This was a severely and chronically victimized group that averaged 5 years of abuse. Overall, the level of physical violence was quite severe. Examination of the frequency of physical violence revealed that the women had suffered bruises to the head (81%), bruises to the body (84%), broken bones in the head (17%), broken bones in the body (22%), cuts to the face or head (64%), cuts to the body (41%), loss of consciousness (49%), damage to the teeth (26%), ruptured eardrums (19%), damage to internal organs (12%), transmission of sexually transmitted diseases from their abusive partner (25%), and miscarriages (13%) as a result of the violence.
Clinical interviews revealed that this group of domestic violence survivors was also a highly symptomatic group, with 38 (54.3%) out of 70 meeting criteria for major depression. In addition, 62 (88.6%) met criteria for full PTSD (N=52 [74.3%]) or subthreshold PTSD (N=10 [14.3%]). Sub-threshold PTSD was defined here as participants who were a total of one symptom short of full PTSD (N=8) or two symptoms short but with a total Clinician-Administered PTSD Scale score over 45 (N=2). Previous research has demonstrated the diagnostic utility of using a total Clinician-Administered PTSD Scale score in this manner (26
). Hereafter the term “PTSD” will be used to include those participants diagnosed with full and subthreshold PTSD. In the total group there were 25 (36%) out of 70 with PTSD only, 37 (53%) with comorbid PTSD and major depression, and eight (11%) with neither diagnosis. The clinical data from these three groups are presented in .
Demographic and Clinical Characteristics of 70 Female Domestic Violence Survivorsa
In the DST-compliant group, 42 (93%) out of 45 met criteria for full PTSD (N=36 [80%]) or subthreshold PTSD (N= 6 [13%]), and 28 (62%) out of 45 met criteria for major depression. Of the DST-compliant subgroup with PTSD, there were a total of 15 participants with PTSD only and 27 with comorbid PTSD and major depression. There were only three compliant participants who did not have either diagnosis.
Overall there were no demographic or abuse characteristic differences between the three groups except for a tendency for the group with comorbid PTSD and depression having been the victim of a higher level of psychological aggression than those in the no diagnosis group. However this difference did not exceed our adjusted alpha level of 0.01 for multiple comparisons. There were significant group differences in total and subscale scores on the Clinician-Administered PTSD Scale. Significant group differences are noted in but generally followed the tendency of the no diagnosis group having the lowest scores and the comorbid group displaying the highest scores. As expected, the PTSD-only group and the comorbid group had significantly higher scores on the Beck Depression Inventory than the no diagnosis group.
Mean plasma cortisol and dexamethasone levels for the domestic violence survivors with PTSD, PTSD plus depression, and no diagnosis and the nontraumatized healthy comparison subjects as well as the percent of cortisol suppression from day 1 to day 2 are presented in . presents the individual cortisol values for the subjects with PTSD, PTSD plus depression, and the healthy comparison group. Among the trauma survivors there were only three participants with no diagnosis who took dexamethasone, therefore they were not included in this graph or statistical analyses. A two-way ANCOVA examining the effect of day (day 1 [before DST], day 2 [after DST]) and group (PTSD, PTSD plus depression, healthy nontraumatized) on cortisol levels with dexamethasone level entered as a covariate revealed a significant day-by-group interaction effect (F=15.2, df=2, 52, p<0.001). Follow-up analyses of cortisol levels indicated a significant group difference on day 1 (F=32.8, df=2, 53, p<0.001); Tukey’s honestly significant difference test showed that the healthy group had a significantly higher baseline cortisol level than the two domestic violence groups, which did not differ from each other. A separate one-way ANOVA of only the day 1 cortisol values for all subjects (trauma survivors with PTSD [N=25], PTSD plus depression [N=37], and no diagnosis [N=8] and nontraumatized comparison subjects [N=14]) confirmed this finding in the larger study group (F=30.9, df=3, 80, p<0.001). Post hoc analyses revealed that baseline cortisol levels were not significantly different between the trauma survivors with PTSD (mean=6.6 μg/dl, SD=2.6) and those with PTSD plus depression (mean=7.7, SD=2.7) and that both were significantly lower than the baseline cortisol levels of the trauma survivors with no diagnosis (mean=17.7, SD=8.3) and the nontraumatized comparison group (mean=15.2, SD=4.3), which did not differ statistically from each other. shows a plot of the individual day 1 cortisol values against the total Clinician-Administered PTSD Scale score for all of the domestic violence survivors.
