Child sexual abuse as a predictor of psychiatric co-morbidity and its implications for drug and alcohol treatment

Suicide Risk and Addiction: The Impact of Alcohol and Opioid Use Disorders

Purpose of Review

Suicide is a major public health concern and a leading cause of death in the US. Alcohol and opioid use disorders (AUD/OUD) significantly increase risk for suicidal ideation, attempts, and death, and are the two most frequently implicated substances in suicide risk. We provide a brief overview of shared risk factors and pathways in the pathogenesis of AUD/OUD and suicidal thoughts and behaviors. We also review clinical recommendations on inpatient care, pharmacotherapy, and psychotherapeutic interventions for people with AUD/OUD and co-occurring suicidal ideation and behavior.

Recent Findings

Among people with an underlying vulnerability to risk-taking and impulsive behaviors, chronic alcohol intoxication can increase maladaptive coping behaviors and hinder self-regulation, thereby increasing the risk of suicide. Additionally, chronic opioid use can result in neurobiological changes that lead to increases in negative affective states, jointly contributing to suicide risk and continued opioid use. Despite significantly elevated suicide risk in individuals with AUD/OUD, there is a dearth of research on pharmacological and psychosocial interventions for co-occurring AUD/OUD and suicidal ideation and behavior.

Summary

Further research is needed to understand the effects of alcohol and opioid use on suicide risk, as well as address notable gaps in the literature on psychosocial and pharmacological interventions to lower risk for suicide among individuals with AUD/OUD.

Dual Diagnosis in Prisoners: Childhood Sexual and Physical Abuse as Predictors in Men and Women

The study aims to determine the rate of dual diagnosis (DD), examine the most common mental disorders, and determine whether a history of childhood sexual/physical abuse (CSA/CPA) is associated with this phenomenon. One-hundred and eighty inmates from a Spanish prison were assessed using the Mini International Neuropsychiatric Interview and the Addiction Severity Index-6. The data showed that 46.8% of the males and 65.1% of the females had a substance use disorder. With regard to CPA, similar percentages were found in both genders. Nevertheless, rates of CSA were highest in females. Logistic regression analysis was performed by gender. CPA was predictor of DD for males, and CSA was predictor of DD for females, showing the greatest weight. In addition, in both cases, the number of drugs of abuse was an adequate predictor. We can state that these forms of maltreatment are risk factors for the development of a broad range of psychopathological problems.

Characteristics of Sexual Abuse Among Individuals With Serious Mental Illnesses

The deleterious effects of sexual abuse (SA) are well documented, as many studies have found that SA can increase the risk for psychiatric disorders. While SA has been examined in multiple samples, no studies have examined the characteristics of SA in individuals with severe mental illnesses (SMI). This study examined the prevalence rate and characterized the nature of SA among individuals with SMI who were under psychiatric care in three different inpatient facilities. Utilizing data from the MacArthur Violence Risk Assessment Study, 1,136 individuals with SMI were assessed for SA histories, psychiatric diagnoses, and other demographics. Nearly half of this sample ( n = 511) identified SA histories, with almost half indicating that the person was a stranger or someone outside of the family unit. One third reported SA occurred "too many times to count," and approximately a third indicated the abuse consisted of intercourse, occurring at a mean age of 11.22 years. Results found that individuals with SA histories were often never married, Caucasian, female, had children, described themselves as psychologically unwell, and were commonly voluntary psychiatric admissions. Those with SA histories had significantly higher psychopathology and lower functioning, and were more likely to be diagnosed with depression but less likely to be substance dependent. Identifying SA characteristics in individuals with SMI is a critical component to successful treatment. Thorough screening and assessment of this common problem can help clinicians identify accompanying issues that may exacerbate SMI symptomology, and improve the prognosis for long-term outcomes.

Providers' Perceptions of Gender-Specific Drug Treatment

This study examined substance abuse treatment providers' perceptions of the gender-specific service needs of women in treatment as well as the obstacles that impede the delivery of services to meet those needs. Surveys were administered to more than 100 staff members of five treatment agencies that were participating in the Chicago Practice Improvement Collaborative. These surveys were followed up with focus group discussions. Most participants reported that their treatment agencies delivered gender-specific services but also described the numerous barriers to addressing women's specific needs, such as limited resources and the psychosocial challenges experienced by women in treatment (e.g., depression, child care, and family responsibilities). We discuss these findings in light of previous studies, the strengths and limitations of our research design, and the value of collaborations between researchers and practitioners.

