Many psychiatrists diagnose problematic Internet use with schemas based on substance use disorders and pathologic gambling. These predefined diagnoses, however, may lead to premature conclusions and prevent you from fully exploring other treatable diagnoses.

We propose a screening tool called “MOUSE” and diagnostic criteria for problematic Internet use, which we developed from research by our group and others. This article discusses the new criteria and answers three questions:

• How does problematic Internet use present?
• Is it an addiction or an impulse control disorder?
• How can we help those afflicted with this problem?

When Internet use goes over the line

Recognizing problematic Internet use is difficult because the Internet can serve as a tool in nearly every aspect of our lives—communication, shopping, business, travel, research, entertainment, and more. The evidence suggests that Internet use becomes a behavior disorder when:

• an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function¹
• and employment and relationships are jeopardized by the hours spent online² (Box).

Box

Case: Computer gamer out of control

Mr. A is 32 and in his fourth year of college. His psychiatric history includes obsessive-compulsive disorder (OCD), paraphilia not otherwise specified, and bipolar disorder, most recently depressed in partial remission. He has had only one manic episode 10 years ago and took lithium briefly. He experienced pleasure from masturbating in public, but his paraphilia did not meet criteria for voyeurism as he did not want to be seen. He engaged in this behavior from ages 16 to 18 and found it distressing.

He is taking no medications. The only clinically significant family history is his father’s apparent OCD, undiagnosed and untreated.

Mr. A’s excessive computer use started in high school, when he played computer games to the point where his grades suffered. He began using the Internet at age 28, just before starting college, and spent most of his time online playing multi-player, video/strategy games.

Mr. A underestimates the time he spends online at 24 hours per week, including 21 hours in nonessential use and 3 hours in essential use (required for job or school). His actual average is 35.9 hours per week—nearly equivalent to a full-time job. He divides his nonessential use among various online activities, mostly related to playing computer games:

• 35% in chat forums, communicating with gaming partners he has never met
• 25% in multi-player, video/strategy games
• 15% using e-mail
• and lesser times surfing the Web (5%), transferring files (5%), viewing pornography (5%), shopping (5%), listening to music (3%), and selling (2%).

He reports rising tension before logging on and relief after doing so. He admits to using the Internet for longer periods than intended and especially when emotionally stressed. He knows his behavior has hurt him academically, and he has tried unsuccessfully to cut down or stop his Internet use.

Internet overuse: An ‘addiction’?

Ivan Goldberg introduced the idea of Internet addiction in 1995 by posting factitious “diagnostic criteria” on a Web site as a joke.³ He was surprised at the overwhelming response he received from persons whose Internet use was interfering with their lives. The first case reports were soon published.^4,5

Initially, excessive Internet use was called an “addiction”—implying a disorder similar to substance dependence. Recently, however, Internet overuse has come to be viewed as more closely resembling an impulse control disorder.^5-8 Shapira et al studied 20 subjects with problematic Internet use, and all met DSM-IV criteria for an impulse control disorder, not otherwise specified. Three also met criteria for obsessive-compulsive disorder.¹

As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.⁸

Diagnostic criteria. Although Mr. A’s comorbid psychiatric illnesses complicate his presentation, his behavior clearly could be described as representing an impulse control disorder. His case also meets our proposed criteria for problematic Internet use (Table 1),⁹ which we define as:

• uncontrollable
• markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
• and not solely present during mania or hypomania.

Teasing out comorbid disorders

As in Mr. A’s case, Internet overuse can serve as an expression of and a conduit for other psychiatric illnesses. Studies have found high rates of comorbidity with mood and anxiety disorders, social phobias, attention-deficit disorder with or without hyperactivity, paraphilias, insomnia, pathologic gambling, and substance use disorders.^10-12

Although some researchers feel that the many comorbid and complicating factors cannot be teased out,¹³ most agree that compulsive Internet use or overuse can have adverse consequences and that more research is needed.

A predisposition? Are “Internet addicts” predisposed to or susceptible to Internet overuse? Researchers are exploring whether Internet overuse causes or is an effect of psychiatric illness.

Shapira et al^1,14 found at least one psychiatric condition that predated the development of Internet overuse in 20 subjects. In a similar study of 21 subjects with excessive computer use, Black¹¹ found:

• 33% had a mood disorder
• 38% had a substance use disorder
• 19% had an anxiety disorder
• 52% met criteria for at least one personality disorder.

On average, these 41 subjects were in their 20s and 30s and reported having problems with Internet use for about 3 years. They spent an average of 28 hours per week online for pleasure or recreation, and many experienced emotional distress, social impairment, and social, occupational, or financial difficulties.^1,11

Table 1

PROPOSED DIAGNOSTIC CRITERIA FOR PROBLEMATIC INTERNET USE

Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al¹⁵ hypothesized that the Internet use caused the depression. Pratarelli et al¹⁶ noted a maladaptive cycle in some persons; the more isolated they feel, the more they use the Internet and increase their social withdrawal.

In a survey of college students, individuals with “Internet addiction” were found to:

• have obsessive characteristics
• prefer online interactions to real-life interactions
• use the Internet “to feel better,” alleviate depression, and become sexually aroused.¹⁶

Personality traits. In another study, Orzack¹² found that subjects viewed the computer as a means to satisfy, induce excitement, and reduce tension or induce relief. Six personality traits were identified as strong predictors of “Internet addiction disorder:”

• boredom
• private self-consciousness
• loneliness
• social anxiety
• shyness
• and low self-esteem.

Table 2

5 SCREENING QUESTIONS FOR PROBLEMATIC INTERNET USE

Diagnosing Internet overuse

Screening. During any psychiatric interview, ask patients how they spend their free time or what they most enjoy doing. If patients say they spend hours on the Internet or their use appears to usurp other activities, five questions—easily recalled by the mnemonic MOUSE—can help you screen for problematic Internet use (Table 2).

History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.¹⁷ Ask which application they use, how many hours they use it, how they rank the importance of various applications, and what they like about their preferred application.

To determine how the Internet may alter the patient’s moods, ask how he or she feels while online as opposed to offline. Keeping an hourly log and a “feelings diary” may help the patient sort through his or her emotions.¹⁷

Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy.¹⁷ They tend to take pride in their computer skills² and incorporate them into their daily lives in many ways, allowing them to rationalize their excessive Internet use (“I’m using it for work, academics, travel, research, etc.”).

Chomorbidities. Given the high incidence of psychiatric comorbidity,¹ it is important to complete a thorough psychiatric evaluation and treat any underlying illness. Whether the illness is primary or comorbid, it is likely exacerbating the symptoms of problematic Internet use.

Changing problematic behaviors

Psychotherapy. Once you find the motives and possible causes of Internet overuse, what is the best form of treatment? This question warrants further study, but cognitive-behavioral therapy (CBT) is the primary treatment at this time.

The goal of CBT is for patients to disrupt their problematic computer use and reconstruct their routines with other activities. They can:

• use external timers to keep track of time online
• set goals of brief, frequent sessions online
• carry cards listing the destructive effects of their Internet use and ranking other activities they have neglected.¹⁷

Using emotion journals or mood monitoring forms may help the patient discover which dysfunctional thoughts and feelings are triggering excessive Internet use.¹² Support groups and family therapy can help repair damaged relationships and engage friends and family in the treatment plan.

Drug therapy. No studies have looked at drug therapy for problematic Internet use, beyond treating comorbid psychiatric illnesses.

Treatment declined. Mr. A declined treatment for his problematic Internet use. As in many other psychiatric illnesses, insight into impulse control disorders tends to be limited. We can address the problem directly and offer to help patients change their online behaviors, but we cannot force them into treatment if they are not endangering themselves or others.

Related resources

• Computer Addiction Services. Maressa Hecht Orzack, PhD. www.computeraddiction.com; (617) 855-2908.
• Center for Online Addiction. Kimberly S. Young, PhD. www.netaddiction.com; (877) 292-3737.

