JOURNAL

10.1177/0886260504267882
Woods / INTIMATE
OF INTERPERSON
PARTNERAL
VIOLENCE
VIOLENCE
AND
/ April
PTSD 2005

Intimate Partner Violence and

Post-Traumatic Stress Disorder
Symptoms in Women
What We Know and Need to Know

STEPHANIE J. WOODS
The University of Akron

This article presents a review of knowledge regarding post-traumatic stress disorder

(PTSD) in women experiencing intimate partner violence. Knowledge related to the
prevalence and predictors of PTSD in battered women, the association between
PTSD and physical health, and the emerging science regarding PTSD and physiolog-
ical and immune parameters is addressed. Primary recommendations for future
research includes the need for longitudinal and intervention research that incorpo-
rates a range of psychosocial and physiologic health outcomes.

Keywords: intimate partner violence; post-traumatic stress disorder (PTSD);

physiologic and immunologic parameters

CURRENT KNOWLEDGE AND FUTURE NEEDS

Although researchers’ interest in the phenomenon of human responses to

traumatic events began over a century ago, the early literature on battered
women assumed pathology of the woman and focused little or no attention on
the consequences of experiencing intimately violent acts (Gelles & Harrop,
1989; Walker & Browne, 1985). One of the first investigations to examine
intimate partner violence (IPV) as a traumatic event and the occurrence of
post-traumatic stress disorder (PTSD) in battered women was published by
the Journal of Interpersonal Violence in 1991. Houskamp and Foy (1991),
using the Structured Clinical Interview (Spitzer & Williams, 1985) and sev-
eral self-report instruments, found a significant relationship between the

Author’s Note: Correspondence concerning this article should be addressed to Stephanie J.

Woods, The University of Akron, College of Nursing, Akron, OH 44325; e-mail: sw5@uakron.
edu.
JOURNAL OF INTERPERSONAL VIOLENCE, Vol. 20 No. 4, April 2005 394-402
DOI: 10.1177/0886260504267882
© 2005 Sage Publications
394
 Woods / INTIMATE PARTNER VIOLENCE AND PTSD 395

intensity and extent of intimate violence and the severity of PTSD symptoms
in women. Almost one half of the 26 women seeking help at domestic vio-
lence clinics in their study met DSM-III-R criteria for the diagnosis of PTSD.
In the same year, Kemp, Rawlings, and Green (1991) reported in the Journal
of Traumatic Stress that 84.4% of 77 battered women in shelters met PTSD
criteria based on self-report instruments. The groundbreaking work of these
investigators raised awareness and advanced understanding of the linkages
between IPV and PTSD. The purpose of this article is to discuss the most
important insights gained about IPV and PTSD since these initial studies and
suggest directions for future investigation. Specifically, the prevalence and
predictors of PTSD in battered women, the association between PTSD and
physical health, and the emerging science regarding PTSD and physiological
and immune factors are addressed.

Prevalence and Predictors

Research since 1991 has consistently demonstrated that some battered
women experience PTSD symptoms. In a meta-analysis of 11 studies, Golding
(1999) reported that 31% to 84.4% of women who experienced IPV met
PTSD criteria (weighted mean prevalence = 63.8%). The wide variation in
Golding’s analysis may be related to the different analytic techniques and
instruments used to measure PTSD. For example, 7 of the 11 studies used the
Conflict Tactics Scale (CTS; Straus, 1990) or a modified version of the CTS
to measure IPV instead of using multiple measures with established reliabil-
ity and validity to assess for distinct types of IPV. Other studies used only one
or two screening questions to assess for IPV. In addition, prevalence was
related to whether study samples were population based or from clinical sites
such as shelters or other intervention settings. All types of IPV, that is physi-
cal, emotional, and sexual abuse, threats of violence, and risk of homicide,
are predictive of PTSD symptom severity (Wineman, Woods, & Zupanic,
2004; Woods & Isenberg, 2001).
The evidence also shows that PTSD is a long-term mental health conse-
quence of IPV. In two separate cross-sectional studies totaling 102 post-
abused women, approximately half of the women were experiencing PTSD
symptomatology even though they had been out of the intimately abusive
relationship an average of 6 to 9 years (Woods, 2000a, 2000b). These find-
ings, along with the dearth of longitudinal research on the course or progres-
sion of PTSD symptoms in battered women (Jones, Hughes, & Unterstaller,
2001), emphasize the need for intervention and long-term research, not only
for women currently experiencing intimate violence but also on the lasting
effects of IPV.
396 JOURNAL OF INTERPERSONAL VIOLENCE / April 2005

