CHAPTER

125 Psychiatric
Management of
Victims of Physical
and Sexual Abuse and
Rape
Donna E. Stewart
Simone N. Vigod
University Health Network, University of Toronto, Toronto, Ontario, Canada

Introduction (vaginal or anal) intercourse, but sexual assault is a broader

Physical and sexual abuse and rape are prevalent in all
current societies and are often followed by serious physical
and psychological disturbances. Women, men, and children
may be affected from all walks of life: rich and poor, across
ethnicities, from the developed and developing world, and in
peace and conflict zones. The common theme throughout is
the use of violence as an expression of power, control, and
domination.
Throughout the vast literature exploring these issues,
there are many definitions of physical and sexual abuse and
rape. The World Health Organization WHO (1996) sub-
sumes physical and sexual abuse and rape under the cat-
egory of interpersonal violence and defines violence as:
“The intentional use of physical force or power,
threatened or actual, against oneself, another
person, or against a group or community, that
either results in or has a high likelihood of
resulting in injury, death, psychological harm,
maldevelopment or deprivation.”
Physical abuse involves contact intended to cause
pain, injury, or other physical suffering. Examples include
hitting, punching, pushing, pulling, pinching, kicking,
burning, and strangling. Sexual abuse includes unwanted
or forced sexual acts and is most often applied as a term
in situations where an individual is, or has been, repeatedly
victimized. Rape is defined as unwanted or forced sexual
term that covers other unwanted sexual acts that do not
include penetration. Any of these acts may include use of
a weapon either as a coercive mechanism or as physically
a part of the abuse or assault. There is overlap between
these groups.
It is outside the scope of this chapter to discuss the
acute management of child physical and sexual abuse. The
objective of this chapter will be to focus on the psychiatric
management of interpersonal violence and sexual assault
and its sequelae in adults in nonconflict zones.
Victims of interpersonal violence will be divided into:
(1) victims of childhood physical and sexual abuse. (2) those
experiencing physical and sexual abuse as adults. (3) victims
of rape or sexual assault. The first section of the chapter will
review the prevalence of these problems and describe who
are at risk. In the second part of the chapter, we will outline
management issues on initial presentation that include med-
ical stability and safety as well as early psychological inter-
vention. Attention will then be directed to long-term mental
health sequelae for victims in all three groups, with a specific
focus on posttraumatic stress disorder (PTSD). Although
victims of physical and sexual abuse and rape can present
with symptoms of almost any mental disorder, symptoms
of hyperarousal, reexperiencing of traumatic memories, and
avoidance behaviors are very common and fall into the cat-
egory of PTSD and related disorders. The goal of the last
part of the chapter will be to review in detail the manage-
ment of PTSD and related syndromes in victims of physical
and sexual abuse and rape.

