269
Journal of Affective Disorders, 1 (1979) 269-277 0 Elsevier/North-Holland Biomedical Press
DEPRESSIVE
ELLEN
FRANK,
SYMPTOMS
SAMUEL
IN RAPE
M. TURNER
VICTIMS
and BARBARA
DUFFY
Department of Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh School of Medicine, Pittsburgh, PA 15261 (U.S.A.) (Received (Accepted
University
of
9 July, 1979) 11 July, 1979)
SUMMARY Thirty-four recent rape victims were assessed for depressive symptomatology using a well-validated self-report instrument in combination with formal psychiatric evaluation. Fifteen subjects were found to be moderately or severely depressed when measured on A closer examination of these 15 subjects revealed that the self-report questionnaire. 8 were suffering from a major depressive disorder. The authors emphasize that all clinicians working with rape victims should be alert to the emergence of depression in this population.
INTRODUCTION
Although the literature on the crime of rape is extensive, almost none of it has dealt with the victim’s immediate emotional response or subsequent psychological problems. In this context, it is noteworthy that in what is probably the largest and most detailed single study on rape, Amir (1971) never once mentions the victim’s emotional or psychological reaction to the assault. Only within the last 10 years have researchers and clinicians begun to concern themselves with the nature and treatment of psychological response to rape. The first modern report of the psychological response exhibited by rape victims occurs in the context of an article on their medical management. In addition to many somatic symptoms, Halleck (1962) points out that the physician can observe in the victim severe anxiety, angry feelings, selfdoubt, self-recrimination, and concern about her role as a woman. He states that the victim sees herself as degraded and helpless, and wonders whether she will ever be attracted to men again or interested in normal sexual relations. Since that time the major studies of rape victims have tended to emphasize fear and anxiety as the predominant psychological sequelae of a sexual assault. Although Sutherland and Scherl (1970), Burgess and Holmstrom
270
(1974a), The Queen’s Bench Foundation (1975) and Notman and Nadelson (1976) saw victims under differing circumstances, all point to the symptoms of fear and anxiety seen in their study population. Only two of the studies (Sutherland and Scherl 1970; Peters 1975a, b) mention depression as a feature of the ‘normative’ response to rape. Burgess and Holmstrom apparently observed depression only in victims with a previous history of physical or psychiatric problems. Furthermore, the few studies which have suggested that depression is an important element of the post-rape clinical picture have been handicapped in that none was based on quantifiable, objectively measured data. We, on the other hand, have been impressed with the extent to which the women in our rape victim study evidence depressive symptoms and, in some cases, exhibit a full depressive syndrome. The current report is based on an investigation of the psychological sequelae of rape victimization in adolescent and adult females and of the relative efficacy of two treatments in reducing the symptoms which follow a sexual assault. This study makes use of objective assessment instruments and provides a quantifiable data base from which to assess the prevalence of depressive symptoms in rape victims. The data for this report are drawn from the initial assessments which were all conducted within the first 4 weeks following the assault. Our intent is to determine which of 8 common depressive symptoms occur most frequently in rape victims and to examine to what extent recent rape victims meet criteria for a major depressive syndrome when assessed by an objective self-report inventory in combination with subjective clinical impression. METHOD
The population is comprised of recent victims of sexual assault referred to the investigators by the Allegheny County Center for Victims of Violent Crime between June 1978 and May 1979. All assessments and treatment sessions were conducted in a suite of rooms at the Center for Victims. Although the investigators are faculty members in a department of psychiatry, a specific effort was made to disassociate the project from that department and have it be viewed as an adjunct service of the Center for Victims. To be eligible for inclusion, a subject must have been sexually assaulted within one-month prior to referral, be between 14 and 60 years of age and show no current evidence of psychosis, organic brain syndrome or severe drug or alcohol abuse. Each subject was interviewed and assessed by her project counselor (a Master’s level psychiatric social worker or clinical psychologist) within 1-4 weeks after the assault. All the victims were asked to complete the Beck Depression Inventory (BDI), as one of a battery of 5 self-report instruments given to subjects at the time of their first meeting with a project counselor. The BDI is a 21-item instrument in which each item describes a specific symptom of depression (Beck et al. 1961). Each item is composed of 4 self-
271 TABLE
1
BECK DEPRESSION a. b. c. d. e. f. g.
INVENTORY
mood pessimism failure dissatisfaction guilt feelings of punishment self-hate
h. i. j. k. 1. m. n.
