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. Author manuscript; available in PMC: 2019 Nov 1.
Published in final edited form as: Psychol Trauma. 2017 Nov 20;10(6):628–635. doi: 10.1037/tra0000335

The Impact of Comorbid Diagnoses on the Course of PTSD Symptoms in Residents of Battered Women's Shelters

Katherine M Fedele 1, Nicole L Johnson 2, Jennifer C Caldwell 3, Yuliya Shteynberg 4, Sarah E anders 5, Samantha C Holmes 6, Dawn M Johnson 7
PMCID: PMC5960595  NIHMSID: NIHMS920627  PMID: 29154591

Abstract

Objective

The current investigation sought to explore the impact of the comorbidities of substance use disorder (SUD), major depressive disorder (MDD), and borderline personality disorder (BPD) on the trajectory of intimate partner violence (IPV) related posttraumatic stress disorder (PTSD) symptoms across a 6-month follow-up period in IPV survivors who seek shelter. Research has found significant comorbidity of SUD, MDD, and BPD with PTSD (see Green et al., 2006; Kessler, 1995; Pagura et al., 2010); however little to no research has explored these relationships in this unique population over time.

Method

A sample of 147 residents of battered women's shelters completed study measures at baseline and 1-week, 3- and 6-months following shelter stay. Participants completed measures assessing for demographics, abuse, and DSM-IV-TR diagnoses.

Results

Results of Latent Growth Modeling (LGM) with the time-invariant covariates of SUD, MDD, and BPD yielded a significant effect of SUD (β = .002, p = .007) on the slope of IPV-related PTSD symptoms controlling for IPV victimization. Significant effects were not identified for BPD (β = .001, p > .05) or MDD (β = .002, p > .05). Results suggest IPV survivors with SUD demonstrated less improvement in PTSD symptoms over six months after they left shelter as compared to women without SUD.

Conclusion

Findings emphasize the deleterious effects of SUD, above and beyond MDD and BPD, on IPV-related PTSD and highlight the need for assessment and treatment of SUD and PTSD simultaneously in residents of battered women's shelters.

Keywords: Intimate partner violence, PTSD, substance use disorders, comorbidity

Introduction

Intimate partner violence (IPV) is a pervasive social and health issue, with approximately 1/3 of women reporting a history of IPV (Black, Sussman, & Unger, 2010). Research has found that posttraumatic stress disorder (PTSD) has a lifetime prevalence of 11.7% in women in the United States (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Specifically, Black, Latina, and White women often have the highest prevalence rates of IPV (Caetano, Field, Ramisetty-Minkler, & McGrath, 2005; Capaldi, Knoble, Shortt, & Kim, 2012). PTSD is highly prevalent in victims of IPV, with prevalence rates varying from 31-84% worldwide (Jones, Hughes, & Unterstaller, 2001). Furthermore, PTSD is associated with significant morbidity, often co-occurring with other disorders, including substance use disorder (SUD), major depressive disorder (MDD), and borderline personality disorder (BPD) (Green et al., 2006; Kessler, 1995; Pagura et al., 2010). Among women, the lifetime co-occurrence rate of SUD and PTSD is 28% in the U.S. (Kessler, 1995). The prevalence ratings of SUD-PTSD in IPV survivors specifically are limited. However, one study conducted in the U.S. found 45-50% of women in an outpatient sample with both morbidities (N = 58) experienced IPV in the past year (Najavits, Sonn, Walsh, & Weiss, 2004). Research also estimates high co-occurrence rates of PTSD and MDD (30-55%) and PTSD and BPD (24-56%) in IPV populations in the United States (Edmond, Bowland, & Yu, 2013; Harned, Rizvi, & Linehan, 2010; Kelly, 2010). The current study represents an initial attempt to investigate the impact of these comorbid diagnoses on the course of IPV-related PTSD symptoms in IPV survivors who seek shelter.

