Issues in Mental Health Nursing, 31:456–460, 2010
Copyright © Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840903581108
Sexual Abuse and Posttraumatic Stress Disorder in Adult
Women with Severe Mental Illness: A Pilot Study
Rebecca Bonugli, PhD, RN, PMHCNS, Margaret H. Brackley, PhD, RN, FAAN,
Gail B. Williams, PhD, RN, PMHCNS-BC, and Janna Lesser, PhD, RN
The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
Research indicates that women with serious mental illness
(SMI) are vulnerable to sexual abuse, resulting in adverse health
outcomes such as posttraumatic stress disorder (PTSD). The pur-
pose of this pilot study was to examine the prevalence of un-
diagnosed PTSD among a cohort of 20 women with SMI and
reporting past sexual abuse. Furthermore, the researcher sought
to identify specific symptom manifestations of PTSD among
women with SMI and sexual abuse histories. Finally, the fea-
sibility of using specific data collection tools was examined.
Results indicated that PTSD was not previously diagnosed or
recognized in the study sample, in spite of the presence of a
sexual trauma history. The screening tools were effective in iden-
tifying depression, guilt, emotional withdrawal, blunted affect,
decreased psychomotor activity, suicidal ideations, sexual dysfunc-
tion, and substance abuse. Additionally, the data collection tools
provided a framework for discussing sensitive issues related to
sexual abuse. Implications of this pilot study suggest the need
to evaluate all women with SMI and history of sexual abuse for
PTSD.
Posttraumatic stress disorder (PTSD), occurring among
women with serious mental illness (SMI), is a major health
concern that often goes unrecognized by health care providers.
When unrecognized, PTSD can significantly complicate treat-
ment of co-occurring psychiatric disorders, resulting in in-
creased expenditure of health care dollars as well as poor func-
tional outcomes in social and life satisfaction domains (Brady,
Killeen, Brewerton, & Lucerini, 2000). Because the prevalence
of PTSD is considerably higher among women with SMI as
compared to those found in the general population (Gearon,
Kaltman, Brown, & Bellack, 2003), there is a need to identify
this disorder in order to provide effective treatment. Yet, clini-
cians often avoid addressing issues or consequences of trauma
with women with SMI, believing that asking about such events
will lead to further distress (Cusack, Grubaugh, Knapp, & Frueh,
2006).
Address correspondence to Rebecca Bonugli, UTHSCSA School
of Nursing, 7703 Floyd Curl Drive, San Antonio, Texas 78229. E-mail:
bonuglir@uthscsa.edu
456
BACKGROUND
Posttraumatic stress disorder, an anxiety disorder, may fol-
low exposure to a traumatic life-threatening event, provoking
feelings of horror, helplessness, or fear (American Psychiatric
Association, 2000). Individuals experiencing PTSD feel over-
whelmed as usual coping strategies fail to allay increased anx-
iety. To minimize the psychological discomfort of PTSD, ex-
posures to situations associated with the original trauma are
avoided, through emotional numbing, evasion, or detachment.
Suppression of thoughts and feelings related to the event serve
as a protective measure. Withdrawal from social situations and
decreased participation and interest in social activities may be
reflected as a lack of life progress. Psychotic symptoms, such
as hallucinations, may be present in PTSD. In addition, indi-
viduals experience problems with depression, suicidal ideations
and attempts, poor impulse control, and substance abuse (Foa,
Keane, & Friedman, 2000; McMillen, North, & Smith, 2000).
In comparison, serious mental illnesses (SMI) are brain
disorders that persist over time, may not have precipitating
socio-environmental factors and extensively impair daily living
activities and social functioning (Peck & Scheffler, 2002).
According to the Epidemiological Catchment Area Project,
2.8% of the adult population in the United States experience
one of these disorders in a one-year period (Robbins & Reiger,
1990). Family relations, social interaction, task completion,
communication, health maintenance, and vocational and educa-
tional endeavors are often compromised (Kessler et al., 2001).