-
SYMPTOM
ATTITUDE
CATEGORIES o. p. q. r. s. t. u.
self-approach suicidal ideation crying irritability loss of interest indecisiveness body image
work inhibition sleep disturbance fatigue appetite disturbance weight loss somatic complaints loss of libido
evaluative statements which are ranked from 0 (neutral) to 3 (maximal) to reflect the severity of the symptom. Each subject was instructed to circle the statement in each category which best reflected her attitude at the present time. The BDI symptom-attitude categories are presented in Table 1. In addition to administering the self-report inventories, counselors conducted a structured interview regarding the subject’s social functioning as well as a lengthy interview in which data regarding past medical and psychiatric history were gathered. Information relating to specific problems the subject had been experiencing since the assault were also obtained at this interview. At the termination of each assessment interview, the counselor recorded her observations of the subject she had just interviewed, including the presence of any depressive symptomatology. In ail cases, the counselor recorded her observations prior to reviewing the subject’s responses on the BDI. Once all of the BDI’s had been tallied and scored, each subject was placed in one of the 4 severity categories ennumerated in Table 2. The Beck Depression Inventories of all subjects having a total of 16 or greater (moderatelyto-severely depressed) were then selected for comparison with the respective counselor initial interview summaries to determine which subjects in this subgroup met criteria for major depressive disorder (Spitzer et al. 1978). In order to make this determination we asked an independent psychiatrist, experienced in research on depression, (David J. Kupfer), to review the interview summaries of those subjects who, on the basis of their higher BDI scores, had been selected as having a higher probability of being depressed. TABLE BECK Score
o10-15 16-23 24+
2 DEPRESSION
9
INVENTORY
-
SUBJECT
SEVERITY
Severity
N
Normal Mildly depressed Moderately depressed Severely depressed
11 8 8 7
LEVELS
272 RESULTS
The subject population consisted of 34 females, all of whom were recent (within one month prior to assessment) victims of sexual assault. Subjects ranged in age from 15 to 52 years, with a mean age of 24 years and a median age of 21. Approximately 80% of the subjects were Caucasian, while 20% were non-white. Sixty-five percent of the subjects were single, approximately 17% were married, 12% divorced, and 6% separated from their legal spouses. As can be seen from Table 3, the frequency of depressive symptoms reported on the BDI is relatively high. Of the depressive symptoms we chose to review, depressed mood (dysphoria) is the most prevalent, with 17 subjects (50% of the entire sample) reporting acute sadness, low mood, and/or irritability. Fifty percent of the subjects also reported extreme feelings of guilt at the time they completed the BDI. Loss of interest in normal activities was the third most frequent complaint as 35.3% reported serious difficulty in this area. Decreased concentration, sleep disturbance and appetite disturbance, although less common than the above-named symptoms were nevertheless reported as major concerns by over 20% of the sample population. Finally, loss of energy and suicidal ideation were symptoms reported by 11.8 and 2.9% of the sample, respectively. Having conducted this preliminary review, we next identified those subjects who scored a total of 16 or more on the Beck Depression Inventory, thereby reducing the sample to those victims appearing moderately or severely depressed upon initial inspection. The BDI’s for each member of this subgroup were subsequently reviewed for evidence of depressive symptom clustering. Fifteen subjects (44%) scored above 16 on the BDI and also showed evidence of such depressive symptom clustering. The overall mean BDI score for this subgroup of victims was 24.5. For these subjects, the four most fre-
TABLE
3
FREQUENCY
OF COMMON
DEPRESSIVE
SYMPTOMS
Present
Depressed mood Appetite/weight Sleep disturbance Loss of energy Loss of interest Guilt Decreased concentration Suicidal ideation
N
%
17 7 9 4 12 17 10 1
50.0 20.6 26.5 11.8 35.3 50.0 29.4 2.9
AS REPORTED
ON THE BDI
273
quently reported symptoms were depressed mood (86.7%), guilt (86.7%), decreased concentration (66.7%), and loss of interest (60.0%). The remaining 4 symptoms reported in order of frequency were sleep disturbance (40.0%), appetite disturbance/weight loss (33.3%), loss of energy (26.7%), and suicidal ideation (6.7%). As mentioned above, the clinical notes (initial interview notes) recorded for these 15 subjects were reviewed by an outside psychiatrist for the purpose of making a more subjective determination of the presence of major depressive disorder in these 15 subjects. In all cases, the psychiatrist reviewed the clinical notes, made a preliminary determination of the presence of a disorder and only then reviewed the BDI information for each subject. On the basis of this review, eight (53.3%) of the 15 subjects with BDI’s in the moderate-to-severe range were classified as suffering from a major depressive disorder according to RDC criteria, suggesting a percentage of 24 in the overall group. Two of the remaining 7 subjects in the subgroup of 15 with elevated BDI scores were believed to be suffering from other pre-existing psychiatric disorders, to which depression was only secondary. Despite their respective scores and evidence of symptom clustering on the BDI, the remaining 5 subjects in the subgroup were not believed to be suffering from a major depressive disorder. DISCUSSION
Our data suggest that depressive symptoms are both prevalent and clinically important among recent victims of sexual assault. As mentioned above, previous recognition of depressive symptoms in rape victims has been sparse. An intensive review of the literature on rape fails to make clear why this omission has occurred. Notman and Nadelson (1976), for example, described the rape response as having much in common with other stress reactions, but with unique ‘dynamic’ considerations involving feelings of anger, guilt, and shame, as well as concern about ‘unconscious fantasies’. The authors also noted that the life stage of the victim at the time of the rape may have important implications for her specific reaction to the stress. While their paper points to the presence of several symptoms which fall within the depressive symptom cluster, no specific mention of depression is made. In a detailed study of all aspects of rape victimization, the Queen’s Bench Foundation (1975) described the impact of rape on 55 female victims. The subjects interviewed ranged in age at the time of rape from 8 to 55 and represented a wide range of socioeconomic, ethnic, and occupational backgrounds as well as temporal distances from the rape event (2 weeks to 25 years). Sixty-seven percent of this group felt that they had suffered long-term psychological effects as a result of the rape. Eighty-nine percent reported their ‘concept of safety’ was most affected; long after the rape they continued to