IPV, relative to many other traumatic events, is pervasive and chronic. Unlike victims of single traumatic events, IPV survivors face the ongoing threat of trauma from their abuser, often long after the relationship has ended (Dutton, 1992). Frequently, IPV survivors have continuing contact with their abuser, especially when co-parenting (Dutton, 1992). IPV survivors who seek shelter are particularly unique in that they tend to report more severe IPV and related injury, as well as higher rates of IPV-related PTSD relative to IPV survivors who do not seek shelter (Jones et al., 2001; Kemp, Rawlings, & Green, 1991). Women who seek shelter also are likely to be unemployed, receive government assistance, and generally have low socio-economic status (Johnson, Johnson, Perez, Palmieri, & Zlotnick, 2016; Panchanadeswaran & McCloskey, 2007). In addition, IPV-related PTSD is associated with significant impairment and can interfere with shelter women's ability to effectively utilize shelter resources to establish safety for themselves and their children (Johnson, Zlotnick, & Perez, 2008).

IPV-related PTSD and SUD

Extensive empirical evidence indicates an association between IPV and SUD in women who do not seek shelter (Cohen, Field, Campbell, & Hien, 2013; Golding, 1999; Smith, Homish, Leonard, & Cornelius, 2012). The relationship between IPV and SUD can be bidirectional, with women who abuse substances more likely to experience IPV, and experiencing IPV associated with greater substance use (Devries et al., 2014; Weaver, Gilbert, El-Bassel, Resnick, & Noursi, 2015). IPV survivors with SUD may have an increased risk of relapse and re-traumatization (Devries et al., 2014; Gilbert et. al., 2006; Peters, Khondkaryan, & Sullivan, 2012).

A meta-analysis (Golding, 1999) found the prevalence of alcohol use disorder among female IPV survivors ranged from 6.6% to 44%, with an average prevalence of 18% across 10 studies. Further, drug abuse among IPV survivors ranged from 7% to 25%, with an average prevalence of 9% across four studies. One study included in Golding's (1999) meta-analysis (McCauley et al., 1995) examined differences between women reporting experiencing IPV within the last year and those denying such experiences within a primary care setting (N = 1952). Of these women, 5.5% (n=108) endorsed experiencing IPV within the last year and were significantly more likely to report abusing drugs or alcohol compared to those denying experiences of IPV (McCauley et al., 1995). This finding has been replicated in recent research examining the relationship between IPV and SUD (Devries et al., 2014; Najavits et al., 2004; Peters et al., 2012; Weaver et al., 2015). Despite the strong empirical evidence supporting the association between IPV and SUD in non-shelter seeking women, there are little to no studies specifically examining this relationship within shelter populations.

Further, little research on SUD and IPV-related PTSD has been explored longitudinally. Cohen and colleagues (2013) examined IPV outcomes of women with comorbid PTSD-SUD (N = 288; 44% White, 37% Black, 13% Multi-racial, 7% Latina) in a one-year longitudinal study. The authors found that participants who were abstinent from drugs and alcohol at baseline were significantly less likely to experience IPV over the one year follow up period, while severity of PTSD symptoms was not associated with IPV over follow-up. Comorbid diagnoses, such as MDD and BPD, were not assessed, which may have influenced the study's findings. In another study, Najavits and colleagues (2007) examined six-month treatment outcomes in cocaine-dependent individuals with PTSD (n = 34) and without PTSD (n = 394) in a multisite randomized control trial. Within this study, individuals with comorbid SUD-PTSD were significantly more impaired at baseline and remained so across time compared to those with SUD alone. Moreover, the individuals with SUD-PTSD improved significantly less across time than those with SUD alone. Of note, this sample was broad in scope including survivors of various types of trauma and IPV survivors who did not seek shelter.

Comorbid PTSD-MDD in IPV Survivors

As previously mentioned, research demonstrates high rates of comorbidity between MDD and PTSD, with rates ranging from 30-55% in IPV survivors (Edmond et al., 2013; Kelly, 2010). Further demonstrating this comorbidity, Fedovskiy, Higgins, and Paranjape (2007) found that in a sample of Latina immigrant women (N= 105) from a primary care clinic individuals who met criteria for PTSD (19%) were 10 times more likely to have comorbid MDD than those who did not have PTSD. Additionally, women with a history of IPV had three times the odds of having PTSD, and almost twice the odds of having MDD, than those without an IPV history. In a longitudinal, randomized controlled depression treatment trial, Green and colleagues (2006) assessed low-income Black, Latina, and White women (N= 267) in a metropolitan area. Of these women, 65% were uninsured and 60% were below the poverty level. The authors found that women with comorbid MDD and PTSD (n = 175; 40% Black, 50% Latina, 11% White) had significantly higher depressive symptoms over time than those without PTSD (n = 91; 46% Black, 50% Latina, and 3% White) across three different interventions. Also, participants with MDD-PTSD had significantly less social functioning improvement and significantly worse physical functioning across 12 months than those without PTSD.