Psychiatry, Third Edition. Edited by Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B. First and Mario Maj.
© 2008 John Wiley & Sons, Ltd. ISBN 978-0470-06571-6.
 Chapter 125 • Psychiatric Management of Victims of Physical and Sexual Abuse and Rape
Epidemiology
Adult Survivors of Childhood Physical and
Sexual Abuse
The US Department of Health and Human Services estimated
the rate of child maltreatment in 2001 to be 12.4/1000 or over
903,000 children (US Department of Health and Human
Services Administration on Children, Youth and Families
2003). Of these cases, 19% were physically abused and 10%
suffered sexual abuse. Gorey and Leslie (1997) calculated the
prevalence of child sexual abuse at 16.8% for girls and 7.9%
for boys after adjusting for sample variation, response rates,
and definition differences in 16 North American community
studies. In general, it is estimated that up to 90% of cases of
sexual abuse are not reported (Horner 2002).
Physical and Sexual Abuse of Adults
The most common type of ongoing physical and sexual abuse
in adults is intimate partner violence (IPV). This includes
acts of physical aggression, psychological abuse, forced
intercourse and other forms of sexual coercion, and various
controlling behaviors such as isolating a person from family
and friends or restricting access to information, finances, and
assistance. Elder abuse and maltreatment of persons with
intellectual disabilities are also significant problems in which
the intimate partner is not necessarily the perpetrator.
Intimate Partner Violence
Case #1—Mary
Mary, age 28 years, is referred by her primary care physician
with a history of depression and anxiety for 6 years. She is
the mother of two daughters aged 5 and 3 years and has been
married for 7 years to a police officer. Her husband, John,
comes to the psychiatric consultation and says Mary is too
upset to answer questions, so they would like to be seen
together. Mary nods her head in agreement. You agree to see
them together initially and advise them that you will need to
see Mary alone in the latter part of the consultation.
You note that when they are together, John does most of
the talking but occasionally says “isn’t that so?”, and Mary
nods her head in agreement. You then ask to see Mary alone
and John replies, “can’t you see she’s not up to answering
questions?” You thank him for his helpful information and
insist that you need to spend some time with Mary alone. As
he reluctantly leaves the room, he stares at Mary and says,
“I’ll be right outside, don’t be long.”
Once alone with her, you ask Mary how she feels. She
begins to cry and wring her hands. You gently ask if she feels
safe and she shakes her head “no.” You quietly ask if any-
one has threatened her or hurt her physically, and she nods
affirmatively and then abruptly says, “I can’t talk now.” You
ask why and she points to the door. You ask if it is safe for
her and her children to be at home tonight and she nods yes.
You give her the number for the police and an emergency
abuse shelter helpline, assure that she has a means of trans-
portation, and arrange for her to return the following day
by herself to get further information and decide together on
the best plan.
The literature supports the idea that IPV is a preva-
lent problem with serious consequences. The FBI reports
that 30–40% of female murder victims and 4% of male
2577
murder victims each year are killed by their partners or
ex-partners (Barrier 1998). In the US population-based
National Violence against Women (NVAW) survey, IPV was
defined as physical or sexual assault and/or rape by an inti-
mate partner (a current or former cohabitant, at least some
of the time). In this study, 22% of women and 7% of men
reported lifetime IPV (Tjaden and Thoennes 2002). In the
WHO multicountry study on violence against women, there
were wide variations in prevalence by country and by area
within countries (i.e., urban or rural). Women who experi-
enced sexual or physical violence from an intimate partner
ranged from a low of 15% in urban Japan to a high of 71%
in rural Ethiopia. Generally, rates of IPV were higher in
rural than in urban areas of countries (WHO 2005).
It has been well established that most acts of IPV are
not reported to police and are underreported in health-care
settings. The data reported from epidemiological studies
may be a gross underestimate (Cherniak et al. 2005).
Risk Factors
Sex Data from the NVAW survey suggest that women who
cohabitate with women incur less IPV than women overall
(11% vs. 22%) and that men who live with men incur more
IPV than men overall (15% vs. 7%). However, women are
more likely to be chronically assaulted with more injurious
consequences. For example, in the NVAW survey, women
averaged 6.9 assaults by one partner, where men averaged
4.4. During their most recent assault, 41.5% of women
were injured, compared to 19.9% of the men (Tjaden and
Thoennes 2002).
Socioeconomic Factors Many studies have examined risk
factors for IPV (For a review, see Acierno et al. 1997).
Although there have been differences in rates of IPV in
various racial and ethnic populations (usually with ethnic
minorities at greater risk), IPV affects all parts of society.
Racial and cultural differences are often eliminated when
controlling for socioeconomic status where lower income
women are at greater risk than higher income women. How-
ever, even women from middle and higher socioeconomic
families may have no access to cash, credit cards, or bank
accounts, as abusive partners often carefully control these
by preventing access.
Relationship-Specific Characteristics Worldwide, violence is
linked to emotionally abusive and controlling behavior in
the home. In the NVAW survey, having a verbally abusive
partner was associated with the having twice the odds of
experiencing IPV. A particularly at-risk time may be directly
after one member of the couple has left the cohabitation
environment. Unmarried cohabitating female partners
(but not males) tend to be at greater risk than married couples.
Couples where there is greater financial or educational
disparity are at greater risk. For men, being a different race
from the other partner is a significant risk factor for abuse.
Alcohol and drug abuses are also significant risk factors.
At-Risk Populations Individuals who experienced assault as
children are more likely to be victimized as adults (Bohn and
Holz 1996). Persons with a disability (in particular those
with intellectual disability) are at higher risk. It is estimated
2578 Section IX • Specific Populations and Clinical Settings
that up to 20% of women are beaten during pregnancy, and
there are reports that ongoing violence escalates during the
pregnancy and postpartum periods (Cherniak et al. 2005).
However, it is controversial whether pregnancy itself is a risk
factor for IPV. Women are at highest risk of domestic abuse
when they are of child-bearing age, and the most consistent
finding in the literature is that women who experience IPV
during pregnancy have suffered abuse prior to pregnancy
(Bowen et al. 2005).
Elder Abuse
Although the elderly can also experience IPV, they are also
at risk of physical and sexual abuse from other sources. Per-
petrators include nonpartner family members (often trans-
generational) and, if the individual is institutionalized in a
nursing home, can include nursing home staff or strangers.
In addition to the types of physical abuse commonly seen
in adult IPV, in the elderly physical abuse can include force
feeding, improper medicating, or improper use of physi-
cal restraints (particularly in institutional settings). It is
thought to account for about 14% of all elderly trauma.
Estimates from the US National Center for Elder Abuse
(2005) are that 2–10% of community-dwelling elders are vic-
tims of maltreatment (which includes neglect, psychological
and financial abuse, as well as physical and sexual abuse).
The National Center for Elder Abuse (1996) estimates that
physical abuse accounts for 14.6% and sexual abuse for
0.3% of the total. In institutional settings, the prevalence is
thought to be much higher. One survey in the USA of nurs-
ing home staff found that 10% of nurses’ aides reported that
they had committed at least one act of physical abuse in the
preceding 12 months (Pilemer and Moore 1989). However,
elder abuse is thought to be widely underreported, with as
many as five in every six cases going unreported (National
Center for Elder Abuse 2005). This may be for many of the
same reasons as underreporting in IPV, with the additional
provision that there is more likely to be physical depend-
ency on a perpetrating caregiver. As well, some elderly vic-
tims may feel that their allegations will be dismissed due to
ageism or attributed to declining cognitive functions.
Risk Factors (Collins 2006)
Risk factors for physical and sexual abuse of the elderly
include age >75 years, female, social isolation, living with or
close to the perpetrator, and being dependent on the perpe-
trator (physically and financially). Cognitive, physical, and
functional impairment; incontinence; and nursing home
placement all increase risk of abuse. In addition, a history
of physical or sexual abuse in the home increases the risk
of recurrence in the elderly (even if the elderly victim was
historically a perpetrator).
Rape and Sexual Assault
In the USA, the estimated prevalence for rape in women is
9–13% and 0.7–5% for men (Spitzberg 1999). The prevalence
of sexual assault is even higher, with estimates as high as
one in three for women. Data from the National Centre for
Victims of Crime and Crime Victims Research and Treat-
ment Centre (1992) reports that 1.3 women are raped every
minute in the USA. Rape and sexual assault are epidemic
in some countries and may be used as a weapon of war to
demoralize large sectors of society. In the WHO multicountry
study on violence against women (WHO 2005), rates of
rape and sexual assault in women >15 years perpetrated by
nonpartners were highest (between 10% and 12%) in rural
Peru, Samoa, and Tanzania, with the lowest levels reported
in rural Bangladesh and Ethiopia (<1%).
In recent years, there has been the advent of “date rape”
drugs, such as the benzodiazepine flunitrazepam (rohypnol)
and the GABA-agonist gamma-hydroxybutyrate (GHB).
The existence of these drugs obscures prevalence estimates
of rape because the drugs leave the victim without memory
of the assault.
Clinical Pearl
Flunitrazepam can go undetected if added to any drink,
has an onset of action within 30 minutes with peak at 2
hours, and can exert its effects for up to 8–12 hours. Along
with the well-known effect of associated amnesia, there
is somnolence, muscle relaxation, and profound sedation
(Kaplan et al. 2001).
Risk Factors
Young women appear to be most vulnerable to rape. In
1987, Koss et al. conducted a national survey of college
women and found that 1 in 4 women had a lifetime history
of rape or attempted rape. More than half of all rape and
sexual assault victims in the NVAW were women under the
age of 18 (Tjaden and Thoennes 2002). Men appear to be
most at risk in the prison population where it is estimated
that up to 14% of inmates are raped (Dumond 2003).
In general, strangers account for 22% of rapes; partners
or dates for 19% and 38% are perpetrated by family mem-
bers (Tjaden and Thoennes 2002). In the Koss et al. (1987)
study of the college students, 84% of women knew their
attacker. In older adolescents, date rape appears to be most
common, whereas with younger adolescents, perpetrators
tend to come from the victim’s extended family (Kaplan et
al. 2001).
Management—Acute Presentations of
Physical or Sexual Abuse and Rape
Acute presentation of physical and sexual abuse or rape may
be to primary care, specialist, or emergency room settings.
Adult Physical and Sexual Abuse
Presentation
Any type of injury can be sustained from physical abuse.
Risk of injury is associated with threats to harm or
kill, use of a weapon, and substance use (Tjaden and
Thoennes 2002). Injuries may include contusions, abrasions,
lacerations, fractures, or sprains. It is important to consider
that head injury can also occur (Dutton et al. 2006). This
has been referred to as “shaken adult syndrome” and may
be manifested by symptoms such as blurred vision, vomit-
ing, confusion, and headaches. There may be presentation
after choking including loss of consciousness and seizure.
Victims may also present with exacerbations of chronic
health conditions (e.g., diabetes and cardiac disease) because
the abuse has interfered with their ability to manage these
conditions. They may present with chronic pain or other
somatic symptoms, eating and sleep disturbance, substance
 Chapter 125 • Psychiatric Management of Victims of Physical and Sexual Abuse and Rape
use disorders, mood and anxiety disorders, and suicidality
(Cherniak et al. 2005).
IPV
Clues to the presence of IPV in the clinical setting are out-
lined in Table 125–1. It should be noted that some of these
behavior patterns such as avoidance of eye contact, refusal
to completely disrobe, or a male partner refusing to have his
female partner seen alone by a male physician may actually
be normative in some cultures.
Table 125–1 Clues That Lead to Suspicion of Intimate
Partner Violence
Depression Evasiveness
Substance Abuse Fear
Sexual complaints Frequent crying
Injuries inconsistent with One partner refusing to have
explanation of mechanism the other partner seen alone
Multiple visits with vague Refusal to completely disrobe
complaints
Frequently missed Avoidance of eye contact
appointments
Clinical Pearl
Abusive partners are often overcontrolling and may find
many reasons to not allow the patient to be interviewed
privately. It is essential to find a way to speak with the
patient without the partner, even if it requires obtaining
a nonfamily interpreter and moving the patient briefly for
“a test” where family is not permitted to enter (remember
Mary from Case #1).
Elder Abuse
Clues to the presence of elder abuse are similar. Injuries
in the elderly to areas not commonly affected during daily
activities are most worrisome: bruising on inner thighs, pinna
of the ear, and patterns that might indicate that physical
restraint was used (over abdomen, wrists, or ankles).
Case #2—Harry
Harry, age 75 years, has advancing Alzheimer’s disease and
has been in a nursing home for 6 months. You are asked to
see him because his primary care doctor thinks Harry is also
depressed and agitated.
Harry is tearful and looks frightened but is unable to
give a coherent history. His daughter reports that he is losing
weight and is apathetic and many of his personal items includ-
ing his radio, wedding ring, and watch are “lost.” His daugh-
ter also reports that Harry is poorly groomed and his clothes
are often soiled with food or urine. During a visit to Harry,
his daughter reports that she used her father’s washroom
and overheard an aide speaking angrily to her father about
needing a shower again. On emerging from the washroom a
few moments later, the daughter saw her father on the floor
being dragged down the hall for a shower by one arm. She
is afraid to complain because she is fearful her father will be
discharged from the nursing home or treated worse.
You speak with the primary care doctor and to-
gether with Harry’s daughter you meet with the nursing
2579
supervisor in the home and express your concerns. To your
surprise, she reports that she has been suspicious of the
aide’s behavior for some time but has not had grounds to
dismiss her.
Harry’s daughter later writes you a note to tell you that
her father is gaining weight and is much less agitated and
depressed since the aide no longer works at the home.
Case Identification
As noted, victims are often hesitant to disclose. Identified
barriers include shame, embarrassment, and fear of retali-
ation from partners. There may be economic constraints,
child custody concerns, or cultural pressure not to disclose
abuse. However, disclosure occurs more when questions
about abuse or assault are asked.
Clinical Pearl
A major barrier to case identification is lack of comfort and
knowledge about what to do subsequent to disclosure on the
part of clinicians. It is important that frontline clinicians be
apprised of resources available to assist victims of physical
and sexual abuse and rape in their communities. Physicians
need to remember that they do not have to manage every
aspect, and referrals to social workers are usually available.
Useful principles to facilitate disclosure include a non-
judgmental, empathic, and respectful clinical environment.
“How” the questions are asked (i.e., with sensitivity) matters
more than the exact wording of the questions.
• Clinicians must give the message that abuse is a health
issue and that they are capable of dealing with “taboo”
subjects. This communicates that the problem is not too
irrelevant, insignificant, deviant, or shameful to talk
about. It may be helpful to normalize the situation
(e.g., this is a question that I ask all patients). Good
areas to place information about abuse and assault
are in waiting rooms and private examination rooms.
Restrooms are a great place for posters about abuse, as
they are private and the partner is not usually
present.
• Show concern. The goal is to communicate that discom-
fort and reactions are understandable.
• Show an ability to help. This communicates that the situ-
ation is not hopeless.
• Show an interest in helping, communicating that the
victim is not to blame.
• If a patient initially denies abuse, this could mean that he
or she does not yet feel safe to disclose the abuse, does
not consider abuse behaviors as abusive, or may not have
suffered abuse. It is important to accept this response,
provide education around abuse in general, and consider
asking again in the future.
There have been studies investigating the utility of
universal screening for ongoing physical and sexual abuse;
however, there is little evidence that universal screening is
effective either at identifying abuse or at reducing it. There-
fore, targeted screening is recommended. Some health-
care providers do include screening for violence at annual
health examinations, or in the assessment of new patients.
2580 Section IX • Specific Populations and Clinical Settings

