Sex Differences in Traumatic Events and Psychiatric Morbidity Associated to Probable Posttraumatic Stress Disorder among Latino Prisoners

Abstract

Latinos comprised 17.1% of the U.S. population and 33.1 % of US prisoners, yet they are underrepresented in the psychopathology literature. Despite higher rates of trauma among incarcerated individuals than in the general population, most of the previous research in this area focused primarily on women samples, and very few studies examined sex differences in PTSD and traumatic experiences. In addition, there is a need for research assessing traumatic experiences and probable PTSD in men and women Latino inmates to inform culturally competent care and sex sensitive care for this vulnerable and underserved population. Our study examined whether men and women Latino inmates with probable Posttraumatic Stress Disorder (PTSD), based on the cut off 40 or more symptoms on the Davidson Trauma Scale (DTS), differed significantly by the number of event types experienced, the type of potentially traumatizing event, and in co-occurring psychiatric conditions. A multi-stage sample design was used to select a probabilistic sample of 1,331 inmates from 26 penal institutions in PR of which 1179 participated in the study. Bivariate associations were calculated for each type of traumatic event and probable PTSD. Mean number of types of potentially traumatizing event experienced was comparable for both sexes (F= 3.83, M=3.74) yet sex differences were found in the nature of the event. Women with probable PTSD had higher rates of experiencing rape and sexual abuse. Men had higher rates of experiencing combat in war, a life-threatening accident, of witnessing violence, and being threatened with a weapon. Men with significant ADHD symptoms in childhood and with Generalized Anxiety Disorder (GAD) during adulthood were almost 5 and 7 times as likely to score above threshold on the DTS whereas women were >3 times as likely in the presence of ADHD symptoms in childhood or depression during adulthood. This study underscores the need to improve understanding of the clinical manifestations of trauma and co-occurring psychiatric conditions for appropriate sex sensitive interventions targeting Latinos living in prisons.

Compared to the general population, incarcerated individuals demonstrate significantly higher rates of traumatic exposure (Green et al., 2005; Grella et al., 2005). It has been estimated that over 75% of incarcerated individuals are exposed to a substantial number of traumatic events during their lifetimes (Boşgelmez et al., 2010; Huang et al., 2006; Kubiak, 2004). One study reported a mean of 8.1 traumatic events among inmates (Payne et al., 2008). Three primary factors may account for the higher prevalence of traumatic events in the prison population. First, many inmates report being victims of physical and sexual abuse prior to their incarceration (Briere et al., 2016; Grella et al., 2013). Second, exposure to extreme forms of violence may co-occur with their offence (Collins and Bailey, 1990; Pollock, 1999). Third, many inmates experience new traumatic events during their confinement, such as solitary confinement (Hagan et al., 2017) and physical and sexual assaults from other inmates or correctional staff (Kubiak, 2004; Laub and Sampson, 2003; Neal and Clements, 2010; Sindicich et al., 2014).

Available evidence suggests that the number of event types experienced and probable PTSD tend to follow sex-specific patterns (Komarovskaya et al., 2011; Tolin and Foa, 2006; Tolin and Breslau, 2007). For example, in general population, women tend to show lower rates of exposure to traumatic event types but significantly higher rates of PTSD when exposed. In contrast, men experience a greater number of event types, but the risk of developing PTSD is lower (Breslau et al., 2004; Gavranidou and Rosner, 2003; Kessler, 2000). Sex differences are also reported for the type of potentially traumatizing event in incarcerated populations. For example, men are more likely than women to report physical assault, and witnessing someone seriously injured or killed (Gibson et al., 1999). Utilizing a sample of 581 men inmates from various Ohio prisons, Wooldredge (1998) found that approximately 10% reported being physically assaulted, 20% reported being a victim of theft and, 50% reported being a victim of some type of crime while in prison in the previous six months. A study with women found that they are more likely to report childhood physical abuse, intimate partner abuse, sexual abuse before the age of 13, witnessing family violence, sudden death of a loved one, and sexual assault by a stranger (Huang et al., 2006).

It is noteworthy that certain traumas are reported as being more distressing than others. Individuals who reported sexual and childhood trauma, demonstrated greater difficulty disclosing their trauma than those with other traumatic experiences (Bedard-Gilligan et al., 2012). Trauma researchers have found that after exposure to a traumatic stressor, those who tend to develop PTSD report greater difficulty in disclosing their traumatic event and its details compared to those exposed who did not develop PTSD (Foa and Kozak, 1986; Foa and Cahill, 2001).

