Helzer et al. 1987). These data indicate the importance

of examining the relative roles of biological and environmental factors

in the etiology of alcohol abuse or dependence among women.

As reviewed by Rose (1995), data from population-based twin

studies indicate large effects for genetic factors in women in the development of alcohol dependence. Percentages of variance accounted for by

genetic factors ranged from approximately 0.50 to 0.67. Other findings

indicated that smaller heritability quotients for women than for men

may have been related to alcohol use among nonrepresentative clinical

samples (Rose 1995). These data suggest the possibility of a substantial

role for genetic factors in women’s alcohol dependence and emphasize

the importance of using epidemiological samples in the study of etiological factors.

In terms of environmental factors associated with alcohol dependence among women, researchers have begun to study associations

between severe traumatic events and alcohol and other substance use

or abuse. Several studies indicate that substance use disorders are

more prevalent in individuals with a history of criminal victimization

(Burnam et al. 1988; Cottler et al. 1992; Elliot et al. 1989; George and

Winfield-Laird 1986; Helzer et al. 1987; Kilpatrick 1990; Kulka et al.

1990). For example, in a study of 3,125 Los Angeles residents that was
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part of the National Institute of Mental Health ECA project (Burnam

et al. 1988), lifetime rates of alcohol abuse or dependence were

significantly higher among sexual assault victims than among nonvictims

(18.38 percent v. 13.80 percent), as were rates of drug abuse or dependence (20.41 percent v. 5.49 percent).

Other studies of women seeking treatment for substance use disorders

report high rates of violent assault among women with substance abuse

problems (Brady et al. 1994; Cohen and Densen-Gerber 1982; Ladwig

and Andersen 1989; Miller et al. 1987).

An important issue that has not been adequately addressed in such

studies is the temporal sequence of substance abuse and violent assault.

Because substantial evidence exists that violent assault can produce

posttraumatic stress disorder (PTSD) (Breslau et al. 1991; Kessler et al.

1995; Kilpatrick et al. 1989; Resnick et al. 1993), another important

issue in understanding the relationship between violence and substance

abuse is whether PTSD and substance use and abuse are related. Kessler

and coworkers (1995) reported that women with PTSD were 2.48 times

as likely as women without PTSD to have alcohol abuse and/or dependence (27.9 percent v. 13.5 percent) and were 4.46 times as likely to

have drug abuse and dependence (26.9 percent v. 7.6 percent). Thus,

it is important to determine whether PTSD may mediate development

of substance abuse after the crime and whether PTSD and substance

abuse are independently associated with crime and to identify issues

of chronology.

Extant findings of studies examining relationships among these

variables have been contradictory. Burnam and associates (1988)

observed a pattern representing a vicious cycle in which sexual abuse

victimization was a significant risk factor for initial development of

alcohol or other drug abuse or dependence. Substance abuse or dependence also significantly increased risk of subsequent sexual victimization.

A measure of PTSD was not included in the study. In contrast to these

findings, Cottler and colleagues (1992) reported that within a St. Louis

sample of the ECA survey, substance use onset preceded and significantly

predicted initial development of PTSD. Thus, they suggested that

substance use probably increases risk of exposure to traumatic events

that could lead to PTSD. They also found that cocaine or opiate abuse

was particularly likely to be related to a history of traumatic events

(Cottler et al. 1992).
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An important factor that may relate to these contradictory findings

is substantial differences in the methods used to assess history of sexual

assault incidents. Burnam and colleagues (1988) included a screening

question presented to all respondents that behaviorally defined the

experience of forced sexual contact, ranging from molestation incidents

to completed rape incidents. Their procedure did not use culturally

loaded terms such as “rape” but instead specifically asked about touching

of sexual parts of the body and sexual intercourse. In contrast, Cottler

and coworkers’ (1992) procedure used solely the word “rape” in a more

general assessment of any traumatic incidents a respondent may have

experienced. This approach has been criticized as leading to great

underestimates of true rates of sexual assault and rape because many

women do not classify their actual experiences by using legal terms that

are often associated with cultural stereotypes about these crimes (Resnick

et al. 1993).