273
be fearful, felt unable to protect themselves, were cautious about going out alone or after dark, moved to a new area, were suspicious of all strangers, and avoided situations in which they had felt comfortable prior to the rape. Sixteen percent reported loss of self-esteem involving feelings of worthlessness, shame, guilt, or helplessness. Fourteen percent said they had experienced disruption of their sexual identity and responsiveness, or disturbance in their relationships with their husband or boyfriend. Sixteen percent withdrew from social relationships with both men and women. When asked to recall their immediate response to the rape, 49% of the Queen’s Bench Foundation sample reported great fear for their physical safety. A small group (16%) felt anger and outrage (often seen in cases where the victim knew the assailant), and 11% reported a feeling of detachment from the experience as it was taking place. Shortly after the attack, feelings of shame (34%) and guilt (30%) also played a significant role. When asked to rate responses according to their strength, ‘very strong’ feelings of anxiety (79%), fear (68%), and helplessness (68%) were reported by these women. Again we find a study in which some depressive symptoms are mentioned, but no specific mention of depression is made by the authors who, it should be mentioned, came from legal rather than psychiatric or psychological backgrounds. The first interview and follow-up study of the response pattern of rape victims was done in 1970 on a small and remarkably homogeneous sample. Sutherland and Scherl (1970) treated 13 single white females between the ages of 18 and 24 who were workers in poverty communities, all of whom were seen in a community mental health center setting. Drawing on their experience with these women, the authors described a three-phase response to rape. They noted that the first phase (acute reaction) may be characterized by shock, disbelief and/or dismay. The victim can be highly agitated or withdrawn. These immediate responses are succeeded by gross, non-specific anxiety. The authors then observed a second phase (outward adjustment), beginning a few days to a few weeks following the rape in which the victim is able to resume many of her normal routines, but which may represent only a pseudo-adjustment based on much denial and suppression of deeply felt fears and anxieties. The third phase of adjustment (integration and resolution) seen in these 13 young women was characterized by depression and a desire to talk to someone about this experience. Sutherland and Scherl described the emergence of two themes in the third phase: (1) the need to integrate a new view of oneself, and (2) the need to accept the event and come to a realistic appraisal of one’s complicity in it. The generalizability of Sutherland and Scherl’s findings are limited both by the sample size and the extreme homogeneity of that sample. Furthermore, the information presented was obtained solely from clinical interviews; however, depression, clearly, was seen as an integral part of the response to rape victimization. Basing their report on a much larger and more heterogeneous population, Burgess and Holmstrom (1974b) described a ‘rape trauma syndrome’. The
275
authors interviewed rape victims in an emergency room setting following the incident. Ninety-two adult women ranging in age from 17 to 73 were interviewed. During these emergency room interviews, the authors used a structured interview guide (Burgess and Holmstrom 1974a) developed specifically for the purpose of interviewing rape victims. Follow-up was conducted by the use of telephone counseling or home visits usually beginning 24 h after the rape and continuing for up to several months. These victims were from a wide variety of ethnic and socioeconomic backgrounds and occupations. The sample included single, married, divorced, as well as women living with men by separated, and widowed women, consensual agreement. The authors found a two-phase response. The acute impact reaction (phase one) was again observed to take two forms: (1) ‘the expressed style’ in which anger and anxiety were clearly visible in behaviors such as crying, sobbing, smiling, restlessness, and tenseness, or (2) ‘the controlled style’ distinguished by the absence of observable affect. In addition to many somatic difficulties (physical trauma, muscle tension, gastrointestinal irritability, genitourinary disturbance) which appeared during this phase, the authors found a wide variety of emotional reactions including fear, humiliation, embarrassment, anger, self-blame, and a desire for revenge. However, the primary feeling described was fear of physical violence and death. Although all victims did not experience the same symptoms or the same sequence of symptoms, the pattern of a phase of acute disorganization lasting for several weeks followed by a long-term reorganization process in which many victims experienced mild to moderate symptoms, was consistent in the 92 women studied. These symptoms of the second phase were almost without exception varieties of fear responses. Women moved either temporarily or permanently to new residences, experienced upsetting dreams and nightmares, and exhibited a variety of phobic reactions (fear of indoors, fear of outdoors, fear of being alone, fear of people behind them, fear of crowds, and sexual fears), According to Burgess and Holmstrom, only those victims with a previous history of physical, psychiatric, or social difficulties, tended to show what the authors termed a ‘compounded’ reaction in which depression, psychotic behavior, acting-out behavior, (alcoholism, drug abuse and sexual promiscuity) combined with the difficulties mentioned above. The Center for Rape Concern at Philadelphia General Hospital followed 70-100 rape victims of all ages each month beginning October, 1970. Peters (1975a, b) reported that analysis of several hundred cases revealed one or more post-rape changes in 73% of the victims. Twenty-seven percent reported fear of strange men; 22% experienced decreased sexual desire; 20% had trouble sleeping; 20% had an increased number of frightening dreams (higher in adults than minors); 17% were more withdrawn emotionally (higher in minors than adults); 10% feared offender retaliation for reporting the crime; 10% feared all men; 10% feared being raped again. Finally, Peters reported that 10% were clinically depressed.