These disorders include, but are not limited to, schizophrenia,
schizoaffective disorder, recurrent major depression, and
bipolar disorder (Lyon, 2001).
Exposure to traumatic life events, such as sexual abuse, com-
mon among women with SMI, places this population at in-
creased risk for the development of PTSD. Research findings
indicate that women with SMI are more likely to be victimized
than those without SMI. In a study of 158 community based
women with SMI, 55% reported having experienced adult sex-
ual abuse and 47% reported adult physical abuse (Coverdale &
Turbott, 2000). To add to the risks, many individuals with SMI
are socially and economically disenfranchised, living in areas
 SEXUAL ABUSE AND PTSD IN WOMEN WITH MENTAL ILLNESS
where crime is high, which can lead to an increased chance
of traumatic exposure (Schwartz, Bradley, Sexton, Sherry, &
Ressler, 2005; McKinnon, Cournos, & Herman, 2002).
Because an array of overlapping symptoms accompany
PTSD and SMI, differentiation of these disorders is difficult.
Features common to both disorders may include hallucinations,
marked diminished interest in engaging in social activities,
isolation, and feelings of detachment (Cusack et al., 2006).
Untangling the two disorders requires that clinicians distin-
guish between similarities such as the negative symptoms of
schizophrenia and the avoidant symptoms of PTSD (Gearon et
al., 2003). Psychiatric nurses are in a unique position to assess
and identify PTSD among women with SMI thereby providing
more comprehensive treatment.
Effective treatment of PTSD includes specific therapies that
are unique to the disorder. Exposure therapy, systematic desensi-
tization, cognitive behavioral therapy (CBT), and eye movement
desensitization and reprocessing (EMDR) are all known to be ef-
fective therapies for PTSD survivors (Lombardo & Gray, 2005;
Soloman & Heide, 2005; Falsetti, Resnick, & Davis, 2005).
Psychopharmacological treatment of PTSD may include the
use of medications not traditionally used for treatment of SMI
(Bostrom & Schwecke, 2007). Efficacious treatment of PTSD
and SMI hinges on the identification and distinction of symp-
toms.
PURPOSE AND RESEARCH QUESTIONS
The purpose of this pilot study was to examine the prevalence
of undiagnosed PTSD among a cohort of 20 women with SMI
and who reported past sexual abuse. Additionally, the researcher
sought to identify specific symptom manifestations of PTSD
among women with SMI and sexual abuse histories. Finally, the
feasibility of using specific data collection tools was examined.
The specific research questions were:
1. Do specific symptoms of PTSD occur and go unrecognized
among hospitalized adult females with SMI and a history of
sexual abuse?
2. How do symptoms of PTSD express themselves in women
with SMI and a history of sexual abuse?
3. What is the feasibility of utilizing specific screening in-
struments in order to assess history of sexual abuse among
women with SMI?
METHOD
Design
In this pilot study, both quantitative and qualitative methods
were used to collect and analyze the data. Quantitative methods
were used to screen for the presence of PTSD symptoms among
women with SMI and a history of sexual abuse that had no doc-
umented chart diagnosis of PTSD. Qualitative data, in the form
457
of field notes kept by the researcher, focused on the responses
and reactions of the women during their interview.
Sample
The purposive sample consisted of 20 women, ranging in
age from 21 to 65, hospitalized on an acute care psychiatric
inpatient unit in a large urban area of south central Texas. After
obtaining the approval of the Institutional Review Board, refer-
rals for potential participation in the pilot study were made by
the treatment team. After referral, each individual was carefully
screened by the Principal Investigator, to ensure all inclusion cri-
teria were met. Inclusion criteria consisted of a history of sexual
abuse with no diagnosis of PTSD, a diagnosis of schizophrenia,
schizoaffective disorder, bipolar disorder, or major depressive
disorder, and a voluntary desire to participate in the project.
