Sexual Traumatic Event Exposure, Posttraumatic Stress Symptomatology, and Alcohol Misuse Among Women: A Critical Review of the Empirical Literature

Sexual Assault-Related Interactions and Social Reactions in the Initial Months Following Assault: A Daily Diary Study

Most sexual assault survivors disclose to informal supporters and receive both negative and positive social reactions. Converging evidence suggests that the first months after sexual assault are a period of increased support-seeking that may be uniquely important to survivors' recovery, especially among survivors at risk of chronic post-traumatic stress and alcohol misuse. However, no research has examined when and how often survivors talk about their assault and what social reactions they receive during this time. As such, the goal of this study was to characterize the day-to-day assault-related interactions and social reactions received by a high-risk group of survivors during the first months following sexual assault. Adult female survivors of past-10-week sexual assault with elevated assault-related post-traumatic stress and alcohol use (N = 41) completed a baseline assessment and daily diaries over 21 days as part of a larger mHealth clinical trial. Results demonstrated that assault-related interactions occurred on an average of 24.4% of days (range: 1-14 days), were more likely to occur earlier in the daily dairy period, and decreased in frequency over time. Across days, most survivors (75%) received both positive and negative reactions in these interactions, whereas fewer (20%) received only positive reactions and no one received only negative reactions. These findings suggest that survivors commonly have assault-related interactions with their supporters in the initial aftermath of the assault and that receiving both positive and negative social reactions is typical. Findings could inform future early interventions aiming to improve supporter reactions and better support survivors' recovery.

Sexual Violence Victimization and Pregaming Protective Behavioral Strategies Among College Students

BACKGROUND

Sexual violence is a major public health concern that has a detrimental impact on mental health, physical health, and academic performance. College students represent a population that is at an increased risk of experiencing sexual violence. Alcohol use, and more specifically, heavy drinking during pregaming events, is associated with increased risk of sexual violence. Studies have demonstrated that protective behavioral strategies have effectively reduced heavy drinking and the risk of alcohol-related consequences, including sexual violence victimization.

OBJECTIVES

This study aims to examine the association between experiences of sexual violence in college and subsequent use of pregaming protective strategies.

RESULTS

Data from 468 college students (67% female, 33% male) were analyzed. Over 42% of participants reported experiencing sexual violence in college. While adjusting for pregaming frequency and sex, results revealed that those who reported experiencing sexual violence in college were significantly less likely to use pregaming protective behavioral strategies compared to those without such experiences. Specifically, survivors of sexual violence were less likely to report using the protective behavioral strategies of minimizing intoxication, as well as behaviors related to safety and familiarity (e.g., using a designated driver after pregaming).

CONCLUSIONS

The findings have important implications for interventions aimed at empowering survivors of sexual violence. Future research should focus on understanding survivor's motives and mechanisms to use pregaming protective behavioral strategies to reduce the risk of re-victimization.

mHealth Early Intervention to Reduce Posttraumatic Stress and Alcohol Use After Sexual Assault (THRIVE): Feasibility and Acceptability Results From a Pilot Trial

BACKGROUND

Sexual assault is associated with increased risk for both posttraumatic stress (PTS) and alcohol misuse. Mobile health interventions have shown promise in addressing PTS and substance use in trauma survivors and might be a promising strategy in extending the reach of early interventions to individuals who have recently experienced trauma.

OBJECTIVE

This study assesses the feasibility and acceptability of THRIVE, a mobile health early intervention for recent survivors of sexual assault involving a cognitive behavioral app used daily over 21 days with weekly telephone coaching.

METHODS

Twenty adult female survivors of past-10-week sexual assault with elevated PTS and alcohol use were randomized to receive the THRIVE intervention as part of a pilot randomized controlled trial. We sought to understand feasibility by examining rates of completion of intervention activities and testing changes in participants' self-reported knowledge of key intervention concepts from baseline to after the intervention. We assessed acceptability by collecting self-report ratings of satisfaction with the intervention and app usability in a follow-up survey. The coach took notes during coaching calls to track call content and record participant feedback; these notes were qualitatively analyzed to elaborate on the aforementioned domains.