276
In trying to ascertain why previous investigators generally failed to note clinical phenomena which, to us, were quite pronounced, we can suggest a number of possibilities. Probably foremost among those is that our data are drawn from a systematic evaluation of subjects making use of well-validated psychometric instruments, structured interviews and formal psychological evaluation techniques. A second possible explanation is that both the investigators and the counselors are operating from a specifically psychological framework; this was true for only a portion of the earlier investigators in this area. An additional possible explanation is that the particular population of rape victims in our study may have been more dysfunctional prior to the assault than those seen in previous studies. In general, the women in our study had multiple life problems including family discord, economic problems and physical health problems, to which the sexual assault was an added complication. Finally, the women in our study were followed closely over time. Only Sutherland and Scherl (1970), one of the two previous groups to identify depression in rape victims, had a comparable amount of contact with rape victims over a comparable time period. It may be that there is a particular period in the recovery from rape when depressive symptoms are prominent. This might account for why both those who studied victims in the emergency room immediately after an assault as well as those who studied women who were several years post-attack would fail to see depressive symptoms. Among those victims who do begin to appear depressed within the first month after the assault, it is probable that most would no longer be so classified 6 months later. However, if we assume, as some have suggested, (Miller et al. 1979), that the response to rape bears strong similarities to a grief reaction, we would then expect that a certain percentage of victims would remain depressed at one year as did a percentage of the widows in the Bornstein et al. (1973) study of grief reaction. Certainly, our clinical experience suggests that there are women who remain depressed many years after a sexual assault and point to the assault, whether correctly or not, as the event which precipitated their depression. Clearly, the results described in this report do not represent a comprehensive or systematic evaluation of affective disorder in a population of rape victims. At the outset of our study we were interested primarily in symptoms of fear and anxiety and were ourselves surprised by the extent to which our population exhibited depressive symptoms. The current report suggests that clinicians of all disciplines working with victims of sexual assault should be alert to the presence or emergence of depression in this ‘at risk’ population. It also points out the need to determine whether specific intervention directed at depressive symptoms is effective in reducing either the intensity or duration of such symptoms and, if so, what type of treatment offered at what point in the recovery process is likely to produce the most rapid and durable treatment effects.
277 ACKNOWLEDGEMENTS
This research was supported by National Institute of Mental Health Grants MH-29692 and MH-30915. The authors gratefully acknowledge the assistance of David J. Kupfer, M.D. Director of Research at Western Psychiatric Institute and Clinic. REFERENCES Amir, M., Patterns of Forcible Rape, University of Chicago Press, Chicago, 1971, pp. l394. Beck, A.T., Ward, C.H., Mendelsohn, M., Mock, J. and Erbaugh, J., An inventory for measuring depression, Arch. Gen. Psychiat., 4 (1961) 561-571. Bornstein, P.E., Clayton, P.J., Halikas, J.A., Maurice, W.L. and Robins, E., The depression of widowhood after thirteen months, Brit. J. Psychiat., 122 (1973) 561-566. Burgess, A.W. and Holmstrom, L.L., Crisis counseling requests of rape victims, Nurs. Res., 23 (1974a) 196-202. Burgess, A.W. and Holmstrom, L.L., Rape trauma syndrome, Amer. J. Psychiat., 31 (1974b) 981486. Halleck, S.L., The physician’s role in management of victims of sex offenders, J. Amer. Med. Ass., 180 (1962) 273-278. Miller, W.R., Williams, A.M. and Bernstein, M.H., The effects of rape on marital and sexual adjustment. Paper presented at the 5th Annual Meeting of the American Society for Sex Therapy and Research, Philadelphia, 1979. Notman, M.T. and Nadelson, C.C., The rape victim - Psychodynamic considerations, Amer. J. Psychiat., 133 (1976) 408-413. Peters, J.J., Social, legal and psychological effects of rape on the victim, Pennsylv. Med., 78 (1975a) 34-36. Peters, J.J., Social psychiatric study of victims reporting rape. In: Scientific Proceedings of the 128th Annual Meeting, American Psychiatric Association, Washington, 1975b, pp. 111-112. Queen’s Bench Foundation, Rape Victimization Study, Queen’s Bench Foundation, San Francisco, 1976, pp. 1 l-29. Spitzer, R.C., Endicott, J. and Robins, E., Research diagnostic criteria, Arch. Gen. Psychiat., 35 (1978) 173-782. Sutherland, S. and Scherl, D.J., Patterns of response among victims of rape, Amer. J. Orthopsychiat., 40 (1970) 503-511.
