Elizabeth Fitelson, MD

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

The goal of this activity is to provide an understanding of intimate partner violence (IPV), ie, those most likely to be victims of IPV, those most likely to commit IPV, sequelae of IPV.

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• Understand prevalence of intimate partner violence (IPV);

• Identify who is most likely to commit/be a victim of IPV;

• Define the Centers for Disease Control and Prevention criteria for IPV;

• Describe the sequelae of IPV and its impact on victims and perpetrators.

This continuing medical education (CME) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Recognizing and Addressing Domestic Violence: Issues for Psychiatrists

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Intimate partner violence (IPV), is described as abuse occurring within the context of an intimate relationship, including physical, sexual, and psychological harm as well as economic, legal, or other forms of coercion. While the term 

 (DV) is often colloquially used interchangeably with IPV, DV can encompass a larger scope of family violence, including child abuse. The Centers for Disease Control and Prevention (CDC) defines IPV as: “physical violence, sexual violence, stalking, and psychological aggression (including coercive tactics) by a current or former intimate partner (eg, spouse, boyfriend/girlfriend, dating partner, ongoing sexual partner).”

While legal definitions vary by country, IPV is highly prevalent worldwide. The World Health Organization has called IPV a global public health problem of epidemic proportions that affects millions of individuals and families worldwide. Within the US, the CDC reports that one in three women and one in four men will experience physical and/or sexual violence by a partner or sexual violence by a non-partner.

 However, these reports are likely to be underestimated, because non-physical abuse (ie, psychological aggression: name calling, insulting or humiliating tactics, and behaviors intended to monitor, control, or threaten a partner) is often more difficult to capture in large cross-sectional studies. Strangulation, a common but unrecognized form of physical abuse, is less likely to be reported, despite its high morbidity and correlation with homicide.

With the advent of technology, newer forms of surveillance and control are available including tracking locations, phone usage, and monetary spending. These forms of harassment are not often captured in wide epidemiological studies.

IPV is often referred to as a form of gender-based violence, and the most common portrayal is one of a male perpetrator and female victim in a heterosexual couple. However, epidemiologic studies and surveys suggest a more complex relationship between gender and relationship violence. For example, in a large telephone-based survey, men and women reported roughly the same 12-month prevalence of IPV (5.8% and 5.6%, respectively).

 Nevertheless, there are significant differences by gender in the severity, frequency, type, and lifetime impact of IPV. Women are twice as likely to experience severe physical violence and are three times as likely to be injured due to rape, physical violence. or stalking (

). Moreover, they are more likely to die by homicide by a current or former intimate partner.

 Despite these differences, it is important to remember that men are also significantly affected by IPV and may not self-identify or present for services because of cultural and gender roles.

One theory for the discrepancy between the essentially equal rates of reported physical violence by gender in survey studies and the higher burden of severity and impact on women is to see IPV through the lens of power and control. Unlike mutual violence in high conflict relationships, “intimate partner terrorism” involves the use of multiple tactics-of which physical violence may be just one-to achieve an imbalance of power between the partners and to maintain the need for dominance.

Nevertheless, the situational concerns of IPV can apply to both the victim and the partner doing harm; and often a person can be both the victim and the abuser, regardless of gender. The WHO advocates an ecological framework that views IPV as the interaction among many factors-individual, relationship, community, and societal (

). All these factors should be considered in discussing, preventing, and treating IPV for both the victim and the abuser.

The health effects from IPV include physical injury as well as chronic conditions such as mental health disorders, urological and gynecological problems, sexual and reproductive health issues, sexually transmitted diseases, with consequent increases in morbidity and mortality (

). Furthermore, IPV is associated with risky health behaviors such as unsafe sex, poor nutrition, cigarette use, and alcohol and drug use as well as limited health care seeking behavior, which also applies to the abusers.

The likely causal pathways between exposure to violence and health outcomes are starting to be explored and better understood. These pathways are often complex, with environmental, physiological, behavioral and other factors influencing the likelihood of disease through poor coping behaviors (eating, substance dependence), immune and neuroendocrine dysregulation, neural pruning, alterations in brain connectivity, telomere shortening, and epigenetic modification of gene expression.

In addition to the physical sequalae of IPV, the mental health effects also place a considerable health care burden on the survivors. As mental health professionals, psychiatrists may see a heterogenous range of psychological adverse sequelae. Several studies have extensively demonstrated an association between IPV and psychiatric disorders such as major depression, generalized anxiety disorder, posttraumatic stress disorder, eating disorder, panic disorder, substance use disorder, bipolar disorder, and psychosis.

 Within the outpatient and inpatient psychiatric population, the prevalence of prior and present IPV is more than 30%.

 Even those exposed to IPV without a diagnosed disorder commonly report insomnia, fatigue, irritability, forgetfulness, difficulty concentrating, and somatic complaints.

