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DOI 10.1007/978-3-319-08613-2_57-1
# Springer International Publishing Switzerland 2015
Abstract
Women in prison often have significant trauma histories, and PTSD is much more common among female
inmates than in their community counterparts. Among female prisoners, PTSD is the second most
common disorder, after substance use disorders. In this population, PTSD is often comorbid with
substance use disorders, personality disorders, serious mental illnesses, and HIV. Pharmacotherapy
options are limited in prisons, impacting treatment options. As well, psychotherapy usually must occur
within group settings in prison, posing unique challenges in this population.
List of Abbreviations
AA Alcoholics Anonymous
ADHD Attention deficit hyperactivity disorder
BPD Borderline personality disorder
CBT Cognitive behavioral therapy
DBT Dialectical behavioral therapy
HIV Human immunodeficiency virus
PD Personality disorder
PTSD Post-traumatic stress disorder
SMI Serious mental illness
SSRI Selective serotonin reuptake inhibitor
SUD Substance use disorder
Introduction
Prison is primarily meant as a place to punish perpetrators of criminal acts. However, its other goals
include protection of the public, the reformation of the criminal into a member of society, and the
reduction of re-offending.
Rates of incarceration among women are on the rise, internationally (Strathopoulos 2012). In women’s
prisons, mental illnesses are more common than among women in the community. Consistently in women’s
prison populations, there is an overrepresentation of women who are under-educated and unemployed,
with limited social support (Tye and Mullen 2006; Lynch et al. 2014; Strathopoulos 2012). As well, women
*Email: susanhfmd@hotmail.com
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in prisons are consistently noted to have high rates of victimization (both in childhood and as adults) and
other traumas in their backgrounds.
Women in prison usually have less serious criminal offending histories than men in prison
(Strathopoulos 2012). Yet, women in prison are more likely than their counterpart males to have mental
health problems, physical health problems, and trauma histories (Lewis 2006). Female inmates’ mental
health backgrounds are not only different from those of male inmates, but they are also different from
non-incarcerated females (Lewis 2006; Zlotnick et al. 2003, 2009; Pelissier and Jones 2006; Colosetti and
Thyer 2000; Drapalski et al. 2009; Wolff et al. 2012; Cole et al. 2007). PTSD is highly prevalent across
samples of incarcerated women, second only to substance use disorders.
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while 9 % of incarcerated males did (Simpson et al. 1999). Similarly an Australian sample found 29 % of
incarcerated females had current PTSD, as did 10 % of corresponding males. These rates are clearly
higher than rates in the community (Goff et al. 2007).
Over a third (36 %) of the incarcerated women met criteria for PTSD in another Australian study (Tye
and Mullen 2006). The American study of nearly 500 female prisoners from four localities (Lynch
et al. 2014) found that 29 % of incarcerated women met current criteria for PTSD.
Among (N = 387) incarcerated women in an American maximum security prison, 44 % met PTSD
criteria. The severity of the PTSD correlated unsurprisingly with the likelihood of receiving PTSD
treatment in prison (Harner et al. 2013). In the aforementioned Iowa study, 30 % of the female inmates
and 17 % of the males met PTSD criteria (Gunter et al. 2012). Similarly another recent American study
(N = 203) found that 51 % of female prison inmates met criteria for PTSD, despite many more having
experienced trauma across their lives (Warren et al. 2009). Those with PTSD had higher numbers of
lifetime traumas on average and more frequent BPD (Warren et al. 2009).
In total, the lifetime prevalence of PTSD for the female prisoner population is thought to be as high as
30–42 % (Lewis 2006). Similar to the prevalence data of other mental illnesses, these numbers vary by
geographic location. The aforementioned Chinese study found a lifetime prevalence of PTSD of 16 % and
a current prevalence of 11 % (Huang et al. 2006).
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violence within prison were high, experiencing trauma symptoms did not predict being either the victim or
the perpetrator of such violence in prison (Brown 2011).