Childhood abuse and neglect and transitions in stages of alcohol involvement among women: a latent transition analysis approach

BACKGROUND

Childhood abuse and neglect have been linked with alcohol disorders in adulthood yet less is known about the potential of early trauma to influence transitions in stages of alcohol involvement among women. Study aims were to (1) identify stages of women's alcohol involvement, (2) examine the probability of transitions between stages, and (3) investigate the influence of four domains of childhood abuse and neglect (sexual abuse, physical abuse, neglect, and witness to domestic violence), assessed individually and as poly-victimization, on transitions.

METHODS

The sample consisted of 11,750 adult female current drinkers identified in Wave 1 (2001-2002) and re-interviewed in Wave 2 (2004-2005) of the National Epidemiological Survey on Alcohol and Related Conditions.

RESULTS

Three stages of alcohol involvement emerged from latent class analysis of 11 DSM-IV abuse/dependence criteria: severe (1.5% at Wave 1, 1.9% at Wave 2), hazardous (13.6% at Wave 1, 16.0% at Wave 2), and non-problem drinking (82.1% at Wave 1, 84.5% at Wave 2). Adjusted latent transition analyses determined transition probabilities between stages across waves. Women reporting any childhood abuse and neglect were more likely to advance from the non-problem drinking class at Wave 1 to severe (AOR=3.90, 95% CI=1.78-8.53) and hazardous (AOR=1.56, 95% CI=1.22-2.01) drinking classes at Wave 2 relative to women without this history. Associations were also observed between individual domains and transition from no problems to severe alcohol stage.

CONCLUSIONS

Results suggest a long-term impact of childhood abuse and neglect as drivers of progression in women's alcohol involvement.

Desire to dissociate: implications for problematic drinking in college students with childhood or adolescent sexual abuse exposure

Alcohol use to replace inadequate dissociative capabilities, or chemical dissociation, has been linked to college students with childhood or adolescent sexual abuse (CASA). Insofar as CASA-exposed persons experience a restricted range of dissociative capabilities, what remains relatively unclear is whether some desire to achieve greater dissociative experiences. Nonclinical levels of dissociative tendencies have positively predicted alcohol-related blackouts in CASA-exposed students, and dissociation mediated the relations between CASA and intoxication frequency. Although alcohol (similar to dissociation) can reduce physiological and psychological responses to stress, alcohol consumption may be prompted by a desire to dissociate rather than inadequate dissociative tendencies alone. To investigate this interpretation of the chemical dissociation phenomenon, researchers examined the mediating potential of dissociative tendencies using the Dissociative Experiences Scale-II (DES-II) as well as the desire to dissociate concept (ie, a modified version of the DES-II) on the relations between CASA exposure and problematic alcohol use in college students (N = 298). Results indicated that dissociation scores did not replicate previous mediation findings whereas desire to dissociate scores fully mediated CASA exposure and problematic alcohol use. Implications of the results are discussed including possible reasons why prior mediation results were not replicated as well as links to experiential avoidance.

Childhood trauma among individuals with co-morbid substance use and post traumatic stress disorder

BACKGROUND: Little is known about the impact of childhood trauma (CT) on the clinical profile of individuals with co-occurring substance use disorder (SUD) and post traumatic stress disorder (PTSD). AIMS: To compare the clinical characteristics of individuals with SUD+PTSD who have a history of CT with SUD+PTSD individuals who have experienced trauma during adulthood only. METHOD: Data were collected on 103 individuals as part of a randomised controlled trial examining the efficacy of an integrated psychosocial treatment for SUD+PTSD. Participants were recruited from substance use treatment services, community referrals and advertising. Data were collected on demographic characteristics, substance use and treatment histories, lifetime trauma exposure, and current physical and mental health functioning. RESULTS: The vast majority (77%) of the sample had experienced at least one trauma before the age of 16, with 55% of those endorsing childhood sexual abuse. As expected individuals with a CT history, as compared to without, evidenced significantly longer duration of PTSD. Those with a CT history also had more extensive lifetime trauma exposure, an earlier age of first intoxication, and reported more severe substance use (e.g., a greater number of drug classes used in their lifetime, higher severity of dependence scores and greater number of drug treatment episodes). CONCLUSION: Individuals with co-morbid SUD+PTSD who have experienced CT present with a more severe and chronic clinical profile in relation to a number of trauma and substance use characteristics, when compared to individuals with adulthood only trauma histories. It is therefore important for SUD+PTSD treatment planning that CT be carefully assessed.