1. Have you been kicked, hit, punched or otherwise hurt by someone within the
past year? If so, by whom?

2. Do you feel safe in your current relationship?

3. Is there a partner from a previous relationship who is making you feel unsafe?

1. Within the past year, or since you have become pregnant, have you been hit,
slapped, kicked or otherwise physically hurt by someone?

2. Are you in a relationship with a person who threatens or physically hurts you?

3. Has anyone forced you to have sexual activities that made you uncomfortable?
Figure 125–1 Partner violence screen (PVS).

1. Have you ever been emotionally or physically abused by your partner or someone importan
to you? A. Yes B. No

2. Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by
someone? A. Yes B. No
If yes, by whom? (Circle all that apply)
1. Husband
2. Ex-husband
3. Boyfriend
4. Stranger
5. Others (specify)__________
Number of times _______

3. Since you have been pregnant, have you been hit, slapped, kicked or otherwise physically
hurt by someone? A. Yes B. No
If yes, by whom? (Circle all that apply)
1. Husband
2. Ex-husband
3. Boyfriend
4. Stranger
5. Others (specify)__________
Number of times _______
Indicate the area of injury:____________________________

Score the most severe incident to the following scale:

1. Threats of abuse, including use of a weapon
2. Slapping, pushing; no injuries and/or lasting pain
3. Punching, kicking, bruises, cuts and/or continuing pain
4. Beaten up, severe contusions, burns, broken bones
5. Head, internal, and/or permanent injury
6. Use of weapon, wound from weapon

4. Within the past year, has anyone forced you to have sexual activities? A. Yes B. No
If yes, by whom?
1. Husband
2. Ex-husband
3. Boyfriend
4. Stranger
5. Others (specify)__________
Number of times _______ Figure 125–2 (a) Antenatal psychological
health assessment. (b) Abuse assessment
5. Are you afraid of your partner or anyone you listed above? A. Yes B. No screen (AAS).

The American College of Obstetricians and Gynecologists
(ACOG 2006) recommends that all pregnant women should
be screened for abuse at the first prenatal visit, once per
trimester, and at the postpartum visit.
Figures 125–1 and 125–2(a) and (b) offer methods for
asking about IPV called the “partner violence screen (PVS)”
(Feldhaus et al. 1997), the “antenatal psychological health
assessment” (ACOG 2004), and the widely used “abuse
assessment screen” (McFarlane et al. 1992). Questions
detailing specific behaviors (e.g., slap, hit, and unwanted
sexual intercourse) are more sensitive than using the words
“abuse” or “assault.”
 Chapter 125 • Psychiatric Management of Victims of Physical and Sexual Abuse and Rape
Initial Management Plan
Once physical or sexual abuse has been disclosed, the first
task is to ensure the physical safety of the victim. For
example, will emergency accommodation be needed? Is
there someone who should or should not be contacted?
Are there children involved requiring the assistance of child
protective services? Then, it is important to assess the vic-
tim’s motivation for change in the situation. Many victims
are fearful of retaliation or feel bound by financial con-
straints; children; and familial, cultural, or religious expec-
tations to remain in their current situation. No assumptions
should be made about the assistance that the victim wants.
Interventions should be targeted to match the victim’s readi-
ness for change. For example, if the victim is in a stage where
he or she is minimizing the problem, forming an action plan
for leaving the relationship would not be appropriate—and
would not likely be successful.
Steps in management of physical and sexual abuse:
1. Ensure and explain limits of confidentiality (in most
jurisdictions there is no legal responsibility on the part
of the health-care professional to report IPV).
2. Document abuse in victim’s words, using diagrams or
photographs if possible.
3. Physical examination if appropriate (and document
when physical examination seems inconsistent with
mechanism of injury).
4. Medical stabilization if necessary (e.g., if victim is in
your office, does he or she need to go to the emergency
department for X-rays, stitches, or investigation of
internal injuries?).
5. Validate victim’s right to live without abuse.
6. Discuss safety and develop a safety plan (for
immediate or later use). This can include planning an
escape route from home, strategizing ways to reduce
harm done during the abuse or ready important
documents and necessities should the victim decide to
leave in a rush, before, during, or after an assault.
7. Consider need for child protection (including need for
reporting to child welfare authorities if child danger
or abuse is suspected).
8. Assess motivation for change and tailor subsequent
interventions accordingly.
9. Make referrals to social and legal services as indi-
cated—physicians should realize that they do not need
to manage all aspects by themselves.
10. Make referrals to mental health professionals as indi-
cated.
11. Ensure a follow-up appointment.
Management considerations for the long-term mental
health consequences will be discussed in detail in subse-
quent sections.
Rape
Rape or sexual assault leaves both men and women at risk
of physical injury and sexually transmitted infection, with
women at risk of (unplanned) pregnancy. Men are more
likely to suffer physical harm, as they are more likely to have
had multiple assailants and it is more likely that weapons
were used. Rape and sexual assault are massively under-
reported. In particular, adolescents tend to delay seeking
2581
care longer than adults and tend to press legal charges less
frequently than adults, with males underreporting more than
females (Kaplan et al. 2001). Proposed reasons for under-
reporting include shame, fear of retribution, lack of confi-
dence in police, as well as a desire to forget the event. Many
victims of rape or sexual assault may be reluctant to disclose
this information and may present instead for STI testing,
contraception, or needing treatment for other injuries.
Clinical Pearl
Sexual assault or rape may be present in cases of IPV or
elder abuse.
Disclosure
It is well established that case identification improves in
settings where clinicians directly ask about the possibility
of sexual assault. This happens most often in clinical set-
tings in which clinicians are encouraged to ask, and studies
show that most patients do not mind being asked. In order
to ensure that the disclosure of information about sexual
assault can occur, it is extremely important for the clinician
to be explicit about confidentiality and allow for privacy,
safety, and adequate time for the victim to tell his or her
story. It is important to be nonjudgmental and to acknowl-
edge how difficult it may be for the victim to disclose. It
is important to acknowledge that feelings of fear, shame,
or guilt are common and to begin to correct any cognitive
misattributions such as self-blame.
Clinical Pearl
First disclosure is not the time for determining the accu-
racy of the allegations. The task of investigating the assault
will be that of the police, if the victim chooses to pursue
this avenue.
Acute Management of Sexual Assault or Rape
Case #3—Felicia
An 18-year-old college student named Felicia arrives in the
Emergency Room tearful and mute. You are asked to see her
for a psychiatric consultation.
You notice that Felicia appears dazed and has a swol-
len, bleeding lip. You ask her what happened and she shrugs
her shoulders and cries. You offer her a tissue that she uses
on her eyes and lip and then begins to rock back and forth
in her chair. You gently comment that you can see she is very
distressed and if she can tell you why, perhaps you can help.
She eventually appears to collect herself and reports
that she went out with a friend to celebrate her 17th birth-
day and drank too much. One of the men in the bar stopped
her as she was entering the women’s washroom at the end
of the long hall in the basement. He punched her in the
face and threatened to kill her if she did not cooperate and
have sex with him. Following the assault, he told her that if
she talked he would “come after her” and anyway he knows
she was drinking underage and the police would charge
her. She tearfully says, “It’s all my fault, anyway. There is
nothing anyone can do now.”
2582 Section IX • Specific Populations and Clinical Settings