PTSD and Physical Health

Research across several trauma survivor groups has shown that individu-
als with PTSD are at increased risk of morbidity and mortality (Beckman
et al., 1998; Boscarino, 1997; Schnurr & Spiro, 1999; Taft, Stern, King, &
King, 1999; Wagner, Wolfe, Rotnitsky, Proctor, & Erickson, 2000). Chronic
PTSD has been associated with higher lifetime prevalence of respiratory,
cardiovascular, gastrointestinal, musculoskeletal, and nonsexually transmit-
ted infectious diseases (Beckman et al., 1998; Boscarino, 1997; Kimerling,
Clum, & Wolfe, 2000; Schnurr & Spiro, 1999; Wolfe, Schnurr, Brown, &
Furey, 1994; Zoellner, Goodwin, & Foa, 2000). In addition, the current evi-
dence demonstrates that the more severe the PTSD symptoms, the greater the
physical health problems experienced by trauma survivors (Fontana, Litz, &
Rosenbeck, 2001; Kimerling et al., 2000; Zoellner et al., 2000).
Moreover, there is empirical evidence to suggest that specific PTSD
symptom clusters have differential relationships with health outcomes in
women. The PTSD hyperarousal cluster was a significant, unique predictor
of the variance in the physical health in female war veterans (Kimerling et al.,
2000). Similar results were found in currently abused women when control-
ling for age, childhood maltreatment, and IPV (Woods, Campbell, Hall, &
Wineman, 2003). In contrast, reexperiencing (intrusion) explained a signifi-
cant portion of the variance in the physical health of female victims of sexual
assault when negative life events and depression were statistically controlled
(Zoellner et al., 2000). These research findings suggest that even though the
context of war and IPV differ in many aspects, battered women and female
war veterans experience the effects of multiple acute episodes of trauma in
long-term situations (Woods, Campbell, et al., 2003). These long-term situa-
tions contrast with the single event of sexual assault. Research is needed to
examine the similarities and differences in the PTSD symptom clusters that
develop following exposure to traumatic events that differ in context and
duration.

PTSD and Physiological and Immune Parameters

Examination of the relationships among the physiologic and psychosocial

consequences of IPV and how they affect the health of battered women is in
its infancy. Decreased cortisol levels have been associated with chronic
PTSD across multiple types of traumas, in men and women, from young chil-
dren to Holocaust survivors, when compared to those with other psychiatric
disorders and healthy comparison groups (Boscarino, 1996; Goenjian et al.,
1996; Kanter et al., 2001; Mason, Giller, Kosten, Ostroff, & Podd, 1986;
 Woods / INTIMATE PARTNER VIOLENCE AND PTSD 397

Yehuda, Kahana, et al., 1995; Yehuda, Southwick, Nussbaum, et al., 1990;

Yehuda, Teicher, Trestman, Levengood, & Siever, 1996). An initial investi-
gation of 116 battered women experiencing moderate to severe PTSD
symptomatology showed that approximately one half of these women had
altered diurnal cortisol patterns (Woods, Page, & Alexander, 2003). Of bat-
tered women in this sample, 22% had a flat cortisol pattern in which the PM
(approximately 10 PM) and AM (approximately 8 AM) levels varied little, and
4% had a reverse rhythm with PM levels higher than AM levels. There were no
significant relationships between PM and AM cortisol, and age, body mass
index (BMI), and last menstrual period in these intimately abused women.
These research findings raise many questions and promising areas for
future investigation about the physiologic consequences of PTSD. Do the
alterations in diurnal cortisol patterns seen in battered women reflect an en-
hanced negative feedback sensitivity of the hypothalamus-pituitary-adrenal
(HPA) axis as posited by Yehuda and her colleagues (Mason et al., 1986;
Yehuda & McFarlane, 1995; Yehuda, Southwick, Krystal, et al., 1993) or
adrenocortical hyporesponsivess as put forth by Kanter et al. (2001)? Are
biologic changes in PTSD progressive, with alterations evolving over time as
suggested by Yehuda (2002)? Do the different cortisol patterns initially
found in intimately abused women reflect the so-called staging of biological
alterations with PTSD? What are the long-term consequences of changes in
adrenocortical hormones on physical health? Answers to these questions
would advance the understanding of the integrated nature of psychological
and physiological responses to IPV and possibly provide insights to the long-
term physical consequences that have not yet been examined.
In addition, the finding that 22% of battered women had a flat diurnal
cortisol pattern (Woods, Page, et al., 2003) is particularly important in light
of the results from Sephton, Sapolsky, Kraemer, and Spiegel (2000), who
reported that a relatively flat or abnormal diurnal cortisol variation was pre-
dictive of early mortality in women with metastatic breast cancer. A rela-
tively flat diurnal cortisol rhythm was also associated with low circulating
counts of natural killer (NK) cells and suppressed NK activity in women with
metastatic breast cancer (Sephton et al., 2000). These results highlight the
importance of longitudinal examination of diurnal cortisol patterns and their
relationship to health outcomes, including immune function, in battered
women.
Research has also shown alterations in immune cell enumeration and effi-
cacy in some persons with PTSD. Similar to findings with PTSD-positive
male combat veterans (Boscarino, 1997; Boscarino & Chang, 1999), abused
women experiencing PTSD have been found to have significantly higher leu-
kocyte and absolute lymphocyte subset counts, controlling for smoking and
398 JOURNAL OF INTERPERSONAL VIOLENCE / April 2005