Many psychiatrists diagnose problematic Internet use with schemas based on substance use disorders and pathologic gambling. These predefined diagnoses, however, may lead to premature conclusions and prevent you from fully exploring other treatable diagnoses.

We propose a screening tool called “MOUSE” and diagnostic criteria for problematic Internet use, which we developed from research by our group and others. This article discusses the new criteria and answers three questions:

• How does problematic Internet use present?
• Is it an addiction or an impulse control disorder?
• How can we help those afflicted with this problem?

When Internet use goes over the line

Recognizing problematic Internet use is difficult because the Internet can serve as a tool in nearly every aspect of our lives—communication, shopping, business, travel, research, entertainment, and more. The evidence suggests that Internet use becomes a behavior disorder when:

• an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function¹
• and employment and relationships are jeopardized by the hours spent online² (Box).

Box

Case: Computer gamer out of control

Mr. A is 32 and in his fourth year of college. His psychiatric history includes obsessive-compulsive disorder (OCD), paraphilia not otherwise specified, and bipolar disorder, most recently depressed in partial remission. He has had only one manic episode 10 years ago and took lithium briefly. He experienced pleasure from masturbating in public, but his paraphilia did not meet criteria for voyeurism as he did not want to be seen. He engaged in this behavior from ages 16 to 18 and found it distressing.

He is taking no medications. The only clinically significant family history is his father’s apparent OCD, undiagnosed and untreated.

Mr. A’s excessive computer use started in high school, when he played computer games to the point where his grades suffered. He began using the Internet at age 28, just before starting college, and spent most of his time online playing multi-player, video/strategy games.

Mr. A underestimates the time he spends online at 24 hours per week, including 21 hours in nonessential use and 3 hours in essential use (required for job or school). His actual average is 35.9 hours per week—nearly equivalent to a full-time job. He divides his nonessential use among various online activities, mostly related to playing computer games:

• 35% in chat forums, communicating with gaming partners he has never met
• 25% in multi-player, video/strategy games
• 15% using e-mail
• and lesser times surfing the Web (5%), transferring files (5%), viewing pornography (5%), shopping (5%), listening to music (3%), and selling (2%).

He reports rising tension before logging on and relief after doing so. He admits to using the Internet for longer periods than intended and especially when emotionally stressed. He knows his behavior has hurt him academically, and he has tried unsuccessfully to cut down or stop his Internet use.

Internet overuse: An ‘addiction’?

Ivan Goldberg introduced the idea of Internet addiction in 1995 by posting factitious “diagnostic criteria” on a Web site as a joke.³ He was surprised at the overwhelming response he received from persons whose Internet use was interfering with their lives. The first case reports were soon published.^4,5

Initially, excessive Internet use was called an “addiction”—implying a disorder similar to substance dependence. Recently, however, Internet overuse has come to be viewed as more closely resembling an impulse control disorder.^5-8 Shapira et al studied 20 subjects with problematic Internet use, and all met DSM-IV criteria for an impulse control disorder, not otherwise specified. Three also met criteria for obsessive-compulsive disorder.¹

As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.⁸

Diagnostic criteria. Although Mr. A’s comorbid psychiatric illnesses complicate his presentation, his behavior clearly could be described as representing an impulse control disorder. His case also meets our proposed criteria for problematic Internet use (Table 1),⁹ which we define as:

• uncontrollable
• markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
• and not solely present during mania or hypomania.

Teasing out comorbid disorders

As in Mr. A’s case, Internet overuse can serve as an expression of and a conduit for other psychiatric illnesses. Studies have found high rates of comorbidity with mood and anxiety disorders, social phobias, attention-deficit disorder with or without hyperactivity, paraphilias, insomnia, pathologic gambling, and substance use disorders.^10-12

Although some researchers feel that the many comorbid and complicating factors cannot be teased out,¹³ most agree that compulsive Internet use or overuse can have adverse consequences and that more research is needed.

A predisposition? Are “Internet addicts” predisposed to or susceptible to Internet overuse? Researchers are exploring whether Internet overuse causes or is an effect of psychiatric illness.

Shapira et al^1,14 found at least one psychiatric condition that predated the development of Internet overuse in 20 subjects. In a similar study of 21 subjects with excessive computer use, Black¹¹ found:

• 33% had a mood disorder
• 38% had a substance use disorder
• 19% had an anxiety disorder
• 52% met criteria for at least one personality disorder.

On average, these 41 subjects were in their 20s and 30s and reported having problems with Internet use for about 3 years. They spent an average of 28 hours per week online for pleasure or recreation, and many experienced emotional distress, social impairment, and social, occupational, or financial difficulties.^1,11

Table 1

PROPOSED DIAGNOSTIC CRITERIA FOR PROBLEMATIC INTERNET USE

Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al¹⁵ hypothesized that the Internet use caused the depression. Pratarelli et al¹⁶ noted a maladaptive cycle in some persons; the more isolated they feel, the more they use the Internet and increase their social withdrawal.

In a survey of college students, individuals with “Internet addiction” were found to:

• have obsessive characteristics
• prefer online interactions to real-life interactions
• use the Internet “to feel better,” alleviate depression, and become sexually aroused.¹⁶

Personality traits. In another study, Orzack¹² found that subjects viewed the computer as a means to satisfy, induce excitement, and reduce tension or induce relief. Six personality traits were identified as strong predictors of “Internet addiction disorder:”

• boredom
• private self-consciousness
• loneliness
• social anxiety
• shyness
• and low self-esteem.

Table 2

5 SCREENING QUESTIONS FOR PROBLEMATIC INTERNET USE

Diagnosing Internet overuse

Screening. During any psychiatric interview, ask patients how they spend their free time or what they most enjoy doing. If patients say they spend hours on the Internet or their use appears to usurp other activities, five questions—easily recalled by the mnemonic MOUSE—can help you screen for problematic Internet use (Table 2).

History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.¹⁷ Ask which application they use, how many hours they use it, how they rank the importance of various applications, and what they like about their preferred application.

To determine how the Internet may alter the patient’s moods, ask how he or she feels while online as opposed to offline. Keeping an hourly log and a “feelings diary” may help the patient sort through his or her emotions.¹⁷

Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy.¹⁷ They tend to take pride in their computer skills² and incorporate them into their daily lives in many ways, allowing them to rationalize their excessive Internet use (“I’m using it for work, academics, travel, research, etc.”).

Chomorbidities. Given the high incidence of psychiatric comorbidity,¹ it is important to complete a thorough psychiatric evaluation and treat any underlying illness. Whether the illness is primary or comorbid, it is likely exacerbating the symptoms of problematic Internet use.

Changing problematic behaviors

Psychotherapy. Once you find the motives and possible causes of Internet overuse, what is the best form of treatment? This question warrants further study, but cognitive-behavioral therapy (CBT) is the primary treatment at this time.

The goal of CBT is for patients to disrupt their problematic computer use and reconstruct their routines with other activities. They can:

• use external timers to keep track of time online
• set goals of brief, frequent sessions online
• carry cards listing the destructive effects of their Internet use and ranking other activities they have neglected.¹⁷

Using emotion journals or mood monitoring forms may help the patient discover which dysfunctional thoughts and feelings are triggering excessive Internet use.¹² Support groups and family therapy can help repair damaged relationships and engage friends and family in the treatment plan.

Drug therapy. No studies have looked at drug therapy for problematic Internet use, beyond treating comorbid psychiatric illnesses.

Treatment declined. Mr. A declined treatment for his problematic Internet use. As in many other psychiatric illnesses, insight into impulse control disorders tends to be limited. We can address the problem directly and offer to help patients change their online behaviors, but we cannot force them into treatment if they are not endangering themselves or others.

