Journal of Traumatic StressJune 2012, 25, 353–357

BRIEF REPORT

Ethnic Differences in Symptoms Among Female VeteransDiagnosed With PTSD

Janet C’de Baca,1 Diane Castillo,1 and Clifford Qualls2

1Behavioral Health Care Line, New Mexico VA Health Care System, Albuquerque, New Mexico, USA2Clinical & Translational Science Center and University of New Mexico, Albuquerque, New Mexico, USA

Among U.S. male Vietnam veterans, Hispanics have been shown to have higher rates of posttraumatic stress disorder (PTSD) than AfricanAmericans and non-Hispanic Whites (Kulka et al., 1990). In terms of gender, Tolin and Foa’s (2006) meta-analysis suggested womenexperience higher rates of PTSD than men. This study examined ethnic differences in PTSD and other symptomatology among 398 femaleveterans (63% non-Hispanic White, 28% Hispanic, 9% African American) seeking treatment for PTSD from 1995 to 2009 at a VeteransAdministration (VA) behavioral health clinic. The following symptom clusters were examined: anxiety/PTSD, depression, anger/hostility,and psychotic/dissociative symptoms. Few differences were found among the groups, suggesting the 3 ethnic groups studied were moresimilar than different. African American female veterans, however, scored higher on measuring ideas of persecution/paranoia, althoughthis may reflect an adaptive response to racism. These findings warrant further investigation to elucidate this relationship.

Posttraumatic stress disorder (PTSD) is an anxiety disor-der that may develop following a traumatic event (Ameri-can Psychiatric Association [APA], 2000). Lifetime and 12-month U.S. prevalence rates are 2%–14% and 3.5%, respec-tively (APA, 2000; Kessler, Chiu, Demler, & Walters, 2005).Military personnel and women comprise at- risk groups for de-veloping PTSD (Breslau, 2002; Kessler et al., 2005). Hispanicand African American women make up 32% of active forces(U.S. Department of Labor Statistics, 2006).

Studies of men and women indicate rates of PTSD are higheramong women, although men are more likely to experiencetraumatic events (Tolin & Foa, 2006). Reported ethnic dif-ferences include higher rates among African Americans andHispanics (Pole et al., 2001). Rates for Hispanics are high evenwith trauma exposure in a multivariate model (Marques, Robin-augh, LeBlanc, & Hinton, 2011). One explanation that has beenoffered is that Hispanics perceive greater racism and have lessfamilial/social support (Pole, Best, Metzler, & Marmar, 2005).

Our study expands on Monnier, Elhai, Frueh, Sauvageot, andMagruder’s (2002) work by examining ethnic difference amongnon-Hispanic White, African American, and Hispanic womenveterans seeking treatment for PTSD. Monnier et al. reported

Correspondence concerning this article should be addressed to Janet C’de Baca,Behavioral Health Care Line (116), New Mexico VA Health Care System, 1501San Pedro SE, Albuquerque, NM 87108. E-mail: Janet.CdeBaca@va.gov

Copyright C© 2012 International Society for Traumatic Stress Studies. Viewthis article online at wileyonlinelibrary.comDOI: 10.1002/jts.21709

few differences between African American and non-HispanicWhite males. We expected Hispanics to experience more se-vere PTSD symptomatology, however, as has been previouslyreported (Kulka et al., 1990; Pole et al., 2005).

Method

Participants and Procedure

Data were collected from 398 women (63% non-HispanicWhites, 28% Hispanics, and 9% African Americans) at theNew Mexico VA Women’s Stress Disorder Clinic from 1995–2009. Veterans completed a sequential battery of computer-ized psychological tests (average completion time, 90 min-utes), and were administered the Clinician Administered PTSDScale (CAPS; Blake et al., 1990) by staff psychologists orsupervised psychology interns. The mean age by ethnicitywas non-Hispanic Whites 45 (SD = 10.8), Hispanics 40(SD = 11.1), and African Americans 42 (SD = 7.5). Most weresingle, served in the Army or Air Force, and report multipletraumas in both childhood and adulthood, with sexual assaultthe most frequent trauma (Table 1). Excluded from the anal-ysis were 27 subjects not meeting the ethnicity criteria, sevensubjects with True Response Inconsistency scale T scores ≥100 or Variable Response Inconsistency scale T scores ≥ 80on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher et al., 2001), and 17 invalid profiles on the MillonClinical Multiaxial Inventory-III (MCMI-III; Millon, Millon,& Davis, 1994).