Patients who were acutely psychotic were excluded from the
study. After reading and signing an informed consent form, the
women completed a structured interview with the investigator.
Quantitative Data Collection and Analysis
Psychiatric diagnosis and demographic data were identified
through chart review. Descriptive information including ethnic-
ity, marital/relationship status, education, current living situa-
tion, and use of illicit drugs were recorded on a demographic
information form. History of sexual abuse was measured by the
Abuse Assessment Screen (AAS; Soeken, McFarlane, Parker,
& Lominick, 1998) adapted for this study with permission from
the author. This instrument measures the type of abuse as well
as information about the perpetrator. In order to ascertain if
the participants met the diagnostic criteria for PTSD, the Struc-
tured Clinical Interview for DSM-IV (SCID-IV), PTSD module
(First, Spitzer, Gibbon, & Williams, 1996), was administered by
the researcher. A number of studies using the SCID-TSD mod-
ule suggest that it has good reliability and validity (Keane et al.,
1998; McFall, Smith, Roszell, Tarver, & Malas, 1990; Weiss,
1996). Other psychotic symptoms were measured by the Brief
Psychiatric Rating Scale (BPRS; Ventura, Green, Shaner, &
Liberman, 1983), a Likert-type scale measuring 24 positive and
negative symptom constructs. To measure specific symptoma-
tology related to childhood and adult traumatic experiences, the
Trauma Symptom Checklist 40 (TSC-40; Eliot & Briere, 1992;
Briere & Runtz, 1989) was used. Studies reveal this 40-item self-
report checklist has predictive validity and reliability in regard
to a wide variety of traumatic experiences (Demare & Briere,
1995; Dutton & Painter, 1993, Elliot & Briere, 1992). The scale
measures the long-term effects of physical and sexual abuse
in the following subscales: dissociation, anxiety, depression,
sexual abuse trauma index, sexual problems, and sleep distur-
bances. The researcher selected these specific tools in order to
capture the full range of potential clinical correlates of PTSD.
SPSS software was utilized to analyze descriptive statistics and
calculate means for each of the tools.
458 R. BONUGLI ET AL.
Qualitative Data Collection and Analysis
In order to explore both the feasibility and acceptability of
using these instruments with the study sample, the investigator
maintained handwritten field notes regarding responses, reac-
tions, and behaviors of the women throughout each interview.
As the researcher desired to provide a descriptive summary of
the field notes, qualitative content analysis (Sandelowski, 2000)
was used in the analysis phase. Qualitative descriptive analysis
follows six analytic steps: (1) coding of data from notes and
interviews, (2) recording insights and reflections on the data,
(3) sorting through the data to find similar phrases, patterns, and
themes, (4) looking for commonalities and differences in the
data, (5) deciding on a small group of data or generalizations
that hold true for the data, and (6) examining the findings in light
of knowledge that is known (Sullivan-Bolyai, Bova, & Harper,
2005).
FINDINGS
The women (n = 20) in this study ranged in age from 21–65
years with an average age of 37 years. Forty-five percent iden-
tified as Latina, 10% identified as African American, and 45%
reported being Caucasian. In regard to relationship status, 35%
of the women reported they were divorced, 30% reported being
single, 15% were currently married, 5% were living with same
sex partner, 5% were living with opposite sex partner, 5% were
separated, and 5% were widowed. Forty percent of the women
reported completing some college, 25% obtained a high school
diploma or GED, 25% completed some high school, and 10%
reported educational levels below eighth grade. At the time of
admission, 70% of the women received a diagnosis of Major
Depressive Disorder, 25% received a diagnosis of Bipolar Dis-
order, and 5% were diagnosed with Schizophrenia. The average
age of first sexual trauma was 12 years.
Concerning the first research question—whether specific
symptoms of PTSD occur and go unrecognized among hospital-
ized adult females with SMI and a history of sexual abuse—all
the participants met the diagnostic criteria for PTSD, according
to the SCID-PTSD module. Although all the women previously
had reported a history of childhood sexual assault (CSA) and/or
adult sexual assault (ASA) to a health care provider, none re-
ported being evaluated or informed of having a diagnosis of
PTSD. None of the women had a chart diagnosis of PTSD.