Related resources

• Computer Addiction Services. Maressa Hecht Orzack, PhD. www.computeraddiction.com; (617) 855-2908.
• Center for Online Addiction. Kimberly S. Young, PhD. www.netaddiction.com; (877) 292-3737.

Many psychiatrists diagnose problematic Internet use with schemas based on substance use disorders and pathologic gambling. These predefined diagnoses, however, may lead to premature conclusions and prevent you from fully exploring other treatable diagnoses.

We propose a screening tool called “MOUSE” and diagnostic criteria for problematic Internet use, which we developed from research by our group and others. This article discusses the new criteria and answers three questions:

• How does problematic Internet use present?
• Is it an addiction or an impulse control disorder?
• How can we help those afflicted with this problem?

When Internet use goes over the line

Recognizing problematic Internet use is difficult because the Internet can serve as a tool in nearly every aspect of our lives—communication, shopping, business, travel, research, entertainment, and more. The evidence suggests that Internet use becomes a behavior disorder when:

• an individual loses the ability to control his or her use and begins to suffer distress and impaired daily function¹
• and employment and relationships are jeopardized by the hours spent online² (Box).

Box

Case: Computer gamer out of control

Mr. A is 32 and in his fourth year of college. His psychiatric history includes obsessive-compulsive disorder (OCD), paraphilia not otherwise specified, and bipolar disorder, most recently depressed in partial remission. He has had only one manic episode 10 years ago and took lithium briefly. He experienced pleasure from masturbating in public, but his paraphilia did not meet criteria for voyeurism as he did not want to be seen. He engaged in this behavior from ages 16 to 18 and found it distressing.

He is taking no medications. The only clinically significant family history is his father’s apparent OCD, undiagnosed and untreated.

Mr. A’s excessive computer use started in high school, when he played computer games to the point where his grades suffered. He began using the Internet at age 28, just before starting college, and spent most of his time online playing multi-player, video/strategy games.

Mr. A underestimates the time he spends online at 24 hours per week, including 21 hours in nonessential use and 3 hours in essential use (required for job or school). His actual average is 35.9 hours per week—nearly equivalent to a full-time job. He divides his nonessential use among various online activities, mostly related to playing computer games:

• 35% in chat forums, communicating with gaming partners he has never met
• 25% in multi-player, video/strategy games
• 15% using e-mail
• and lesser times surfing the Web (5%), transferring files (5%), viewing pornography (5%), shopping (5%), listening to music (3%), and selling (2%).

He reports rising tension before logging on and relief after doing so. He admits to using the Internet for longer periods than intended and especially when emotionally stressed. He knows his behavior has hurt him academically, and he has tried unsuccessfully to cut down or stop his Internet use.

Internet overuse: An ‘addiction’?

Ivan Goldberg introduced the idea of Internet addiction in 1995 by posting factitious “diagnostic criteria” on a Web site as a joke.³ He was surprised at the overwhelming response he received from persons whose Internet use was interfering with their lives. The first case reports were soon published.^4,5

Initially, excessive Internet use was called an “addiction”—implying a disorder similar to substance dependence. Recently, however, Internet overuse has come to be viewed as more closely resembling an impulse control disorder.^5-8 Shapira et al studied 20 subjects with problematic Internet use, and all met DSM-IV criteria for an impulse control disorder, not otherwise specified. Three also met criteria for obsessive-compulsive disorder.¹

As with other impulse control disorders (such as eating disorders and pathologic gambling), researchers have noticed increased depression associated with pathologic Internet use.⁸

Diagnostic criteria. Although Mr. A’s comorbid psychiatric illnesses complicate his presentation, his behavior clearly could be described as representing an impulse control disorder. His case also meets our proposed criteria for problematic Internet use (Table 1),⁹ which we define as:

• uncontrollable
• markedly distressing, time-consuming, or resulting in social, occupational, or financial difficulties
• and not solely present during mania or hypomania.

Teasing out comorbid disorders

As in Mr. A’s case, Internet overuse can serve as an expression of and a conduit for other psychiatric illnesses. Studies have found high rates of comorbidity with mood and anxiety disorders, social phobias, attention-deficit disorder with or without hyperactivity, paraphilias, insomnia, pathologic gambling, and substance use disorders.^10-12

Although some researchers feel that the many comorbid and complicating factors cannot be teased out,¹³ most agree that compulsive Internet use or overuse can have adverse consequences and that more research is needed.

A predisposition? Are “Internet addicts” predisposed to or susceptible to Internet overuse? Researchers are exploring whether Internet overuse causes or is an effect of psychiatric illness.

Shapira et al^1,14 found at least one psychiatric condition that predated the development of Internet overuse in 20 subjects. In a similar study of 21 subjects with excessive computer use, Black¹¹ found:

• 33% had a mood disorder
• 38% had a substance use disorder
• 19% had an anxiety disorder
• 52% met criteria for at least one personality disorder.

On average, these 41 subjects were in their 20s and 30s and reported having problems with Internet use for about 3 years. They spent an average of 28 hours per week online for pleasure or recreation, and many experienced emotional distress, social impairment, and social, occupational, or financial difficulties.^1,11

Table 1

PROPOSED DIAGNOSTIC CRITERIA FOR PROBLEMATIC INTERNET USE

Isolation and depression. Increasing Internet use and withdrawal from family activities has been associated with increased depression and loneliness; Kraut et al¹⁵ hypothesized that the Internet use caused the depression. Pratarelli et al¹⁶ noted a maladaptive cycle in some persons; the more isolated they feel, the more they use the Internet and increase their social withdrawal.

In a survey of college students, individuals with “Internet addiction” were found to:

• have obsessive characteristics
• prefer online interactions to real-life interactions
• use the Internet “to feel better,” alleviate depression, and become sexually aroused.¹⁶

Personality traits. In another study, Orzack¹² found that subjects viewed the computer as a means to satisfy, induce excitement, and reduce tension or induce relief. Six personality traits were identified as strong predictors of “Internet addiction disorder:”

• boredom
• private self-consciousness
• loneliness
• social anxiety
• shyness
• and low self-esteem.

Table 2

5 SCREENING QUESTIONS FOR PROBLEMATIC INTERNET USE

Diagnosing Internet overuse

Screening. During any psychiatric interview, ask patients how they spend their free time or what they most enjoy doing. If patients say they spend hours on the Internet or their use appears to usurp other activities, five questions—easily recalled by the mnemonic MOUSE—can help you screen for problematic Internet use (Table 2).

History. Typically, persons with problematic Internet use spend time in one Internet domain, such as chat rooms, interactive games, news groups, or search engines.¹⁷ Ask which application they use, how many hours they use it, how they rank the importance of various applications, and what they like about their preferred application.

To determine how the Internet may alter the patient’s moods, ask how he or she feels while online as opposed to offline. Keeping an hourly log and a “feelings diary” may help the patient sort through his or her emotions.¹⁷

Often patients use the Internet to escape from dissatisfaction or disappointment or to counteract a sense of personal inadequacy.¹⁷ They tend to take pride in their computer skills² and incorporate them into their daily lives in many ways, allowing them to rationalize their excessive Internet use (“I’m using it for work, academics, travel, research, etc.”).

Chomorbidities. Given the high incidence of psychiatric comorbidity,¹ it is important to complete a thorough psychiatric evaluation and treat any underlying illness. Whether the illness is primary or comorbid, it is likely exacerbating the symptoms of problematic Internet use.

Changing problematic behaviors

Psychotherapy. Once you find the motives and possible causes of Internet overuse, what is the best form of treatment? This question warrants further study, but cognitive-behavioral therapy (CBT) is the primary treatment at this time.