Resnick and associates (1993) suggested that studies using such

terminology may lead to misinterpretations about chronology of traumatic events and the development of mental health disorders. Thus, one

possible reason for the contradictory findings regarding the relationships

among substance use or abuse, traumatic event history, and PTSD is the

lack of sensitive assessment of sexual assault events, which often occur

early in an individual’s life (Kilpatrick et al. 1992). Kilpatrick and

coworkers (1992) found that of all rapes reported among a national

sample of women, 29 percent occurred earlier than age 11. An additional

32 percent of all cases occurred when the women were 11 to 17 years of

age. If such early events are missed, the absence of important historical

information may in some cases mistakenly lead to the assumption that

substance use or abuse precedes victimization by sexual assault or other

trauma. Differing interpretations of findings could have important

implications for understanding the etiology or maintenance of each type

of problem. Similarly, such interpretations of relationships influence the

development of intervention approaches and populations targeted for

treatment.

In addition to discrepancies in approaches to assessment of traumatic

event histories, extant studies of the relationship among substance abuse,

trauma exposure, and PTSD in women have been retrospective, which

limits interpretations about the chronology of critical variables. Finally,

no studies that adequately address these issues have included a measure to
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estimate the role of such stressors in conjunction with family history

variables that may affect genetic and/or environmental factors.

An evaluation of family history, along with information about

exposure to intrafamilial and/or extrafamilial crime at various ages, might

yield important information about the chronology of critical variables

and relative contributions of environmental and biological factors.

Addressing the temporal sequence of substance abuse, PTSD, and

crime victimization in women requires a research design that includes

the following elements: (1) use of a probability sample, not a treatmentseeking sample; (2) careful assessment of baseline history of violent

assault and onset of substance use; (3) longitudinal followup assessment

of study participants to detect new cases of violent assault and substance

use or abuse; and (4) inclusion of an estimate of potential biological

contributing factors to attempt to separate biological from environmental influences.

NATIONAL WOMEN’S STUDY METHODOLOGY

This chapter, which is based on the authors’ National Women’s

Study, a longitudinal study of a nationally representative sample of

women that was designed to address many of the aforementioned problems, includes the following:

• Presentation of descriptive information about the prevalence of

violent assault, substance use or abuse, and PTSD among this

nationally representative sample of adult women.

• Examination of data on age of onset of critical variables to

evaluate chronology factors.

• Description of the violent assault and PTSD history of women

from this sample who have received substance abuse treatment.

• Discussion of these hypotheses about the vicious cycle theory:

– A history of violent assault increases the risk of alcohol

dependence.

– A history of substance use or abuse increases the risk of

violent assault.

– Risk of alcohol dependence at followup is predicted by a

history of violent assault, substance abuse, past-year violent

assault, and PTSD.
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The random-digit-dialing telephone survey method was used to

locate and interview a national probability sample of adult women,

2,008 of whom were age 18 and older (n=4,008) and 2,000 of whom

were an oversample of younger women between the ages of 18 to 34.

To correct for the effects of oversampling, the data were weighted by age

and race to 1989 estimates of the distribution of these characteristics in

the U.S. population of adult women. The mean age for the entire sample

was 44.9 years (standard deviation=18.4). Most of the women were

high school graduates (63.4 percent) and were married or cohabiting

(63.7 percent). More than half the sample reported household income

between $15,001 and $50,000, with a substantial minority (27.3 percent)

reporting incomes at or less than $15,000. For more detail on descriptive

data from wave 1 of the study, see Resnick and colleagues (1993).

Of the designated respondents, 4,008 (85 percent) completed wave 1

interviews, 3,359 (83.8 percent) completed at least one of two followup

interviews, and 2,892 (72.2 percent) completed both followup interviews.