In addition to the development of PTSD among this vulnerable population, there is also a high prevalence of other co-occurring psychiatric disorders among men and women inmates. One of the most common mental disorders associated with a history of trauma is major depression. According to the Bureau of Justice, 23.5% of inmates in US prisons reported symptoms of major depression, which contrasts to non-imprisoned population estimates of 6.0%–7.9% (James and Glaze, 2006). A study which examined the psychiatric disorders comorbid with PTSD in an inmate sample found that those who had experienced PTSD at some point in their lifetime were more likely to have experienced major depressive disorder, dysthymia and, generalized anxiety disorder than other inmates who had never met criteria for PTSD (Gibson et al., 1999; Karg et al., 2012). Higher comorbidity rates of mental health disorders and Substance Use Disorders (SUD’s) have also been found among inmates. For example, the Bureau of Justice Statistics found that 41.7% of inmates have symptoms or mental health disorders that co-occur with a SUD (James and Glaze, 2006). Lynch and colleagues (2014) found that a majority of the women in prison met criteria for co-occurring PTSD and SUD, with a 12-month prevalence of 32%. In the case of men inmates, co-occurring symptoms of PTSD and SUD have been reported (Chilcoat and Breslau, 1998; Kubiak, 2004; McClellan et al., 1997). High rates of Attention Deficit Hyperactivity Disorder (ADHD) have also been founded for both sexes (Barkley et al., 2008).

Cultural experiences and beliefs influence the interpretation of and reaction to traumatic stressors, expression of PTSD, symptom severity, coping skills for dealing with symptoms, and likelihood of seeking and completing treatment programs (Jobson and O’Kearney, 2008; Stephens et al., 2010; Trepasso-Grullon, 2012). Additionally, type of trauma exposure affect development of PTSD differently across ethnic groups (Brewin et al., 2000). African American and Hispanic adults are more likely than Caucasian adults to report childhood maltreatment, witnessing domestic violence, and war-related events as traumatic events (Alim et al., 2006; Roberts et al., 2011) after controlling for demographic differences (Alim et al., 2006).

In the United States, the lifetime prevalence of PTSD differs slightly between Latinos (4.4% – 7.0%), non-Latino Whites (6.5% –7.4%), and African Americans (8.6% – 8.7%) (Alegria et al., 2008; Roberts et al., 2011). However, when researchers focused on differences in the risk of developing PTSD, of endorsing more severe PTSD symptoms, or of experiencing more persistent PTSD over time, retrospective and prospective research suggests the risk for PTSD is higher among Latinos than non-Latinos (Alcántara et al., 2013; Pole et al., 2008).

Studies on the subject of PTSD in adult prison inmates have been performed mainly with Caucasians and African Americans (U.S. Department of Health and Human Services, 2001). Estimates from the Federal Bureau of Prisons (2017) reveal that 33% of US prisoners are Latinos, but little is known about which type of potentially traumatizing events are associated to PTSD in incarcerated Latinos of both sexes (Komarovskaya et al., 2011) and whether it co-occurs with other psychiatric conditions such as ADHD (González et al., 2015; Komarovskaya et al., 2011; Pole et al., 2005; Roberts et al., 2011; Ruzich et al., 2014; U.S. Department of Health and Human Services, 2001). Although community studies reveal that childhood ADHD is more common among men, among persons in correctional facilities the prevalence has been reported higher for women (Edvinsson et al., 2010; Rösler et al., 2009), yet little is known of whether this difference persists when assessing the co-occurrence of ADHD with PTSD in this population.

Understanding the expression of PTSD among Latinos prisoners has significant clinical implications. First, the effect of interventions for PTSD on co-occurring conditions varies according to the type of psychiatric illness (Driessen et al., 2008; Ouimette et al., 1998). Second, such understanding will enhance providers’ cultural competence in delivery of treatment interventions aimed at addressing and alleviating PTSD (Pole et al., 2008; U.S. Department of Health and Human Services, 2001). In addition, identifying and understanding of the complexity of this issue will provide much needed relevant data to inform rehabilitation and treatment efforts in the correctional setting.