The goal of CBT is for patients to disrupt their problematic computer use and reconstruct their routines with other activities. They can:

• use external timers to keep track of time online
• set goals of brief, frequent sessions online
• carry cards listing the destructive effects of their Internet use and ranking other activities they have neglected.¹⁷

Using emotion journals or mood monitoring forms may help the patient discover which dysfunctional thoughts and feelings are triggering excessive Internet use.¹² Support groups and family therapy can help repair damaged relationships and engage friends and family in the treatment plan.

Drug therapy. No studies have looked at drug therapy for problematic Internet use, beyond treating comorbid psychiatric illnesses.

Treatment declined. Mr. A declined treatment for his problematic Internet use. As in many other psychiatric illnesses, insight into impulse control disorders tends to be limited. We can address the problem directly and offer to help patients change their online behaviors, but we cannot force them into treatment if they are not endangering themselves or others.

Related resources

• Computer Addiction Services. Maressa Hecht Orzack, PhD. www.computeraddiction.com; (617) 855-2908.
• Center for Online Addiction. Kimberly S. Young, PhD. www.netaddiction.com; (877) 292-3737.

Posttraumatic stress disorder (PTSD) was first recognized as a diagnosis in male Vietnam War veterans, but studies since then have consistently found PTSD to be more common in women than in men. Understanding the gender-related differences in PTSD’s presentation can help us craft optimal treatment for women suffering with this persistent disorder.

Data from the National Comorbidity Survey suggest a lifetime PTSD prevalence of 10.4% in women and 5.0% in men.¹ PTSD also tends to be more chronic in women. In one study of patients with PTSD, median time from symptom onset to remission was 4 years for women and 1 year for men.²

Evidence suggests that women:

• experience more or different types of trauma than men, including labor and delivery, rape, and childhood sexual abuse
• may react to trauma more often and more robustly than men because of sex hormones, cultural gender roles, or some combination of those factors.

How women experience trauma

Among studies that show gender differences in response to specific trauma, nearly all have found higher PTSD rates in women than in men. This pattern emerges early in life and is seen in children and adults.

A meta-analysis comparing PTSD symptoms in females and males of all ages after specific traumas³ found that females were much more likely than males to report PTSD symptoms after some types of trauma but not others. None of the trauma types predicted PTSD more often for males than for females.

Amount of trauma. Men are more likely than women to be exposed to traumatic events, such as violent assault, during their lifetimes.⁴ However, the types of trauma that women experience predominantly or exclusively—such as childhood sexual abuse, traumatic labor and delivery, pregnancy loss, severe health problems in a newborn, and prostitution—are rarely included in trauma questionnaires (Table 1). As a result, the full range of traumatic experiences in women’s lives is likely underestimated.

Instruments designed to measure trauma may inadvertently introduce gender bias in other ways.⁵ For example, questionnaires asking about single traumatic events may underestimate the impact of repetitive traumas, such as childhood sexual abuse and domestic violence, which are more frequently experienced by girls and women. Further, women may not acknowledge sexually linked traumas—such as childhood sexual abuse and rape—unless the questions are asked in a sensitive manner and describe specific behaviors.

Table 1

TRAUMAS THAT CAUSE PTSD PREDOMINANTLY IN WOMEN

Types of trauma. Certain types of trauma are associated with especially high conditional risk of PTSD, defined as the risk of developing PTSD after being exposed to the trauma. Childhood sexual abuse, domestic violence, and rape are among the traumas with the highest conditional risk, and women are more likely to be exposed to these trauma types than men.⁶

Childhood sexual abuse has a particularly high conditional risk of PTSD.⁷ Such abuse happens over long periods during developmentally vulnerable stages of life. Sexual abuse perpetrated by a family member creates a greater sense of betrayal than does trauma at the hands of a stranger or an impersonal force of nature. In many cases, the victims blame themselves.

Domestic violence, like sexual abuse, has a high conditional PTSD risk because of the intimate nature of the relationship and the usual pattern of multiple assaults over time.

Rape carries the highest conditional risk of any trauma,⁸ possibly because of the degree to which rape violates a victim’s assumptions about the world as a reasonably safe place.³ PTSD risk after rape is intensified when the victim blames himself or herself and when society—such as the family or court system—reinforces this tendency toward self-blame.⁹

Influence of sex hormones. Neurophysiologic systems that lie beneath stress responses are closely linked with reproductive physiology.¹⁰ Evolution may have favored this association, allowing reproductive efforts to shut down during extreme stress.

Key components of the primary stress-activated hormonal system—corticotropin-releasing hormone, adrenocorticotropic hormone, and the glucocorticoids—inhibit secretion of gonadotropin-releasing hormone and the gonadotropins, the major reproductive hormones. In turn, sex hormones modulate hypothalamic-pituitary adrenal (HPA) axis activity, stress-linked neurotransmitter changes, and behavioral responses to stress.

This intertwining of stress and reproductive hormones suggests that men’s and women’s physiologic response to trauma may differ. Women’s vulnerability to PTSD also may vary at different parts of their menstrual cycles, during pregnancy, or postpartum.

Several animal studies have shown a more intense HPA axis response to stress in females than in males’.¹¹ To date, however, studies have not shown clear gender differences in human physiologic response to trauma. Increased sympathetic nervous system activity, enhanced dexamethasone suppression of cortisol, and hippocampal atrophy have been found in both men and women with PTSD.^11,12

Some human studies suggest gender differences in PTSD-related neurophysiologic changes. For example, activation of both the sympathetic and adrenocortical systems (epinephrine and cortisol) has been seen in women with PTSD from childhood sexual abuse, whereas activation of only the sympathetic system (epinephrine but not cortisol) has been seen in men with combat-related PTSD.¹³ Research with improved methodology is investigating whether sex hormones modulate human response to trauma.

Gender role differences. Because of cultural expectations, women may more easily acknowledge and report distress and feelings of being traumatized.¹⁴ This behavioral difference may contribute to higher PTSD prevalence rates in women than in men. Women also may develop more negative beliefs in response to some types of trauma, such as nonsexual assault by a stranger.³

Treating PTSD in women

Drug therapy. Antidepressants—including tricyclics, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors (SSRIs)—have shown efficacy in treating PTSD. Some studies have found that women respond more robustly to SSRI antidepressants than men.¹⁵

Cognitive-behavioral therapy. Trauma victims tend to avoid reminders of the trauma. Although this coping strategy can provide short-term relief, it can also constrict a person’s life and preclude opportunities to correct distorted information. For example, a person may attribute danger to benign stimuli that were coincidentally associated with the trauma, such as fearing all men with mustaches after being raped by a man with a mustache.³

Table 2

MALADAPTIVE REACTIONS DURING LABOR AND DELIVERY

Cognitive-behavioral therapy (CBT) for PTSD aims to activate and correct information by prolonged exposure to traumatic stimuli and to restructure incorrect cognitions. CBT approaches to PTSD include exposure therapy, cognitive therapy, cognitive processing, stress inoculation training, assertiveness training, systematic desensitization, biofeedback, and relaxation training. Of these, exposure therapy has been studied the most systematically and found to work especially well for female rape victims.¹⁶ Exposure therapy consists of confronting feared stimuli—such as returning to the scene of a rape or recalling detailed memories of childhood sexual abuse—until anxiety diminishes.

Psychodynamic therapy aims to re-engage normal adaptive mechanisms by introducing the unconscious into consciousness in tolerable doses.¹⁷ Therapy serves as a means of processing traumatic events, such as childhood sexual abuse, and exploring the psychological meanings of traumas.¹⁸ Few well-controlled studies have examined psychodynamic therapy in PTSD, in part because of the difficulty in operationally defining and assessing mechanisms of change. However, at least one relatively controlled study found reduced avoidance symptoms with psychodynamic therapy, compared with wait list and active treatment groups.¹⁹

EMDR. During eye movement desensitization and reprocessing (EMDR), the patient focuses on a disturbing image, a negative cognition, and somatic sensations associated with the trauma while tracking the movement of the clinician’s finger within her visual field.²⁰ The procedure is repeated until the patient’s distress is reduced and she develops more adaptive thoughts about the trauma.