BMI, than comparison women (Woods, Page, et al., 2003). Yet, despite hav-
ing higher levels of circulating lymphocytes, the cytotoxic potential of the T
cells and NK cells in abused women was decreased, indicating reduced func-
tional efficacy of these immune cells. Declines in several lymphocyte subset
counts and NK cell cytotoxicity were also reported in survivors of natural
disasters (Ironson et al., 1997; Solomon, Segerstrom, Grohr, Kemeny, &
Fahey, 1997). Abused women also had lower PM salivary immunoglobulin A
(IgA) levels than nonabused women (Alexander, Woods, Page, Define, &
Beach, 2003). Although speculative, if these findings hold true in women
who have experienced IPV over time, they may help explain the increased
incidence of morbidity in this population.
Cytokines link the immune, nervous, and neuroendocrine systems
(Rabin, 1999; Webster, Tonelli, & Sternberg, 2002) and help stimulate and
regulate the HPA axis (Spath-Schwalse et al., 1994; Sredni-Kenigsbuch,
2002), just as the HPA axis influences the immune response (Chrousos,
1995; Wong, 2002). Studies exploring the relationships among PTSD, cyto-
kines, diurnal adrenocortical functioning, and physical health symptoms
among trauma groups, including battered women, are few. However, altered
diurnal cortisol patterns coupled with high interleukin-6 (IL-6) levels have
been reported in long-standing situations of psychosocial stress (Theorell,
Hasselhorn, Vingard, & Andersson, 2000). Furthermore, increased IL-6,
along with decreased Th1 cell production, may compromise immune func-
tion during periods of acute and chronic stress (Kang & Fox, 2001). Thus,
these physiologic and immunologic parameters may be altered in women
experiencing long-standing IPV, just as it is with individuals who are in other
chronically stressful situations. Research that includes measurements of
psychosocial, physiologic, and immunologic parameters in one study may
foster understanding of the integrative nature of women’s responses to IPV
immediately and over the long-term.

MOST PROMISING INNOVATION FOR STUDY OF IPV

Scientific knowledge regarding the dynamic interplay among the physio-

logic and psychological parameters affecting the health of individuals who
have experienced violence and trauma is limited, especially with persons
who experience chronic trauma. Although PTSD may be descriptive of the
array of psychological and some of the physical symptoms women experi-
ence as a result of IPV, it does not capture their holistic responses to battering.
The effects of trauma are far reaching and affect the physical, emotional,
mental, social, and spiritual aspects of the person (Donovan, 1993; Valent,
 Woods / INTIMATE PARTNER VIOLENCE AND PTSD 399

1998). The majority of research across trauma survivor groups, including

battered women, is conducted cross-sectionally, yielding much information
about the emotional and mental health effects of exposure to trauma. How-
ever, research has not consistently addressed the person as an integrated
human being. In addition, little is known about how physiological and psy-
chological factors evolve over time or how they might influence health.
Expanding the range of health outcomes to include not only self-report phys-
ical symptoms but also reliable indicators of immune and diurnal adreno-
cortical hormone functioning, particularly in longitudinal studies, would
provide empirical evidence of changes over time between PTSD and physio-
logic indicators.
Longitudinal analyses with advanced statistical procedures such as struc-
tural equation modeling and latent variable growth curve modeling could be
used to examine the direction of causality in the relationship between IPV,
PTSD, and an expanded range of physical health outcomes. Latent growth
curve modeling would allow examination of trajectories of change in diurnal
adrenocortical hormones, immune function, and PTSD longitudinally in bat-
tered women. A longitudinal design would also make it possible to detect
more-complex forms of relationships such as nonrecursive relationships in
which PTSD and physical health reciprocally interact. Triangulating these
quantitative longitudinal designs with qualitative data about the woman’s
lived experience would also help advance holistic understanding of the wom-
an’s experience and her responses to it.
In summary, this article examined the current body of knowledge related
to IPV and PTSD. The emerging science about the relationships among
PTSD and physiologic and immunologic parameters informs future research
with women experiencing, or who have experienced, violence in a relation-
ship. Furthermore, the strength of the extant empirical evidence underscores
the importance of holistic examination of a person’s experiences and conse-
quences of trauma, including women who have experienced IPV.

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Stephanie J. Woods, Ph.D., R.N., is an associate professor of nursing at The University of

Akron, College of Nursing. Her current research focuses on the physiologic and
psychosocial factors affecting the physical and mental health of women who have experi-
enced intimate partner violence and childhood trauma.