Sample selection and interviewing were done by female interviewers

from a New York City-based survey research firm. Lifetime prevalences

of rape, aggravated assault, and PTSD were assessed at wave 1. Descriptive information about lifetime rape and aggravated assault cases was

collected at wave 1 and information about new victimization cases at

waves 2 and 3. The 3,359 women with at least 1 year’s followup data

were separated into two groups: those victimized in the followup period

and those not subsequently victimized. Current PTSD status was assessed

at both followup interviews.

The following are operational definitions of key variables.

• Demographic variables assessed at wave 1

– Current age: Measured in years at wave 1

– Race: African-American, Asian, Hispanic, Native American,

white; simplified to white v. nonwhite for multivariate analyses

based on population distribution and ease of interpretation of

results

– Education: Non-high school graduate, high school graduate,

college graduate; measured at wave 1

– Household income: Subdivided for conceptual reasons into

poverty level (less than $10,000 in 1988) or above poverty

level (more than $10,000 in 1988)
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– Marital status: Single, cohabiting, married, separated, divorced, widowed; simplified to married v. nonmarried for

multivariate analyses

• Family history of substance abuse problems measured at wave 1;

assessed based on the report that at least one of the respondent’s

biological parents had one or more of the following substance

abuse-related problems when the respondent was growing up:

– Problems with family or friends

– Problems with work

– Problems with health

– Problems with the law

– Injuries or accidents

• Assault incidents

– Rape: Defined as nonconsensual assault using force or threat

of force involving some type of sexual penetration of victim’s

vagina, rectum, or mouth. Up to three incidents were assessed

during wave 1 (first, most recent, and worst, if distinct from

first or most recent). Only one incident was assessed at each

followup interview. The specific questions to assess rape used

sensitive, behaviorally specific phrasing following the orienting preface below:

Another type of stressful event that many women

have experienced is unwanted sexual advances.

Women do not always report such experiences to the

police or discuss them with family or friends. The

person making the advances isn’t always a stranger,

but can be a friend, boyfriend, or even a family

member. Such experiences can occur anytime in a

woman’s life—even as a child. Regardless of how long

ago it happened or who made the advances . . .

Has a man or boy ever made you have sex by using

force or threatening to harm you or someone close to

you? Just so there is no mistake, by sex we mean

putting a penis in your vagina.

Has anyone ever made you have oral sex by force

or threat of harm? Just so there is no mistake, by oral
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sex we mean that a man or boy put his penis in your

mouth or someone penetrated your vagina or anus

with their mouth or tongue.

Has anyone ever made you have anal sex by force

or threat of harm?

Has anyone ever put fingers or objects in your

vagina or anus against your will by using force or

threats?

An affirmative response to any of these questions indicated

that a woman had been a victim of rape, defined as vaginal,

anal, or oral penetration that occurred through the use of

force or threat of force, whether or not the woman subjectively defined the incident as rape or reported it to police or

other authorities.

– Aggravated assault: Defined as an attack with a weapon or

without a weapon with intent to kill or seriously injure the

victim. Descriptive data were gathered about a respondent’s

only or worst incident during wave 1. Data were gathered on

only one incident per followup assessment. A positive history

of aggravated assault was defined as a positive response to

either of the following questions.

Another type of stressful event women

sometimes experience is being physically attacked

by another person. Not counting any incidents

already described to me, has anyone, including family

members or friends, ever attacked you with a gun,

knife, or some other weapon, regardless of when it

happened or whether you ever reported it or not?

Has anyone, including family members and

friends, ever attacked you without a weapon, but

with the intent to kill or seriously injure you?