In regard to the second research question—identification of
specific clinical correlates of PTSD—high levels of depres-
sion, guilt, emotional withdrawal, affective blunting, anxiety,
decreased psychomotor activity, and somatic concerns were
noted on the BPRS. Symptoms of depression sleep disturbances,
dissociation, anxiety, and sexual problems were captured on the
TCS-40. Fifty percent (n = 10) of the women admitted to sui-
cidal ideations. Ninety-five percent (n = 19) of the participants
reported a history of substance abuse to include alcohol, mar-
ijuana, crack cocaine, heroin, and amphetamines. Fifty-eight
percent (n = 12) of the sample reported feeling dissatisfied
with their sexual lives. Eighty percent (n = 16) reported feeling
dissatisfied with their relationship status.
The third research question regarding the feasibility of uti-
lizing specific data collection tools demonstrated that all the
women were willing and able to complete the instruments. Of
note, the instruments provided a framework for discussing sen-
sitive issues related to sexual abuse. The participants talked
openly about their sexual abuse histories. The women recalled
multiple episodes of sexual abuse that spanned years and they
expressed feelings of guilt. For example, one woman stated, “It
started with my brother when I was 4 or 5. Then, when I was 6,
my mother’s boyfriend made me rub him. He told me if I kissed
it, it would get bigger. Then he pushed my head down on it. Af-
ter that, I was scared, and I wouldn’t go to confession.” Another
woman reported first being raped by her stepfather at age 9. She
recalled tearfully, “I don’t hate him. There is nothing I can do,
nowhere to go. There is a thing in me, I say it happened, first
fondling, then rape. He took my virginity. My mom tells me it is
all my fault.” The women described factors affecting their abil-
ity to engage in meaningful sexual relationships. For example,
one woman stated “I don’t trust men; I tend to think they just
don’t care about me.” Another woman stated, “I just don’t feel
safe with men.” Interestingly, the participants associated PTSD
with war time experiences and lacked knowledge of PTSD as a
consequence of sexual abuse. For example, one woman stated, “I
only thought PTSD happened to soldiers in war. I never though
it could happen to me.” Another woman recalled experiences
of watching her mother being physically abused by a boyfriend.
She stated that she never thought that any of her psychiatric ill-
nesses were linked to this event. Finally, several of the women
expressed hope that the information would be helpful to others
in similar circumstances. As one woman stated, “I hope that this
information will help other women like me.”
DISCUSSION
Findings of this study indicate that based on the SCID-PTSD
module, all of the participating women met the diagnostic crite-
ria for PTSD. This occurrence of a sexual abuse history and un-
diagnosed PTSD among women with SMI is congruent with re-
search findings. Despite documented histories of sexual trauma,
mental health consumers with a history of sexual trauma are
more likely diagnosed with an affective disorder, such as depres-
sion (Cusack et al., 2006; Zanville & Cattaneo, 2009). Although
PTSD has been found to be comorbid with major depression,
generalized anxiety disorder, panic disorder, somatization dis-
order, and substance abuse disorders (McMillen, North, Mosley,
& Smith, 2002), the diagnosis of the disorder remains elusive.
There maybe several explanations for this lack of diagnosis.
Specific symptoms of PTSD might not be clear cut, and reports
of negative life experiences complicate the clinical presenta-
tion. Distinguishing flashbacks from hallucinations and delu-
sions might be difficult. In addition, often the traumatic event is
long past, making the relevance of the event to the current status
 SEXUAL ABUSE AND PTSD IN WOMEN WITH MENTAL ILLNESS
of the patient questionable (Briere, 1997). Regardless, proper
assessment and treatment of PTSD among sexual abuse victims
with SMI is imperative.