Comorbid BPD-PTSD in IPV Survivors

In addition to the frequency of comorbidity between MDD and PTSD, research indicates high rates of co-occurring BPD and PTSD ranging from 24-56% in female trauma survivors (Harned et al., 2010; Pagura et al., 2010). Female trauma survivors (i.e., not exclusively IPV survivors) with comorbid PTSD and BPD present with increased severity of clinical symptoms and greater occurrence of lifetime sexual trauma compared to those with either diagnosis alone (Harned et al., 2010). For example, in an outpatient psychotherapy outcome study, Harned and colleagues (2010) found that within a sample of women diagnosed with BPD (n = 94), 56% of participants met criteria for comorbid PTSD. Participants with comorbid BPD-PTSD endorsed significantly greater frequency of lifetime traumatic events and unwanted sexual events, more nonsuicidal self-injury, and higher rates of concurring disorders (e.g., panic disorder) than those with BPD alone. Additionally, Pagura and colleagues (2010) found that participants diagnosed with comorbid BPD-PTSD (n = 643) endorsed a lower quality of life and increased comorbidity with mood, anxiety, and substance use disorders than those with BPD-only (n = 1290) or PTSD-only (n = 1820). Of the 643 participants with comorbid BPD-PTSD, 66% identified as female, 62% White, 18% Black, and 12% Latino/a. Those with both diagnoses also had higher odds of a lifetime suicide attempt and a greater number of repeated childhood traumas. Furthermore, individuals with comorbid BPD-PTSD endorsed higher symptoms of both BPD and PTSD than those with either BPD or PTSD alone.

Additional Considerations

To examine the unique effects of SUD, MDD, and BPD on IPV-related PTSD, it is crucial to recognize the potential influence of additional factors including: socioeconomic status (SES), treatment involvement, presence of other comorbid diagnoses, and revictimization of partner violence. Research suggests these factors may be influential on IPV-related PTSD, with women reporting IPV within the last year more likely to have a household income less than $20,000 and to receive governmental assistance (McCauley et al., 1995; Pagura et al., 2010); women receiving treatment demonstrating significant reductions in IPV-related PTSD over time (Johnson et al., 2016); decreased prognosis associated with comorbidity (Harned et al., 2010; Pagura et al., 2010); and women experiencing revictimization reporting greater symptom severity than those denying revictimization (Krause, Kaltman, Good, & Dutton, 2008). Thus, it appears critical for future research to control for the influence of these variables on IPV-related PTSD, especially with women residing in shelter given their unique vulnerability (Jones et al., 2001; Johnson et al., 2016; Kemp et al., 1991; Panchanadeswaran & McCloskey, 2007).

The Current Study

Given the significant comorbidity and deleterious effects of SUD, MDD, and BPD with PTSD, it is essential to examine the impact of these diagnoses on IPV survivors in shelter, as little to no research has explored these relationships in this unique population over time. Extant research findings on the impact of these comorbid diagnoses on PTSD may not generalize to PTSD from IPV in shelter women. Because of the chronicity of abuse and subsequent risk for re-victimization experienced by IPV survivors who seek shelter, as well as the impact IPV-related PTSD may have on IPV victims' long-term safety, more research on this vulnerable population is greatly needed. The present study is an attempt to address these gaps in the literature. To our knowledge, the current study is the first to examine the impact of MDD, SUD, and BPD simultaneously on the trajectory of IPV-related PTSD symptoms, in a sample of women residing in battered women's shelters. It is hypothesized that women with a co-occurring diagnosis of MDD, SUD, or BPD at baseline (in shelter) would exhibit more severe PTSD symptoms after leaving shelter relative to women without one of these comorbid diagnoses at baseline. Given the multitude of factors that can influence IPV-related PTSD in shelter women discussed above, receipt of treatment outside shelter, abuse across follow-up, receipt of public assistance, and presence of other comorbidities were initially controlled for in all analyses.