Plasma Cortisol and Dexamethasone Levels Among Female Domestic Violence Survivors and Nontraumatized Comparison Subjects Before and After a Low-Dose (0.5 mg) Dexamethasone Suppression Test
Individual Cortisol Blood Levels in Female Survivors of Domestic Violence and Demographically Matched Non-traumatized Women Before and After a Low-Dose (0.5 mg) Dexamethasone Suppression Test
Baseline Cortisol and PTSD Severity Levels for 70 Female Domestic Violence Survivors
Analysis of cortisol level on day 2 after dexamethasone administration in the DST-compliant group showed that there was also a significant group difference (F=8.0, df=2, 53, p<0.001) such that the PTSD plus depression and healthy comparison groups did not differ from each other. Trauma survivors with a sole diagnosis of PTSD had significantly lower day 2 cortisol levels than did the healthy group but missed being significantly lower than the PTSD plus depression group (p=0.08, Tukey honestly significant difference). Analysis of dexamethasone levels across the three groups revealed no significant difference in dexamethasone metabolism.
Changes in cortisol level from day 1 to day 2 also were converted into percentages and reflected the relative amount of cortisol suppression to dexamethasone administration (). A one-way ANOVA of these percent change scores showed a tendency toward a greater percentage change in those subjects with a sole diagnosis of PTSD (F=2.7, df=2, 53, p=0.07).
Additional analyses were conducted that focused on the PTSD and comorbid depression group in an attempt to elucidate the role of depression in the hypothalamicpituitary-adrenal (HPA) axis alterations. This group was split on the basis of Beck Depression Inventory score into those with more severe depression (score >29; mean=42.6, SD= 7.1) and those with less severe depression (score ≤29; mean=22.1, SD=7.1). As seen in , group comparisons of day 1 cortisol levels revealed no significant difference (t=0.6, df=25, p=0.53). However, the less severely depressed participants had a significantly lower day 2 mean cortisol level (t=2.1, df=25, p<0.05) and produced a significantly greater amount of cortisol suppression expressed as a percentage of baseline level (t=2.1, df=25, p<0.05) than did the more severely depressed participants. Levene’s test for equality of variance in the two groups revealed a significantly greater amount of variance in the scores of the more severely depressed participants for both the day 2 cortisol values and suppression percentage (Levene’s F= 19.4 and 15.6, respectively, p<0.001).
Cortisol Measurements for Female Domestic Violence Survivors With PTSD and Comorbid Major Depression, by Depression Severitya
A comparison of women living in domestic violence shelters versus those not living in shelters at the time of the DST revealed no significant difference in baseline cortisol values (mean=8.0 μg/dl [SD=2.8] and 8.9 μg/dl [SD= 6.6], respectively). Examination of intercorrelations in the domestic violence survivors among the clinical variables from the Clinician-Administered PTSD Scale (the reexperiencing, avoidance, and arousal symptom clusters), Beck Depression Inventory scores, abuse severity variables (subscale scores from the Conflict Tactics Scale), and the endocrine measures (cortisol levels on day 1 and day 2 and cortisol suppression percentage) revealed only one significant correlation that indicated an inverse relationship between Beck Depression Inventory score and cortisol suppression percentage (r=−0.43, df=42, p=0.01).
Comparisons of the domestic violence participants who were compliant with the dexamethasone administration instructions (N=45) versus those who were noncompliant (N=25), using an adjusted alpha level for multiple comparisons (0.01), indicated that there were no significant differences in the demographic variables, abuse variables, or continuously scored clinical variables. In addition there was not a significant difference in the frequency of PTSD diagnosis (χ2=2.8, df=1, p=0.10) or major depression (χ2= 1.8, df=1, p=0.18). Analysis of the baseline cortisol level from day 1 also showed no significant difference (t=0.9, df=68, p=0.37) between the compliant (mean=8.9 μg/dl, SD=5.4) and the noncompliant participants (mean=7.7 μg/dl, SD=4.0).
The noncompliant participants who did not take dexamethasone at all (N=21) provided a built-in test-retest measure of baseline cortisol levels on successive days. Specifically, the noncompliant group allowed for an examination of the consistency of the very low cortisol levels observed in the larger sample of domestic violence survivors with a psychiatric diagnosis. The correlation between day 1 and day 2 cortisol values was high (r=0.80, df=19, p<0.01), which confirmed a high degree of within-participant consistency in cortisol output as expected. shows a plot of the individual cortisol values on days 1 and 2 in the noncompliant group organized by psychiatric diagnosis. A one-way ANOVA on the average cortisol value from day 1 and day 2 revealed that the domestic violence survivors with PTSD and those with comorbid PTSD and depression had significantly lower baseline cortisol values than the trauma victims with no PTSD or depression diagnosis (F= 13.8, df=2, 22, p<0.001). This pattern mirrored the findings in the larger sample of domestic violence survivors.
Individual Cortisol Values for Female Domestic Violence Survivors Noncompliant With a Low-Dose (0.5 mg) Dexamethasone Suppression Test, by Diagnosisa