The risk for retaliation in prison may also prevent the reporting of trauma. Thus, female inmates may be
reluctant to seek psychiatric treatment, and they may be unwilling to discuss their exposure to trauma in
the prison setting. However, alternatively, for a subset of female inmates, the prison has been reported to
be a safer environment with fewer barriers to care, compared to the community setting (Warren et al. 2009;
Drapalski et al. 2009). Those who are known to have been victimized in prison should be screened
for PTSD.
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behavioral patterns that lead to the development of a PD. This in turn may lead to increased risk-taking
behaviors, which further increase the likelihood of traumatic events. Emotional dysregulation and
affective instability are common to both BPD and PTSD, and both may become more pronounced in
the prison setting. Personality disorders in prison can present with symptoms such as intense anger, self-
harm, rapid mood swings, and impulsivity, for example. A recent study of incarcerated women found that
“trauma was associated with impulsivity, recurrent suicidal threats/attempts, unstable mood, intense
inappropriate anger, feelings of emptiness, and stress-related dissociation or suspiciousness” (Gunter
et al. 2012). Female prisoners with cluster B personality pathology (such as BPD) report higher levels and
a greater variety of maternal and paternal physical and psychological abuse than their non-cluster
B counterparts. However, levels of childhood sexual abuse appear to be similar for both groups (Loper
et al. 2008).
Early prolonged exposure to trauma is common among female inmates. These factors are predictors of
complex PTSD, characterized by more severe symptomatology, as well as enduring personality changes.
These individuals have more symptoms of affect dysregulation, dissociation, and somatization. This is of
particular importance in the prison setting, as self-destructiveness, chronic pain, poor anger modulation,
suicidal behavior, excessive risk taking, and interpersonal relationship difficulties are prevalent. Women
with complex PTSD are known to have poorer treatment outcomes. As such, addressing dissociation and
interpersonal relationship problems in these inmates may be warranted prior to attempts at treatment of
PTSD (Hebert et al. 2007).
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In the United States, HIV-positive women with lifetime PTSD are more likely to have a history of
arrests for prostitution, high-risk sexual behavior, and intravenous drug use (Lewis 2005; Hutton
et al. 2001). HIV-positive women with PTSD are also more likely to have other comorbidities including
cannabis use disorder, major depression, and antisocial PD (Lewis 2005).
The diagnosis of PTSD in HIV-positive inmates may pose treatment challenges. PTSD is associated
with poorer outcomes from HIV reduction interventions, as well as noncompliance with medical
management of HIV (Lewis 2005). HIV risk reduction efforts among female prisoners should therefore
screen for the presence of PTSD. Similarly, incarcerated women with PTSD should be evaluated for a
history of risky behaviors and HIV status.
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permanent culture. This includes prison gangs, friendships, and intimate relationships. Prison inmates
may have a long time before release, which may lead to more behavioral problems since inmates may
have less incentive for good behavior.
Despite barriers to the provision of mental health services (Table 2), treatment may improve the
efficiency of correctional facility and improve safety by decreasing suicides, reducing behavioral prob-
lems, improving adjustment to the facility, and lowering substance use within the system (Lewis 2006;
Zlotnick et al. 2009; Cole et al. 2007; Kinsler and Saxman 2007; Hicks et al. 2010).