Methods

Participants and Procedures

One hundred and forty-seven women residing in one of two battered women's shelters in the Midwest were enrolled in the current study. Participants' ages ranged from 19 to 64 with a mean age of 36, SD = 9. Consistent with the shelter population sampled from, a majority of the sample identified as Black, n = 90, 61%, with remaining participants identifying as White, n = 57, 39%, and n = 13, 9%, endorsing Latina descent (See Table 1 for additional demographic information). The majority of participants, n = 91, 61.9%, reported receiving public assistance (e.g., Medicaid, food stamps) suggestive of low socioeconomic status. Several participants engaged in psychiatric treatment outside of shelter (i.e., therapy and/or psychotropic medication) across the follow-up period: one-week post-shelter (PS) n = 77, 65.8%; 3-months post-shelter (3PS) n = 40, 35.4%; 6-months post-shelter (6PS) n = 51, 43.2%. All participants received standard shelter services which included safe housing and safety planning, a therapeutic milieu, psychoeducation, and case management. Participants were not provided treatment for PTSD symptoms or comorbid diagnoses by research or shelter staff. The majority of participants reported IPV victimization across the follow-up period: PS n = 94, 64.63%; 3PS n = 82, 55.78%; 6PS n = 70, 47.62%. The majority of participants, 66.7%, met DSM-IV-TR criteria for current IPV-related PTSD at baseline; 12.9% met criteria for current SUD, 29.3% for BPD, and 53.1% for current MDD. Further, over half of the participants, n = 83, 56.5%, met criteria for an additional mood/anxiety disorder according to the DSM-IV-TR. For additional sample characteristics at baseline, see Table 2.

Table 1. Sample Demographic Characteristics (N = 147).

n %
Race/Ethnicity
 Black 90 61.2
 White 57 38.8
 Latina 13 8.8
Highest Education Obtained
 Less than high school 35 23.8
 Graduated from high school/GED 50 34.0
 Completed some college 48 32.7
 Graduated from college/beyond 14 9.5
Employed 31 21.1
Public Assistance 91 61.9
Marital Status
 Single, never married 42 28.6
 Married 11 7.5
 Separated 37 25.2
 Divorced 27 18.4
Living with Abuser 113 76.9
Sexual Orientation
 Heterosexual 134 91.2
 Lesbian 13 13
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Note. IPV = intimate partner violence

Table 2. Sample Characteristics at Baseline (N = 147).

n %
IPV-related PTSD 98 66.67
SUD 19 12.93
BPD 43 29.25
MDD 78 53.06
PTSD-SUD 15 10.20
PTSD-BPD 34 23.13
PTSD-MDD 64 43.54
Other Mood Dx 39 26.53
Other Anxiety Dx 67 45.57
Psychiatric Treatment 45 30.60
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Note. IPV-related PTSD = intimate partner violence related post-traumatic stress disorder; SUD = Substance Use Disorder; BPD = Borderline Personality Disorder; MDD = Major Depressive Disorder; PTSD-SUD = Comorbid IPV-related PTSD and SUD; PTSD-BPD = Comorbid IPV-related PTSD and BPD; PTSD-MDD = Comorbid IPV-related PTSD and SUD; Other Mood/Anxiety Dx = additional (beyond PTSD, SUD, BPD, and MDD) mood or anxiety diagnosis according to the SCIP I/P; Psychiatric Treatment = individual therapy within the 6 months prior to shelter and/or active use of psychotropic medication.

Recruitment was conducted through a series of strategies, including disseminating flyers and brochures and attending shelter meetings. If interested, participants were instructed to call the research office and complete a phone screen assessing whether they were current shelter residents and endorsed IPV as their reason for coming to shelter. Following completion of the phone screen, eligible participants were invited to participate in a baseline interview. Follow-up interviews were completed at 1-week, 3- and 6-months following shelter stay. Retention rates for each follow-up assessment were: 80% at one-week post-shelter (PS) (n = 118), 78% at 3-months post-shelter (3PS) (n = 115), and 81% at 6-months post-shelter (6PS) (n = 119). Data for all follow-up periods were completed by 70% of participants (n = 103). All interviews were completed by trained graduate students under the supervision of a licensed psychologist in safe, confidential locations. Sullivan and Cain's (2004) ethical and safety guidelines for conducting research with women with IPV were followed throughout the research period. Baseline interviews occurred in a private room at the shelters and follow-up interviews were completed at private, safe, and convenient locations for the participants (e.g., participants' home, public library conference room). Participants were compensated $50 for each assessment.