Routines and rituals: a grounded theory of the pain management of drug users in acute care settings

AIM

This study reviewed the perceptions and strategies of drug users and nurses with regard to pain management in acute care settings.

BACKGROUND

Drug users present unique challenges in acute care settings with pain management noted to be at best suboptimal, at worst non-existent. Little is known about why and specifically how therapeutic effectiveness is compromised.

DESIGN

Qualitative: constructivist grounded theory.

METHOD

A constructivist grounded theory approach incorporating a constant comparative method of data collection and analysis was applied. The data corpus comprised interviews with drug users (n = 11) and five focus groups (n = 22) of nurses and recovering drug users.

RESULTS

Moral relativism as the core category both represents the phenomenon and explains the basic social process. Nurses and drug users struggle with moral relativism when addressing the issue of pain management in the acute care setting. Drug users lay claim to expectations of compassionate care and moralise via narration. Paradoxically, nurses report that the caring ideal and mutuality of caring are diminished. Drug users' individual sensitivities, anxieties and felt stigma in conjunction with opioid-induced hyperalgesia complicate the processes. Nurses' and hospitals' organisational routines challenge drug user rituals and vice versa leading both protagonists to become disaffected. Consequently, key clinical issues such as preventing withdrawal and managing pain are left unaddressed and therapeutic effectiveness is compromised.

CONCLUSION

This study provides a robust account of nurses' and drug users' struggle with pain management in the acute care setting. Quick technological fixes such as urine screens, checklists or the transient effects of (cognitive-based) education (or training) are not the answer. This study highlights the need for nurses to engage meaningfully with this perceptibly 'difficult' group of patients.

RELEVANCE TO CLINICAL PRACTICE

The key aspects likely to contribute to problematic interactions with this patient cohort are outlined so that they can be prevented and, or addressed.

Harsh humour: a therapeutic discourse

Humour research in healthcare has tended to focus on rehearsed as opposed to spontaneous humour. This paper reports an empirical example of spontaneous humour in healthcare interactions: a negative case analysis from a constructivist grounded theory study. Twenty Clinical Nurse Specialist (CNS)-patient interactions and CNS pre- and postinteraction audio diaries provided the baseline data corpus. Follow-up interviews, field notes, focus groups and observations serviced theory generation with a constant comparison approach to data collection and analyses. Interpretative and illustrative frameworks incorporating humour theories, non-laughter humour support, discursive features and prosodical features of speech were applied to all data. This paper is based upon the negative case comprising a 90-minute follow-up interview and 10 hours of field note observations. The negative case - a CNS working with female drug users' sexual and reproductive health needs - contradicted emerging findings from the baseline data corpus. First, the negative case had greater awareness of humour, deliberately initiated humour and recognised parameters and exclusion zones. Second, a good patient personal was evident in the baseline data corpus but the negative case worked with 'bad' patients. Accordingly, a specific type of humour - harsh humour - was evident in the negative case. Harsh humour used areas of potential discord (e.g. drug use) as a focus of humour creation and maintenance. The deliberate initiation of harsh humour enabled the negative case and her colleagues to achieve their aims by engaging effectively with unpredictable, reluctant and recalcitrant patients. The negative case demonstrates how humour can be used to therapeutically enhance healthcare interactions with disenfranchised individuals. Humour is not superficial but integral to the accomplishment of key aspects of interactions. Health and social care workers should consider the potential for therapeutic humour to engage and maintain all patients - disenfranchised or otherwise - in healthcare interactions.

