Claire L. Hebenstreit

Perceptions of Participating in Longitudinal Trauma Research among Women Exposed to Intimate Partner Abuse

We examine motivations for, and costs/benefits of, participation in three interviews across a one-year period among women recently exposed to intimate partner abuse (IPA). Recruited from publicly accessible police reports, women were not informed that the study focused on IPA in recruiting materials or when they scheduled the first interview. Womens ratings on the Response to Research Participation Questionnaire (RRPQ) indicated a positive benefit-to-cost ratio across all three interviews. Negative responses to participation as well as severity of IPA and PTSD symptoms did not predict retention at the next interview. These data demonstrate that studies asking about IPA experiences, even when survivors do not know in advance that IPA will be the focus of study, can be implemented within a stable benefit-to-cost ratio over time.

An Examination of the Gender Inclusiveness of Current Theories of Sexual Violence in Adulthood: Recognizing Male Victims, Female Perpetrators, and Same-Sex Violence

Although the majority of adulthood sexual violence involves a male perpetrator and a female victim, there is also substantial evidence that members of both genders can be victims and perpetrators of sexual violence. As an alternative to viewing sexual violence within gender-specific terms, we advocate for the use of a gender inclusive conceptualization of sexual aggression that takes into account the factors that contribute to sexual victimization of, and victimization by, both men and women. The goal of the current review is to examine the need and importance of a gender inclusive conceptualization of sexual violence and to discuss how compatible our current theories are with this conceptualization. First, we examine evidence of how a gender-specific conceptualization of sexual violence aids in obscuring assault experiences that are not male to female and how this impacts victims of such violence. We specifically discuss this impact regarding research, law, public awareness, advocacy, and available victim treatment and resources. Next, we provide an overview of a number of major sexual violence theories that are relevant for adult perpetrators and adult victims, including neurobiological and integrated biological theories, evolutionary psychology theory, routine activity theory, feminist theory, social learning and related theories, typology approaches, and integrated theories. We critically examine these theories’ applicability to thinking about sexual violence through a gender inclusive lens. Finally, we discuss further directions for research, clinical interventions, and advocacy in this area. Specifically, we encourage sexual violence researchers and clinicians to identify and utilize appropriate theoretical frameworks and to apply these frameworks in ways that incorporate a full range of sexual violence.

Latent classes of PTSD symptoms in Iraq and Afghanistan female veterans

BACKGROUND Recent studies have used latent class analysis (LCA) to identify subgroups of individuals who share similar patterns of PTSD symptom endorsement; however, further study is needed among female veterans, whose PTSD symptom expression may vary from that of their male counterparts. The current study examined latent PTSD symptom classes in female veterans who returned from recent military service in Iraq and Afghanistan, and explored military and demographic variables associated with distinct PTSD symptom presentations. METHODS A retrospective analysis was conducted using existing medical records from female Iraq and Afghanistan veterans who were new users of VA mental health outpatient (MHO) care, had received a PTSD diagnosis anytime during the post-deployment period, and completed the PTSD checklist within 30 days of their first MHO visit (N=2425). RESULTS The LCA results identified four latent classes of PTSD symptom profiles in the sample: High Symptom, Intermediate Symptom, Intermediate Symptom with High Emotional Numbing (EN), and Low Symptom. Race/ethnicity, age, time since last deployment, and distance from a VA facility emerged as predictors of PTSD symptom presentation. LIMITATIONS The current study was cross-sectional and utilized administrative data. The results may not be generalizable to female veterans from other service eras. CONCLUSIONS Longer times between end of last deployment and initiation of MHO services were associated with more symptomatic classes. Exploration of PTSD symptom presentation may enhance our understanding of the service needs of female veterans with PTSD, and suggests potential benefits to engaging veterans in MHO soon after last deployment.