– History of prior victimization: The number of rapes or

aggravated assaults occurring prior to wave 1 interview was

determined. The range of this variable was zero to 4.
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– New victimization: The question of whether a rape or

aggravated assault occurred in the interval between wave 1

and waves 2 and 3 was assessed. This variable was scored

dichotomously as negative (zero) if no incidents had occurred

or positive (1) if any incident was reported. In a small subset

of cases in which a victimization occurred during both waves,

analyses were based on data from the earliest followup assessment, wave 2, for purposes of defining assault status and

current PTSD status.

• Current PTSD: Measured by the National Women’s Study

PTSD Module (Resnick et al. 1993) at wave 2 and wave 3

interviews. PTSD status was scored dichotomously on the basis

of absence (zero) or presence (1) of sufficient symptoms to meet

Diagnostic and Statistical Manual of Mental Disorders (Third

Edition-Revised) (DSM-III-R) (American Psychiatric Association

1987) criteria within the past 6 months. This measurement

instrument has high sensitivity compared with the Structured

Clinical Interview for DSM-III-R (Spitzer et al. 1987) with an

overall kappa of 0.77 for lifetime PTSD and 0.71 for current

PTSD based on the Diagnostic and Statistical Manual of Mental

Disorders (Fourth Edition) (American Psychiatric Association

1994) PTSD Field Trial data (Kilpatrick et al., in press). Further

validity data relate to the consistent population- and eventspecific rates of PTSD obtained with this instrument using the

telephone assessment method employed in this study and those

obtained using in-person structured clinical interviews (Resnick

et al. 1993).

• Sensation-seeking: A six-item short form of the DisinhibitionIntentions for the Future Subscale of Zuckerman’s Sensation

Seeking Scale Form VI was used to measure this variable

(Zuckerman 1984). Scores range from 6 to 18. The scale asks

respondents:

Regardless of whether you have actually done any of

the following things in the past, for each, I’d like to

know whether you probably would do it if the

opportunity arose, have thought about it but probably won’t do it, or have no desire to do it.
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Doing something illegal but enjoyable . . .

Doing what feels good regardless of the consequences . . .

Going out with someone just because they are physically

exciting . . .

Doing unconventional things, even if they are a little

frightening . . .

Refusing to follow orders from someone in authority . . .

• Alcohol dependence

– Lifetime: Respondent met DSM-III-R criteria for alcohol

dependence sometime during her lifetime; assessed at wave 1.

Scored dichotomously according to the presence or absence

of a history of alcohol dependence.

– Past year at wave 1: Respondent met DSM-III-R criteria for

alcohol dependence within 1 year prior to wave 1 or had

consumed two or more alcoholic drinks per day each day of

that period. Scored dichotomously according to the presence

or absence of criteria.

– Current: Respondent was measured at waves 2 and 3 followup

interviews. Scored dichotomously according to presence or

absence of meeting criteria for alcohol dependence within the

most recent followup period, or consumption of two or more

alcoholic drinks per day during the most recent followup period.

• Substance use categories: A slight modification of a Guttman

scale of increasing drug use categories developed by Elliott and

colleagues (1989) was used. Numerical scores were based on the

following categories for use reported at wave 1:

– Category 0 No alcohol dependence, no heavy alcohol use,

no other drug use

– Category 1 Alcohol dependence or heavy alcohol use,

without other drug use

– Category 2 Marijuana use, without amphetamine, barbiturate,

cocaine, opiate, or other drug use

– Category 3 Polydrug use (four or more instances of use of

cocaine, heroin, barbiturates, amphetamine,

hallucinogens, or inhalants)
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Categorization was based on data obtained about lifetime and

past-year usage at the wave 1 assessment.

• Substance abuse treatment: Scored dichotomously according to

whether or not respondent reported that she had ever received

substance abuse treatment at wave 1 assessment.

PROCEDURE

On the basis of wave 1 data, respondents were divided into groups

that were positive or negative for lifetime and past-year alcohol dependence. Univariate analyses were conducted to evaluate relationships

between these variables and the variables reflecting demographics, family

history of substance abuse problems, sensation-seeking scores, violent

assault history, and PTSD. Multivariate analyses then were conducted,

including significant associated variables to predict lifetime and past-year

alcohol dependence or heavy-use groups.