Factors Associated with the History of Attempted Suicide

Background: The present study examines a population of criminal justice clients for suspected substance-related problems. Aims: It aims to identify variables associated with a history of suicide attempt (SA). Method: 6,836 clients were interviewed with the Addiction Severity Index (ASI). Attempters were compared to nonattempters regarding substance use, medical/psychiatric status, family history, and social relationships in a stepwise forward logistic regression. Results: Attempters (21%) were more likely to report binge drinking, intake of illicit drugs, injection of drugs, physical and mental illness, problematic family history, and history of being abused. After logistic regression, SA was independently associated with older age, female gender, binge drinking, delirium tremens, injection, overdose, medical problems, psychiatric symptoms, family history of alcohol or psychiatric problems, and sexual, physical, and emotional abuse. The psychiatric and family/social domains (including being abused) most strongly separated attempters from nonattempters. Conclusions: Family background factors, psychiatric symptoms, severity of substance use, and sexual, physical, and emotional abuse appear to be factors associated with SA among criminal justice clients.

Struggling to Reconnect: Women's Perspectives on Alcohol Dependence, Violence, and Sexual Function

Until recently, substance use disorders and sexual function were two areas in which women received comparatively less attention then men. Recent studies have challenged sexual stereotypes about women who drink and use other substances. This study explores the experiences of women dependent on alcohol and/or other substances who have stopped their use. These women were subjected to significant abuse during both childhood and adulthood. A pattern of using alcohol and other substances as a means of managing negative feelings, disconnecting from abuse, reconnecting to form new relationships, and disconnecting from subsequent abuse was prominent in the women's stories. The women in this study also experienced problems with sexual function both while using and following cessation of use. Findings highlight the complex relationships among substance abuse, trauma, and sexual problems as well as the importance of routinely assessing for sexual problems. Suggestions for treatment and future research are offered. J Am Psychiatr Nurses Assoc, 2009; 14(6), 421-428.

Treatment dropout in drug-addicted women: are eating disorders implicated?

A high prevalence of eating disorders among drug-addicted female patients has been noted, and it could be associated to psychopathological underlying factors. Our aim was to assess eating disorder traits in women approaching a residential program for drug addiction. We hypothesized that these traits would correlate to more general psychopathological factors, and would influence treatment relapse. A sample of 204 substance dependent women attending a residential treatment was screened for psychopathological indices, and follow-up data were obtained at the end of the treatment. Clients had a high risk for eating disorders (15%), and lifetime prevalence was even higher (20%). Disordered eating was associated to psychopathological distress, in particular harm avoidance resulted significantly lower (p=0.005), evoking higher unresponsiveness to danger. Drug addiction treatment outcome is associated to completion of defined programs, and eating disorder was a key covariable in determining treatment relapse or success (p=0.03). Clinicians should be aware of this potential co-morbidity, and concurrent treatments should be attempted, in order to prevent symptomatic shifting.

Childhood sexual abuse and non-suicidal self-injury: meta-analysis

BACKGROUND

Many theorists posit that childhood sexual abuse has a central role in the aetiology of self-injurious behaviour. Studies that report statistically significant associations between a history of such abuse and self-injury are cited to support this view.

AIMS

A meta-analysis was conducted to determine systematically the magnitude of the association between childhood sexual abuse and self-injurious behaviour.

METHOD

Forty-five analyses of the association were identified. Effect sizes were converted to a standard metric and aggregated.

RESULTS

The relationship between childhood sexual abuse and self-injurious behaviour is relatively small (mean weighted aggregate phi=0.23). This figure may be inflated owing to publication bias. In studies that statistically controlled for psychiatric risk factors, childhood sexual abuse explained little or no unique variance in self-injurious behaviour.

CONCLUSIONS

Theories that childhood sexual abuse has a central or causal role in the development of self-injurious behaviour are not supported by the available empirical evidence. Instead, it appears that the two are modestly related because they are correlated with the same psychiatric risk factors.