Journal of Affective Disorders, 1 (1979) 269-277 0 Elsevier/North-Holland Biomedical Press
DEPRESSIVE
ELLEN
FRANK,
SYMPTOMS
SAMUEL
IN RAPE
M. TURNER
VICTIMS
and BARBARA
DUFFY
Department of Psychiatry, Western Psychiatric Institute and Clinic, Pittsburgh School of Medicine, Pittsburgh, PA 15261 (U.S.A.) (Received (Accepted
University
of
9 July, 1979) 11 July, 1979)
SUMMARY Thirty-four recent rape victims were assessed for depressive symptomatology using a well-validated self-report instrument in combination with formal psychiatric evaluation. Fifteen subjects were found to be moderately or severely depressed when measured on A closer examination of these 15 subjects revealed that the self-report questionnaire. 8 were suffering from a major depressive disorder. The authors emphasize that all clinicians working with rape victims should be alert to the emergence of depression in this population.
INTRODUCTION
Although the literature on the crime of rape is extensive, almost none of it has dealt with the victim’s immediate emotional response or subsequent psychological problems. In this context, it is noteworthy that in what is probably the largest and most detailed single study on rape, Amir (1971) never once mentions the victim’s emotional or psychological reaction to the assault. Only within the last 10 years have researchers and clinicians begun to concern themselves with the nature and treatment of psychological response to rape. The first modern report of the psychological response exhibited by rape victims occurs in the context of an article on their medical management. In addition to many somatic symptoms, Halleck (1962) points out that the physician can observe in the victim severe anxiety, angry feelings, selfdoubt, self-recrimination, and concern about her role as a woman. He states that the victim sees herself as degraded and helpless, and wonders whether she will ever be attracted to men again or interested in normal sexual relations. Since that time the major studies of rape victims have tended to emphasize fear and anxiety as the predominant psychological sequelae of a sexual assault. Although Sutherland and Scherl (1970), Burgess and Holmstrom
270
(1974a), The Queen’s Bench Foundation (1975) and Notman and Nadelson (1976) saw victims under differing circumstances, all point to the symptoms of fear and anxiety seen in their study population. Only two of the studies (Sutherland and Scherl 1970; Peters 1975a, b) mention depression as a feature of the ‘normative’ response to rape. Burgess and Holmstrom apparently observed depression only in victims with a previous history of physical or psychiatric problems. Furthermore, the few studies which have suggested that depression is an important element of the post-rape clinical picture have been handicapped in that none was based on quantifiable, objectively measured data. We, on the other hand, have been impressed with the extent to which the women in our rape victim study evidence depressive symptoms and, in some cases, exhibit a full depressive syndrome. The current report is based on an investigation of the psychological sequelae of rape victimization in adolescent and adult females and of the relative efficacy of two treatments in reducing the symptoms which follow a sexual assault. This study makes use of objective assessment instruments and provides a quantifiable data base from which to assess the prevalence of depressive symptoms in rape victims. The data for this report are drawn from the initial assessments which were all conducted within the first 4 weeks following the assault. Our intent is to determine which of 8 common depressive symptoms occur most frequently in rape victims and to examine to what extent recent rape victims meet criteria for a major depressive syndrome when assessed by an objective self-report inventory in combination with subjective clinical impression. METHOD
The population is comprised of recent victims of sexual assault referred to the investigators by the Allegheny County Center for Victims of Violent Crime between June 1978 and May 1979. All assessments and treatment sessions were conducted in a suite of rooms at the Center for Victims. Although the investigators are faculty members in a department of psychiatry, a specific effort was made to disassociate the project from that department and have it be viewed as an adjunct service of the Center for Victims. To be eligible for inclusion, a subject must have been sexually assaulted within one-month prior to referral, be between 14 and 60 years of age and show no current evidence of psychosis, organic brain syndrome or severe drug or alcohol abuse. Each subject was interviewed and assessed by her project counselor (a Master’s level psychiatric social worker or clinical psychologist) within 1-4 weeks after the assault. All the victims were asked to complete the Beck Depression Inventory (BDI), as one of a battery of 5 self-report instruments given to subjects at the time of their first meeting with a project counselor. The BDI is a 21-item instrument in which each item describes a specific symptom of depression (Beck et al. 1961). Each item is composed of 4 self-
271 TABLE
1
BECK DEPRESSION a. b. c. d. e. f. g.
INVENTORY
mood pessimism failure dissatisfaction guilt feelings of punishment self-hate
h. i. j. k. 1. m. n.