Measures

The Clinician Administered PTSD Scale (CAPS; Blake et al., 1995) was utilized to assess IPV-related PTSD diagnosis and past-month symptom severity at all time points (baseline, 1-week, 3-months, and 6-months post shelter). The CAPS is a 30-item semi-structured interview that assesses DSM-IV-TR (2000) PTSD symptom frequency and intensity. Frequency is rated on a 5-point Likert scale, ranging from 0 (never) to 4 (daily or almost every day). Symptom intensity is also rated on a 5-point Likert scale, ranging from 0 (absent) to 4 (extreme). PTSD severity is calculated by adding the frequency and intensity scores for each symptom cluster. Higher scores indicate greater severity of symptoms. The CAPS has established reliability and validity (Weathers, Keane, & Davidson, 2001) and has shown good internal consistency, with alphas ranging from .73 to .85, as well as concurrent validity with other empirically validated PTSD measures, including the Mississippi Scale for Combat Related PTSD, the PTSD subscale of the Minnesota Multiphasic Personality Inventory (MMPI), and the Combat Exposure Scale (r's = .42 to .84) (Blake et al., 1995). Inter-rater reliability for diagnosing IPV-related PTSD from the CAPS was established with 21 randomly selected interviews (κ = .83). The CAPS evidenced excellent internal reliability for symptom frequency and intensity in this study (α = .93).

To assess SUD and MDD comorbidity at baseline, the mood and substance use modules of the Structured Clinical Interview for Axis I Disorders (SCID-I/P; First, Spitzer, Gibbon, & Williams, 2002) was used to assess current (i.e., past month) DSM-IV-TR diagnostic status. BPD was assessed with the BPD module of the Structured Clinical Interview for Axis II Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997). Further, to control for the potential impact of other comorbid diagnoses, a categorical variable was created utilizing data from the SCID I/P anxiety and mood modules. Participants were coded as ‘0’ if they met criteria for PTSD, MDD, SUD, or BPD only. Conversely, participants were coded as ‘1’ if they met criteria for any additional mood or anxiety disorders according to the SCID I/P. Both measures have established reliability and validity and are considered the benchmark structured interview for clinical diagnoses (First & Gibbon, 2004; Lobbestael, Leurgans, & Arntz, 2011). Interrater reliability was calculated for the current sample's most frequent comorbid diagnosis, Major Depression, for 16 randomly selected interviews (κ = .87).

The Conflict Tactics Scale second edition (CTS-2; Straus, Hamby, McCoy, & Sugarman, 1996) was used to assess participant's intimate partner violence (IPV) victimization across time points: baseline, 1-week, 3-months, and 6-months post shelter. Participants rated the frequency of behaviorally defined acts of violence utilizing a 7-point Likert scale 0 (never) to 6 (more than 20 times in the past month). To establish an overall severity score across time points, an average was calculated combining baseline, 1-week, 3-months, and 6-months post shelter victimization scores. The CTS-2 has demonstrated reliability and validity with alphas ranging from .79 to .95 (Straus et al., 1996). Cronbach's alphas ranged from .96 to .97 for the current sample demonstrating excellent internal consistency.

Statistical Analyses

Latent growth modeling (LGM) with time-invariant independent variables (i.e., SUD, BPD, and MDD) was used to evaluate group differences in IPV-related PTSD symptoms over time while controlling for IPV victimization across time. Time scores were specified due to nonequidistant time between longitudinal data points resulting from differing lengths of shelter stay. Data were analyzed using Mplus (Muthen & Muthen, 2010). Given the potential influence of socioeconomic status (measured via receipt of public assistance), other comorbid diagnoses at baseline and psychiatric treatment across the follow-up period on IPV-related PTSD, a LGM was initially run controlling for these variables. Given that none of these covariates significantly influenced IPV-related PTSD and inclusion of these variables did not significantly impact findings, for purposes of readability and retention of sample size, data is reported without including these variables as covariates.