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354 C’de Baca, Castillo, and Qualls

Table 1Demographic Characteristics by Ethnicity for Eligible Pool of Participants

Non-Hispanic White Hispanic African American(n = 250) (n = 111) (n = 37)

Variable n % n % n %

Marital statusMarried/cohabitating 68 27.2 34 30.6 13 35.1Single/divorced/separated/widowed 182 72.8 77 69.4 24 64.9

Armed Forces branchArmy 104 41.6 51 45.9 13 35.1Navy 52 20.8 24 21.6 9 24.3Air Force 73 29.2 24 21.6 15 40.5Marine Corps/Coast Guard/Reserves 21 8.4 12 10.8 0 0.0

Combat exposureYes 28 11.2b 26 23.4a 3 8.1a,b

No 222 88.8 85 76.6 34 91.9Trauma in childhood/adulthood

Child (<age 18) 22 8.8 9 8.2 4 10.8Adult 84 33.6 48 43.6 10 27.0Both 144 57.6 53 48.2 23 62.2

Number of traumasOne 30 12.0 13 11.7 4 11.1Two or more 220 88.0 98 88.3 32 88.9

Trauma typeSexual assault only 134 53.6 46 41.4 21 58.3Sexual assault and other traumas 98 39.2 57 51.4 14 38.9Other traumas 18 7.2 8 7.2 1 2.8

Diagnostic statusPTSD only 77 30.8 44 39.6 11 29.7PTSD and ≥1 Axis I or II diagnosis 173 69.2 67 60.4 26 70.3

Note. PTSD = Posttraumatic stress disorder. Frequencies with differing superscripts were significantly different in post hoc analyses at p < .05 using Fisher’s LeastSignificance Difference test.

Measures

The CAPS (Blake et al., 1990) is a semistructured clinical in-terview used to make current or lifetime diagnoses. Cronbach’sα range is .73 to .85 (Blake et al., 1990). The total CAPS scoreis frequency plus intensity, with a 0–136 range. Current andlifetime internal consistency in our sample was .89 and .86, re-spectively. The MMPI-2 (Butcher et al., 2001) assesses a num-ber of personality, emotional, and behavioral disorders. Clin-ical, content, supplementary, and restructured clinical scalesinternal consistency coefficients range from .39 to .87, .68 to.86, .24 to .90, and .62 to .89, respectively (Wise, Streiner,& Walfish, 2010). The MCMI-III (Millon, Millon, & Davis,1994) produces scales for personality disorders and clinicalsyndromes. Internal consistency ranges from .66 to .95 with 20of 26 scales exceeding .80 (Wise et al, 2010). The Beck De-pression Inventory-II’s (BDI-II; Beck, Steer, & Brown, 1996)total score ranges from minimal to severe depression. Inter-nal consistency is .74 to .90 (Storch, Roberti, & Roth, 2004).The Buss-Durkee Hostility Inventory (BDHI; Buss & Durkee,

1957) measures differences in trait hostility and guilt. The inter-nal consistency estimates range for Assault is .54 to .87, Guilt.61 to .72, Indirect Hostility .49 to .68, Irritability .53 to .73,Negativism .50 to .64, Resentment .49 to .69, Suspicion .63to .68, Verbal Hostility .50 to .77, and composite measure (allitems) .67 to .96 (Vassar & Hale, 2009). Item information forthe MMPI-2, MCMI-3, BDI-II, and BDHI was not available inour sample to compute αs.