Next, data from waves 2 and 3 were used to classify respondents into

groups based on histories of alcohol dependence during the most recent

followup assessment period and reports of new assaults during followup

assessment periods. Several measures from wave 1 (i.e., family history of

substance abuse problems, lifetime and past-year alcohol dependence,

substance use category, lifetime PTSD status, and current PTSD status)

were used to predict alcohol dependence at waves 2 and 3, as well as

having experienced new assaults at waves 2 and 3.

RESULTS

Relationship Between Wave 1 Violent Assault,

PTSD, and Lifetime Alcohol Dependence

Descriptive data (wave 1) indicated that 10.3 percent of women

had been victims of aggravated assault and 12.7 percent had been victims

of rape at some time in their lives. Lifetime prevalence of PTSD was

12.3 percent and past-6-month prevalence of PTSD was 4.6 percent

within the entire sample. Lifetime prevalence of alcohol dependence

or heavy drinking was 6.4 percent, and past-year prevalence was

3.0 percent.
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Univariate Risk Factors for Lifetime Alcohol Dependence

Women with a family history of substance abuse problems,

sensation-seeking, and lifetime PTSD were significantly more likely to

have lifetime alcohol dependence than their counterparts (figure 1).

Risk of lifetime alcohol dependence increased substantially as a function

of the number of lifetime assaults a woman had experienced (figure 2).

Multivariate Analysis

Multivariate logistic regression analysis was used to evaluate relationships between variables identified as significant in univariate

analyses with the lifetime alcohol dependence/heavy use variable.

Variables significant in the final model of this procedure significantly

increase the odds of alcohol dependence after controlling for the effects

of all other variables in the model. Eight predictor variables were

entered simultaneously into the final model: the four variables just

described in the univariate analyses and the demographic control

variables age, race, income, and education. In the final model, four

FIGURE 1. Univariate risk factors for lifetime alcohol dependence

at wave 1
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FIGURE 2. Relationship between number of violent assaults and

lifetime alcohol dependence at wave 1

variables were significant predictors of lifetime alcohol dependence,

controlling for each of the other variables within the model (table 1).

Women reporting a family history of alcohol abuse or dependence

were 1.99 times more likely to experience lifetime alcohol dependence

or heavy use than women without such a history. Higher sensationseeking scores were also associated with significantly increased odds of

TABLE 1. Final multivariate logistic regression model predicting

lifetime alcohol dependence at wave 1

Confidence

Variable Range Odds Ratio Interval

Family substance abuse problem 0-1 1.99 1.43-2.77

Sensation-seeking 6-18 1.26 1.18-1.34

History of violent assault 0-3 1.43 1.20-1.70

Lifetime posttraumatic stress disorder 0-1 2.39 1.68-3.39

NOTE: Current age, race, household income, and education were not significant factors in the

final model.
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lifetime alcohol dependence, with an odds ratio of 1.26 for each unit

increase in the sensation-seeking scale score. Violent assault history,

which ranged from zero to three possible assaults in wave 1, was associated

with increased odds of lifetime alcohol dependence of 1.43 with each unit

increase in the number of violent assaults. Thus, women with one assault

had increased odds of 1.43 over those with no assaults. Women with two

assaults had increased odds of 2.05 over those with no assaults. Women

with three assaults had increased odds of 2.92 over those with no assaults.

Finally, women with lifetime PTSD were 2.39 times more likely to be

dependent on alcohol than women without PTSD.

Timing of Violent Assault, First Alcohol

Consumption, and Alcohol Intoxication

Of the 638 assault victims from whom data about age of first assault

and age of first drink were available, 10.1 percent reported never having

consumed alcohol. For 50.1 percent, their first alcohol consumption

occurred after the year of their first reported assault. For 5.6 percent, the

age of first drink and age of first assault were the same. For 34.2 percent,

the first drink occurred before the first assault.