Most EMDR practitioners recommend its use primarily for single-event traumas, such as rape or traumatic labor and delivery. Meta-analyses have suggested that EMDR may be as effective as other exposure therapy,²¹ although methodologic problems in several studies limit our ability to determine EMDR’s efficacy in treating women with PTSD.²²

Treating and preventing perinatal PTSD

Historically, common outcomes of giving birth included death or chronic disability. Despite advances in obstetric care, labor and delivery remains painful, frightening, and potentially dangerous. Although childbirth is a normative experience for many women, an estimated 2.8 to 5.6% of new mothers develop labor-related PTSD.^23-25 Risk of PTSD is increased in women with:

• high general anxiety levels prior to labor
• a history of mental illness
• unplanned pregnancy
• absence of partner during labor and delivery
• the perception that obstetric staff is unsupportive or ineffective
• a need for obstetric interventions, including episiotomy, emergency cesarean section, or use of forceps
• a perception of lack of control.

Table 3

LABOR INTERVENTIONS FOR VICTIMS OF CHILDHOOD SEXUAL ABUSE

Untreated PTSD may impair the woman’s functional ability and compromise her relationship with the infant:

Avoidance can extend to subsequent health care (such as not attending the postpartum checkup), sexual relationships, caring for the baby, and future pregnancies. Some women request general anesthesia and cesarean sections for future deliveries.

Arousal may intensify postpartum sleep disturbance and fatigue and may cause a mother to be hypervigilant about her baby.

Flashbacks can influence feelings about the baby, such as when the mother has repeated, vivid memories of the newborn being limp and blue after delivery, even though the infant is healthy now.

Preventive interventions that can minimize PTSD risk after labor and dshlivery include:

• explaining to women before the onset of labor that emergency obstetric interventions might be necessary
• providing adequate social support during labor and delivery
• ensuring that the obstetric staff communicates clearly with the patient
• effectively managing pain to minimize trauma.

Postpartum, it is important to screen for PTSD symptoms among high-risk women. Prompt intervention can alleviate symptoms and minimize adverse effects on the family and the mother-infant relationship.

Role of sexual abuse in perinatal PTSD. For a woman who was sexually abused as a child, even an uncomplicated labor and delivery may trigger memories, flashbacks, and emotions associated with the abuse.²⁶ Physical sensations associated with gynecologic examinations and labor contractions may remind her of abuse-related sensations. Some women with sexual abuse histories react adversely to the loss of control and need to depend on others during labor and delivery.

Unrecognized posttraumatic reactions during labor may result in maladaptive behaviors (Table 2).²⁶ Obstetric staff who encounter these behaviors without being aware of their origins may think the patient is oppositional or noncompliant and may regard her as an adversary to be defeated or bypassed in order to safely deliver the baby.²⁷ The psychiatrist can minimize this problem early in labor by alerting the staff to signs of possible sexual abuse-related PTSD. These may include:

• little or no prenatal care (due to fear of obstetric procedures)
• unusual fears of needles, intravenous lines, etc.
• recoiling when touched during obstetric examinations
• insistence on female obstetric staff
• extreme sensitivity about bodily exposure.^26,28

Table 4

USE OF ANTIDEPRESSANTS FOR PTSD DURING BREAST FEEDING

Intervention. Once abuse-related perinatal PTSD is diagnosed, the interventions in Table 3 can help a woman through labor and delivery.^26,28 When successful, they can turn childbirth into a healing experience that promotes the mother’s sense of accomplishment, positive association with sexuality, and a new relationship with her body.²⁸

Breastfeeding can also trigger flashbacks and frightening emotions in a woman who was sexually abused as a child.²⁹ She may confuse normal sensations of skin-to-skin contact with the baby or the milk ejection reflex with unpleasant sexually-linked feelings. In such cases, it may help to:

• explain the normal sensations associated with breastfeeding and normal behaviors of breastfeeding infants
• show her how to gently redirect her baby if it does something she finds uncomfortable
• identify situations that are especially difficult for her (such as nighttime feedings) and substitute bottle feeding at those times.

These measures may promote feelings of self-efficacy and help more in the long run than prematurely giving up on breastfeeding.

Prescribing to the nursing woman. When prescribing medication for PTSD in a breast-feeding woman, minimize potential infant side effects by choosing agents that produce relatively low drug levels in breast milk (Table 4).^30-34 Sertraline—the first medication to receive Food and Drug Administration approval for treating PTSD—is recommended during breastfeeding.³⁵

Pregnancy loss. Although the prevalence of PTSD in response to miscarriage or stillbirth is unknown, some women clearly develop PTSD after pregnancy loss. The degree of associated physical trauma—and of social and professional support—influence anxiety levels in response to miscarriage³⁶ and may also influence the likelihood of developing PTSD. Pregnancy loss after the first trimester may be more likely to result in PTSD than earlier loss, and subsequent pregnancies may exacerbate PTSD symptoms. In one study, spontaneous fetal loss after the 18th week of gestation led to high rates of PTSD symptoms in a subsequent pregnancy and up to 1 year postpartum.³⁷

Asking a woman how she wants to grieve her pregnancy loss and helping her in that process may minimize her risk of subsequent PTSD. Couples counseling may help in some cases, as each partner may have a different grieving style.

Related resources

• Foa EB, Keane TM, Friedman MJ. Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress studies. New York: Guilford Publications, 2000.
• Kimerling R, Ouimette P, Wolfe J (eds). Gender and PTSD. New York: Guilford Publications, 2002.
• Madison Institute of Medicine. Facts for Health: posttraumatic stress disorder. www.ptsd.factsforhealth.org

Drug brand names

• Citalopram • Celexa
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Posttraumatic stress disorder (PTSD) was first recognized as a diagnosis in male Vietnam War veterans, but studies since then have consistently found PTSD to be more common in women than in men. Understanding the gender-related differences in PTSD’s presentation can help us craft optimal treatment for women suffering with this persistent disorder.

Data from the National Comorbidity Survey suggest a lifetime PTSD prevalence of 10.4% in women and 5.0% in men.¹ PTSD also tends to be more chronic in women. In one study of patients with PTSD, median time from symptom onset to remission was 4 years for women and 1 year for men.²

Evidence suggests that women:

• experience more or different types of trauma than men, including labor and delivery, rape, and childhood sexual abuse
• may react to trauma more often and more robustly than men because of sex hormones, cultural gender roles, or some combination of those factors.

How women experience trauma

Among studies that show gender differences in response to specific trauma, nearly all have found higher PTSD rates in women than in men. This pattern emerges early in life and is seen in children and adults.

A meta-analysis comparing PTSD symptoms in females and males of all ages after specific traumas³ found that females were much more likely than males to report PTSD symptoms after some types of trauma but not others. None of the trauma types predicted PTSD more often for males than for females.

Amount of trauma. Men are more likely than women to be exposed to traumatic events, such as violent assault, during their lifetimes.⁴ However, the types of trauma that women experience predominantly or exclusively—such as childhood sexual abuse, traumatic labor and delivery, pregnancy loss, severe health problems in a newborn, and prostitution—are rarely included in trauma questionnaires (Table 1). As a result, the full range of traumatic experiences in women’s lives is likely underestimated.

Instruments designed to measure trauma may inadvertently introduce gender bias in other ways.⁵ For example, questionnaires asking about single traumatic events may underestimate the impact of repetitive traumas, such as childhood sexual abuse and domestic violence, which are more frequently experienced by girls and women. Further, women may not acknowledge sexually linked traumas—such as childhood sexual abuse and rape—unless the questions are asked in a sensitive manner and describe specific behaviors.