PTSD detection and symptom presentation: Racial/ethnic differences by gender among veterans with PTSD returning from Iraq and Afghanistan

BACKGROUND To determine differences in positive PTSD screenings and symptom presentation by race/ethnicity and gender for Iraq and Afghanistan veterans diagnosed with PTSD. METHOD We conducted a retrospective analysis using existing records from Iraq and Afghanistan veterans who enrolled in VA care, received a post-deployment PTSD diagnosis, initiated mental health outpatient treatment between 10/01/07 and 12/31/11, and had a PTSD screen result at the start of treatment (N=79,938). PTSD outcomes were measured using the PC-PTSD and PCL. RESULTS At treatment initiation, differences in race/ethnicity and gender were found for PTSD screens and PTSD symptoms. Compared to their white counterparts, Asian/Pacific Islander (A/PI) women and black men were more likely to screen positive for PTSD (adjusted ORs=1.42 and 1.17, ps=.04 and <.0001, respectively) and endorse all measured symptoms (adjusted ORs=1.09 to 1.66, ps≤.000-.04) except avoidance for A/PI women and hyperarousal for black men; A/PI men were less likely to endorse hyperarousal (adjusted OR=.88, p=.04) and did not differ otherwise; and black women did not differ from their white counterparts. Additional differences in PTSD symptom presentation by race/ethnicity and gender were found. LIMITATIONS The current study utilized administrative data and was cross-sectional. The results may not be generalizable to veterans from other service eras. CONCLUSIONS PTSD screens differ by race/ethnicity and gender, and further by PTSD symptoms, which can influence initiation and planning of PTSD treatment. Awareness of such differences may aid in detecting PTSD to provide care for diverse veterans.

Latent profiles of PTSD symptoms in women exposed to intimate partner violence

BACKGROUND Studies have utilized latent class analysis (LCA) and latent profile analysis (LPA) to examine posttraumatic stress disorder (PTSD) symptom profiles in a range of populations. Further study is needed to explore symptom profiles among women exposed to intimate partner violence (IPV). The current study examined latent symptom profiles in a sample of IPV-exposed women, and explored trauma-related cognitive appraisals associated with these PTSD symptom presentations. METHODS An LPA was conducted using cross-sectional data from a non-treatment seeking community sample of women recruited following a police-reported incident of IPV by a male perpetrator (N=229). Multinomial regression analyses determined associations between latent profile membership and trauma-related appraisals. RESULTS The LPA identified five PTSD symptom profiles: Low Symptom (46% of the sample); Low Symptom with High Hypervigilance (17%); Intermediate Symptom (16%); Intermediate Symptom with High Hypervigilance (11%); and High Symptom (10%). Trauma-related appraisals, including fear, alienation, and self-blame, were the strongest independent predictors of PTSD symptom profile membership. LIMITATIONS The study focused on female victims of IPV by a male partner, and findings may not generalize to other gender configurations (e.g. same-sex couples, male victims, etc.). The LPA is cross-sectional, and the stability of these profiles over time warrants further study. CONCLUSIONS These findings suggest the need for careful consideration of differences among IPV-exposed women within the larger context of PTSD research and clinical intervention. Identifying latent subgroups may provide an empirical basis for practitioners to design and implement PTSD intervention efforts that are tailored to specific symptom profiles.

Race/ethnicity and gender differences in mental health diagnoses among Iraq and Afghanistan veterans

Veterans who served in Operation Enduring Freedom (OEF; predominantly in Afghanistan) and Operations Iraqi Freedom and New Dawn (OIF and OND; predominantly in Iraq) and are enrolled in the VA are comprised of a growing cohort of women and higher proportions of racial/ethnic minorities than civilians. To compare rates of mental health disorders by race/ethnicity and gender for this diverse cohort, we conducted a retrospective analysis of existing records from OEF/OIF/OND veterans who were seen at the VA 10/7/01-8/1/2013 (N=792,663). We found that race/ethnicity was related to diagnoses of mental health disorders. Asian/Pacific Islanders (A/PIs) were diagnosed with all disorders at lower rates than whites, and American Indian/Alaska Native (AI/AN) males were diagnosed with most disorders at higher rates than white males. Research is needed to identify contributing factors to differential rates of diagnoses based on race/ethnicity and gender. A/PIs and AI/ANs have unique patterns of mental health diagnoses indicating they should be considered separately to present a comprehensive picture of veteran mental health.

Interpersonal Violence, Depression, and Executive Function

This study considers links between the number of types of violence to which women have been exposed, depression, and executive functions (EFs). Substantial research has established EF deficits among depressed individuals as well as individuals exposed to trauma. Studies have also indicated a relationship between trauma exposure and depressive symptoms across a range of traumatic events, such as combat exposure, motor vehicle accidents, natural disasters, and assaults. This study examines this relationship in an ethnically diverse community sample of 93 women exposed to interpersonal violence who completed a battery of EF tasks that assessed processing speed, working memory, response inhibition, and set shifting. Women reported an average of 5.8 types of interpersonal violence events. The number of types of interpersonal violence events was significantly related to depressive symptoms, although not EF performance. Specific EFs, such as working memory and response inhibition, were positively related to depressive symptoms.