Results

Pearson's chi-squared tests were conducted to identify any demographic differences between those lost at follow-up and those retained throughout the follow-up period. No differences were identified. Additionally, data were screened for pattern of missingness and found to be missing completely at random (MCAR) according to Little's MCAR test, χ2 (16) = 20.81, p = .19. Therefore, full information maximum likelihood (FIML) was utilized to account for missing data and all participants were included in the analyses. Finally, data was explored for normality and CAPS scores were determined to be positively skewed at baseline; therefore, CAPS scores were log transformed to increase normality. Following the transformation, CAPS scores demonstrated normality.

Results of the LGM with time-invariant independent variables (i.e., SUD, BPD, and MDD) and average IPV victimization across time as a covariate yielded a significant effect of SUD on the slope of IPV-related PTSD symptoms, with those with SUD reporting less decline in PTSD symptoms over time as opposed to those without SUD (see Table 3 and Figure 1 for means across follow-up). Significant effects were not identified for BPD or MDD when all four variables were included in the model, thus demonstrating the role of SUD on IPV-related PTSD above and beyond MDD and BPD. Further, IPV victimization across time, M = 9.41, SD = 6.27, was identified as a significant covariate on the slope of IPV-related PTSD symptoms, with more IPV victimization across time predicting less decline in PTSD symptom over time (see Table 4 for model statistics).

Table 3. IPV-Related PTSD Symptoms across Follow-Up by Substance Use Disorder (N = 147).

SUD (n = 19) No SUD (n = 128)
M SE M SE
Baseline 65.21 6.64 51.64 2.68
Post Shelter 37.57 6.90 40.12 2.78
3-months Post Shelter 42.28 5.80 27.17 2.34
6-months Post Shelter 32.80 6.48 24.91 2.62
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Note. IPV-related PTSD = intimate partner violence related posttraumatic stress disorder; SUD = substance use disorder; M = mean; SE = standard error; values are corrected controlling for major depressive disorder, borderline personality disorder, and IPV victimization.

Figure 1. Change in IPV-related PTSD symptoms across time by Substance Use Disorder.

Figure 1

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Table 4. Latent growth model showing predictors of IPV-related PTSD symptoms over time.

Variables IPV-related PTSD symptoms over time
Estimate SE p value
SUD 0.002 0.001 .007
BPD 0.001 0.001 .437
MDD 0.002 0.001 .111
IPV victimization 0.000 0.000 .007
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Note. Estimates are unstandardized value; IPV-related PTSD = intimate partner violence related post-traumatic stress disorder; SUD = Substance Use Disorder; BPD = Borderline Personality Disorder; MDD = Major Depressive Disorder; IPV victimization = average experience of intimate partner violence across time points.

Due to the significant effect of IPV victimization on IPV-related PTSD symptoms over-time a post-hoc analysis was conducted exploring the potential interaction between SUD and IPV victimization. A significant interaction was not identified, β < .000, SE < .000, p = .576, suggestive of unique main effects for both SUD and IPV victimization on the course of IPV-related PTSD symptomology.

Discussion

The current study represents the first attempt, to our knowledge, to examine the impact of MDD, SUD, and BPD, concurrently, on the course of IPV-related PTSD symptoms in women residing in shelter. Overall, results suggest that SUD is associated with a significantly worse course of IPV-related PTSD symptoms in survivors who seek shelter. More specifically, IPV survivors with current SUD demonstrated less improvement in IPV-related PTSD symptoms over the six months after they left shelter as compared to women without SUD. Further, when SUD was included in the model, MDD and BPD did not significantly impact the course of IPV-related PTSD symptoms while controlling for IPV victimization (see Figure 1). IPV victimization was also found to significantly impact the course of PTSD, with women encountering IPV victimization across follow-up experiencing less reduction in PTSD symptoms (see Table 4). The finding that IPV impacts the course of IPV-related PTSD is not surprising, as previous research demonstrates an association between re-victimization and PTSD symptom severity over time in IPV survivors (Krause et al., 2008). Of note, the interaction between IPV victimization and SUD was not significant, suggesting a unique impact for both SUD and IPV victimization on the course of IPV-related PTSD symptoms. Sociocultural and other contextual factors (i.e., SES, other comorbidities, receipt of psychosocial or psychiatric treatment) did not have a significant impact on IPV-related PTSD, further highlighting the importance of SUD on the course of PTSD symptoms in this vulnerable population.