First instance of being drunk was also examined in relation to age of

first assault. Of those reporting assault histories, 22.5 percent reported

never having been drunk, 44.1 percent had only been drunk after their

first assault, 6 percent became drunk and had their first assault the same

year, and 27.5 percent became drunk before the year they were first

assaulted.

Timing of onset of first drink, first being drunk, and assault onset was

examined separately among women who met criteria for alcohol dependence or heavy use. Among women with alcohol dependence or heavy

use who also had assault histories, 27 percent reported having their first

drink before their first assault, whereas 29.6 percent of assault victims with

alcohol dependence reported first being drunk before their first assault.

Relationship Between Lifetime Alcohol Dependence

and Past-Year Alcohol Dependence at Wave 1

Of the 101 women who met past-year diagnostic criteria for alcohol

dependence or heavy drinking at wave 1, 38 did so on the basis of heavy

drinking and 63 on the basis of alcohol dependence.
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Multivariate logistic regression analysis was performed using age,

household income, family substance abuse problems, sensation-seeking,

history of violent assault, lifetime PTSD, and lifetime alcohol dependence (all of which were significantly associated with past-year alcohol

dependence or heavy use in univariate analyses) to predict past-year

alcohol dependence or heavy drinking (table 2). After controlling for

other variables in the model, only lifetime alcohol dependence or heavy

use and sensation-seeking scores were significant predictors of past-year

alcohol dependence or heavy use. Odds for past-year alcohol dependence or heavy drinking were 25.99 times greater among those with

lifetime alcohol dependence than among those without such dependence. Of the lifetime positive group, 63 percent also had met criteria

during the past year. Controlling for lifetime alcohol dependence,

sensation-seeking was also associated with increased odds of past-year

alcohol dependence or heavy drinking: Odds of past-year alcohol

dependence or heavy drinking at wave 1 increased as a function of

increases in sensation-seeking.

Relationship Between Past-Year Substance Use at Wave 1

and New Assaults During Waves 2 and 3 Followup

Among women completing at least one followup assessment period

(n=3,359), 4.3 percent reported experiencing at least one rape or

aggravated assault during the followup interval. Substance use during

the year prior to followup (assessed at wave 1) was examined in association with risk of new assaults. Among the wave 1 sample respondents

who participated in at least one followup assessment, 93.7 percent were

classified as non-alcohol dependent and nonusers of other drugs.

Alcohol dependence or heavy use with no other drug use was reported

TABLE 2. Final multivariate logistic regression model predicting pastyear alcohol dependence or heavy drinking at wave 1

Confidence

Variable Range Odds Ratio Interval

Sensation-seeking 6-18 1.12 1.03-1.21

Lifetime alcohol dependence 0-1 25.99 15.64-43.38

NOTE: Current age, race, household income, and education were not significant factors in the

final model.
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by 2.3 percent, marijuana use with no other drug use by 3.2 percent, and

polydrug use by 0.7 percent.

A significant relationship existed between past-year substance use

and the likelihood of assault during the followup period. Rates of new

assault were lowest among women with no heavy alcohol use or drug use

and increased among women with alcohol dependence. Women with

marijuana use had still higher rates of new assault, and women with hard

drug use had the highest rates of new assault (figure 3).

Logistic regression analysis using the four-point past-year substance

use score to predict likelihood of new assault was also significant. Odds

of new assault were 1.77 times greater for women with alcohol dependence than for nonusers, 3.10 times higher for marijuana users than for

nonusers, and 5.45 times higher for polydrug users than for nonusers.