Table 1

TRAUMAS THAT CAUSE PTSD PREDOMINANTLY IN WOMEN

Types of trauma. Certain types of trauma are associated with especially high conditional risk of PTSD, defined as the risk of developing PTSD after being exposed to the trauma. Childhood sexual abuse, domestic violence, and rape are among the traumas with the highest conditional risk, and women are more likely to be exposed to these trauma types than men.⁶

Childhood sexual abuse has a particularly high conditional risk of PTSD.⁷ Such abuse happens over long periods during developmentally vulnerable stages of life. Sexual abuse perpetrated by a family member creates a greater sense of betrayal than does trauma at the hands of a stranger or an impersonal force of nature. In many cases, the victims blame themselves.

Domestic violence, like sexual abuse, has a high conditional PTSD risk because of the intimate nature of the relationship and the usual pattern of multiple assaults over time.

Rape carries the highest conditional risk of any trauma,⁸ possibly because of the degree to which rape violates a victim’s assumptions about the world as a reasonably safe place.³ PTSD risk after rape is intensified when the victim blames himself or herself and when society—such as the family or court system—reinforces this tendency toward self-blame.⁹

Influence of sex hormones. Neurophysiologic systems that lie beneath stress responses are closely linked with reproductive physiology.¹⁰ Evolution may have favored this association, allowing reproductive efforts to shut down during extreme stress.

Key components of the primary stress-activated hormonal system—corticotropin-releasing hormone, adrenocorticotropic hormone, and the glucocorticoids—inhibit secretion of gonadotropin-releasing hormone and the gonadotropins, the major reproductive hormones. In turn, sex hormones modulate hypothalamic-pituitary adrenal (HPA) axis activity, stress-linked neurotransmitter changes, and behavioral responses to stress.

This intertwining of stress and reproductive hormones suggests that men’s and women’s physiologic response to trauma may differ. Women’s vulnerability to PTSD also may vary at different parts of their menstrual cycles, during pregnancy, or postpartum.

Several animal studies have shown a more intense HPA axis response to stress in females than in males’.¹¹ To date, however, studies have not shown clear gender differences in human physiologic response to trauma. Increased sympathetic nervous system activity, enhanced dexamethasone suppression of cortisol, and hippocampal atrophy have been found in both men and women with PTSD.^11,12

Some human studies suggest gender differences in PTSD-related neurophysiologic changes. For example, activation of both the sympathetic and adrenocortical systems (epinephrine and cortisol) has been seen in women with PTSD from childhood sexual abuse, whereas activation of only the sympathetic system (epinephrine but not cortisol) has been seen in men with combat-related PTSD.¹³ Research with improved methodology is investigating whether sex hormones modulate human response to trauma.

Gender role differences. Because of cultural expectations, women may more easily acknowledge and report distress and feelings of being traumatized.¹⁴ This behavioral difference may contribute to higher PTSD prevalence rates in women than in men. Women also may develop more negative beliefs in response to some types of trauma, such as nonsexual assault by a stranger.³

Treating PTSD in women

Drug therapy. Antidepressants—including tricyclics, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors (SSRIs)—have shown efficacy in treating PTSD. Some studies have found that women respond more robustly to SSRI antidepressants than men.¹⁵

Cognitive-behavioral therapy. Trauma victims tend to avoid reminders of the trauma. Although this coping strategy can provide short-term relief, it can also constrict a person’s life and preclude opportunities to correct distorted information. For example, a person may attribute danger to benign stimuli that were coincidentally associated with the trauma, such as fearing all men with mustaches after being raped by a man with a mustache.³

Table 2

MALADAPTIVE REACTIONS DURING LABOR AND DELIVERY

Cognitive-behavioral therapy (CBT) for PTSD aims to activate and correct information by prolonged exposure to traumatic stimuli and to restructure incorrect cognitions. CBT approaches to PTSD include exposure therapy, cognitive therapy, cognitive processing, stress inoculation training, assertiveness training, systematic desensitization, biofeedback, and relaxation training. Of these, exposure therapy has been studied the most systematically and found to work especially well for female rape victims.¹⁶ Exposure therapy consists of confronting feared stimuli—such as returning to the scene of a rape or recalling detailed memories of childhood sexual abuse—until anxiety diminishes.

Psychodynamic therapy aims to re-engage normal adaptive mechanisms by introducing the unconscious into consciousness in tolerable doses.¹⁷ Therapy serves as a means of processing traumatic events, such as childhood sexual abuse, and exploring the psychological meanings of traumas.¹⁸ Few well-controlled studies have examined psychodynamic therapy in PTSD, in part because of the difficulty in operationally defining and assessing mechanisms of change. However, at least one relatively controlled study found reduced avoidance symptoms with psychodynamic therapy, compared with wait list and active treatment groups.¹⁹

EMDR. During eye movement desensitization and reprocessing (EMDR), the patient focuses on a disturbing image, a negative cognition, and somatic sensations associated with the trauma while tracking the movement of the clinician’s finger within her visual field.²⁰ The procedure is repeated until the patient’s distress is reduced and she develops more adaptive thoughts about the trauma.

Most EMDR practitioners recommend its use primarily for single-event traumas, such as rape or traumatic labor and delivery. Meta-analyses have suggested that EMDR may be as effective as other exposure therapy,²¹ although methodologic problems in several studies limit our ability to determine EMDR’s efficacy in treating women with PTSD.²²

Treating and preventing perinatal PTSD

Historically, common outcomes of giving birth included death or chronic disability. Despite advances in obstetric care, labor and delivery remains painful, frightening, and potentially dangerous. Although childbirth is a normative experience for many women, an estimated 2.8 to 5.6% of new mothers develop labor-related PTSD.^23-25 Risk of PTSD is increased in women with:

• high general anxiety levels prior to labor
• a history of mental illness
• unplanned pregnancy
• absence of partner during labor and delivery
• the perception that obstetric staff is unsupportive or ineffective
• a need for obstetric interventions, including episiotomy, emergency cesarean section, or use of forceps
• a perception of lack of control.

Table 3

LABOR INTERVENTIONS FOR VICTIMS OF CHILDHOOD SEXUAL ABUSE

Untreated PTSD may impair the woman’s functional ability and compromise her relationship with the infant:

Avoidance can extend to subsequent health care (such as not attending the postpartum checkup), sexual relationships, caring for the baby, and future pregnancies. Some women request general anesthesia and cesarean sections for future deliveries.

Arousal may intensify postpartum sleep disturbance and fatigue and may cause a mother to be hypervigilant about her baby.

Flashbacks can influence feelings about the baby, such as when the mother has repeated, vivid memories of the newborn being limp and blue after delivery, even though the infant is healthy now.

Preventive interventions that can minimize PTSD risk after labor and dshlivery include:

• explaining to women before the onset of labor that emergency obstetric interventions might be necessary
• providing adequate social support during labor and delivery
• ensuring that the obstetric staff communicates clearly with the patient
• effectively managing pain to minimize trauma.

Postpartum, it is important to screen for PTSD symptoms among high-risk women. Prompt intervention can alleviate symptoms and minimize adverse effects on the family and the mother-infant relationship.

Role of sexual abuse in perinatal PTSD. For a woman who was sexually abused as a child, even an uncomplicated labor and delivery may trigger memories, flashbacks, and emotions associated with the abuse.²⁶ Physical sensations associated with gynecologic examinations and labor contractions may remind her of abuse-related sensations. Some women with sexual abuse histories react adversely to the loss of control and need to depend on others during labor and delivery.