You tell her that no one deserves to have this happen
and that sexual assault is illegal. There is something that can
be done. You encourage her to allow the sexual assault team
to examine her and make sure that she is physically okay,
by testing for sexually transmitted diseases and taking preg-
nancy precautions if necessary. Her options for reporting to
the police can be considered. You inform her about common
psychological symptoms after sexual assaults and discuss
possible ways of coping. You enquire if she has a safe place
to stay with family or friends. You offer her a follow-up
appointment for further assessment and management the
following day.
Once again, the first task is to ensure the physical safety
of the victim. For example, will emergency accommodation
be needed? Who should or should not be contacted for
support? In some jurisdictions, it will be possible to refer to
a sexual assault center where the staff is expert at the medi-
cal, forensic, and psychological evaluation of acute sexual
assault. For example, in the USA, many facilities have
begun to use the Sexual Assault Nurse Examiner (SANE)
program, which encompasses the principles discussed below
(Ledray 1999). However, there are many places where such a
specialized service is unavailable and acute management will
be referred to the general emergency department team.
Clear documentation is vital, particularly if the victim
decides to report the rape to police. Informed consent for
each stage of the management plan is essential.
help direct the clinician in terms of what protocol to
follow for DNA and other specimen. However, victims
often change their minds with time, so ensure that
proper specimens are collected.
Physical Examination
Physical examination should involve a general examination
that includes a screen for external injuries as well as a
genital examination for both men and women. When using a
proctoscope (anal examination) or speculum (vaginal exami-
nation), special care should be taken to explain to the victim
exactly what is being done and the reason for it. It can be
very important to give feedback about genital damage, as
patients may be worried that future partners may be able
to see or somehow know that they have been raped. Details
for physical examination and documentation are outlined in
an American College of Emergency Physicians’ Handbook
“Evaluation and Management of the Sexually Assaulted or
Sexually Abused Patient” (ACEP 1999).
Clinical Pearl
Explaining all procedures and getting consent is vital.
Warning the patient about the possibility that the examina-
tion might trigger a reexperiencing of the event is crucial to
ensuring a sense of safety and normalcy.

History Laboratory Investigation

1. A brief history of the assault is needed.
(a) What orifices were penetrated?
(b) Was barrier contraception used?
(c) Were any weapons used?
(d) Are there characteristics of the perpetrator known
that would help inform risk assessment of STI or
HIV status?
(e) Does the victim suspect that drugs were used unknow-
ingly?
2. Take the victim’s medical history (including pregnancy
status and date of last menstrual period if applicable),
psychiatric history, medications, and allergies.
3. It is helpful to know the victim’s initial thoughts about
reporting the abuse or assault to the police. This can
Investigation for pregnancy and sexually transmitted infec-
tions should be done according to need. Investigations and
proposed follow-up are outlined in Table 125–2.
Forensic Referral
DNA samples for forensic evidence can be collected up to
10 days after assault (particularly if the samples have been
stored in a nondamp environment). It is important to ask
victims not to wash themselves or the clothes that they were
wearing during the assault prior to forensic investigation. If
the victim has changed clothes prior to presenting for treat-
ment, then usually only the undergarments are collected.
Local sexual assault response teams will have specific
protocols for forensic documentation. Even if the victim is
undecided about whether he or she will report the assault,

Table 125–2 Guidelines for Laboratory Investigation in Acute Sexual Assault of Adolescents and Adults