The logistic regression model predicting new assault at waves 2 and 3 by

past-year substance use category at wave 1 was as follows:

Confidence

Variable Range Odds Ratio Interval

Past-year alcohol dependence at wave 1 0-3 1.77 1.49-2.11

FIGURE 3. Relationship between past-year substance use at wave 1

and new assault during waves 2 and 3 followup
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Relationship Between Past-Year Alcohol Dependence (Wave 1), Assault

and PTSD (Waves 2 and 3), and Alcohol Dependence at Followup

Results of multivariate logistic regression analysis are shown in

table 3. Significant predictors of alcohol dependence or heavy use at

followup waves included past-year alcohol dependence assessed at wave

1, exposure to new assault at followup waves, and current PTSD at

followup. Women with past-year alcohol dependence at wave 1 were

9.33 times more likely to be alcohol dependent at waves 2 and 3 than

women without past-year alcohol dependence at wave 1. For women

with a new violent assault during the followup period, the odds were

3.25 times greater than for women without such assaults of alcohol

dependence at waves 2 and 3. Finally, women with PTSD were

5.52 times more likely to be alcohol dependent than women without

PTSD. All three variables were significantly related to the chances of

alcohol dependence in the followup period, accounting for the effects of

the other two variables and indicating that new assault and PTSD were

important predictors even when controlling for past-year alcohol

dependence at wave 1.

Relationships between past-year alcohol dependence at wave 1, new

assault, PTSD, and alcohol dependence at followup are shown in figure 4. Women with alcohol dependence immediately prior to the

followup period were substantially more likely to have alcohol dependence at followup across all conditions than women without alcohol

dependence at followup. Among women without past-year alcohol

dependence, the impact of new assaults and PTSD on alcohol dependence at followup was clear: Rates of alcohol dependence increased

substantially after assault and after PTSD, particularly among assault

victims with PTSD.

TABLE 3. Final multivariate logistic regression model predicting

alcohol dependence at waves 2 and 3

Confidence

Variable Range Odds Ratio Interval

Past-year alcohol dependence at wave 1 0-1 9.33 4.57-18.92

New assault at waves 2 and 3 0-1 3.25 1.52-6.96

Current posttraumatic stress disorder

at waves 2 and 3 0-1 5.52 2.89-10.59

NOTE: Current age, household income, family history of substance abuse problems, sensationseeking, and history of violent assaults at wave 1 were not significant in the final model.
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FIGURE 4. Relationship between past-year alcohol dependence at

wave 1, assault and posttraumatic stress disorder at waves

2 and 3, and alcohol dependence at waves 2 and 3

Women Receiving Substance Abuse Treatment

Patterns of drug and alcohol use and patterns of violent assault history

and PTSD were evaluated separately among a subset of 70 women who

had received treatment for substance abuse, reported at wave 1. The

receipt of treatment provides an objective indicator separate from selfreport that indicates a subsample that is likely to have serious substance

use problems. Among women who had received substance abuse treatment, 60 percent were polydrug users, 17 percent were alcohol dependent,

16 percent used marijuana, and 7 percent were nonusers of drugs and did

not meet alcohol dependency criteria (figure 5). In contrast, among all

women who completed wave 1, 72 percent had a lifetime nonuser classification (figure 6).

As shown in figure 7, only 16 percent of women seeking treatment for

substance abuse did not have a history of violent assault or PTSD. Seventy-three percent had a history of rape or aggravated assault, and
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44 percent had a history of PTSD. One-third had a history of violent

assault and PTSD.

DISCUSSION

Data were consistent with the three major hypotheses stated. As

predicted by hypothesis 1, a history of violent assault increases the risk of

alcohol dependence at wave 1 even after controlling for family history of

substance abuse problems and sensation-seeking. PTSD also increased

risk of alcohol dependence after controlling for family history, sensationseeking, and violent assault.

Hypothesis 2, that a history of substance use or abuse increases the

risk of violent assault, was partially supported. Specifically, women with

increasing categories of substance use were increasingly more likely to

suffer violent assault at followup. Although women with alcohol dependence were slightly more likely than nonusers to be assaulted, risk of

assault was considerably higher among polydrug users, more than

one-quarter of whom were assaulted in the 2-year followup period.