Dissociation in major depressive disorder: a pilot study

The principal objective of this study was to evaluate the occurrence of various dissociative phenomena in patients with major depressive disorder (MDD) and their possible implications in manifestation and course of depression. We administered the Dissociative Experiences Scale (DES) and a self-questionnaire of life events to 27 patients with MDD and to 40 healthy participants in order to collect information on traumatic events. Patients who scored >or= 20 on the DES were also assessed to determine the presence of dissociative disorder. Patients with MDD reported a significantly higher mean score on the DES than the comparison healthy participants. In all, 12 out of 27 patients with MDD reported childhood trauma, and their mean score on the DES representing absorption and imaginative involvement was significantly higher than that of participants without childhood trauma. Also, 7% of our MDD patients were diagnosed with dissociative disorder during this study. The principal limitations of the study were its small sample size and the use of a nonstandardized trauma measure. These findings indicate that dissociative phenomena should not be overlooked in MDD. Screening methods and structured interview for dissociative disorders are useful in psychiatric and psychological practice. Further studies should analyze the role and clinical consequence of different forms of dissociation experiences.

Comparison of drug use and psychiatric morbidity between prostitute and non-prostitute female drug users in Glasgow, Scotland

AIMS

To compare psychiatric morbidity between 176 female drug users with lifetime involvement in prostitution (prostitutes) and 89 female drug users with no involvement (non-prostitutes) in Glasgow, Scotland.

METHOD

The Revised Clinical Interview Schedule (CIS-R) measured current neurotic symptoms.

RESULTS

Prostitutes were more likely to report adult physical (OR 1.8) or sexual abuse (OR 2.4), to have attempted suicide (OR 1.7) and to meet criteria for current depressive ideas (OR 1.8) than non-prostitutes. Seventy-two percent of prostitutes and sixty-seven percent of non-prostitutes met criteria for a level of current neurotic symptoms likely to need treatment (CIS-R > or = 18). Being in foster care (OR 8.9), being prescribed medication for emotional problems in the last 30 days (OR 7.7), adult sexual abuse (OR 4.5), poly drug use in the last 30 days (OR 3.6) and adult physical abuse (OR 2.6) were significantly associated with a CIS-R score of > or = 18 for prostitutes using multiple logistic regression.

CONCLUSIONS

Higher rates of adulthood abuse among prostitutes may explain the greater proportion of prostitutes than non-prostitutes meeting criteria for current depressive ideas and lifetime suicide attempts.

Motives to drink as mediators between childhood sexual assault and alcohol problems in adult women

Two models are proposed to relate maladaptive emotion regulation strategies and alcohol-related problems for women with a history of childhood sexual assault (CSA). The distress coping model suggests only one motive-drinking to cope with negative emotions-mediates the relationship between CSA and alcohol problems. The emotion regulation model suggests two motives mediate the relationship between CSA and alcohol problems: drinking to cope with negative emotions and drinking to enhance positive emotions. These models were tested in a random community sample of 697 women, ranging from 25 to 75 years old. Both motives partially mediated the relationship between CSA and alcohol problems. Effects were small, but reliable.

Attempted suicide among entrants to three treatment modalities for heroin dependence in the Australian Treatment Outcome Study (ATOS): prevalence and risk factors

AIMS

To determine the lifetime and recent histories of attempted suicide among entrants to treatment for heroin dependence in three treatment modalities and a non-treatment comparison group; and to ascertain factors associated with a recent history of attempted suicide.

DESIGN

Cross-sectional structured interview.

SETTING

Sydney, Australia.

PARTICIPANTS

Six hundred and fifteen current heroin users: 201 entering methadone/buprenorphine maintenance (MT), 201 entering detoxification (DTX), 133 entering drug free residential rehabilitation (RR) and 80 not in treatment (NT).

FINDINGS

A lifetime history of attempted suicide was reported by 34% of subjects, 13% had attempted suicide in the preceding year and 5% had done so in the preceding month. Females were more likely to have lifetime (44% versus 28%) and 12 month (21% versus 9%) suicide attempt histories. The 12 month prevalence of attempted suicide among treatment groups ranged between 11% (MT, NT) and 17% (RR). Factors associated with recent suicide attempts were: being an RR entrant, female gender, younger age, less education, more extensive polydrug use, benzodiazepine use, recent heroin overdose, Major Depression, current suicidal ideation, Borderline Personality Disorder (BPD)and Post-Traumatic Stress Disorder.

CONCLUSIONS

Recent suicidal behaviour is a major clinical problem for heroin users, and for females and RR entrants in particular. An essential adjunct to treatment for heroin dependence is routine screening for depression and suicidal ideation, with the provision of appropriate treatment where needed.