Test Site Timing

Pregnancy bhcg Blood Baseline, 2 weeks
Neisseria gonorrhoea Polymerase chain reaction (PCR) or culture and Endocervical Baseline or at 2 weeks
sensitivity (C & S)
Chlamydia trachomatis PCR Endocervical Baseline, 2 weeks
Trichomonas C&S Vaginal Baseline, 2 weeks
Hepatitis B Surface antibody (anti-HBs) for immunity; Blood Baseline, 3 months
hepatitis B surface antigen (HBsAg); core
antibody (anti-HBc)
Syphilis Rapid plasma regain (RPR) and treponema Blood Baseline, 3 months
pallidum hemagglutination assay (TPHA)
HIV HIV antibody (ELISA test) Blood Baseline, 3–6 months
Investigation of unknown Toxicology: alcohol, amphetamines, barbiturates, Urine Within 36 hours
ingested substances benzodiazepines, cocaine, GHB, ketamine,
marijuana, muscle relaxants, and opiates
 Chapter 125 • Psychiatric Management of Victims of Physical and Sexual Abuse and Rape
forensic evidence can be collected and stored until such a
decision is made.
Medical Treatment
Pregnancy Prophylaxis Postcoital contraception can be used
up to 72 hours after rape. There are two main methods:
progesterone only (two 750 μg tablet given 12 hours apart)
or the Yuzpe method where 2 50 μg estrogen birth control
tablets are given 12 hours apart. Progesterone only is the
preferred method, as it is just as effective with fewer side
effects (Mein et al. 2003).
STI Prophylaxis The Centre for Disease Control and Pre-
vention (ACEP 1999) recommends:
1. Prophylaxis for chlamydia, gonorrhea, trichomonas,
and bacterial vaginosis.
(a) ceftriaxone 125 mg IM (intramuscular) once and
(b) metronidazole 2 g p.o. once and
(c) azithromycin 1 g p.o. once or doxycycline 100 mg
p.o. BID for 7 days.
Note that some centers will substitute cefixime 400 mg
p.o. once for ceftriaxone.
2. Hepatitis B immune globulin (400 IU IM) and hepatitis
B vaccination if not immune.
HIV Considerations for HIV exposure prophylaxis involve
weighing the risk of infection with that of treatment. It is
important to consider the time since exposure occurred,
the likelihood of transmission, the probability that the per-
petrator is infected with HIV, the efficacy and side effects of
the proposed regimen, and the expected patient compliance.
In Canada, the British Columbia Centre for Excellence in
HIV/AIDS recommends that patients who are sexually
assaulted receive postexposure antiretroviral therapy. There
are no data on postexposure prophylaxis after rape; how-
ever, in cases of occupational needlestick injuries or perinatal
transmission, postexposure prophylaxis reduces risk of infec-
tion by approximately 67% (ACEP 1999). Risk of HIV trans-
mission in various situations is summarized in Table 125–3.
Table 125–3 Risk of HIV Transmission during Sexual
Exposure, with Comparison to Other Types of
Exposure (ACEP 1999, Mein et al. 2003)
Risk of Transmission of HIV Infec-
Type of Exposure tion per Exposure (%)
Receptive vaginal 0.1–0.2
Receptive anal 0.1–3
Receptive oral Has been reported, prevalence
unknown
Needlestick injury in 0.3–0.9
health-care workers
Shared HIV-contaminated 67%
needle
Early Psychological Treatment
Although many victims are in shock and sometimes denial
at the outset, initial dissociative and numbing responses have
been associated with later mental health difficulties. Therefore,
referrals for counseling should be offered at onset. To ensure
2583
continuity of care, patients should also be referred back to
their primary care physician for ongoing monitoring.
Initial psychological intervention should be individ-
ual, supportive, and educational in nature about the effects
of trauma and rape. It is important to acknowledge with
the patient that any reaction he or she might be having is
acceptable and that it is normal to need support. Also, it will
be difficult for the patient to process and assimilate general
information about rape or specific information about his or
her own physical health concerns until there is a sense of psy-
chological safety. Ensure that the patient recognizes that he or
she is now in a safe place and that the assault is over. Some-
times dissociative phenomena can be observed in the emer-
gency room. One can assist the patient by providing “ground-
ing strategies” such as touching a table or other object in the
examination room. In situations where the victim’s symptoms
are so overwhelming that they preclude psychotherapeutic
support of any kind, pharmacotherapy may be indicated,
either with short-term use of benzodiazepines or with the
institution of SSRI or SNRI medication to treat the severe
anxiety. Any person being started on medication should
be closely monitored. Once the patient is feeling safe enough
to assimilate information ensure that he or she obtains specific
information about health status and educate about the risks
of future health problems (victims will often be very con-
cerned about contracting sexually transmitted infections).
Involvement of Family or Friends Social support is crucial to
Clinical Pearl
It is important to give written instruction, as patients may
not be able to store verbal information in the overwhelmed
state subsequent to an assault.
help restore effective coping. However, the clinician should
gain the patient’s involvement in deciding who to contact.
There is evidence that negative social support (blame,
criticism, etc.) can lead to worse mental health outcomes
(American Psychiatric Association 2004). In addition, due
to the high prevalence of known assailants, one should
take care to ensure that the perpetrator is not mistaken
for the intended support system. It can be helpful to discuss
the acute and potential longer-term effects of rape with
family. Education about sleep disturbance, irritability, hyper-
arousal, and reexperiencing phenomena can help to ensure
a safe and supportive environment, as well as early referral
to mental health treatment if symptoms persist. Education
of family members about potential misattributions can also
help reduce the victim’s experience of shame or self-blame.
Clinical Pearl
Victims’ sexual partners should know that unusual respons-
es to sexual advances after rape are universally experienced
and do not reflect on the partner him- or herself.
Debriefing There is no evidence for “debriefing” groups where
the victim is asked to describe his or her experience. There is
in fact some concern that this might be detrimental for some
2584 Section IX • Specific Populations and Clinical Settings
patients, exposing them to triggers of reexperience unneces-
sarily and possibly causing them to redefine their own rape
experience as more horrific in light of hearing others’ experi-
ences (American Psychiatric Association 2004).
Long-Term Mental Health Sequelae of
Physical and Sexual Abuse and Rape
Adult Survivors of Childhood Physical and
Sexual Abuse
Abuse in childhood leads to significant biological, psycho-
logical, and social consequences. Adult survivors of
childhood physical and sexual abuse often have profound
mental health sequelae and frequently present for psychiatric
treatment. Adult consequences of physical and sexual abuse
in women include lower perceptions of overall health, greater
physical and emotional disability, more physical health
symptoms and a greater number of health-risk behaviors
(e.g., physical inactivity, smoking, drug abuse, and prosti-
tution). Risk is at least doubled for psychiatric sequelae of
PTSD, major depressive disorder (MDD), anxiety disorders,
and somatization (including gastrointestinal, gynecological,
and neurological symptoms). Risk is significantly increased
for substance abuse, dissociation, aggressive behaviors, and
personality disorders.
Although mental health sequelae of childhood sexual
abuse in males have been less well studied, there is an increased
prevalence of PTSD, depression, anxiety disorders, eating
disorders, substance use disorders, personality disorders
(borderline and antisocial), poor self-image, future sexu-
ally related problems, legal difficulty, and attempted suicide.
Men who were abused as children have even greater rates
of psychological distress (e.g., up to fourfold increased risk
of major depression), substance abuse, and sexually related
problems compared to men who were not abused as children
than do women who were abused compared to those not
abused (Holmes and Slap 1998). For depression, this may
reflect the lower baseline prevalence of depression in males.
However, it may also reflect the impact of societal beliefs
about abuse in males that affects disclosure, feelings of self-
blame, and sense of masculinity.
Risk Factors for Long-Term Mental Health
Sequelae of Childhood Maltreatment
In discussion of risk factors for long-term mental health
sequelae of child maltreatment, it is very important to note
that child sexual and physical abuses are strongly associ-
ated with mental health sequelae regardless. The following
factors may mediate or increase risk, but their effect is small
relative to the association between abuse and mental health
sequelae in general.
Social Factors
The majority of the research on risk factors for long-term
sequelae of abuse has been focused on the characteristics of
the abuse. Individuals who suffer multiple types of maltreat-
ment (i.e., physical and sexual abuse as opposed to one or the
other), perpetrators and incidents have a higher risk of devel-
oping mental health symptoms than those who experience
a single type of maltreatment, perpetrator, or incident. The
risk of developing psychiatric difficulties is also increased
with longer duration of abuse and earlier age of onset.
In addition, it has been suggested that “invasiveness” of
the abuse (i.e., penetration vs. noncontact) and violence or
injury resulting from abuse result in more serious mental
health consequences. Studies have shown that having a closer
relationship to the perpetrator is also a risk factor, but this
is complicated by the fact that a closer relationship (e.g.,
father–daughter incest) may mean an earlier age of onset,
multiple incidents, and longer duration (Lesserman 2005).
Additional traumatic experiences may also be risk
factors. In some environments where childhood maltreat-
ment occurs, there is also familial dysfunction and there may
be other traumas (e.g., witnessing abuse). Such adverse child
experiences, particularly in the absence of protective factors
that would help a child develop stable emotional resources,
may be mediating factors in the development of long-term
mental health sequelae. In addition, for women, at least,
there are higher levels of psychiatric symptomatology
among those revictimized in adulthood than among those
women abused only as adults (Arias 2004).
Psychiatric History and Comorbidity
Psychological manifestations such as depression or anxiety
in childhood at the time of the abuse may increase the risk
of future mental health complications. The development of
drug and alcohol use disorders is associated with poorer
mental health outcomes for abuse survivors. In addition,
early childhood abuse may interfere with the establishment
of basic trust, an essential ingredient to later stable inter-
personal relationships. An important question for the future
is whether childhood intervention can prevent the develop-
ment of long-term mental health sequelae.
Neurobiology
There is some evidence to suggest that individuals with
a history of sexual abuse may actually have measur-
able hypothalamic–pituitary–adrenocortical (HPA) axis
dysregulation and greater autonomic activation (e.g., higher
catecholamines) both at baseline and in response to stress.
In those with depression, anxiety, or PTSDs as adults,
the HPA axis dysregulation and autonomic reactivity are
greater. More research needs to be done in this area to
determine whether the neurobiology could usefully predict
who will develop psychiatric sequelae of childhood trauma
(Lesserman 2005).
Physical and Sexual Abuse of Adults
Over the long term, individuals exposed to IPV report more
physical symptoms than those not exposed (Dutton et al.
2006). Common somatic symptoms are headaches, insomnia,
choking sensations, hyperventilation, gastrointestinal symp-
toms, and back, chest, and gynecological pain. Chronic pain
syndromes are common in women who report histories of
abuse. They also report poorer health status than those not
exposed (Campbell and Soeken 1999). In addition, there is a
higher risk of engaging in negative health behaviors such as
smoking, alcohol and drug use, unsafe sex, and poor eating
behaviors. There is a higher risk of HIV or other sexually
transmitted infection (Zierler et al. 1996).
At the center of the psychological response to interper-
sonal trauma is the experience of intense fear, helplessness,
or horror. IPV disrupts an individual’s sense that the world
is a safe place and that others can be trusted. It disrupts an
 Chapter 125 • Psychiatric Management of Victims of Physical and Sexual Abuse and Rape 2585