This study contributes to the research literature by focusing on men and women Latino inmates to inform culturally appropriate care for this population. We examine whether men and women from a representative sample of sentenced individuals confined in the Puerto Rico prison system with probable PTSD as defined by the Davidson Trauma Scale (Davidson et al., 1997), a screener for PTSD, differed significantly by the number of event types experienced, the type of potentially traumatizing event, and in co-occurring psychiatric conditions. We hypothesize that: (1) men prisoners will report greater number of traumatic event types when compared to women; (2) probable PTSD will vary by the type of potentially traumatizing event; (3) probable PTSD will vary by the number of event types experienced; and (4) men and women with probable PTSD will not differ in the prevalence of the following co-occurring conditions: childhood ADHD, major depression and generalized anxiety disorder.

Methods

Participants

This study used data from a cross-sectional survey of sentenced inmates in the state prisons of Puerto Rico in 2005–2006 (Albizu-García et al., 2005). A complex probabilistic, multi-stage sample design was used to select a probabilistic sample of 1,331 inmates from 26 penal institutions in PR of which 1179 participated in the study for an 89% response rate. This study was approved by the [removed for blind review].

Measures

The anonymous survey used two computer assisted interview modalities. The Audio Computer Assisted Self Interview (ACASI) that is self-administered was used for sensitive questions such as illicit drug use and experiences of violence during incarceration to reduce socially desirable responses. The remaining questions were formulated using the Computer Assisted Personal Interview (CAPI) that involved a face to face interview by an experienced interviewer assisted by the computer. This tool decreases interview and data entry errors. Both questionnaires were programmed using the Questionnaire Development System version 2.1.

Socio demographic characteristics

In addition to age, sex, marital status, and educational attainment, we included variables that reflect adverse childhood experiences that have been associated with mental and physical illnesses (Felitti et al., 1998). These include removal from home during childhood or adolescence, and family members with a Substance Use Disorder (SUD).

Post-Traumatic Stress Symptoms

Participants responded with Yes or NO when asked about personal or vicarious experiences with 15 traumatic event types that included rape or sexual assault, assaultive violence (e.g., shot, stabbed), witnessing trauma to others, and non-violent trauma (e.g., serious accident, sudden death of a loved one). They selected the most distressing event to evaluate for probable PTSD. The Spanish translation of the Davidson Trauma Scale (DTS) (Ferrando et al., 2000) was purchased from Multi-Health System, Inc. and validated for this study (Caraballo et al., 2013). Based on the DSM-IV, (American Psychiatric Association, 1994) a 5-category Likert scale ranging from 0 to 4 rated the frequency and severity during the preceding week of seventeen symptoms grouped in three clusters (intrusion, avoidance/numbing, and hypervigilance). Scores range from 0 to 136, with 40 or greater considered as probable PTSD, as recommended by the scale’s author (Davidson et al., 1997). The DTS has demonstrated good internal consistency (alpha = 0.99), convergent validity (CAPS, R = 0.78), divergent validity (extroversion, R = 0.04), and concurrent validity, as well as strong test–retest reliability (0.86) (Davidson et al., 1997).

Major Depression

The Spanish version of the Major Depression Disorder module of the University of Michigan version of the Composite International Diagnostic Interview (UM CIDI) (Andrews and Peters, 1998) was administered to diagnose lifetime and last year prevalence of major depression. A study conducted by Kessler and Ustun (2003) demonstrated the validity of the CIDI diagnostic assessment against a trained clinical interviewer. Depressive symptoms including suicidal ideation during the previous week were assessed using the Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977), which has demonstrated high internal consistency (above 0.80), excellent concurrent validity (high correlation with other self-report depression scales) and strong evidence for construct validity (through confirmatory factor analyses) in U.S. adult populations. This non-diagnostic checklist has been widely used in surveys of Hispanic groups (Guarnaccia et al., 1989; Sheenan et al., 1995). In a previous sample of Puerto Ricans, the Cronbach’s alpha coefficient was 0.91 (Rivera-Medina et al., 2010).

Drug Dependence and Generalized Anxiety

The Spanish version of the Alcohol and other Drug Dependence and the Generalized Anxiety Disorder modules of the UM CIDI (Andrews and Peters, 1998) were administered to diagnose their lifetime and last year prevalence. Both measures have been used in epidemiologic studies with Puerto Ricans demonstrating adequate good test-retest reliability estimates (Rubio-Stipec et al., 1999).

Attention Deficit and Hyperactivity Disorder (ADHD)

We administered a validated Spanish version of the Wender Utah Rating Scale (Rodríguez-Jiménez et al., 2001). The Cronbach’s alpha coefficient was 0.94. The version showed an adequate psychometric characteristics that indicate an adequate validity for the detection of adult patients with antecedents of ADHD in early ages.