-
SYMPTOM
ATTITUDE
CATEGORIES o. p. q. r. s. t. u.
self-approach suicidal ideation crying irritability loss of interest indecisiveness body image
work inhibition sleep disturbance fatigue appetite disturbance weight loss somatic complaints loss of libido
evaluative statements which are ranked from 0 (neutral) to 3 (maximal) to reflect the severity of the symptom. Each subject was instructed to circle the statement in each category which best reflected her attitude at the present time. The BDI symptom-attitude categories are presented in Table 1. In addition to administering the self-report inventories, counselors conducted a structured interview regarding the subject’s social functioning as well as a lengthy interview in which data regarding past medical and psychiatric history were gathered. Information relating to specific problems the subject had been experiencing since the assault were also obtained at this interview. At the termination of each assessment interview, the counselor recorded her observations of the subject she had just interviewed, including the presence of any depressive symptomatology. In ail cases, the counselor recorded her observations prior to reviewing the subject’s responses on the BDI. Once all of the BDI’s had been tallied and scored, each subject was placed in one of the 4 severity categories ennumerated in Table 2. The Beck Depression Inventories of all subjects having a total of 16 or greater (moderatelyto-severely depressed) were then selected for comparison with the respective counselor initial interview summaries to determine which subjects in this subgroup met criteria for major depressive disorder (Spitzer et al. 1978). In order to make this determination we asked an independent psychiatrist, experienced in research on depression, (David J. Kupfer), to review the interview summaries of those subjects who, on the basis of their higher BDI scores, had been selected as having a higher probability of being depressed. TABLE BECK Score
o10-15 16-23 24+
2 DEPRESSION
9
INVENTORY
-
SUBJECT
SEVERITY
Severity
N
Normal Mildly depressed Moderately depressed Severely depressed
11 8 8 7
LEVELS
272 RESULTS
The subject population consisted of 34 females, all of whom were recent (within one month prior to assessment) victims of sexual assault. Subjects ranged in age from 15 to 52 years, with a mean age of 24 years and a median age of 21. Approximately 80% of the subjects were Caucasian, while 20% were non-white. Sixty-five percent of the subjects were single, approximately 17% were married, 12% divorced, and 6% separated from their legal spouses. As can be seen from Table 3, the frequency of depressive symptoms reported on the BDI is relatively high. Of the depressive symptoms we chose to review, depressed mood (dysphoria) is the most prevalent, with 17 subjects (50% of the entire sample) reporting acute sadness, low mood, and/or irritability. Fifty percent of the subjects also reported extreme feelings of guilt at the time they completed the BDI. Loss of interest in normal activities was the third most frequent complaint as 35.3% reported serious difficulty in this area. Decreased concentration, sleep disturbance and appetite disturbance, although less common than the above-named symptoms were nevertheless reported as major concerns by over 20% of the sample population. Finally, loss of energy and suicidal ideation were symptoms reported by 11.8 and 2.9% of the sample, respectively. Having conducted this preliminary review, we next identified those subjects who scored a total of 16 or more on the Beck Depression Inventory, thereby reducing the sample to those victims appearing moderately or severely depressed upon initial inspection. The BDI’s for each member of this subgroup were subsequently reviewed for evidence of depressive symptom clustering. Fifteen subjects (44%) scored above 16 on the BDI and also showed evidence of such depressive symptom clustering. The overall mean BDI score for this subgroup of victims was 24.5. For these subjects, the four most fre-
TABLE
3
FREQUENCY
OF COMMON
DEPRESSIVE
SYMPTOMS
Present
Depressed mood Appetite/weight Sleep disturbance Loss of energy Loss of interest Guilt Decreased concentration Suicidal ideation
N
%
17 7 9 4 12 17 10 1
50.0 20.6 26.5 11.8 35.3 50.0 29.4 2.9
AS REPORTED
ON THE BDI
273
quently reported symptoms were depressed mood (86.7%), guilt (86.7%), decreased concentration (66.7%), and loss of interest (60.0%). The remaining 4 symptoms reported in order of frequency were sleep disturbance (40.0%), appetite disturbance/weight loss (33.3%), loss of energy (26.7%), and suicidal ideation (6.7%). As mentioned above, the clinical notes (initial interview notes) recorded for these 15 subjects were reviewed by an outside psychiatrist for the purpose of making a more subjective determination of the presence of major depressive disorder in these 15 subjects. In all cases, the psychiatrist reviewed the clinical notes, made a preliminary determination of the presence of a disorder and only then reviewed the BDI information for each subject. On the basis of this review, eight (53.3%) of the 15 subjects with BDI’s in the moderate-to-severe range were classified as suffering from a major depressive disorder according to RDC criteria, suggesting a percentage of 24 in the overall group. Two of the remaining 7 subjects in the subgroup of 15 with elevated BDI scores were believed to be suffering from other pre-existing psychiatric disorders, to which depression was only secondary. Despite their respective scores and evidence of symptom clustering on the BDI, the remaining 5 subjects in the subgroup were not believed to be suffering from a major depressive disorder. DISCUSSION
Our data suggest that depressive symptoms are both prevalent and clinically important among recent victims of sexual assault. As mentioned above, previous recognition of depressive symptoms in rape victims has been sparse. An intensive review of the literature on rape fails to make clear why this omission has occurred. Notman and Nadelson (1976), for example, described the rape response as having much in common with other stress reactions, but with unique ‘dynamic’ considerations involving feelings of anger, guilt, and shame, as well as concern about ‘unconscious fantasies’. The authors also noted that the life stage of the victim at the time of the rape may have important implications for her specific reaction to the stress. While their paper points to the presence of several symptoms which fall within the depressive symptom cluster, no specific mention of depression is made. In a detailed study of all aspects of rape victimization, the Queen’s Bench Foundation (1975) described the impact of rape on 55 female victims. The subjects interviewed ranged in age at the time of rape from 8 to 55 and represented a wide range of socioeconomic, ethnic, and occupational backgrounds as well as temporal distances from the rape event (2 weeks to 25 years). Sixty-seven percent of this group felt that they had suffered long-term psychological effects as a result of the rape. Eighty-nine percent reported their ‘concept of safety’ was most affected; long after the rape they continued to