individual’s sense of him- or herself. One of the first concep-
tualizations of the psychological effects of IPV was the “bat-
tered woman syndrome” (Walker 1991). Symptoms included
anxiety, depression, posttraumatic stress, helplessness, pas-
sivity, and low self-esteem. It was thought that many of these
symptoms arose from the chronic, unpredictable nature of
the violence. It is more common now to avoid the use of this
term in favor of a DSM-IV-TR diagnosis.
Mental health consequences of physical and sexual
abuse in adults include PTSD, depression, anxiety, alcohol
and drug abuse, attempted suicide, and suicide. In a review
by Golding (1999), victims of IPV had a 3–5 × greater likeli-
hood of the above than non-victims. It has been suggested
that rates of MDD in physically abused women range from
66% to 80%. It is also important to note that subthreshold
symptoms of depression and PTSD are common in this
group and can cause significant functional impairment
(Hegadoren et al. 2006).
Sexual Assault and Rape
Similar to the evidence in IPV, the effects of rape can be
mediated through health behaviors. In a cross-sectional
survey of adolescent girls in Massachusetts (Silverman
et al. 2001), physical and/or sexual abuse by a dating part-
ner resulted in increased substance use, unhealthy weight
control behaviors, sexual-risk behaviors (including earlier
age at first “consensual” intercourse), and pregnancy.
In 1974, Burgess and Holstrom (1974) described the
“rape trauma syndrome,” which consisted of two phases.
First is the acute stage immediately after a rape where symp-
toms include disorganization, denial, and shock. The reor-
ganization stage occurs weeks to months later. Symptoms of
this second stage typically included anxiety (fear and avoid-
ance), depression, emotional and social withdrawal, sleeping
and eating disturbances (including nightmares), self-blame,
shame, guilt, somatization, and sexual dysfunction. These
two stages are most similar to the DSM-IV-TR diagnoses of
acute stress disorder (acute stage) and PTSD (reorganization
stage). There is evidence that dissociation in the peritrau-
matic phase characterized by the acute stress reaction may be
a risk factor for the subsequent development of PTSD. See
Figure 125–3 for DSM-IV-TR diagnostic criteria for acute
stress disorder. Note the time period requirements for acute
stress disorder, and the symptoms must occur within 4 weeks
of the trauma and last for between 2 days and 4 weeks.
The US National Comorbidity Survey (Kessler et al.
1995) found that 49.5% of women and 65% of men who
experienced rape met DSM-IV-TR criteria for PTSD. PTSD
does not only occur in the acute time after a rape, but many
victims continue to suffer for months, if not years subse-
quent to an assault. Major depression is purported to be
higher in rape survivors, although some authors suggest that
this is more of a factor in individuals who have experienced
repeated sexual trauma. Once again, symptoms that do

A. The person has been exposed to a traumatic event in which both of the following were
present:

(1) the person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, or a threat to the physical integrity
of self or others

(2) the persons response involved intense fear, helplessness, or horror

B. Either while experiencing or after experiencing the distressing event, the individual
has three (or more) of the following dissociative symptoms:

(1) a subjective sense of numbing, detachment, or absence of emotional responsiveness

(2) a reduction in awareness of his or her surroundings (e.g.,"being in a daze")
(3) derealization
(4) depersonalization
(5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

C. The traumatic event is persistently reexperienced in at least one of the following ways:
recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving
the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts,
feelings, conversations, activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability,

poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning or impairs the individual's ability to
pursue some necessary task, such as obtaining necessary assistance or mobilizing
personal resources by telling family members about the traumatic experience.

Figure 125–3 DSM-IV-TR criteria for acute
stress disorder (Source: Adapted from the
Diagnostic and Statistical Manual of Mental
Disorders, fourth Edition. Copyright 1994
American Psychiatric Association).
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs
within 4 weeks of the traumatic event.
H. The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition, is not better accounted for
by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or
Axis II disorder.
2586 Section IX • Specific Populations and Clinical Settings
not meet full criteria for DSM-IV-TR syndromes are com-
mon. It is clear that symptoms of anxiety, such as persistent
fears, persist in the long term after rape in many individuals.
Dissociative reactions including amnesia and depersonaliza-
tion can be acute and chronic consequences. Suicidality is
also of concern, with up to 50% of rape victims reporting
suicidal ideation over time. Themes of shame, guilt, and self-
blame abound. Sometimes anger is manifest as a symptom.
Although there is less research in men who have been
raped, it is important to consider some unique issues for
male victims. Long-term psychological themes can include
sexual dysfunction and sexual identity confusion, particu-
larly if they ejaculated during the rape. They may not be
aware that pressure on the prostate (from anal insertion of
a penis) can cause involuntary ejaculation.
Management Considerations for Long-Term
Psychiatric Sequelae of Physical and Sexual
Abuse and Rape
As discussed in previous sections, individuals who have been
victims of physical and sexual abuse and rape are at increased
risk of various psychiatric syndromes, including depression,
anxiety, substance abuse, and somatization. In general, the
recommended pharmacotherapeutic and psychotherapeutic
treatments of these conditions are not different for individuals
who have experienced sexual abuse and rape. However, it is
essential to recognize the connection between the presenting
symptoms and the traumatic experience(s) and to consider
the individual’s behavior and symptoms in the context of
traumatic reenactment. The following are some important
factors to consider in the general management of psychiatric
illness in individuals with a history of interpersonal trauma:
1. Safety: It is important to consider that sometimes the
psychiatric difficulty cannot be resolved if the abuse is
ongoing—no matter the treatment.
2. Comorbidity: In many cases, there will be a number of
different problems or symptoms that will need to be
targets of treatment. As always, a comprehensive assess-
ment is vital and comorbidity needs to be addressed.
It will be difficult to ameliorate symptoms in one area
without addressing the others.
3. Difficulties with interpersonal relationships and affect
regulation: Many victims of abuse and rape have been
unable to develop and/or maintain stable emotional
resources, resulting in affective instability and difficulty
sustaining interpersonal relationships. This will have
significant implications for the therapeutic relationship
that may challenge therapists in the areas of coun-
tertransference and boundary or limit setting. It may
also present a clinical dilemma of how to address the
trauma history during the treatment of a psychiatric
disorder. With significant affective symptoms, particu-
larly if the patient always feels “in crisis,” it is vital to
equip the patient adequately to address the trauma
background. Early on, it is important to help improve
daily functioning and relationships while acknowledging
that trauma has occurred. Exploration of the trauma
itself should only begin after optimal symptom control
has been achieved, there is a strong and reliable thera-
peutic relationship, and there has been some work in
the area of expressing and processing emotions in a safe
way (i.e., not using substances or self-harm to regulate
affect).
While the above points apply to all psychiatric illnesses,
there are some considerations specific to individual disor-
ders. This section will review specific considerations for
treatment of depression, anxiety, substance use, and somato-
form disorders in individuals with a history of interpersonal
trauma. The concept of posttraumatic stress is especially rel-
evant for discussion in a chapter on management of victims
of physical and sexual abuse and rape. Therefore, the phe-
nomenology and management of PTSD in victims of abuse
and rape will be discussed in detail in a subsequent section.
Depression
There is evidence that abuse influences the expression of
mood disorders. There are higher levels of depressive and
psychotic symptoms and suicide attempts, as well as more
comorbidity with personality disorders, eating disorders,
and substance abuse. Individuals with a childhood history
of physical and sexual abuse are more likely to present with
“atypical” depression as identified by reverse neurovegeta-
tive symptoms (e.g., increased appetite and sleep instead of
decreased appetite and insomnia) than individuals without
interpersonal trauma histories (Levitan et al. 1998). In
assessment of a mood disorder in an individual with a
trauma history, it is vital to consider symptoms in the context
of the history. For example, “body memories” or “voices”
may be incorrectly labeled as psychotic phenomenon when
in fact they may be more accurately labeled “reexperiencing
phenomena”.
Furthermore, individuals with “atypical” depression
have earlier ages of onset with a more chronic course of
depression—more frequent mood episodes and longer dur-
ation of episodes (Zlotnick et al. 2001). In tailoring a man-
agement plan for these patients, all of the general consid-
erations apply, but there will almost certainly be a need for
fairly intensive and multimodal treatment that might not be
necessary in the management of an uncomplicated major
depressive episode.
Anxiety
With respect to anxiety disorders, panic disorder and PTSD
are the two types most commonly seen in individuals with
history of interpersonal trauma. PTSD will be discussed
subsequently and panic disorder will be addressed here.
There is evidence that individuals with a history
of trauma (particularly as children) may be particularly
predisposed to panic disorder, given the high degree of auto-
nomic reactivity that can result in HPA axis dysregulation.
From a cognitive perspective, panic disorder is characterized
by high levels of fear of anxiety sensations. It is the fear of
these anxiety sensations that contributes to the maintenance
of panic disorder. In trauma, the original anxiety sensa-
tions signaled impending severe trauma, so the connection
between the anxiety sensation and the cognitive perception
of danger is very strong (Safren et al. 2002).
Therefore, management implications include attention
to severe physiological symptoms that will often require
pharmacotherapy (i.e., SSRIs). With respect to cognitive-
behavior therapy, it will be important to understand
the thoughts associated with panic attacks in the context of
 Chapter 125 • Psychiatric Management of Victims of Physical and Sexual Abuse and Rape
the trauma history, addressing cognitive distortions and
forming exposure therapy hierarchies with this in mind.
Substance Abuse and Dependence
In the treatment of substance use disorders in victims of
interpersonal trauma, it is important to consider two main
points:
1. Memories of the trauma may be triggers for substance
use. Use may be a way of coping with the emotional
pain of the trauma, although cravings later become
associated to drug or alcohol cues as well.
2. As patients start to cut down or become abstinent from
substances, feelings and memories may surface about
past trauma(s). Therefore, it is essential to continually
reassess individuals in treatment for substance use for
comorbid depression or posttraumatic stress symptoms
that may emerge. If these go unmanaged, the person
may not be able to maintain or continue recovery.
Specific therapies for PTSD co-occurring with a sub-
stance use disorder have been developed. Techniques are
mainly cognitive and behavioral, and the focus is on stabilizing
the substance use disorder while developing coping skills to
manage symptoms of hyperarousal and reexperiencing of
trauma. Pharmacotherapeutic recommendations are the
same as for treating these disorders individually, although
it may be advisable to avoid the use of benzodiazepines for
anxiety symptoms in this population due to the potential for
developing dependence.
Somatization
There is not a large literature on the management of somatic
symptoms in individuals with a history of physical and
sexual abuse and rape despite the plethora of evidence that
somatization is prevalent in this population. The prevail-
ing theory is that exposure to physical and sexual abuse or
rape may predispose individuals to respond to stress somati-
cally—perhaps as a result of heightened somatic perception
(Stuart and Noyes 1999). Unfortunately, somatization is
a maladaptive communication of distress because health-
care providers and other potential sources of emotional
support may focus only on the physical symptoms and not
be responsive to the individual’s emotional distress. Par-
ticularly when no physiological etiology of the symptoms is
found and the level of concern by the health-care provider
is lessened, the patient may have feelings of abandonment
and despair (leading to a corresponding increase in somati-
zation). Implications for management, therefore, include an
empathic and consistent therapeutic environment, whereby,
although the health practitioner may set limits on the
number of medical investigations that are to be done, he or
she remains emotionally available to the patient.
Posttraumatic Stress
Herman (1992) conceptualized the response to trauma as
a spectrum, from an acute stress reaction on one end to
“complex PTSD” at the other end, with “simple” PTSD
somewhere in the middle. Changes to a person’s psychological
schema, as well as to his or her neurobiological systems
(mediated by the effects of norepinephrine and cortisol),
can result in a characteristic response pattern that has been
2587
labeled in the DSM-IV-TR as PTSD. Symptoms of PTSD
are clustered into three categories—hyperarousal, intrusion,
and constriction/numbing. Diagnostic criteria are labeled in
Figure 125–4. Hyperarousal refers to the tendency to star-
tle easily, be irritable, and sleep poorly. Intrusion refers to
the flashbacks or nightmares or reexperiencing of traumatic
memories. Constriction refers to the numbing and avoidance
response that is like dissociation from the pain of the trauma.
(See Figure 125–4 for DSM-IV-TR diagnostic criteria.)
Complex PTSD or “disorder of extreme stress, not
otherwise specified” (DESNOS) (van der Kolk et al. 2005)
is thought to arise in individuals who have suffered severe,
prolonged, and repeated interpersonal victimization. This
includes extended child abuse, chronic spousal abuse, or
the effects of forced prostitution or sex trafficking. The
repeated nature of the trauma is linked to cognitive, somatic,
and dissociative disturbances as well as difficulties in
affect regulation, boundary awareness, interpersonal prob-
lems, and identity disturbance. Although complex PTSD/
DESNOS is not considered a distinct DSM diagnosis, it
is widely used by researchers and clinicians who deal with
individuals exposed to recurrent trauma, as it may better
characterize their symptomatology than any specific DSM-
IV-TR diagnosis (see Figure 125–5 for proposed diagnostic
criteria).
Risk Factors for Developing PTSD
Not every victim of physical or sexual abuse or rape develops
PTSD, and it is clear that the pathway to the development
of PTSD is multifactorial. Greater severity and chronicity
of the violence, life threat, use of a weapon, and sexual vio-
lence have all been shown to contribute to a higher risk of
PTSD. Risk varies with victim-specific factors (e.g., female
sex, socioeconomic status, past psychiatric history, less func-
tional coping styles, family psychiatric history, and prior
trauma history) as well as the sociocultural environment
in which the violence takes place. For example, it has been
shown that criticism, blaming responses, or stigmatization
strongly predict poor mental health outcome (Briere and
Jordan 2004).
Management
Case #3—Felicia (continued)
Felicia, who you assessed in the emergency room, did not
keep her follow-up appointment the day following the
assault. You next see her 14 weeks later in the outpatient
department. She reports that she tried “to forget the assault
by pretending nothing had happened.” She has not told any-
one about it and returned to classes the next day.
She has recurrent nightmares of the assault, flashbacks,
episodes of tearfulness, exaggerated startle reactions, and
anxiety. She has avoided all social contacts and has started
skipping classes. She feels that she has brought all these
events on herself as a result of her bad judgment.
You again affirm that no one “deserves” to be raped.
You explain the symptoms and causes of PTSD. You discuss
the proposed treatment plan outlined in Figure 125–6 and
the following pages.
The American Psychiatric Association (2004) published
guidelines for the treatment of PTSD, many principles of
which are applicable to treatment of PTSD in the population
2588 Section IX • Specific Populations and Clinical Settings