RESULTS

Feasibility was demonstrated by moderate rates of activity completion: all participants at least opened the app, 19 (95%) of the 20 participants completed at least 1 cognitive behavioral exercise, and 16 (80%) of the 20 participants attended all 4 coaching calls. Participants completed cognitive behavioral exercises on an average of 10.40 (SD 6.52) out of 21 days. The coaching call notes documented participant comments that app-generated reminders increased completion rates. Feasibility was also demonstrated by the finding that knowledge changes occurred from baseline to after the intervention; this indicated that THRIVE was successful in conveying key concepts. Acceptability was demonstrated by high participant ratings of THRIVE's usability; the ratings corresponded to a B+ usability grade. The coaching call notes documented that usability was increased by the coaching calls, the app exercises' clarity, and the app exercises' inclusion of suggestions; however, the coaching call notes also documented that some of the participants found aspects of the app exercises to be difficult or confusing. Acceptability was also demonstrated by participant ratings of satisfaction: most of the participants (15/16, 94%) rated the app as either moderately helpful or very helpful. The coaching call notes documented that the cognitive behavioral activity modules were seen as appealing and that the positive impact of the intervention contributed to participants' satisfaction.

CONCLUSIONS

These findings suggest that THRIVE is feasible and acceptable to survivors of recent sexual assault and that further testing of THRIVE is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03703258; https://clinicaltrials.gov/ct2/show/NCT03703258.

An ecological approach to understanding the impact of sexual violence: a systematic meta-review

Aim

A systematic meta-review was conducted to examine (1) the broad range of negative and positive individual and interpersonal changes following adult sexual violence, as well as (2) the risk/protective factors at multiple levels of the social ecology (e.g., individual, assault, and micro/meso/exo/macro/chronosystem factors)-influencing the impact of sexual violence.

Methods

Searches of Web of Science, Pubmed, and ProQuest resulted in inclusion of 46 systematic reviews or meta-analyses. Review findings were extracted for summary and a deductive thematic analysis was conducted.

Results

Experiencing sexual violence is associated with many negative individual and sexual difficulties as well as revictimization risk. Only a limited number of reviews reported on interpersonal and positive changes. Factors at multiple levels of the social ecology play a role in the intensity of these changes. Reviews including macrolevel factors were non-existent, however.

Conclusion

Reviews on sexual violence are fragmented in nature. Although the use of an ecological approach is often lacking, adopting such a perspective in research is necessary for a fuller understanding of the multiple influences on survivor outcomes. Future research should evaluate the occurrence of social and positive changes following sexual violence, as well as the role of macrolevel factors in influencing post-assault outcomes.

Trajectories of Emerging Adults' Binge Drinking and Depressive Symptoms and Associations With Sexual Violence Victimization: Examining Differences by Sexual and Gender Minority Status

We examined longitudinal associations between binge drinking (BD), depressive symptoms, and sexual violence (sexual harassment and sexual assault) among sexual and gender minority (SGM) and non-SGM emerging adults. Data were drawn from four annual web-based surveys of a diverse cohort of 2,553 emerging adults, spanning from approximately age 19 (2016) to age 22 (2020). About 18% were SGM individuals. We tested a multigroup parallel process latent growth curve model (recent depression symptoms; past-year BD) with time-varying covariates (past-year sexual harassment; sexual assault) to determine associations of sexual violence with BD and depression outcomes over time, and whether growth curves and associations differed by SGM status. For both SGM and non-SGM emerging adults, past-year sexual harassment was associated with depressive symptoms at each time point, but harassment was not associated with BD. For both groups, sexual assault was associated with both depressive symptoms and BD. To our knowledge, this is the first study to examine longitudinal, contemporaneous associations of sexual violence (including both harassment and assault as distinct constructs), with BD and depressive symptoms among racially and ethnically diverse emerging adults, comparing SGM and non-SGM groups. Although our models do not disentangle directionality or causality, the findings suggest the need to address sexual violence victimization (assault and harassment) in the context of depression screening and treatment, and vice versa. We discuss a number of intervention strategies currently in use for an implicitly non-SGM general population that could be adapted for greater inclusion of and relevance to SGM populations.

Drug-facilitated sexual assault, impaired trauma memory, and implications for mental health treatment

BACKGROUND

Sexual assault (SA) is a highly prevalent global public health problem and a robust predictor of posttraumatic stress disorder (PTSD), substance use disorder (SUD), and suicidality. A large percentage are drug or alcohol facilitated (DFSA), impairing trauma memory and affecting the application of evidence-based treatments. Despite these problems, few have investigated DFSA-specific mental health (MH) needs.