Although MDD and BPD independently have been found to have significant longitudinal effects on PTSD in IPV survivors (e.g., Green et al., 2006; Harned et al., 2010), it appears that these co-occurring disorders may not be as relevant to the course of IPV-related PTSD symptoms in this unique population. Additionally, previous longitudinal studies had not examined SUD, MDD, and BPD together, which may have influenced previous studies' findings (e.g., Cohen et al., 2013; Green et al., 2006; Harned et al., 2010). Given SUD's significant effect on the course of IPV-related PTSD above and beyond MDD and BPD, focusing on the treatment of SUD-PTSD may be more critical than MDD and BPD in IPV survivors leaving shelter. These findings suggest the prioritization of SUD treatment for women with IPV-related PTSD residing in shelter. On the whole, these findings add to the current literature (e.g., Cohen et al., 2013; Najavits et al., 2007; Peters et al., 2012) by demonstrating the detrimental effect of SUD on the course of IPV-related PTSD, while suggesting meaningful clinical implications.

The findings of the current study suggest a number of important implications for treatment and standard shelter services. Interestingly, 1-week after leaving shelter, IPV survivors with and without current SUD reported, on average, similar PTSD symptom severity (see Table 3). Thus, the supportive and safe environment of shelter (e.g., case management, support services, companionship with other IPV survivors in shelter, monitored environment) may help to decrease PTSD symptoms, in particular with women with SUD, as they may have less access, means, or desire to use substances while in shelter (Perez, Johnson, Walter, & Johnson, 2012). However, at 3-months after leaving shelter, women with SUD endorsed greater PTSD symptomatology than they reported 1-week after leaving shelter, whereas women without SUD showed a steady decline in PTSD symptoms at 3- and 6-months. This may suggest that without the supportive environment of shelter, IPV survivors with SUD are at increased risk for relapse or escalation of use, and re-victimization after leaving shelter. This would be consistent with previous studies that have found a bidirectional relationship between IPV and SUD (Devries et al., 2014; Weaver et al., 2015), potentially resulting in greater PTSD symptoms. Previous research has found that SUD may complicate the course of PTSD over time in various populations (see Jacobsen, Southwick, & Kosten, 2001). For example, Read, Brown, and Kahler (2004) found that individuals in inpatient SUD treatment with alcohol use disorders reported a greater number of PTSD re-experiencing symptoms than those without alcohol use disorders over a 6-month follow-up period. In a literature review, Jacobsen and colleagues (2001) explain that withdrawing from substances may increase physiological arousal, thus triggering an increase in PTSD re-experiencing symptoms in individuals with comorbid SUD-PTSD. This may lead to continued substance use as an attempt to decrease arousal and re-experiencing symptoms (e.g., coping). Thus, IPV survivors with comorbid SUD-PTSD may become caught in a cycle of avoidance, utilizing substances to cope with their increased PTSD symptoms, which in turn may result in additional symptomology requiring further use to temporarily reduce distress.

Accordingly, the 3-month period post shelter may be a crucial time to intervene with IPV survivors with a history of SUD and PTSD. Although the standard services provided during shelter are helpful in decreasing PTSD symptoms, these services may not have long-lasting effects for women with comorbid SUD-PTSD. The current study highlights the need to go beyond standard shelter services to more effectively address co-occurring SUD-PTSD in IPV survivors. Dual SUD-PTSD treatment may help to prevent relapse and increase the longevity of symptom reduction. Specifically, an ideal time for SUD-PTSD treatment may be while women are residing in shelter or shortly after shelter termination, given the finding that women with SUD, within the present study, demonstrated significant deterioration in PTSD symptoms at 3-and 6-months post-shelter. However, it is important to recognize that many shelters may not have the funding and resources to provide evidenced-based treatment for SUD-PTSD concerns, which is a larger systemic issue to keep in mind and suggests the importance of increased funding for shelters to provide adequate services to survivors.