Although there is a clear need for mental health treatment in inmates, there are difficulties in providing
evidence-based treatment to an incarcerated population. Many treatments are studied in only voluntary
outpatient settings, and they are not normed on a prison population facing different stressors and
comorbidities, with limited supports and resources available to them (e.g., access to family) (Leigh-
Hunt and Perry 2014; Lewis 2006; Ford et al. 2013; Dixon et al. 2005). For example, many studies on
prolonged exposure therapy were done in outpatient settings and did not include patients with significant
drug abuse histories (Lynch et al. 2012; Colosetti and Thyer 2000). In addition, studies done in
correctional facilities may have methodological flaws for reasons such as limited sample size, lack of a
control group, and difficulties in maintaining study design or accurately assessing effect due to frequent
absenteeism inherent in correctional facilities (e.g., lockdowns, transfers, court hearings, disciplinary
actions preventing participation in groups) (Zlotnick et al. 2003; Saxena et al. 2014; Colosetti and Thyer
2000; Drapalski et al. 2009; Wolff et al. 2012; Cole et al. 2007; Ford et al. 2013). In addition, previous
studies have primarily focused on male prisoners (Friedman et al. 2013; Leigh-Hunt and Perry 2014;
Lewis 2006; Zlotnick et al. 2009; Wolff et al. 2012; Ford et al. 2013; Dixon et al. 2005).
In a very broad sense, there are two standard types of treatments for PTSD whether an individual is
incarcerated or not: psychopharmacologic and psychotherapy (Leigh-hunt and Perry 2014; Wolff
et al. 2011; Nucifora et al. 2011; Hall and Hall 2013a, b). The two medications with FDA approval for
the treatment of PTSD are the SSRIs paroxetine and sertraline (Hall and Hall 2013a; Asnis et al. 2004).
Both are generic, have low potential for abuse, have a relatively safe side effect profile, and are available
in most correctional pharmacies (Hall and Hall 2013a; Asnis et al. 2004). Additional off-label medications
are used to treat PTSD or target its symptoms (Hall and Hall 2013a; Asnis et al. 2004; Chapter on
Treatment of PTSD in elderly). Although quetiapine is not an FDA-approved treatment for PTSD, it is
commonly prescribed in the community for PTSD and generalized anxiety disorders (Ahearn et al. 2011;
Maher and Theodore 2012; Hermes et al. 2013; Maglione et al. 2011). Adjunct medication use may be
more limited in correctional settings due to attempts to limit “black market” supplies, potential for abuse,
public concern regarding over-medication, or potentially dangerous side effect profiles (Hall and Hall
2013a; Wolff et al. 2011). Bupropion and quetiapine (which are not considered to be drugs of abuse in
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non-incarcerated populations) and benzodiazepines (which have abuse potential in all populations) have
an underground “value” in correctional facilities either to ameliorate the withdrawal effects of other
substances (e.g., bupropion to reduce methamphetamine withdrawal) or be crushed up and snorted to
obtain an altered state (Table 3) (Tamburello et al. 2012; Reeves 2012; Sansone and Sansone 2010; Hillard
et al. 2013). It has been estimated that up to 69 % of medications prescribed in incarcerated settings are
“diverted or misused” (Hillard et al. 2013; Lewis 2006). This can be either a voluntary diversion (by the
person who is being prescribed the medication) or it can be a coercive diversion where the individual is
threatened (Hillard et al. 2013; Lewis 2006). Misuse and over-prescription of medications had become
such a concern that the New Jersey prison system issued guidelines stressing non-pharmacologic
treatments for insomnia, which led to a 38 % decrease in prescription of benzodiazepines and a 59 %
decrease in prescription in quetiapine (Reeves 2012). This highlights that factors other than medical
judgment can affect the treatments of PTSD for incarcerated persons.
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Ford et al. 2013; Hick et al. 2010). Due to financial limitations and large volumes of women needing
services, often these psychotherapeutic treatments are done in groups (Lynch et al. 2012; Saxena et al.
2014; Cole et al. 2007; Ford et al. 2013). While the advantages of individual therapy using CBT or
prolonged exposure therapy for the treatment of PTSD has been well documented, group therapy in
correction settings may not work as well (Tables 4 and 5) (Leigh-Hunt and Perry 2014; Hall and Hall
2013b; Lynch et al. 2012; Colosetti and Thyer 2000; Ford et al. 2013).