273
be fearful, felt unable to protect themselves, were cautious about going out alone or after dark, moved to a new area, were suspicious of all strangers, and avoided situations in which they had felt comfortable prior to the rape. Sixteen percent reported loss of self-esteem involving feelings of worthlessness, shame, guilt, or helplessness. Fourteen percent said they had experienced disruption of their sexual identity and responsiveness, or disturbance in their relationships with their husband or boyfriend. Sixteen percent withdrew from social relationships with both men and women. When asked to recall their immediate response to the rape, 49% of the Queen’s Bench Foundation sample reported great fear for their physical safety. A small group (16%) felt anger and outrage (often seen in cases where the victim knew the assailant), and 11% reported a feeling of detachment from the experience as it was taking place. Shortly after the attack, feelings of shame (34%) and guilt (30%) also played a significant role. When asked to rate responses according to their strength, ‘very strong’ feelings of anxiety (79%), fear (68%), and helplessness (68%) were reported by these women. Again we find a study in which some depressive symptoms are mentioned, but no specific mention of depression is made by the authors who, it should be mentioned, came from legal rather than psychiatric or psychological backgrounds. The first interview and follow-up study of the response pattern of rape victims was done in 1970 on a small and remarkably homogeneous sample. Sutherland and Scherl (1970) treated 13 single white females between the ages of 18 and 24 who were workers in poverty communities, all of whom were seen in a community mental health center setting. Drawing on their experience with these women, the authors described a three-phase response to rape. They noted that the first phase (acute reaction) may be characterized by shock, disbelief and/or dismay. The victim can be highly agitated or withdrawn. These immediate responses are succeeded by gross, non-specific anxiety. The authors then observed a second phase (outward adjustment), beginning a few days to a few weeks following the rape in which the victim is able to resume many of her normal routines, but which may represent only a pseudo-adjustment based on much denial and suppression of deeply felt fears and anxieties. The third phase of adjustment (integration and resolution) seen in these 13 young women was characterized by depression and a desire to talk to someone about this experience. Sutherland and Scherl described the emergence of two themes in the third phase: (1) the need to integrate a new view of oneself, and (2) the need to accept the event and come to a realistic appraisal of one’s complicity in it. The generalizability of Sutherland and Scherl’s findings are limited both by the sample size and the extreme homogeneity of that sample. Furthermore, the information presented was obtained solely from clinical interviews; however, depression, clearly, was seen as an integral part of the response to rape victimization. Basing their report on a much larger and more heterogeneous population, Burgess and Holmstrom (1974b) described a ‘rape trauma syndrome’. The
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authors interviewed rape victims in an emergency room setting following the incident. Ninety-two adult women ranging in age from 17 to 73 were interviewed. During these emergency room interviews, the authors used a structured interview guide (Burgess and Holmstrom 1974a) developed specifically for the purpose of interviewing rape victims. Follow-up was conducted by the use of telephone counseling or home visits usually beginning 24 h after the rape and continuing for up to several months. These victims were from a wide variety of ethnic and socioeconomic backgrounds and occupations. The sample included single, married, divorced, as well as women living with men by separated, and widowed women, consensual agreement. The authors found a two-phase response. The acute impact reaction (phase one) was again observed to take two forms: (1) ‘the expressed style’ in which anger and anxiety were clearly visible in behaviors such as crying, sobbing, smiling, restlessness, and tenseness, or (2) ‘the controlled style’ distinguished by the absence of observable affect. In addition to many somatic difficulties (physical trauma, muscle tension, gastrointestinal irritability, genitourinary disturbance) which appeared during this phase, the authors found a wide variety of emotional reactions including fear, humiliation, embarrassment, anger, self-blame, and a desire for revenge. However, the primary feeling described was fear of physical violence and death. Although all victims did not experience the same symptoms or the same sequence of symptoms, the pattern of a phase of acute disorganization lasting for several weeks followed by a long-term reorganization process in which many victims experienced mild to moderate symptoms, was consistent in the 92 women studied. These symptoms of the second phase were almost without exception varieties of fear responses. Women moved either temporarily or permanently to new residences, experienced upsetting dreams and nightmares, and exhibited a variety of phobic reactions (fear of indoors, fear of outdoors, fear of being alone, fear of people behind them, fear of crowds, and sexual fears), According to Burgess and Holmstrom, only those victims with a previous history of physical, psychiatric, or social difficulties, tended to show what the authors termed a ‘compounded’ reaction in which depression, psychotic behavior, acting-out behavior, (alcoholism, drug abuse and sexual promiscuity) combined with the difficulties mentioned above. The Center for Rape Concern at Philadelphia General Hospital followed 70-100 rape victims of all ages each month beginning October, 1970. Peters (1975a, b) reported that analysis of several hundred cases revealed one or more post-rape changes in 73% of the victims. Twenty-seven percent reported fear of strange men; 22% experienced decreased sexual desire; 20% had trouble sleeping; 20% had an increased number of frightening dreams (higher in adults than minors); 17% were more withdrawn emotionally (higher in minors than adults); 10% feared offender retaliation for reporting the crime; 10% feared all men; 10% feared being raped again. Finally, Peters reported that 10% were clinically depressed.