Military sexual trauma is associated with eating disorders, while combat exposure is not.

Objective: There are strong associations among trauma and eating disorders. However, while trauma and eating disorders are more common among veterans than other populations, there is little information on how military-specific stressors affect eating disorder risk. This study’s objective was to determine whether military sexual trauma and combat exposure were independent predictors of eating disorders among women veterans, a high-risk group. Method: Participants were women age 18–70, using VA medical center services, without psychotic disorders or suicidal ideation (N = 407). We estimated a cross-sectional logistic regression model to predict eating disorders (anorexia, bulimia, binge eating disorder) as a function of military sexual trauma and combat exposure, adjusting for demographic variables. Results: Sixty-six percent of participants reported military sexual trauma, 32% reported combat exposure, and 15% met eating disorder criteria. Mean age was 49 years (SD = 13); 40% were veterans of color. Women reporting military sexual trauma had twice the odds of an eating disorder compared to women who did not (odds ratio [OR]: 2.03; 95% CI [1.03–3.98]). Combat exposure was not associated with eating disorders. Asian race (OR: 3.36; 95% CI [1.26–8.97]) and age (OR: 1.03; 95% CI [1.01–1.06]) were associated with eating disorders. Conclusions: The high rates of military sexual trauma and eating disorders highlight a need for continued work. Results suggest that it may be useful to focus on women reporting military sexual trauma when implementing eating disorder screening and treatment programs. Given associations among trauma, eating disorders, obesity, and mortality, such efforts could greatly improve veteran health.

Screen for Disordered Eating: Improving the accuracy of eating disorder screening in primary care

OBJECTIVE To develop a primary care eating disorder screen with greater accuracy and greater potential for generalizability, compared to existing screens. DESIGN Cross-sectional survey to assess discriminative accuracy of a new screen, Screen for Disordered Eating (SDE), compared to Eating Disorders Screen for Primary Care (EDS-PC) and SCOFF screener, using prevalence rates of Binge Eating Disorder (BED), Bulimia Nervosa (BN), Anorexia Nervosa (AN), and Any Eating Disorder (AED), as measured by the Eating Disorder Examination Questionnaire (EDE-Q). RESULTS The SDE correctly classified 87.2% (CI: 74.3%-95.2%) of BED cases, all cases of BN and AN, and 90.5% (CI: 80.4%-96.4%) of AED cases. Sensitivity estimates were higher than the SCOFF, which correctly identified 69.6% (CI: 54.2%-82.3%) of BED, 77.8% (CI: 40.0%-97.2%) of BN, 37.5% (CI: 8.52%-75.5%) of AN, and 66.1% (CI: 53%-77.7%) of AED. While the EDS-PC had slightly higher sensitivity than the SDE, the SDE had better specificity. The SDE outperformed the SCOFF in classifying true cases, the EDS-PC in classifying true non-cases, and the EDS-PC in distinguishing cases from non-cases. CONCLUSIONS The SDE is the first screen, inclusive of BED, valid for detecting eating disorders in primary care. Findings have broad implications to address eating disorder screening in primary care settings.

Influence of military sexual assault and other military stressors on substance use disorder and PTS symptomology in female military veterans

Servicewomen exposed to traumatic stressors over the course of their military service are at increased risk of developing symptoms of substance use disorder (SUD) and posttraumatic stress (PTS). They are also at risk for exposure to military sexual assault (MSA), which is also associated with SUD and PTS symptomology. Research is unclear about the incremental contributions of different forms of traumatic stressors on co-occurring SUD and PTS symptomology. In this study we examined the independent and combined effects of MSA and other military stressors on SUD and PTS symptomology in a sample of female veterans (N=407). Results indicate that MSA and other military stressors exhibit incremental effects on SUD and PTS symptomology. Results further suggest that women exposed to both MSA and other military stressors are at increased risk for developing co-occurring SUD and PTSD. These findings extend previous research on comorbid SUD and PTSD, highlighting the cumulative effects of traumatic stressors on posttraumatic psychopathology, and have implications for future research and clinical practice with female veterans.