Data Analysis

Fifty-one records were excluded from the analysis becauseof missing data. The final sample was 214 non-HispanicWhites, 100 Hispanics, and 33 African Americans. In addition,there were 60 incomplete/incorrect CAPS, 30 MCMI-IIIs, and94 BDIs. Post hoc power analysis indicated sample sizes wereadequate to detect an effect size of .57 or more with 80% powerand α = .05. Ethnic differences on demographic characteris-tics were tested using Fisher’s exact test. On scales with overall

Journal of Traumatic Stress DOI: 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Ethnic Differences in PTSD Symptoms: Female Vets 355

Table 2Means and Standard Deviations of Symptom Measures by Ethnic Group

Non-Hispanic White Hispanic African American

Variable M SD M SD M SD d

CAPS (n = 182) (n = 78) (n = 27)Current total 74.6 24.3 75.4 26.3 73.7 28.4 .06Lifetime total 107.9 20.8 102.8 25.6 110.0 19.8 .31MMPI-2 (n = 214) (n = 100) (n = 33)

Depression (2) 80.4 14.5 79.5 17.2 80.6 15.2 .07Psychopathic deviate (4) 73.8 13.3 70.9 14.0 72.9 12.6 .21Paranoia (6) 74.3 16.0 73.1 17.1 76.4 18.6 .18Psychasthenia (7) 75.3 12.7 75.2 14.6 76.1 12.9 .06Schizophrenia (8) 82.6 14.3 81.4 17.4 85.1 16.9 .22PK-PTSD–Keane 80.0 13.9 78. 9 16.1 82.9 13.5 .27ANX-Anxiety 73.9 11.5 73.2 12.1 75.8 9.4 .24DEP-Depression 73.4 12.1 71.6 14.3 74.0 12.3 .18ANG-Anger 63.4 13.0 63.9 12.5 65.4 11.5 .16BIZ-Bizarre mentation 63.5 14.5 66.6 14.7 68.3 17.3 .30CYN-Cynicism 60.9 11.4 61.6 11.4 64.5 12.2 .30ASP-Antisocial practices 56.6 11.7 57.4 10.0 60.1 11.0 .31RC4-Antisocial behavior 64.4a 11.8 60.5b 10.2 62.1a,b 11.7 .35RC6-Ideas of persecution 64.7b 13.8 65.4b 14.3 72.1a 13.2 .55

MCMI-III (n = 197) (n = 92) (n = 28)Antisocial 59.3 21.3 57.3 19.8 58.2 21.3 .10Paranoid 61.7b 19.2 66.2b 17.8 73.2a 19.2 .60Anxiety disorder 75.5 24.3 80.6 22.1 79.2 23.0 .22PTSD 77.9 14.9 80.0 12.9 79.3 13.8 .15Thought disorder 60.5 16.3 60.5 21.0 61.8 14.0 .09Major depression 72.1 23.1 72.4 25.0 75.2 21.7 .14Delusional disorder 45.9b 25.6 52.3a,b 26.0 55.8a 26.8 .38

BDHI (n = 154) (n = 74) (n = 25)Behavioral scales 51.9 8.5 52.8 8.2 53.7 8.6 .21Assault scale 52.4b 11.6 56.3a,b 11.1 58.6a 12.1 .52Cognitive scales 61.8 9.6 61.9 9.9 63.7 10.2 .19

BDI (n = 215) (n = 99) (n = 23)BDI/BDI-IIc 28.2 11.6 27.4 13.6 27.5 11.4 .06

Note. PTSD = Posttraumatic stress disorder; CAPS = Clinician-Administered PTSD Scale; MMPI-2 = Minnesota Multiphasic Personality Inventory-2; MCMI-III =Millon Clinical Multiaxial Inventory-III; BDHI = Buss-Durkee Hostility Inventory; BDI = Beck Depression Inventory. Effect size d is for largest ethnic difference.a,bDesignations: Different letters indicate significant differences among groups in post hoc testing (p < .05). cLater subjects completed the BDI-II.

significance, Fisher’s Least Significance Difference test for posthoc comparisons of means was employed.