Unrecognized posttraumatic reactions during labor may result in maladaptive behaviors (Table 2).²⁶ Obstetric staff who encounter these behaviors without being aware of their origins may think the patient is oppositional or noncompliant and may regard her as an adversary to be defeated or bypassed in order to safely deliver the baby.²⁷ The psychiatrist can minimize this problem early in labor by alerting the staff to signs of possible sexual abuse-related PTSD. These may include:

• little or no prenatal care (due to fear of obstetric procedures)
• unusual fears of needles, intravenous lines, etc.
• recoiling when touched during obstetric examinations
• insistence on female obstetric staff
• extreme sensitivity about bodily exposure.^26,28

Table 4

USE OF ANTIDEPRESSANTS FOR PTSD DURING BREAST FEEDING

Intervention. Once abuse-related perinatal PTSD is diagnosed, the interventions in Table 3 can help a woman through labor and delivery.^26,28 When successful, they can turn childbirth into a healing experience that promotes the mother’s sense of accomplishment, positive association with sexuality, and a new relationship with her body.²⁸

Breastfeeding can also trigger flashbacks and frightening emotions in a woman who was sexually abused as a child.²⁹ She may confuse normal sensations of skin-to-skin contact with the baby or the milk ejection reflex with unpleasant sexually-linked feelings. In such cases, it may help to:

• explain the normal sensations associated with breastfeeding and normal behaviors of breastfeeding infants
• show her how to gently redirect her baby if it does something she finds uncomfortable
• identify situations that are especially difficult for her (such as nighttime feedings) and substitute bottle feeding at those times.

These measures may promote feelings of self-efficacy and help more in the long run than prematurely giving up on breastfeeding.

Prescribing to the nursing woman. When prescribing medication for PTSD in a breast-feeding woman, minimize potential infant side effects by choosing agents that produce relatively low drug levels in breast milk (Table 4).^30-34 Sertraline—the first medication to receive Food and Drug Administration approval for treating PTSD—is recommended during breastfeeding.³⁵

Pregnancy loss. Although the prevalence of PTSD in response to miscarriage or stillbirth is unknown, some women clearly develop PTSD after pregnancy loss. The degree of associated physical trauma—and of social and professional support—influence anxiety levels in response to miscarriage³⁶ and may also influence the likelihood of developing PTSD. Pregnancy loss after the first trimester may be more likely to result in PTSD than earlier loss, and subsequent pregnancies may exacerbate PTSD symptoms. In one study, spontaneous fetal loss after the 18th week of gestation led to high rates of PTSD symptoms in a subsequent pregnancy and up to 1 year postpartum.³⁷

Asking a woman how she wants to grieve her pregnancy loss and helping her in that process may minimize her risk of subsequent PTSD. Couples counseling may help in some cases, as each partner may have a different grieving style.

Related resources

• Foa EB, Keane TM, Friedman MJ. Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress studies. New York: Guilford Publications, 2000.
• Kimerling R, Ouimette P, Wolfe J (eds). Gender and PTSD. New York: Guilford Publications, 2002.
• Madison Institute of Medicine. Facts for Health: posttraumatic stress disorder. www.ptsd.factsforhealth.org

Drug brand names

• Citalopram • Celexa
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Posttraumatic stress disorder (PTSD) was first recognized as a diagnosis in male Vietnam War veterans, but studies since then have consistently found PTSD to be more common in women than in men. Understanding the gender-related differences in PTSD’s presentation can help us craft optimal treatment for women suffering with this persistent disorder.

Data from the National Comorbidity Survey suggest a lifetime PTSD prevalence of 10.4% in women and 5.0% in men.¹ PTSD also tends to be more chronic in women. In one study of patients with PTSD, median time from symptom onset to remission was 4 years for women and 1 year for men.²

Evidence suggests that women:

• experience more or different types of trauma than men, including labor and delivery, rape, and childhood sexual abuse
• may react to trauma more often and more robustly than men because of sex hormones, cultural gender roles, or some combination of those factors.

How women experience trauma

Among studies that show gender differences in response to specific trauma, nearly all have found higher PTSD rates in women than in men. This pattern emerges early in life and is seen in children and adults.

A meta-analysis comparing PTSD symptoms in females and males of all ages after specific traumas³ found that females were much more likely than males to report PTSD symptoms after some types of trauma but not others. None of the trauma types predicted PTSD more often for males than for females.

Amount of trauma. Men are more likely than women to be exposed to traumatic events, such as violent assault, during their lifetimes.⁴ However, the types of trauma that women experience predominantly or exclusively—such as childhood sexual abuse, traumatic labor and delivery, pregnancy loss, severe health problems in a newborn, and prostitution—are rarely included in trauma questionnaires (Table 1). As a result, the full range of traumatic experiences in women’s lives is likely underestimated.

Instruments designed to measure trauma may inadvertently introduce gender bias in other ways.⁵ For example, questionnaires asking about single traumatic events may underestimate the impact of repetitive traumas, such as childhood sexual abuse and domestic violence, which are more frequently experienced by girls and women. Further, women may not acknowledge sexually linked traumas—such as childhood sexual abuse and rape—unless the questions are asked in a sensitive manner and describe specific behaviors.

Table 1

TRAUMAS THAT CAUSE PTSD PREDOMINANTLY IN WOMEN

Types of trauma. Certain types of trauma are associated with especially high conditional risk of PTSD, defined as the risk of developing PTSD after being exposed to the trauma. Childhood sexual abuse, domestic violence, and rape are among the traumas with the highest conditional risk, and women are more likely to be exposed to these trauma types than men.⁶

Childhood sexual abuse has a particularly high conditional risk of PTSD.⁷ Such abuse happens over long periods during developmentally vulnerable stages of life. Sexual abuse perpetrated by a family member creates a greater sense of betrayal than does trauma at the hands of a stranger or an impersonal force of nature. In many cases, the victims blame themselves.

Domestic violence, like sexual abuse, has a high conditional PTSD risk because of the intimate nature of the relationship and the usual pattern of multiple assaults over time.

Rape carries the highest conditional risk of any trauma,⁸ possibly because of the degree to which rape violates a victim’s assumptions about the world as a reasonably safe place.³ PTSD risk after rape is intensified when the victim blames himself or herself and when society—such as the family or court system—reinforces this tendency toward self-blame.⁹

Influence of sex hormones. Neurophysiologic systems that lie beneath stress responses are closely linked with reproductive physiology.¹⁰ Evolution may have favored this association, allowing reproductive efforts to shut down during extreme stress.

Key components of the primary stress-activated hormonal system—corticotropin-releasing hormone, adrenocorticotropic hormone, and the glucocorticoids—inhibit secretion of gonadotropin-releasing hormone and the gonadotropins, the major reproductive hormones. In turn, sex hormones modulate hypothalamic-pituitary adrenal (HPA) axis activity, stress-linked neurotransmitter changes, and behavioral responses to stress.

This intertwining of stress and reproductive hormones suggests that men’s and women’s physiologic response to trauma may differ. Women’s vulnerability to PTSD also may vary at different parts of their menstrual cycles, during pregnancy, or postpartum.

Several animal studies have shown a more intense HPA axis response to stress in females than in males’.¹¹ To date, however, studies have not shown clear gender differences in human physiologic response to trauma. Increased sympathetic nervous system activity, enhanced dexamethasone suppression of cortisol, and hippocampal atrophy have been found in both men and women with PTSD.^11,12

Some human studies suggest gender differences in PTSD-related neurophysiologic changes. For example, activation of both the sympathetic and adrenocortical systems (epinephrine and cortisol) has been seen in women with PTSD from childhood sexual abuse, whereas activation of only the sympathetic system (epinephrine but not cortisol) has been seen in men with combat-related PTSD.¹³ Research with improved methodology is investigating whether sex hormones modulate human response to trauma.