Data Analysis

Absolute (n) and relative frequencies (%) for demographic and clinical characteristics were examined in terms of sex and probable PTSD screening. For this we developed unadjusted and adjusted logistic regression models for demographic and clinical characteristics in association with sex and probable PTSD screening.

Relative frequencies and χ² tests for weighted samples were used to examine sex and probable PTSD screening for each type of potentially traumatizing event. Student t tests and Cohen’s D were estimated to assess differences by number of event types experienced by sex and by probable PTSD screening, in the whole sample and by sex.

Lastly, adjusted logistic regression models were tested for number of event types experienced on probable PTSD screening on the whole sample and stratified by sex. Odds Ratios (OR) with 95% confidence intervals (CI) were used to measure the magnitude (i.e. effect sizes) of these associations. Independent associations between categories of potentially traumatizing event and outcomes (probable PTSD) were examined by adjusting logistic regression models adding all types of potentially traumatic events simultaneously. An α level of < 0.05 was adopted throughout the study. To account for the complex sampling design of the study, appropriate weights were used on all estimates. Analyses were performed in STATA version 13 (StataCorp, 2013).

Results

Sample characteristics and associations with probable PTSD

Men were significantly younger than women and had higher rates of alcohol dependence (p<0.01). Compared to men, a greater proportion of women reported having a family member with SUD (p<.0.001) and having been removed from home (p<0.05). Women also presented significantly higher rates of childhood ADHD (p<0.01) and suicidal ideation /thoughts (p<0.01). (Data not shown).

We estimated associations between each covariate and probable PTSD stratified by sex. Table 1 includes these adjusted results for men, and Table 2 for women. Among men, childhood ADHD symptoms, SUD, depression, and generalized anxiety during adulthood were significantly associated to probable PTSD. Men with significant ADHD symptoms in childhood and men with generalized anxiety during adulthood were about 5 times as likely to screen positive for probable PTSD in adjusted analyses. Women with either ADHD during childhood or depression during adulthood were more than 3 times to have probable PTSD. Patterns in the total sample followed those observed in men.

Table 1.

Covariates and co-occurring psychiatric conditions by probable PTSD in men

	No PTSD	Probable PTSD
Age	N (%)	N (%)	OR (95%CI)a
18–24	216 (22.8)	27 (21.1)	Ref.
25–34	411 (49.9)	55 (52.7)	1.47 (0.77, 2.82)
≥35	222 (27.3)	28 (26.3)	1.50 (0.69, 3.23)
Education
≥High school	402 (48.1)	45 (36.6)	Ref.
<High school	446 (51.9)	65 (63.4)	1.59 (0.89, 2.84)
Marital status
Married/cohabiting	526 (63.6)	64 (55.5)	Ref.
Single/separated	323 (36.4)	46 (44.5)	1.46 (0.85, 2.52)
Removal from home	46 (5.5)	15 (13.2)	1.52 (0.75, 3.09)
Family members w/SUD	303 (37.2)	40 (32.5)	0.59 (0.35, 0.10)*
Clinical variables
Lifetime SUD	414 (50.4)	71 (69.3)	1.72 (1.05, 2.84)*
ADHD	145 (16.5)	53 (53.4)	4.71 (2.50, 8.88)***
Suicidal thoughts/attempts	135 (16.0)	46 (40.1)	1.84 (0.85, 3.95)
Lifetime depression	112 (13.6)	39 (36.3)	2.64 (1.07, 6.53)*
Lifetime generalized anxiety	15 (12.0)	6 (6.9)	6.54 (1.50, 28.55)*

Note: All weighted estimates (N = 849). Adjusted for all demographic characteristics and all clinical variables

^*p <0.05,

^**p <0.01,

^***p <0.001

Table 2.