Analysis of variance (ANOVA) was computed on CAPSscores, with no differences among groups. Next, as the MMPI-2,MCMI-III, and BDHI have no summary scores, the potentialof α inflation was addressed by using a repeated measuresANOVA to determine an overall test of significance acrossinstrument scales. The between factor consisted of the threeethnicities, the within factor the scales of each instrument. Asignificant main effect for ethnicity for each instrument protectspost hoc ethnic comparisons within the instrument’s scales.Significant main effects for ethnicity on the overall repeated

measures ANOVA suggested post hoc tests were warranted,and an ANOVA was computed on individual scales.

Results

Hispanics were younger at assessment (p = .001), and weremore likely to experience combat (p = .007) than non-HispanicWhites. The overall repeated measures ANOVA revealed sig-nificant main effects for ethnicity on the MMPI-2, F(2, 344) =4.11, p = .02; BDHI, F(2, 250) = 3.12, p = .046; and MCMI-IIIAxis I scales, F(2, 314) = 3.25, p = .04.

Journal of Traumatic Stress DOI: 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

356 C’de Baca, Castillo, and Qualls

Post hoc comparisons on the Anger/Hostility dimension in-dicate non-Hispanic Whites scored higher than Hispanics onthe Antisocial Behavior scale, and African Americans scoredhigher than non-Hispanic Whites on the Assault scale (a mea-sure of physical violence). In the Psychotic/Dissociative dimen-sion, the MCMI-III scores were within normal limits, and theMMPI-2 scales were clinically elevated. Differing results insimilarly labeled scales may be because MCMI-III items werechosen based on a theory of personality with clinical norms,whereas MMPI-2 items were empirically derived with commu-nity norms. African Americans, however, scored significantlyhigher than the other two groups on the Ideas of Persecutionand Paranoia scales, and higher than non-Hispanic Whites onthe Delusional Disorder scale (Table 2).

Discussion

Our study examined ethnic differences in symptomologyamong women veterans in treatment for PTSD. Our data did notreplicate previous findings of more symptoms among Hispanicveterans. Findings generally suggest the three ethnic groupsstudied were more similar than different (Frueh, Brady, & deArellano, 1998; Grubaugh et al., 2006; Monnier et al., 2002).African Americans, however, scored higher on ideas of perse-cution/paranoia, although this may reflect an adaptive responseto historical and contemporary experiences with racism and op-pression that have led to cultural mistrust and a paranoid-likeresponse style (Whaley, 2001).

Hispanics differed from non-Hispanic Whites in that theywere younger when assessed for PTSD and experienced morecombat. Hispanics are generally a younger population than non-Hispanic Whites (U.S. Census Bureau, 2010). Historically, His-panics reported higher rates of combat exposure and PTSD inVietnam, which was attributed to younger age, less education,and lower Armed Forces Qualification Test scores (Dohren-wend, Turner, Turse, Lewis-Fernandez, & Yager, 2008). The2003 Pew Hispanic Center Fact Sheet also notes Hispanics areunderrepresented in U.S. military ranks, but overrepresented incombat positions.

The finding of non-Hispanic Whites scoring higher than His-panics on the Antisocial Behavior scale is puzzling and does notfit with the general finding that minority groups are more fre-quently arrested for antisocial behaviors (Chauhan, Reppucci,Burnette, & Reiner, 2010; Gabbidon & Greene, 2005). Onepossible explanation is the Hispanic traditional female genderrole that emphasizes conforming behavior (Castro & Alarcon,2002).

This study expands our understanding of ethnic differences inPTSD and highlights the need for refined, culturally responsiveassessments reflecting an understanding of the impact of traumain ethnic patients. The clinical presentation of women fromethnic backgrounds may provide a greater variety of symptomsrelated to culture of origin.

Limitations include instruments used not being validated onHispanic and African American populations, though some eth-nic groups were included in the normative sampling. In addi-tion, although the study was limited by the clinical nature ofthe data, the real-world sample did show differences amongethnic groups. It is important, however, to point out there weremore similarities than differences. Studies reviewed indicatediagnostic validity is not well established, non-Whites tend toscore higher on these instruments, and overpathologizing is aconcern.

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Journal of Traumatic Stress DOI: 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.