Several types of named regimented therapy have been specifically studied for incarcerated females with
PTSD (Table 6) (Lynch et al. 2012; Lanza et al. 2014; Zlotnick et al. 2003, 2009; Wolff et al. 2012; Saxena
et al. 2014; Hien et al. 2004; Salgado et al. 2007; Ford et al. 2013). Many studies have involved a
standardized program with workbooks, groups of three to eight individuals, meeting one to three times a
week for 60–150 min for 8–16 weeks (Lynch et al. 2012; Lanza et al. 2014; Zlotnick et al. 2009; Cole
et al. 2007; Ford et al. 2013). Generally those who did best with the treatment were individuals with better
emotional control or ones able to learn control within a short time of initiation of treatment (Bradley and
Follingstad 2003; Ford et al. 2013). The program groups varied on how much they would involve trauma
exposures (Lewis 2006; Lynch et al. 2012; Bradley and Follingstad 2003; Cole et al. 2007; Karlsson
et al. 2014; Ford et al. 2013). Some studies noted it was difficult for participants to engage in traditional
exposure therapy exercises due to lack of privacy, limited ability to do “homework” exercises, high
dropout rate due to distress on re-exposure, concerns over initiation of exposure therapy worsening SUD
or behavioral problems, and concerns about the general incarceration environment being too threatening/
stimulating to allow for the prolonged exposure therapy to successfully work (Lynch et al. 2012; Wolff
et al. 2012, 2011; Saxena et al. 2014; Colosetti and Thyer 2000; Bradley and Follingstad 2003; Karlsson
et al. 2014; Ford et al. 2013; Kinsler and Saxman 2007). Generally, the programs focused on teaching
relaxation techniques, emotional regulation/impulsivity control, coping strategies, relationship skills, and
psychosocial education (Lewis 2006; Lynch et al. 2012; Zlotnick et al. 2003, 2009; Saxena et al. 2014;
Wolff et al. 2012; Bradley and Follingstad 2003; Cole et al. 2007; Ford et al. 2013). Although many
studies have found benefits to these groups, some studies noted that the results were not as positive as
hoped for (Lynch et al. 2012; Colosetti and Thyer 2000; Wolff et al. 2012; Hien et al. 2004; Cole
et al. 2007; Ford et al. 2013). In some cases, studies found conflicting results for comorbid conditions
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(e.g., one condition improved but the other did not) or little to no improvement from the beginning to the
end of treatment (Lynch et al. 2012; Zlotnick et al. 2009; Wolff et al. 2012; Cole et al. 2007; Ford
et al. 2013). Even when there was a lack of statistical improvement, it was usually noted that participants
generally fared the same as or slightly better than the untreated control groups or treatment-as-usual
groups (Lynch et al. 2012; Zlotnick et al. 2009; Wolff et al. 2012; Cole et al. 2007; Ford et al. 2013). There
may have been methodological problems with some of the studies which limited the findings of positive
results – such as inclusion of sub-threshold PTSD cases, under-powered study sizes, participants sharing
materials with treatment-as-usual control groups, and limited time of follow-up (Lynch et al. 2012;
Zlotnick et al. 2009; Cole et al. 2007; Ford et al. 2013).
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• Incarcerated women with HIV have higher rates of PTSD than incarcerated women without HIV, and
incarcerated women with PTSD have higher rates of HIV than those without PTSD.
Summary Points
• This chapter focuses on unique aspects of prevalence, diagnosis, and treatment of PTSD among
incarcerated women.
• PTSD is the second most common disorder after substance use disorders in the female prison
population.
• The types of abuse seen in prisoners often date to early childhood, and patterns of trauma are often
repetitive and long standing.
• Personality disorders and serious mental illnesses are commonly comorbid with PTSD among female
prisoners.
• PTSD pharmacotherapy in correctional settings is limited due to medication diversion, potential for
abuse, and concern about “over-medication.”
• Psychotherapeutic treatment of PTSD in prison often needs to occur in groups.
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