Gender role differences. Because of cultural expectations, women may more easily acknowledge and report distress and feelings of being traumatized.¹⁴ This behavioral difference may contribute to higher PTSD prevalence rates in women than in men. Women also may develop more negative beliefs in response to some types of trauma, such as nonsexual assault by a stranger.³

Treating PTSD in women

Drug therapy. Antidepressants—including tricyclics, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors (SSRIs)—have shown efficacy in treating PTSD. Some studies have found that women respond more robustly to SSRI antidepressants than men.¹⁵

Cognitive-behavioral therapy. Trauma victims tend to avoid reminders of the trauma. Although this coping strategy can provide short-term relief, it can also constrict a person’s life and preclude opportunities to correct distorted information. For example, a person may attribute danger to benign stimuli that were coincidentally associated with the trauma, such as fearing all men with mustaches after being raped by a man with a mustache.³

Table 2

MALADAPTIVE REACTIONS DURING LABOR AND DELIVERY

Cognitive-behavioral therapy (CBT) for PTSD aims to activate and correct information by prolonged exposure to traumatic stimuli and to restructure incorrect cognitions. CBT approaches to PTSD include exposure therapy, cognitive therapy, cognitive processing, stress inoculation training, assertiveness training, systematic desensitization, biofeedback, and relaxation training. Of these, exposure therapy has been studied the most systematically and found to work especially well for female rape victims.¹⁶ Exposure therapy consists of confronting feared stimuli—such as returning to the scene of a rape or recalling detailed memories of childhood sexual abuse—until anxiety diminishes.

Psychodynamic therapy aims to re-engage normal adaptive mechanisms by introducing the unconscious into consciousness in tolerable doses.¹⁷ Therapy serves as a means of processing traumatic events, such as childhood sexual abuse, and exploring the psychological meanings of traumas.¹⁸ Few well-controlled studies have examined psychodynamic therapy in PTSD, in part because of the difficulty in operationally defining and assessing mechanisms of change. However, at least one relatively controlled study found reduced avoidance symptoms with psychodynamic therapy, compared with wait list and active treatment groups.¹⁹

EMDR. During eye movement desensitization and reprocessing (EMDR), the patient focuses on a disturbing image, a negative cognition, and somatic sensations associated with the trauma while tracking the movement of the clinician’s finger within her visual field.²⁰ The procedure is repeated until the patient’s distress is reduced and she develops more adaptive thoughts about the trauma.

Most EMDR practitioners recommend its use primarily for single-event traumas, such as rape or traumatic labor and delivery. Meta-analyses have suggested that EMDR may be as effective as other exposure therapy,²¹ although methodologic problems in several studies limit our ability to determine EMDR’s efficacy in treating women with PTSD.²²

Treating and preventing perinatal PTSD

Historically, common outcomes of giving birth included death or chronic disability. Despite advances in obstetric care, labor and delivery remains painful, frightening, and potentially dangerous. Although childbirth is a normative experience for many women, an estimated 2.8 to 5.6% of new mothers develop labor-related PTSD.^23-25 Risk of PTSD is increased in women with:

• high general anxiety levels prior to labor
• a history of mental illness
• unplanned pregnancy
• absence of partner during labor and delivery
• the perception that obstetric staff is unsupportive or ineffective
• a need for obstetric interventions, including episiotomy, emergency cesarean section, or use of forceps
• a perception of lack of control.

Table 3

LABOR INTERVENTIONS FOR VICTIMS OF CHILDHOOD SEXUAL ABUSE

Untreated PTSD may impair the woman’s functional ability and compromise her relationship with the infant:

Avoidance can extend to subsequent health care (such as not attending the postpartum checkup), sexual relationships, caring for the baby, and future pregnancies. Some women request general anesthesia and cesarean sections for future deliveries.

Arousal may intensify postpartum sleep disturbance and fatigue and may cause a mother to be hypervigilant about her baby.

Flashbacks can influence feelings about the baby, such as when the mother has repeated, vivid memories of the newborn being limp and blue after delivery, even though the infant is healthy now.

Preventive interventions that can minimize PTSD risk after labor and dshlivery include:

• explaining to women before the onset of labor that emergency obstetric interventions might be necessary
• providing adequate social support during labor and delivery
• ensuring that the obstetric staff communicates clearly with the patient
• effectively managing pain to minimize trauma.

Postpartum, it is important to screen for PTSD symptoms among high-risk women. Prompt intervention can alleviate symptoms and minimize adverse effects on the family and the mother-infant relationship.

Role of sexual abuse in perinatal PTSD. For a woman who was sexually abused as a child, even an uncomplicated labor and delivery may trigger memories, flashbacks, and emotions associated with the abuse.²⁶ Physical sensations associated with gynecologic examinations and labor contractions may remind her of abuse-related sensations. Some women with sexual abuse histories react adversely to the loss of control and need to depend on others during labor and delivery.

Unrecognized posttraumatic reactions during labor may result in maladaptive behaviors (Table 2).²⁶ Obstetric staff who encounter these behaviors without being aware of their origins may think the patient is oppositional or noncompliant and may regard her as an adversary to be defeated or bypassed in order to safely deliver the baby.²⁷ The psychiatrist can minimize this problem early in labor by alerting the staff to signs of possible sexual abuse-related PTSD. These may include:

• little or no prenatal care (due to fear of obstetric procedures)
• unusual fears of needles, intravenous lines, etc.
• recoiling when touched during obstetric examinations
• insistence on female obstetric staff
• extreme sensitivity about bodily exposure.^26,28

Table 4

USE OF ANTIDEPRESSANTS FOR PTSD DURING BREAST FEEDING

Intervention. Once abuse-related perinatal PTSD is diagnosed, the interventions in Table 3 can help a woman through labor and delivery.^26,28 When successful, they can turn childbirth into a healing experience that promotes the mother’s sense of accomplishment, positive association with sexuality, and a new relationship with her body.²⁸

Breastfeeding can also trigger flashbacks and frightening emotions in a woman who was sexually abused as a child.²⁹ She may confuse normal sensations of skin-to-skin contact with the baby or the milk ejection reflex with unpleasant sexually-linked feelings. In such cases, it may help to:

• explain the normal sensations associated with breastfeeding and normal behaviors of breastfeeding infants
• show her how to gently redirect her baby if it does something she finds uncomfortable
• identify situations that are especially difficult for her (such as nighttime feedings) and substitute bottle feeding at those times.

These measures may promote feelings of self-efficacy and help more in the long run than prematurely giving up on breastfeeding.

Prescribing to the nursing woman. When prescribing medication for PTSD in a breast-feeding woman, minimize potential infant side effects by choosing agents that produce relatively low drug levels in breast milk (Table 4).^30-34 Sertraline—the first medication to receive Food and Drug Administration approval for treating PTSD—is recommended during breastfeeding.³⁵

Pregnancy loss. Although the prevalence of PTSD in response to miscarriage or stillbirth is unknown, some women clearly develop PTSD after pregnancy loss. The degree of associated physical trauma—and of social and professional support—influence anxiety levels in response to miscarriage³⁶ and may also influence the likelihood of developing PTSD. Pregnancy loss after the first trimester may be more likely to result in PTSD than earlier loss, and subsequent pregnancies may exacerbate PTSD symptoms. In one study, spontaneous fetal loss after the 18th week of gestation led to high rates of PTSD symptoms in a subsequent pregnancy and up to 1 year postpartum.³⁷

Asking a woman how she wants to grieve her pregnancy loss and helping her in that process may minimize her risk of subsequent PTSD. Couples counseling may help in some cases, as each partner may have a different grieving style.

Related resources

• Foa EB, Keane TM, Friedman MJ. Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress studies. New York: Guilford Publications, 2000.
• Kimerling R, Ouimette P, Wolfe J (eds). Gender and PTSD. New York: Guilford Publications, 2002.
• Madison Institute of Medicine. Facts for Health: posttraumatic stress disorder. www.ptsd.factsforhealth.org

Drug brand names

• Citalopram • Celexa
• Fluoxetine • Prozac
• Mirtazapine • Remeron
• Nefazodone • Serzone
• Paroxetine • Paxil
• Sertraline • Zoloft
• Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.