OBJECTIVE

Goals of this study were (1) to identify psychological sequelae characterizing DFSA towards explaining why symptoms have been treatment-refractory, comparing survivors with involuntary substance ingestion (forced, covert: DFSA-I), voluntary ingestion (DFSA-V), and non-DFSA; and (2) to determine how impaired trauma memory relates to the development of PTSD and depression symptoms.

METHOD

Data from a retrospective chart review of 74 adults receiving SA MH services at an outpatient trauma center are presented. The sample includes a 2-year cohort seen acutely at an urban rape treatment center. The study is one of the first to examine therapy records beyond case studies for DFSA. Logistic, Poisson, and negative binomial regression analyses of quantitative data and qualitative thematic analysis of trauma cognitions and treatment foci were conducted.

RESULTS

DFSA-V had five times greater odds of SUD, and notable substance-related self-blame compared to DFSA-I. DFSA-I had prominent relationship distress and self-blame for missing danger of perpetrator drugging. Survivors with impaired trauma memory had significantly fewer hyper-arousal and overall PTSD symptoms, and specifically less hypervigilance. No differences were found in re-experiencing symptoms.

CONCLUSION

Impaired trauma memory is common in DFSA and is associated with fewer baseline hyper-arousal and overall PTS. Despite this, DFSA issues including re-experiencing symptoms that are particularly distressing without the ability to cognitively connect the intrusions contribute to increased treatment needs. Impaired memory limits the application of evidence-based treatments, and collectively these findings call for the development of trauma-specific treatment protocols to enhance recovery for DFSA survivors.

HIGHLIGHTS

Survivors of drug-facilitated sexual assault have prominent PTSD including reexperiencing, though trauma memory may not be encoded. • Those absent trauma memory have less hyperarousal, but DFSA complications explain why it is treatment refractory and inform treatment development.

Depressive Symptoms Following Recent Sexual Assault: The Role of Drug and Alcohol Use, Acute Stress, and Assault Characteristics

Sexual assault is a common traumatic experience that can have a wide-ranging impact on psychological functioning, including experience of depressive symptoms. Although many studies have examined lifetime rates of depression among those with sexual assault history, less is known regarding risk factors for depressive symptoms following recent sexual assault. The study examined whether drug use history is uniquely related to depressive symptoms following recent assault. N = 65 individuals, 95.4% female; 73.8% White; M(SD)_age = 28.89 (10.29), who had recently experienced sexual assault (less than 60 days) and completed a SAMFE (sexual assault medical forensic examination) were interviewed via phone and completed questionnaires regarding depressive and acute/post-traumatic stress symptoms and substance use history. Demographic information as well as information related to the assault was also collected. 68.7% of the sample reported clinically significant levels of depressive symptoms (PHQ-9, Patient Health Questionnaire, scores ⩾ 12). In a linear regression adjusted for acute/post-traumatic stress (b = 0.26, p < .01) and other variables, polydrug use was significantly associated with depressive symptoms (b = 3.26, p = .04). Single-drug use (b = 0.96), physically forced sexual assault (b = -1.11), victim-perpetrator relationship (b = 0.15), prior sexual assault (b = -1.02), alcohol misuse (b = -0.09), age (b = 0.07), race (b = 2.78), and days since assault (b = -0.02) were not significantly associated with depressive symptoms (all ps > .05). Results highlight the potential role of drug use history in increasing risk of experiencing clinically significant depressive symptoms following recent assault.

A Systematic Review of the Self-Medication Hypothesis in the Context of Posttraumatic Stress Disorder and Comorbid Problematic Alcohol Use

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) commonly co-occur and are associated with many negative public health outcomes. There are several etiological models that explain the overlap between PTSD and AUD, including shared genetic risk and phenotypic causality, but the predominant model of etiologic association is the drinking-to-cope self-medication model. Although the self-medication model is conceptually appealing and has been widely accepted within the literature examining alcohol use and anxiety (e.g., PTSD) phenotypes, the findings are inconsistent and there is a lack of rigorous empirical evidence in support of this model. This review, which was, to our knowledge, the first systematic review of the self-medication model in relation to PTSD to date, aimed to synthesize the current literature on the association between PTSD and problematic alcohol use within the context of the self-medication model. In total, 24 studies met the inclusion criteria for the review and assessed the self-medication hypothesis using a variety of measurement instruments and data analytic approaches, such as mediation, moderation, and regression. Overall, the included studies provide evidence for the self-medication hypothesis but are limited in rigor due to methodological limitations. These limitations, which include issues with the operationalization (or lack thereof) of trauma-related drinking to cope, are discussed, and directions for future research are presented.