Covariates and co-occurring psychiatric conditions by probable PTSD in women

	No PTSD	Probable PTSD
Age	N (%)	N (%)	OR (95%CI)a
18–24	25 (14.5)	9 (28.2)	Ref.
25–34	82 (42.6)	13 (37.5)	1.05 (0.23, 4.86)
≥35	81 (42.8)	10 (34.3)	1.33 (0.23, 7.80)
Education
≥High school	88 (42.5)	11 (40.1)	Ref.
<High school	100 (57.6)	21 (59.9)	0.96 (0.32, 2.88)
Marital status
Married/cohabiting	113 (60.1)	21 (62.2)	Ref.
Single/separated	75 (39.9)	11 (37.8)	0.79 (0.30, 2.12)
Removal from home	172 (91.8)	25 (74.4)	2.96 (0.69, 12.76)
Family members w/SUD	125 (66.7)	19 (55.3)	0.47 (0.15, 1.50)
Clinical variables
Lifetime SUD	115 (59.1)	23 (61.3)	1.26 (0.31, 5.12)
ADHD	51 (27.4)	18 (60.8)	3.36 (1.50, 7.51)*
Suicidal thoughts/attempts	44 (26.8)	16 (48.3)	1.06 (0.33, 3.39)
Lifetime depression	30 (15.7)	12 (44.4)	3.61 (1.33, 9.81)*
Lifetime generalized anxiety	4 (2.5)	0 (0)	No observations

Note: All weighted estimates (N = 188).

^aAdjusted for all demographic characteristics and all clinical variables;

^*p <0.05,

^**p <0.01,

^***p <0.001

Prevalence and Associations of Traumatic Events and probable PTSD

The weighted prevalence of probable PTSD was 12% for men and 16% in women (see Table 3). Sex differences were not significant (p<0.10). Table 3 shows the prevalence for each type of potentially traumatizing event. Women had significantly higher rates of being raped (48.5% vs. 2.5%, p<0.001) and of experiencing sexual abuse (42.4% vs. 6.2%, p<0.001). Men had significantly higher rates of experiencing combat in war (25.3% vs. 7.0%, p<0.001), life-threatening accidents (58.9% vs. 47.0%, p<0.01), witnessing violence or murder (80.8% vs. 69.6%, p<0.01), and being threatened with a weapon (59.1% vs. 41.4%, p<0.01). There were no sex differences in the total number of event types experienced.

Table 3.

Prevalence of probable PTSD by sex and for the total sample and associations with type of potentially traumatizing events and the number of event types experienced (N = 1,179)

			Total sample
Type of potentially traumatizing events and PTSD	Women	Men		No PTSD	Probable PTSD
	N (%)	N (%)	P	N (%)	N (%)	p
PTSD	32 (16.2)	110 (12.0)	0.094	-	-	-
Experienced war combat	12 (7.0)	240 (25.3)	<0.001	199 (79.0)	53 (21.0)	0.001
Life threatening accident	104 (47.0)	558 (58.9)	0.004	561 (85.1)	101 (14.9)	0.008
Any natural disaster	43 (19.4)	217 (24.8)	0.107	212 (80.2)	48 (19.8)	<0.001
Witness violence or murder	148 (69.6)	764 (80.8)	0.004	785 (86.5)	127 (13.5)	0.029
Victim of rape	105 (48.5)	24 (2.5)	<0.001	99 (66.5)	30 (33.5)	<0.001
Victim of sexual abuse	89 (42.4)	58 (6.2)	<0.001	114 (74.6)	33 (25.4)	0.001
Victim of violence	128 (58.0)	529 (56.2)	0.566	553 (84.8)	104 (15.2)	0.003
Threatened with a weapon	97 (41.4)	560 (59.1)	0.001	552 (84.9)	105 (15.1)	0.003
Victim of torture	4 (2.2)	21 (2.4)	0.874	19 (88.3)	6 (11.7)	0.932
Other distressing event	45 (21.1)	248 (27.9)	0.056	244 (84.1)	49 (15.9)	0.047
Any other emotional impact	67 (32.7)	368 (40.6)	0.111	354 (80.5)	81 (19.5)	<0.001
Number of event types experienceda	M (sd)	M (sd)	P	M (sd)	M (sd)	p
(0- 11)	3.83 (2.24)	3.74 (2.03)	0.575	3.56 (2.03)	5.19 (1.77)	<0.001

Note: All weighted frequencies and percentages.

^aDifference between mean number of event types by sex estimated with t test.

Number of event types by gender = Cohen’s D effect size = .042

Number of event types by Probable PTSD = Cohen’s D effect size = .813

Table 3 shows bivariate associations between each type of potentially traumatizing event and probable PTSD. Each of the categories of potentially traumatizing events except exposure to torture were associated with PTSD, likely due to the small number of subjects that endorsed it. The categories of potentially traumatizing events associated with PTSD included rape (34%), sexual abuse (25%), and combat in war (21%). Those with probable PTSD had on average 1.63 more type of potentially traumatizing events than inmates without PTSD (p<0.001).