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In trying to ascertain why previous investigators generally failed to note clinical phenomena which, to us, were quite pronounced, we can suggest a number of possibilities. Probably foremost among those is that our data are drawn from a systematic evaluation of subjects making use of well-validated psychometric instruments, structured interviews and formal psychological evaluation techniques. A second possible explanation is that both the investigators and the counselors are operating from a specifically psychological framework; this was true for only a portion of the earlier investigators in this area. An additional possible explanation is that the particular population of rape victims in our study may have been more dysfunctional prior to the assault than those seen in previous studies. In general, the women in our study had multiple life problems including family discord, economic problems and physical health problems, to which the sexual assault was an added complication. Finally, the women in our study were followed closely over time. Only Sutherland and Scherl (1970), one of the two previous groups to identify depression in rape victims, had a comparable amount of contact with rape victims over a comparable time period. It may be that there is a particular period in the recovery from rape when depressive symptoms are prominent. This might account for why both those who studied victims in the emergency room immediately after an assault as well as those who studied women who were several years post-attack would fail to see depressive symptoms. Among those victims who do begin to appear depressed within the first month after the assault, it is probable that most would no longer be so classified 6 months later. However, if we assume, as some have suggested, (Miller et al. 1979), that the response to rape bears strong similarities to a grief reaction, we would then expect that a certain percentage of victims would remain depressed at one year as did a percentage of the widows in the Bornstein et al. (1973) study of grief reaction. Certainly, our clinical experience suggests that there are women who remain depressed many years after a sexual assault and point to the assault, whether correctly or not, as the event which precipitated their depression. Clearly, the results described in this report do not represent a comprehensive or systematic evaluation of affective disorder in a population of rape victims. At the outset of our study we were interested primarily in symptoms of fear and anxiety and were ourselves surprised by the extent to which our population exhibited depressive symptoms. The current report suggests that clinicians of all disciplines working with victims of sexual assault should be alert to the presence or emergence of depression in this ‘at risk’ population. It also points out the need to determine whether specific intervention directed at depressive symptoms is effective in reducing either the intensity or duration of such symptoms and, if so, what type of treatment offered at what point in the recovery process is likely to produce the most rapid and durable treatment effects.
277 ACKNOWLEDGEMENTS
This research was supported by National Institute of Mental Health Grants MH-29692 and MH-30915. The authors gratefully acknowledge the assistance of David J. Kupfer, M.D. Director of Research at Western Psychiatric Institute and Clinic. REFERENCES Amir, M., Patterns of Forcible Rape, University of Chicago Press, Chicago, 1971, pp. l394. Beck, A.T., Ward, C.H., Mendelsohn, M., Mock, J. and Erbaugh, J., An inventory for measuring depression, Arch. Gen. Psychiat., 4 (1961) 561-571. Bornstein, P.E., Clayton, P.J., Halikas, J.A., Maurice, W.L. and Robins, E., The depression of widowhood after thirteen months, Brit. J. Psychiat., 122 (1973) 561-566. Burgess, A.W. and Holmstrom, L.L., Crisis counseling requests of rape victims, Nurs. Res., 23 (1974a) 196-202. Burgess, A.W. and Holmstrom, L.L., Rape trauma syndrome, Amer. J. Psychiat., 31 (1974b) 981486. Halleck, S.L., The physician’s role in management of victims of sex offenders, J. Amer. Med. Ass., 180 (1962) 273-278. Miller, W.R., Williams, A.M. and Bernstein, M.H., The effects of rape on marital and sexual adjustment. Paper presented at the 5th Annual Meeting of the American Society for Sex Therapy and Research, Philadelphia, 1979. Notman, M.T. and Nadelson, C.C., The rape victim - Psychodynamic considerations, Amer. J. Psychiat., 133 (1976) 408-413. Peters, J.J., Social, legal and psychological effects of rape on the victim, Pennsylv. Med., 78 (1975a) 34-36. Peters, J.J., Social psychiatric study of victims reporting rape. In: Scientific Proceedings of the 128th Annual Meeting, American Psychiatric Association, Washington, 1975b, pp. 111-112. Queen’s Bench Foundation, Rape Victimization Study, Queen’s Bench Foundation, San Francisco, 1976, pp. 1 l-29. Spitzer, R.C., Endicott, J. and Robins, E., Research diagnostic criteria, Arch. Gen. Psychiat., 35 (1978) 173-782. Sutherland, S. and Scherl, D.J., Patterns of response among victims of rape, Amer. J. Orthopsychiat., 40 (1970) 503-511.