Examination of a novel measure of trauma-related drinking to cope

OBJECTIVES

The present study sought to fill a gap in the current literature by developing a concise self-report questionnaire assessing drinking motives specific to coping with symptoms of posttraumatic stress disorder (PTSD). This new four-item questionnaire is called the Trauma Related Drinking questionnaire (TRD).

METHOD

Using structural equation modeling, the latent structure of the TRD items and how they relate to other variables of interest were explored among a sample of 1,896 college undergraduates from a large public university.

RESULTS

Broadly, we found evidence to suggest that TRD is a more specific measure of drinking to cope motives compared to the commonly used Drinking Motives Questionnaire coping subscale. Additionally, findings demonstrate support for the external validation of TRD, both with regard to PTSD and alcohol consumption and related problems.

CONCLUSIONS

Results support the use of TRD in future self-medication research and as a clinically useful screening tool.

Post-traumatic Stress Disorder in Victims of Sexual Assault With Pre-assault Substance Consumption: A Systematic Review

Background: Post-traumatic stress disorder (PTSD) and substance consumption commonly co-occur in victims of sexual assault. Substance consumption can occur pre- andi/or post-assault. Pre-assault substance consumption may have an impact on the subsequent development of PTSD. This review aims to provide an overview of current understanding of the effects of acute substance intoxication and chronic pre-assault problematic substance use on symptoms of PTSD amongst individuals who were victims of sexual assault. Methods: PsycINFO, EMBASE, and MEDLINE were searched using terms related to PTSD, sexual assault, and substance consumption. These yielded 2,121 articles, 268 of which were retrieved for more detailed evaluation and 13 of these met inclusion criteria and were appraised in full. Results: Overall, the reviewed papers supported our hypothesis that acute substance intoxication and chronic pre-assault problematic substance use are associated with fewer initial PTSD symptoms but less improvement over time, resulting in slower overall PTSD recovery. They also highlighted post-assault characterological self-blame and negative social reactions as mediators of recovery in the context of pre-assault substance consumption. Conclusions: Acute substance intoxication and chronic pre-assault problematic substance use appear to have an impact on the development of PTSD symptoms amongst victims of sexual assault. The importance of developing early interventions and routine screening and assessment for PTSD and pre-assault substance consumption is emphasized. The limited research on male victims and on substances other than alcohol is highlighted.

Deployment-Related Military Sexual Trauma Predicts Heavy Drinking and Alcohol Problems Among Male Reserve and National Guard Soldiers

BACKGROUND

Military sexual trauma (MST) is associated with a range of deleterious mental and physical health consequences; however, far less attention has been paid to the associations between MST and negative health behaviors, such as substance abuse. This study examined 2 focal research questions: (i) What is the prevalence of experiencing MST during deployment among male Reserve and National Guard soldiers? and (ii) to what extent is the degree of MST exposure during deployment associated with frequent heavy drinking and alcohol problems postdeployment?

METHODS

Data from male soldiers who had been deployed (N = 248) were drawn from the baseline wave of Operation: SAFETY (Soldiers And Families Excelling Through the Years) an ongoing study examining health among U.S. Army Reserve and National Guard and their partners. Participants were recruited over a 15-month period (Summer 2014 to Fall 2015) from units in New York State. Deployments occurred prior to the baseline wave of the study. Analyses examined the relation between degree of MST exposure during soldiers' most recent deployment and (i) frequent heavy drinking and (ii) alcohol problems, measured at baseline, controlling for posttraumatic stress disorder symptoms and age.

RESULTS

17.3% of the male service members reported experiencing MST during their most recent deployment. Further, greater MST exposure was associated with a greater likelihood of engaging in frequent heavy drinking (adjusted risk ratio [aRR] = 1.03, 95% CI [1.01, 1.05]) and experiencing alcohol problems (aRR = 1.03, 95% CI [1.01, 1.06]) at baseline.

CONCLUSIONS

Findings demonstrate that MST rates are high among male Reserve and National Guard soldiers, and greater MST exposure is associated with an increased likelihood of engaging in frequent heavy drinking and experiencing alcohol problems among a population already at risk for problematic alcohol use.