Exploring the relationship between alcohol use, childhood maltreatment, and treatment needs among female prisoners

OBJECTIVE

This study examined the relationship between child maltreatment and adult alcohol dependency among a sample of newly incarcerated female prisoners.

METHOD

This secondary data analysis utilized information gathered through face-to-face interviews with female inmates at intake (N = 1198) within the Texas prison system from 1998 to 1999.

RESULTS

Using DSM-IV criteria we found that, among women who reported drinking at least 10 drinks in the last year, 40% scored as alcohol dependent. Bivariate findings revealed that women who were alcohol dependent were also more likely to have grown up in disorganized family situations, including parental drug and alcohol use-related problems, childhood neglect, and childhood physical and sexual abuse. As adults, these women were far more likely to have utilized mental health services and substance user treatment programs. Supportive of Widom and colleagues (1995), multivariate analyses revealed that childhood neglect (not physical or sexual abuse) was a significant predictor of alcohol dependency. Finally, among the alcohol dependent group, 62% indicated a willingness to participate in substance user treatment programs.

CONCLUSIONS

These findings emphasize that childhood neglect is related to long-term negative consequences in the form of alcohol use related problems in adulthood. Our findings strongly point to the need for improved screening, assessment procedures, and programming for women prisoners.

Comorbid psychiatric and alcohol abuse/dependence disorders: psychosocial stress, abuse, and personal history factors of those in treatment

Factors related to comorbid versus only substance disorders are essential to understanding and treating these complex problems. Medical records of sixty-nine inpatients at a private rehabilitation hospital in Southern California were reviewed to determine the associations between personal history factors and (1) comorbid psychiatric and substance abuse disorders and (2) participant's self-assessed progress in treatment. Results revealed significant differences between dual diagnosis patients (alcohol abuse/dependence and an affective disorder) and alcohol abuse/dependence only in regard to gender, previous diagnosis, length of illness, suicide attempts, psychotropic medication history, maternal emotional, physical and sexual abuse, paternal abuse, legal difficulties, and psychosocial stressors. No significant differences between substance abusing patients and dually diagnosed patients were found in terms of self-assessment of progress in treatment. Significant correlations were found between self-assessed progress in treatment and major depression (versus bipolar disorder), use of psychotropic medication, and less abuse from mother or primary caretaker. Identification of these personal history factors may be useful in developing and implementing treatment plans.

Suicide among heroin users: rates, risk factors and methods

The current paper examines critically the literature on suicide rates, suicide risk factors and methods employed for suicide among heroin users, and compares these to those of the general population. Heroin users have a death rate 13 times that of their peers, and deaths among heroin users attributed to suicide range from 3-35%. Overall, heroin users are 14 times more likely than peers to die from suicide. The prevalence of attempted suicide is also many orders of magnitude greater than that of community samples. The major general population risk factors for suicide also apply to heroin users (gender, psychopathology, family dysfunction and social isolation). Heroin users, however, have extremely wide exposure to these factors. They also carry additional risks specifically associated with heroin and other drug use. Drugs as a method of suicide play a larger role in suicide among heroin users than in the general population. Heroin, however, appears to play a relatively small role in suicide among this group. Overall, suicide is a major clinical issue among heroin users. It is concluded that suicide is a major problem that treatment agencies face, and which requires targeted intervention if the rates of suicide among this group are to decline.

Sexual abuse among women entering methadone treatment

Women who enter drug abuse treatment programs are likely to report histories of sexual abuse that may impact psychosocial functioning, retention, and outcomes. This study investigates differences at admission between women with and without sexual abuse histories who entered an outpatient methadone treatment program in Texas. In a sample of 137 women, 39% reported prior sexual abuse. Findings show that women with sexual abuse histories were more likely also to have experienced physical and emotional abuse, to report poorer family-of-origin relationships, and to report more drug-related problems. These clients also reported more depression, anxiety, thoughts of suicide, trouble concentrating, and trouble controlling violent behavior. Results are discussed in terms of the need for adequate assessment of abuse history at intake and the need for targeted outcome studies to better define the impact of past abuse on treatment participation and outcome.