To model the impact of specific categories of potentially traumatizing events, we reduced the number of categories by combining related types: experienced combat in war, accident or natural disaster, witness of violence or murder, rape or sexual abuse, having been a victim of violence, torture or threat, and any other distressing event. A variable with the derived categories comprised of the sum of these types was developed to relate a potential linear increase of potentially traumatizing event types to probable PTSD.

Table 4 shows that after adjusting for all other types of potentially traumatizing events, experiencing combat in war (p<0.01), rape or sexual abuse (p<0.05), and any other distressing event (p<0.01) were independently associated with increased risk for probable PTSD. Effect modification by sex was estimated for these models, a significant sex by type of potentially traumatizing event interaction was observed for witnessing violence or murder on the risk for probable PTSD, with exposed women at significantly higher risk.

Table 4.

Correlates of probable PTSD: Number of event types experienced and direct associations with derived categories of potentially traumatizing events stratified by sex (N = 1,179)

	Probable PTSD
Exposures	OR (CI 95%)a	OR (CI 95%)b
Number of event types experienced	1.48 (1.30, 1.68)***	1.31 (1.13, 1.53)**
Categories of potentially traumatizing events	OR (CI 95%)a	OR (CI 95%)c
Experienced combat in war	2.79 (1.59, 4.91)**	2.15 (1.24, 3.73)**
Accident or natural disaster	2.39 (1.38, 4.13)**	1.60 (0.84, 3.08)
Witness violence or murder	2.47 (1.13, 5.41)*	1.15 (0.49, 2.73)
Rape or sexual abuse	2.74 (1.46, 5.13)**	2.18 (1.10, 4.32)*
Victim of violence, torture or threat	2.53 (1.32, 4.86)**	1.54 (0.78, 3.04)
Other distressing event	2.84 (1.78, 4.53)***	2.10 (1.26, 3.49)**

Note: All weighted estimates.

^aAdjusted for the following demographic characteristics: age, education level, marital status and being removed from their homes.

^bAdjusted for ^a and psychiatric morbidity

^*p <0.05,

^**p <0.01,

^***p <0.001

Discussion

We examined the rates of probable PTSD and other psychiatric disorders in a large cohort of men and women prisoners in Puerto Rico. We tested the hypotheses that: (1) men prisoners will report greater number of traumatic event types when compared to women; (2) probable PTSD will vary by the type of potentially traumatizing event; (3) probable PTSD will vary by the number of event types experienced; and (4) men and women with probable PTSD will not differ in the prevalence of the following co-occurring conditions: childhood ADHD, major depression and generalized anxiety disorder. Implications for treatment of probable PTSD as well as the psychiatric comorbidities in this population are discussed.

The issue of sex differences in PTSD is both complex and sensitive (Tolin and Foa, 2006). In this study, men prisoners reported greater number of traumatic event types when compared to women. In addition, sex differences were encountered for type of potentially traumatizing event. Men showed higher prevalence in events commonly related to their sex (combat in war, life-threatening accidents, witnessing violence or murder, being threatened with a weapon), whereas women were more probable to report having been a victim of rape or experiencing sexual abuse. The type of potentially traumatizing events most represented among persons with probable PTSD were rape, sexual abuse, and combat in war, in agreement with other studies (Huang et al., 2006; Kubiak, 2004; Laub and Sampson, 2003; MacDonald, 2013).

Sex differences by the number of traumatic event types experienced did not attain significance. A possible explanation is that prison inmates (including both, men and women) report a high number of traumatic stressors during their lifetime (Boşgelmez et al., 2010; Huang et al., 2006; Kubiak, 2004). In addition, most of the study participants resided in areas of poverty that increased the risk of mental health problems through amplified levels of stress, social exclusion, lack of social capital, malnutrition, and exposure to violence and trauma (Palomar Lever, 2008; World Health Organization and Calouste Gulbenkian Foundation, 2014).

Sex differences were also identified among Latino men and women inmates with PTSD and co-occurring psychiatric conditions. Consistent with previous studies (Grella et al., 2013; MacDonald, 2013) women reported more dysfunctional family backgrounds defined as removal from home during childhood or adolescence than men, and significantly higher rates of childhood ADHD, and suicidal ideation. Men who screened positive for childhood ADHD, SUD, and major depression. Contrary to our hypothesis men showed significant association between generalized anxiety during adulthood and probable PTSD.