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened
death or serious injury, or a threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead
by disorganized or agitated behavior

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In
young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable
content.

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions,
hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
Note: In young children, trauma-specific reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the
traumatic event

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the
traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present
before the trauma), as indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the
following:

(1) difficulty falling or staying asleep (4) hypervigilance

(2) irritability or outbursts of anger (5) exaggerated startle response
(3) difficulty concentrating

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas
of functioning.

Specify if: Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor
Figure 125–4 DSM-IV-TR criteria for PTSD (Source: Adapted from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition.
Copyright 2000 American Psychiatric Association).

of victims of physical and sexual abuse and rape. The goal of
treatment is to reduce anxiety, fears, and avoidance behaviors,
ultimately to return the patient to good functioning and
health and prevent relapse. It is important to note that
the psychotherapeutic treatment options described below
have been studied in samples where the victim is in a safe
physical environment. They are not meant to be delivered
in an acute setting, prior to the medical stabilization of
the individual. Principles of the assessment and treatment
can also be applied in the setting of acute stress disorder
and in individuals with subsyndromal posttraumatic stress
symptoms.
Assessment
First, a full psychiatric interview should be undertaken with
exploration into symptoms of posttraumatic stress and
their temporal relationship to the trauma(s). Some aspects
of the full psychiatric assessment may need to be deferred
if the patient is still acutely disturbed from the assault. The
general aim is to confirm diagnosis, identify comorbidity,
and document baseline functioning and available resources
(e.g., stability of housing, social support network, and
financial resources). A psychiatric history should be taken
with special attention to history of past physical and sexual
abuse or rape. There should always be a thorough safety
 Chapter 125 • Psychiatric Management of Victims of Physical and Sexual Abuse and Rape 2589

i) alterations in affect regulation, which in cludes difficulty with modulation

of anger and self-destructiveness

ii) alterations in attention and consciousness leading to amnesias and

dissociative episodes and depersonalizations

iii) alterations in self-perception, such as a chronic sense of guilt and

responsibility, chronically feeling ashamed

iv) alterations in relationship to others, such as not being able to trust, not
being able to feel intimate with people

v) somatization–the expression of somatic symptoms on a somatic level for

which no medical explanations can be found

vi) alterations in systems of meaning

Figure 125–5 Diagnostic criteria of complex
PTSD or DESNOS in the DSM-IV-TR.

Initial Sessions

1. Education about symptoms of PTSD

2. Explain rationale for asking patient to recall traumatic events

3. Do relaxation training

4. Assess patient’s ability to tolerate within-session anxiety

Middle Sessions

5. Using reassurance and relaxation training, traumatic event(s) are imagined

and/or described during the sessions with focus on negative affects and that the
negative affects will subside.