Self-Perceived Effects of SEXUAL TRAUMA Among Women Who Smoke Crack

This descriptive study examined how Black women who smoke crack cocaine spoke about their experiences of sexual trauma, drug use, and the implications of these experiences for their lives. The authors also explored whether the women's perceptions of the effects of sexual abuse were related to objective indicators of mental health and drug use. The most commonly reported effects of sexual trauma were feeling dirty or ashamed or blaming self, having negative feelings toward the perpetrator, experiencing a general dislike of men or sex, and reporting a conscious reluctance to cope with the incident. In addition, conscious or unconscious denial of the effects of sexual trauma was associated with use of drugs to cope with intrapersonal and interpersonal feelings, inwardly directed responses to the trauma (e.g., self-blaming, feeling ashamed) were positively related to depression, and outwardly directed responses to the trauma (e.g., anger at the perpetrator) were positively related to self-esteem. These findings are discussed in terms of their implications for the self-medication model of substance use, treatment implications for women who have been sexually abused, and the role of self-perception in the relationship between sexual trauma and long-term outcomes.

Women's treatment utilization and its relationship to childhood sexual abuse history and lifetime PTSD

A central issue in the substance abuse literature is whether a history of childhood sexual abuse (CSA) is a risk factor for poorer treatment outcomes. Although there is a strong belief that CSA is associated with increased substance abuse treatment utilization and relapse among women clients, most empirical evidence does not support this position. This study addresses this conundrum by exploring several possible explanations among a sample of women in substance abuse treatment. Unexpectedly, the results indicate that women with more severe histories of CSA were likely to have received less lifetime substance abuse treatment, although they were likely to have received more mental health treatment. In addition, the expected interaction between posttraumatic stress disorder (PTSD) status and CSA status and increased rates of both types of treatment was not found. However, participants with both PTSD and CSA concentrated on mental health treatment while those with only PTSD focused on substance abuse treatment.

A meta-analytic examination of the relationship between child sexual abuse and eating disorders

OBJECTIVE

This study had two goals. The first was to assess the magnitude and consistency of the relationship between child sexual abuse (CSA) and eating disorders (ED). The second was to examine methodological factors contributing to the heterogeneity of this relationship.

METHOD

Meta-analysis was used to examine both questions. Fifty-three studies were included in the analysis.

RESULTS

A small, significant positive relationship between CSA and ED emerged. The relationship was marked by heterogeneity. Effect sizes were largest when CSA was the grouping variable, the Eating Disorders Inventory (EDI) or the Eating Attitudes Test (EAT) was used as the measure of eating disorders, and nonclinical groups were compared with clinical samples.

DISCUSSION

Models of CSA and ED need to more clearly specify what aspects of ED (e.g., body image or binge eating) are most influenced by which types of CSA. These specific relationships then need to be examined empirically.

Responding to victimized Alaska Native women in treatment for substance use

High rates of physical and sexual abuse have been found among Alaska Native women entering a residential treatment program in Fairbanks, Alaska. Little information, however, has been available that describes the nature of such abuse and its relationship to treatment outcome. This article describes the extent of such abuse and reviews factors involved in its onset. The implications of the findings are discussed with an emphasis on how they can be applied to enhance treatment outcome.

Suicide in women

This article reviews research into suicide in women during the last 25 years. National rates vary between the extremes of 19/10(5) per year in Sri Lanka and < 1/10(5) per year in the Philippines and Egypt, but almost everywhere rates for women are much lower than male rates, with a median ratio of 2.8/1. The exceptions are in India and China, which report higher rates in young married women. The reproductive process has some influence. While menstruation, hormonal treatment, pregnancy and the puerperium have no major effect, unwanted pregnancy may still lead to suicide under certain circumstances, and severe labour can occasionally do so. Having children protects, but the relative risk is no more than 2.0 in nulliparous women. Social factors also have a limited effect. There are higher rates of suicide in divorced women, but the evidence on widowhood is equivocal. Prosperity and employment have no effect. Sexual abuse, rape and domestic violence undoubtedly lead to suicide attempts, but the evidence on completed suicide is lacking. There are many unanswered questions, especially why rates of completed suicide for women (with a greater prevalence of overt depression) are lower than for men, and why Chinese and Indian women have higher rates. More research is required, especially from developing nations.