According to our hypothesis, substantial comorbidity exists between PTSD and ADHD in both sexes, congruent with prevalence estimates in other studies that report estimates ranging from 12% to 37% across the lifespan (Antshel et al., 2013). Level of trauma exposure and ADHD severity have been significant predictors of PTSD severity in veterans (Harrington et al., 2012). Adler, Kunz, Chua, Rotrosen, and Resnick (2004), suggested that ADHD might increase vulnerability to PTSD after trauma exposure, based on their finding that patients with PTSD reported higher levels of childhood ADHD relative to patients with panic disorder. ADHD can also increase the likelihood of developing PTSD, since people with untreated childhood ADHD may be at increased risk for trauma. Other studies (Hart and Rubia, 2012) have documented neurocognitive alterations due to trauma exposure and mild traumatic brain injury (TBI) that may be confounded with PTSD-ADHD comorbidity (Harrington et al., 2012). More research is needed to determine how the co-occurrence of PTSD and ADHD may interact to influence the symptoms and course of both disorders. An improved understanding of shared cognitive, emotional, and neurobiological mechanisms underlying the comorbidity of PTSD and ADHD could have a profound impact on their diagnosis and treatment (Harrington et al., 2012).

This study explored whether men and women from a representative sample of sentenced individuals confined in the Puerto Rico prison system with probable PTSD differed significantly by the number of event types experienced, the type of potentially traumatizing event, and in co-occurring psychiatric conditions in order to highlight the need for better understanding of and interventions in a Latino inmate population. The impairment associated with probable PTSD is comparable to seriously impairing mental disorders such as major depression, and can lead to significant difficulties in education and employment, adversely affect marital relationships and other role functions (Kessler, 2000; Substance Abuse and Mental Health Services Administration, 2014) which require appropriate performance for successful social reintegration. The compounded impacts of probable PTSD in multiple arenas in inmates’ lives underscore the need for holistic approaches that address varied effects of trauma. Intervention studies are needed to examine strategies for reducing violence and traumatic victimization inside correctional facilities as well as effective treatments for posttraumatic psychopathology (e.g., PTSD, substance use disorders, ADHD), such as trauma-informed correctional care (Messina et al., 2014). Correctional staff need training to respond effectively to trauma symptoms. It is important to also recognize differences between sexes in how attention is given to trauma (Ruzich et al., 2014; U.S. Department of Health and Human Services, 2001). The use of present focused, cognitive-behavioral (Seeking Safety), and coping skills treatments with strong educational components have helped stabilize inmates with PTSD and substance abuse problems (Najavits, 2004). Recognition of the high rates of traumatic event types experienced by prison inmates is needed to better planning for health and public policies addressing trauma prevention, reduction, and treatment in this population.

Several limitations in our study require caution in interpretation of the findings. First, the assessment was not designed to examine the temporal order of trauma exposure and psychiatric comorbidity; it is unclear whether traumatic events occurred before or after the development of other emotional conditions. Despite of use of the ACASI for questions regarding illicit drug use, we did not use it for questions regarding trauma. Thus, we did not assess social desirability so we cannot confirm if certain events were unreported or under reported such as sexual assault in men. Third, because our study is cross-sectional, the results cannot help explain the etiology of probable PTSD and co-occurring mental conditions. Fourth, due to the current study includes a sample mainly from Puerto Rico, these findings cannot generalize to other Latino groups in the US. Despite these limitations, the present study provides data on a representative sample of a Latino inmate population of a statewide prison system that can inform services planning that is sex-sensitive and responsive to probable PTSD and co-occurring mental conditions. We are unaware of other research exploring the association of types and number of traumatic events with PTSD in a prison population.

Highlights.

• Significant sex differences were encountered for type of potentially traumatizing event.

• Men showed higher prevalence in events commonly related to their sex (combat in war, life-threatening accidents, witnessing violence or murder, being threatened with a weapon), whereas women were more likely to report having been a victim of rape or experiencing sexual abuse.

• The types of potentially traumatizing events most represented among persons with probable PTSD were rape, sexual abuse, and combat in war.

• Men with significant ADHD symptoms in childhood and with GAD during adulthood were almost 5 and 7 times as likely to have probable PTSD.

• Women with either ADHD or depression were >3 times as likely to have probable PTSD.