Hypothesis 3, that risk of alcohol dependence at followup is predicted

by history of violent assault, substance abuse, past-year violent assault,

and PTSD, was also partially supported. Past-year alcohol dependence at

wave 1 was the biggest predictor of alcohol dependence

at followup, but new assaults and PTSD still predicted alcohol dependence at followup after controlling for prior alcohol dependence.

Prior assault did not emerge in the multivariate analyses, probably

FIGURE 5. Percent of women receiving treatment for substance

abuse by substance use category (n=70)
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FIGURE 6. Breakdown of women in wave 1 by lifetime substance

use category (percent)

FIGURE 7. Assault and posttraumatic stress disorder history of

women receiving substance abuse treatment (n=70)

because it is highly predictive of both new assault and PTSD at followup

(Kilpatrick et al. 1994).

Evaluation of the timing of alcohol use or dependence and assault is

crucial in this type of study. Although a portion of our evaluation (that

done exclusively with wave 1 data) was retrospective in nature, there was

some evidence that assault tended to precede alcohol use or dependence

rather than vice versa. At wave 1, most victims with alcohol dependence said their first assault occurred before their first alcohol
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consumption or intoxication. This is partially a byproduct of the early

age at which many rapes occur (62 percent of rapes occur before age 18

and 28 percent before age 11) (Kilpatrick et al. 1992; Kilpatrick et al.,

in press).

The longitudinal data provide clearer evidence that assault could be

significantly associated with new onset of alcohol dependence or heavy

use. Among women without alcohol dependence at wave 1, those

assaulted at followup were more likely than their nonassaulted counterparts to develop alcohol dependence at followup. This provides the

strongest evidence regarding the direction of the relationship between

assault and alcohol dependence.

The role of PTSD in alcohol dependence is important. Clearly,

assault victims with PTSD are much more likely to have alcohol dependence than victims without PTSD. This finding has two implications:

(1) It is important to screen women for PTSD as well as for assault

history, and (2) treating assault victims’ PTSD might address some of

their alcohol dependence problems.

Implications for Prevention

Two major implications of these findings for prevention of substance

abuse, particularly alcohol dependence among women, have been

identified. First, assault victims, particularly those with a family history

of substance abuse problems, those high in sensation-seeking, and those

with PTSD, are at high risk of developing alcohol dependence and

should be targeted for substance abuse prevention efforts. Second,

women with alcohol dependence, heavy alcohol use, and other drug use,

particularly hard drug use, are at high risk of being assaulted. This, in

turn, increases the risk of subsequent alcohol dependence or heavy use.

This group, identified by significant substance use, should be targeted to

receive self-protection or crime prevention training. Such strategies

may intervene in the vicious cycle that appears to be maintained between victimization, PTSD, and substance abuse in women.

Implications for Future Research

Because assaults occur at relatively early ages, longitudinal studies

should begin early in life. Because the current study included only

women, the extent to which findings can be generalized to men is
305

unclear. Currently, we are conducting a national study of male and

female adolescents that will address these issues in a much younger age

group.

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ACKNOWLEDGMENT

This research was supported by National Institute on Drug Abuse

grant DA-05220.

AUTHORS

Dean G. Kilpatrick, Ph.D.

Professor

kilpatdg@musc.edu

Heidi S. Resnick, Ph.D.

Associate Professor

resnickh@musc.edu

Benjamin E. Saunders, Ph.D.

Associate Professor

saunders@musc.edu

Connie L. Best, Ph.D.

Associate Professor

bestcl@musc.edu

National Crime Victims Research and Treatment Center

Department of Psychiatry and Behavioral Sciences

Medical University of South Carolina

171 Ashley Avenue

Charleston, SC 29425-0742

(803) 792-2945 (Tel)

(803) 792-3388 (Fax)