In this study, specific symptom correlates of PTSD were iden-
tified. Depression appeared to be a significant clinical feature
for these women. Clinical symptoms of depression and other
disorders can mimic symptoms of PTSD, making diagnosis dif-
ficult. Complaints of sexual dysfunction were noted among the
women. Numbing and hyperarousal symptoms, both symptoms
of PTSD, have been found to be related to sexual dysfunction
(Schnurr et al., 2008). Because sexual expression impacts qual-
ity of life, it is important to investigate this area among women
with SMI and sexual abuse history. Additionally, the women re-
ported current or previous substance abuse. As traumatic sexual
abuse has been shown to be a major risk factor for development
of a substance abuse history among women with SMI (Gearon
et al., 2003), a comprehensive substance abuse evaluation is
warranted for all women with SMI. Because of increased rates
of suicide among individuals with PTSD (Kessler et al., 2001),
safety evaluations and ongoing suicide risks assessments are im-
perative as well. A complete health history, including a mental
status examination with particular attention to PTSD symptoms,
is warranted among women with SMI and sexual abuse histories.
When completing these examinations, the nurse should be aware
of both nonverbal and verbal behaviors of the patient. Trauma
sensitive interventions to reduce comorbidity and mortality rates
among women with SMI and sexual abuse histories are needed.
The responses of the women in this study to the interview
questions and the assessment instruments indicated that the data
collection tools were effective in providing descriptive statistics
as well as providing a framework for discussing sensitive issues
related to sexual abuse. The participants talked openly and freely
about their sexual abuse histories. Although the long-term ef-
fects of disclosing sensitive information regarding sexual abuse
history were not evaluated, none of the participants self-reported
increased agitation or anxiety during or immediately following
the interviews. Instead a number of the participants indicated the
experience of talking about sexual abuse histories was helpful.
Health care providers have been reluctant to inquire about sexual
abuse histories and subsequent PTSD in women with SMI, fear-
ing such inquiry will trigger further psychological discomfort
(Briere, 1997). Nurses can validate the feelings associated with
sexual abuse among women with SMI by offering opportuni-
ties to discuss these sensitive issues related to the development
and treatment of PTSD. Briere (1997) has noted the need to
establish a neutral, nonintrusive evaluation environment for the
assessment of traumatic events. Therefore, the context in which
the instruments are used bears further exploration. In applying
therapeutic use of self, psychiatric nurses can create an atmo-
sphere of trust where individuals with SMI are free to discuss
sensitive personal information related to sexual abuse. Nurses
can dispel notions that individuals with SMI are incapable of
providing accurate sexual abuse histories by providing a forum
for open discussion of sexuality.
459
Implications for Nursing Practice, Research, and
Education
Implications for nursing practice include the need to evalu-
ate all women with SMI a history of sexual abuse for PTSD.
In order to provide effective screening, nurses must be able to
recognize symptoms of PTSD in this population. Because of
the private nature of revealing sexual abuse history, assessments
should be conducted with sensitivity. Research studies exam-
ining specific manifestations of PTSD among this population
are needed. Areas for further study include the exploration of
PTSD on the course of SMI. Nursing interventions addressing
the multiple issues of PTSD in women with SMI need to be de-
veloped. Treatment plans should include teaching women with
SMI about the symptoms of PTSD as well as trauma. Psychi-
atric nursing education that focuses on the recovery of women
with SMI and PTSD is needed. In addition, nurses should be
taught about PTSD among women with SMI in order to provide
timely assessment and intervention.
CONCLUSION
The small sample size in this study limits the generalizabil-
ity of the findings to the larger population of sexually abused
women with SMI and histories of sexual abuse. However, the
results suggest that PTSD is either misdiagnosed or underdiag-
nosed among women with SMI and histories of sexual abuse.
Finally, nurses can frame survivorship in the context of personal
growth, providing women with SMI and sexual abuse histories
a way to build on personal strengths as opposed to illness.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the paper.
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