Strengths of the current study include the longitudinal design and use of standardized interviews with established reliability to assess the occurrence and severity of PTSD symptoms. Further, the current sample is racially diverse, with a majority of women identifying as Black. This is consistent with previous research that has found that rates of IPV tend to be higher in Black women than in Whites and Latinas (Caetano et al., 2005). Approximately 62% of the women in the current study's sample were receiving public assistance and 79% were unemployed at baseline, which is similar to previous studies sampling women in shelters (see Table 1; Johnson et al., 2016; Panchanadeswaran & McCloskey, 2007). Although a detailed discussion of the impact of socio-demographic factors on SUD-PTSD in IPV survivors is outside the scope of the current study, it is important to acknowledge that these factors play a role in the experiences of IPV survivors who seek shelter. Finally, unlike previous longitudinal studies examining the course of PTSD (e.g., Cohen et al. 2013), the current study assessed SUD, MDD, and BPD, concurrently, on the trajectory of PTSD. The inclusion of common comorbid diagnoses and examination of potential covariates (i.e., IPV victimization, socio-economic status, other mood/anxiety disorders, and psychiatric treatment) led to a cleaner picture of SUD's impact on PTSD longitudinally.

In light of these strengths, it is important to identify current limitations. One limitation is the lack of generalizability beyond IPV survivors who seek shelter, as women who seek shelter often present with more severe clinical profiles. In addition, findings may not generalize to survivors of other types of traumatic events or to survivors from other racial or ethnic backgrounds, or socio-economic statuses not represented within the current sample. Future research could explore how socio-cultural factors of IPV survivors who seek shelter may impact their SUD and PTSD outcomes. Additionally, the majority of women within the current sample did not meet criteria for SUD and substance use was not assessed at follow-up time points. Thus, future research should explore the longitudinal impact of SUD on IPV-related PTSD at each time point with a larger sample of women endorsing SUD. Given the limited number of women with a diagnosis of SUD, it was not feasible to explore differences between types of substances used (e.g., alcohol versus drug). Future research could explore these differences in a larger sample, in order to inform the development of efficacious interventions.

Conclusions

Our findings suggest that SUD is associated with a more severe course of IPV-related PTSD in shelter women, above and beyond comorbid diagnoses of MDD and BPD, while controlling for IPV victimization. Given that MDD and BPD did not have a significant effect on IPV-related PTSD symptoms over time, treating co-morbid MDD-PTSD and BPD-PTSD may not be as pertinent for women initially residing in shelter and shortly after leaving shelter. The current findings, as well as the potential of re-victimization, relapse, and/or escalation of substance use in IPV survivors (Devries et al., 2014; Gilbert et. al., 2006; Peters et al., 2012) strongly support addressing both SUD and PTSD in IPV survivors who seek shelter. Typically, standard shelter services do not include chemical dependency intervention given the limited funding and resources and variety of needs of survivors in shelter (see Johnson, Zlotnick, & Perez, 2011); however, current results highlight the importance of integrating such services within the shelter setting and thus, need to identify solutions to the barriers to integration. In addition, these findings reinforce the extant research in support of comorbid SUD-PTSD treatment beyond standard shelter services. The findings also highlight the necessity of assessing and treating SUD-PTSD simultaneously in IPV survivors while residing in shelter or shortly after leaving shelter and following up with these women for at least 3-months post-shelter (Najavits et al., 2007; Weaver et al., 2015). Given the current findings, additional longitudinal research on the impact of SUD on PTSD symptoms in this vulnerable population is sorely needed to help inform integrated SUD-PTSD interventions that will increase the long-term safety of women who seek shelter.

Acknowledgments

This research was supported by NIMH grant K23 MH067648 and pilot funds from the Summa-Kent State Center for the Treatment and Study of Traumatic Stress. We would like to thank Sara Perez, Cynthia Cluster, Keri Pinna, Brigette Shy, and the Battered Women's Shelter of Summit and Medina Counties for their assistance in data collection.

Footnotes

Clinical Impact Statement: Findings suggest the need to go beyond standard shelter services to more effectively address and treat co-occurring SUD-PTSD in IPV survivors.

Contributor Information

Katherine M. Fedele, The University of Akron

Nicole L. Johnson, Lehigh University

Jennifer C. Caldwell, Ohio Guidestone

Yuliya Shteynberg, University of North Texas

Sarah E. anders, The University of Akron

Samantha C. Holmes, The University of Akron

Dawn M. Johnson, The University of Akron

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