Posttraumatic stress disorder symptom expression in racially and ethnically diverse women veterans
Introduction
The growing number of individuals belonging to racial and ethnic minority groups in the U.S. is reflected in the concomitant number and percentage of individuals belonging to racial and ethnic minority groups enlisting in the U.S. military (Barroso, 2020). Additionally, over the past two decades, the women veteran population has doubled, reaching nearly two million (Maguen et al., 2010; Manning, 2008). Of those newly enlisting, racially and ethnically diverse women are among the fastest-growing groups. Consequently, servicewomen are more racially and ethnically diverse than servicemen (National Center for Veterans Analysis and Statistics, 2016).
Given the expanding numbers of racial/ethnic and women minorities entering the military, it is critical to prepare to meet the needs of diverse women when they return from deployments, including their mental health needs. There is already evidence that women and men may have different mental health presentations post-deployment (e.g., Maguen et al., 2010). Given that exposure to traumatic events is common during deployments, a better understanding of PTSD symptom presentations in ethnic/minority women veterans and how they are similar to or distinct from their white counterparts is needed to facilitate appropriate assessment and care.
Research on the presentation of PTSD in racial/ethnic and women minority groups is rare. This gap in our understanding of trauma is problematic because even before reaching adulthood racial/ethnic minorities experience a greater number of distinctive traumatic exposures, including race-based trauma (Maguire et al., 2020; Roberts et al., 2011). Moreover, research indicates both racial/ethnic and women minority groups are more susceptible to developing PTSD than their white (Kulka et al., 1988, 1990; Pole et al., 2005, 2008; Santos et al., 2008) and male counterparts (Bangasser and Valentino, 2014; Breslau et al., 1997, 1998; Kessler et al., 1995; Tolin and Foa, 2006). Women are more susceptible to PTSD even when men endorse more traumatic experiences (Tolin and Foa, 2006).
Studies demonstrate there are racial/ethnic differences in the presentation of PTSD by symptom clusters (i.e., re-experiencing, avoidance, hyperarousal, and emotional numbing) in the general population. Research has shown higher arousal among older white adults (Mainous et al., 2005), Latina women with intimate partner violence (Weiss et al., 2017), and U.S. Mexican hurricane survivors (Norris et al., 2001). Higher rates of avoidance have been observed in Latinx-American police officers (Pole et al., 2005), Latinx survivors of physical injury (Marshall et al., 2009), and Mexicans with higher intrusive symptoms (Norris et al., 2001). Among veterans, such differences exist but vary by cluster type with some minority groups reporting higher PTSD symptoms for particular clusters in some studies, but not in others (e.g., Coleman et al., 2019; Koo et al., 2016; Ortega and Rosenheck, 2000). For example, Black veterans endorsed higher arousal than white veterans in one study (Ortega and Rosenheck, 2000), but not in a national sample (Koo et al., 2016). Moreover, although researchers have examined racial/ethnic differences in PTSD symptom clusters and overall symptom severity in veterans, the analytical methods utilized required comparing preset diagnostic clusters of PTSD (i.e., linear regression models, univariate models, multivariate models). This assumes the PTSD presentation of racial/ethnic groups manifest in clinical profiles based on Western cultural constructs (see Hinton and Lewis- Fernández, 2011). Some of these studies also focused on identifying differences between one particular minority race/ethnicity and non-minority male veterans (e.g., Coleman et al., 2019; Ortega and Rosenheck, 2000). There is also evidence of gender differences within PTSD symptom clusters. For example, Mexican civilian-women report higher symptom severity and arousal than their cultural counterparts (Norris et al., 2001). Investigators have found gender differences in the veteran population with women reporting higher symptoms on all four PTSD clusters in one study (Hourani et al., 2015). Additionally, a national study of veterans found racial/ethnic and gender differences in PTSD symptom clusters (see Koo et al., 2016), suggesting that racial/ethnic differences should be examined by gender. Specifically, Asian/Pacific Islander women rarely endorsed avoidance, Latinx women endorsed more emotional numbness, and Black women were no different than their white counterparts.
Typological techniques (i.e., latent profile analysis) have been used to identify and compare distinct profiles of PTSD symptom presentation. Findings from multiple studies indicate three (mild, moderate, high severity; Contractor et al., 2015; Steenkamp et al., 2012, 2015) or four discrete symptom profiles of PTSD (mild, moderate, moderate with emotional numbing, high severity; Hebenstreit et al., 2014; Maguen et al., 2013; Stripada et al., 2020). In several studies, race/ethnicity was associated with PTSD profiles (e.g., Hebenstreit et al., 2014; Stripada et al., 2020; Wolf et al., 2012) which implies that the manner in which PTSD presents differs across racial/ethnic groups. It is unclear whether there are differences in typological expression of PTSD symptom clusters within different racial/ethnic groups of female veterans. Examining PTSD symptom profiles in a women veteran sample may clarify racial/ethnic differences in PTSD and provide clinically relevant information that can be leveraged to improve mental health care for minority women veterans.
Although studies have found racial/ethnic differences in PTSD symptom clusters using standard regression analyses, no study in the general or veteran population has examined racial/ethnic differences in PTSD symptom configuration and group-typology sets using a clustering approach. In this study, we built upon previous work by examining racial/ethnic differences in PTSD symptoms expression in a sample of women veterans. We first examined racial/ethnic differences among PTSD symptom clusters (intrusions, avoidance, negative alterations in mood/cognition, and hyperarousal) and traumatic events. We next examined whether the configuration of PTSD symptoms differed within different races/ethnicities using a clustering approach.
Section snippets
Participants
Participants in this study were 407 female military veterans seeking treatment at a large Veterans Health Administration (VHA) hospital (and its surrounding outpatient clinics). Participants were asked if they identified as cisgender-male, cisgender-female, or transgender. Women were on average 49.42 years old (SD = 10.03, range: 24–70). Women of different racial/ethnic groups differed somewhat with regard to average age (F = 7.26, p < .05), with women identifying as Asian being younger than
Results
PTSD symptom sets (intrusions, avoidance, negative alterations in mood/cognition, and hyperarousal) correlated highly with each other (rmean = 0.77) as well as with potentially traumatic events women experienced during their military service (rmean = 0.48), but less with more general lifetime traumatic events (rmean = 0.14; see Table 2). Results of our ANOVAs indicated that neither total number of PTSD symptoms nor the severity of symptom clusters differed significantly across racial/ethnic
Discussion
This study was the first to examine racial/ethnic differences in PTSD symptom configuration and group-typology sets using a clustering approach. Our findings emphasize the importance of viewing the PTSD symptom patterns through a cultural lens.
We found a unique pattern of symptom expression in Latinas. Latinas demonstrated an eight-group typology differing in symptom severity and relative elevations or decreases in specific diagnostic clusters. For example, Latinas either demonstrated elevated
Role of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Alejandra Ceja: Conceptualization, Visualization, Writing – original draft, Investigation, Methodology, Investigation, Writing – review & editing, Methodology, Investigation. Matthew M. Yalch: Conceptualization, Visualization, Formal analysis, Writing – original draft, Project administration, Methodology, Investigation. Shira Maguen: Conceptualization, Visualization, Methodology, Investigation, Writing – review & editing.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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