6. Homework assignments are given whereby either patient practices imagining

the events OR exposes him or herself to situations that he/she has been
avoiding. This must be done in a manner of graded exposure

Later Sessions

7. Later sessions focus on sustaining gains and preventing relapse, including the
implementation of relapse plans should there be any recurrence in symptoms.

Figure 125–6 Principles of cognitive-

behavior therapy for PTSD.

assessment that includes assessment of suicidality, homicid-
ality, and the safety of the current environment.
Rating Scales
The clinician can combine the clinical interview with rating
scales such as the PTSD Checklist (Weathers et al. 1994), the
Impact of Event Scale (Horowitz et al. 1979), or the David-
son Trauma Scale (Davidson et al. 1997). This will help to
assess the full range of symptoms and functional impairment
and provide a baseline for comparison during treatment.
Choice of Treatment This may depend on the severity,
recency, or ongoing nature of the trauma. For example, it
may not be the right time to begin cognitive-behavior ther-
apy for PTSD in the case of a woman who continues to fear
for her safety at the hands of an abusive domestic partner.
In such a case, supportive intervention and resource mobili-
zation would be more appropriate.
Choice of treatment may also depend on the severity
of the symptoms, medical and psychiatric preexisting or
comorbid illnesses, or patient preference. Cultural factors
should always be considered. For example, cultural norms
may contribute to support of a person who has suffered
abuse or rape or may contribute negatively through commu-
nication that rape is shameful or that interpersonal violence
should not be discussed outside the family or community.
2590 Section IX • Specific Populations and Clinical Settings
Specific Pharmacotherapy There is no evidence for prevention
of PTSD or ASD using pharmacotherapy.
Studies of pharmacotherapy in PTSD have been
limited, but there are data to support the use of SSRIs or
venlafaxine as first-line treatment. SSRIs (citalopram,
fluoxetine, fluvoxamine, paroxetine, and sertraline) have
been shown to reduce symptoms in all three symptom clus-
ters characteristic of PTSD: hyperarousal, reexperiencing,
and numbing/avoidance (e.g., Marshall et al. 2001, Connor
et al. 1999, Brady et al. 2000). Venlafaxine has been shown
to reduce symptoms in all three clusters and induce remis-
sion better than placebo in 12-week studies. One recent
study of venlafaxine vs. placebo that included follow-up for
6 months revealed continued efficacy of venlafaxine overall,
however not for symptoms of hyperarousal (Davidson et al.
2006).
The use of other antidepressants including monoamine
oxidase inhibitors is supported by moderate clinical
evidence for PTSD, but there are no trials specifically in
interpersonal trauma survivors (Baker et al. 1995). Tricyclic
antidepressants have been found to be helpful primarily
with male combat victims, but not with individuals who
have experienced chronic physical and sexual abuse or rape
(Kosten et al. 1991, Davidson et al. 1990, Reist et al. 1989).
Benzodiazepines are not recommended as mono-
therapy due to the possibility of dependence and the with-
drawal effects from use. However, they may be useful as
temporary adjuncts to treatment, especially in the acute
phase.
There are no good clinical trials to support the use of
second-generation antipsychotics; however, these medica-
tions may be of some use for associated psychotic symptoms.
Most anticonvulsants have not been shown to be of benefit
for symptoms of PTSD, but there are some preliminary
data to suggest that lamotrigine may be helpful in reducing
symptoms of “reexperiencing.”
Adrenergic inhibitors are theoretical treatments in
that alpha-2 adrenergic agonists decrease central adrenergic
activity (possibly being effective at reducing symptoms of
hyperarousal and anxiety). There are no controlled trials,
but there have been open-label studies showing some efficacy
for clonidine and prazosin. There is some evidence that
propanolol (a beta-adrenergic blocker) may reduce later
symptoms of PTSD if administered after acute trauma
(Vaiva et al. 2003).
Psychotherapy There is good evidence (level I) for the effects
of cognitive-behavior therapy. There is some evidence
(level II) for the effectiveness of eye-movement desensiti-
zation and reprocessing or eye movement desensitization
and reprocessing (EMDR). There is also some evidence that
stress inoculation, imagery rehearsal, and prolonged expo-
sure-based techniques may be helpful in PTSD symptom
reduction. It appears that the common element to these
therapies is that they all offer controlled exposure to trau-
matic memories in a safe environment. Theoretically, this
allows for the victim to be reminded of the trauma while in a
setting that is not dangerous and therefore allows him or her
to learn to discriminate between remembering the trauma
and actually being there (i.e., being in danger). In essence,
the goal is to break the conditioned association between
various stimuli and danger.
Cognitive-Behavior Therapy
The principles of cognitive-behavior therapy for PTSD are
described in Figure 125–6. It is important to consider that
short-term treatment may be appropriate for those who have
experienced a single traumatic event and are suffering from
ASD or acute PTSD. However, individuals who are suffer-
ing from chronic PTSD or who have history of repeated
trauma may require longer-term therapy.
Stress inoculation, Imagery Rehearsal, and
Prolonged Exposure
These concepts are closely related to cognitive-behavior
therapy. Unfortunately, studies on the efficacy of these
treatments have been small and relatively short term. Stress
inoculation involves breathing exercises, relaxation, thought
stopping, role playing, and cognitive restructuring with-
out any exposure to imagined or real stimuli and has been
shown to be effective on its own in reducing overall PTSD
symptoms. Prolonged exposure involves imagined or real-
life exposure to situations that are being avoided due to
association with trauma and has demonstrated effectiveness
in reducing symptoms of anxiety and avoidance. Imagery
rehearsal is a type of prolonged exposure where only imag-
ined situations are used. There is evidence to support a
decrease in overall PTSD symptoms and nightmares with this
technique.
Eye Movement Desensitization and
Reprocessing
EMDR is a therapy that involves multiple, brief, interrupted
exposures to memories and images of trauma combined
with rapid lateral eye movements. The eye movements are
thought to help with reprocessing of the event, allowing for
modification of affective and cognitive responses (Shepherd
et al. 2000). There have been several small trials of EMDR
that suggest some efficacy in victims of abuse and rape.
However, some opponents argue that the eye movements
themselves are not necessary for treatment and attribute
benefits to the cognitive-behavioral techniques inherent in
the therapy (Davidson and Parker 2001).
Psychodynamic Psychotherapy
Although psychodynamic psychotherapy has not been
studied systematically in the treatment of PTSD, it may be
useful to aid with developmental, interpersonal, or intrapsy-
chic issues that impact on function. Approaches outlined
in the literature involve classical, object relations, and self-
psychological understandings. Essentially, all approaches
are useful in helping patients identify the disruptions in
their assumptions about themselves, others, and the world
around them that stem from, or were exacerbated by, their
trauma experience. From a classical perspective, therapy can
help the patient understand his or her defenses and cop-
ing abilities in the context of prior psychological conflicts,
development, and relationships. From a self-psychological
perspective, the focus is on how trauma has affected prior
self-object experiences and overwhelmed a person’s sense
of safety, security, and self-esteem, leading to difficulties
with maintaining a cohesive self. Psychodynamic interven-
tions will have to be both supportive and expressive, as indi-
cated by the capacities of the individual at given points of
treatment.
 Chapter 125 • Psychiatric Management of Victims of Physical and Sexual Abuse and Rape
Supportive Interventions
Continued supportive interventions, including case manage-
ment as clinically indicated, have been shown to improve
functional outcome and to aid in symptom reduction.
Nonresponse to Treatment In the case of nonresponse to
treatment, it is important to review the items in the initial
assessment and the original goals of the treatment and
wonder about barriers to treatment adherence (if this appears
to be a factor). Attention should be paid to any difficulties
in the therapeutic alliance and the contribution of previ-
ous trauma or comorbid psychiatric axis I (e.g., substance
abuse) or axis II (personality) disorders.
Conclusions
Physical and sexual abuse and rape are all common and
may be followed by serious physical and psychological dis-
turbances. They are often unreported and should always be
considered in assessing individuals for psychiatric disorders
or emotional perturbations. A confidential, nonblaming,
empathetic line of enquiry is essential for mental health pro-
fessionals during short- and longer-term management of
victims of violence. The treatment, as always, will be deter-
mined by the past history, symptoms, coping mechanisms,
vulnerabilities, and resilience of the individual patient and
the availability of affordable skilled providers.
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