Furthermore, high rates of suicidal ideation and suicide attempts have been documented. In a recently published chart review of 106 patients with history of IPV who had access to mental health clinicians within the community, 40% reported prior suicide attempts and of those, 36% never received mental health care.

 These findings indicate both the severity of illness within this population and the limited access to mental health services.

Factors that increase the risk for the development of mental health sequalae of trauma include biological predisposition to mental illness, prior history of psychosocial adversity, intensity and chronicity of trauma, post-trauma adversities that in cases of IPV include life stress (eg, financial problems, housing access, loss of social support systems), which can be exacerbated when the survivor leaves the abusive relationship. However, it remains unknown how these factors can predict onset or severity of mental health symptoms.

Social support has been identified as a key protective factor against the development of mental health sequelae.

 Therefore, clinicians should engage in efforts to mobilize social supports and facilitate referrals to legal, medical, and psychosocial services as appropriate. These involve not only obtaining appropriate referrals but also educating survivors about the mental health symptoms that may emerge with trauma and that it is normal to need support.

More research is revealing the harm to children who witness IPV, including the effects from the experience of witnessing abuse as well as effects from parenting that is compromised. Witnessing such violence can contribute to psychological distress, behavior disorders, disturbances in self-regulation, difficulties in social interaction, and disorganized attachment as well as the eventual possibility of ongoing transgenerational transmission of violence. Research suggests that witnessing abuse carries the same risk of harm to children’s mental health and learning as direct abuse.

 Additionally, IPV alters caregiving parenting styles and adversely affects the mental health of the caregiver. Caregivers with adverse mental health outcomes from IPV are even more at risk for poor parenting skills.

Given the extent of the seriousness of the mental health symptoms, the seriousness of the crime, and the difficulties of navigating the criminal justice system and the mental health system, survivors of IPV may require a range of sustained resources. These include but are not limited to access to emergency shelter, housing assistance, legal assistance, protection orders, safety planning, support groups, financial assistance, available childcare, and mental, medical, and oral health care. However, sometimes the mental health symptoms of a survivor may impede their ability to obtain adequate help.

There are significant structural and systemic barriers that prevent survivors from accessing mental health care. Some common barriers include perceived stigma associated with accessing services, financial barriers, decreased numbers of mental health clinicians that leads to long waiting lists, lack of services within a geographic area, language limitations, poor quality of treatment, and feelings of being re-traumatized by the medical system. Moreover, as part of coercive tactics in IPV, the abuser may limit the victim’s access to care and/or allege that the victim is a perpetrator of child abuse and neglect.

These obstacles are especially pronounced for minority women. Compared with white women in the US, minority women are less likely to seek help from various formal and informal sources.

 The health care system is currently insufficiently equipped to deal with both the mental health concerns and the advocacy concerns of IPV. Yet, there are few models of psychiatric service provisions aimed at treating survivors who require knowledge of both systems. Nevertheless, because of the high prevalence of mental health sequalae associated with IPV, the Substance Abuse and Mental Health Services Administration (SAMHSA) recommends that mental health professionals practice a trauma-informed model of care for all patients (

). Not only does trauma-informed care apply to individual interactions, it also applies to the clinical environment, space, and all interactions including front staff who greet patients.

A major barrier for survivors to report IPV is the concern of adding systematic monitoring to their lives. As mandated reporters, physicians have a duty to report harm to children. The same does not apply to the adult IPV survivor, which is dependent on state requirements that are often soft and not well defined. For example, in New York state, all potentially life-threatening IPV injuries that result from use of a firearm, a knife, or sharp object must be reported to the local police. California, however, has a more liberal stance. Physicians have a duty to report if they suspect the patient is suffering from a wound or physical injury because of abuse. A serious concern is that the reporting of IPV in the home may result in the removal of children from the home; this disproportionally affects minority communities.

Confidentiality and mandated reporting responsibilities should be addressed with patients who are seeking care, especially when assessing for IPV or sexual violence. Clinicians should familiarize themselves with their state law and reporting requirements. Not disclosing can disrupt the relationship with the patient and may put the patient at risk. Additionally, because a medical record may be used in subsequent legal proceedings, it is vital that the record is accurate and complete. It is useful to use a patient’s own words in quotation marks whether the patient is a victim or the person doing harm.

In terms of treatment for IPV, there are various psychotherapy and psychopharmacological approaches. Because IPV is not a diagnosis but rather a phenomenon consisting of disorders from internalizing to externalizing, it is very difficult to study because, by definition, a randomized-controlled-trial must have a well-defined population. Nevertheless, because of the heterogenicity of mental health disorders stemming from IPV, psychopharmacology should target specific symptoms. Treatment of sleep disorders is frequently requested by those with IPV history and adequate treatment can garner increased rapport.

Psychotherapies may be used to address the multiple stressors of IPV survivors, including the immediate need for safety and resources, loss of an intimate relationship, social isolation, and issues regarding parenting issues. The common scenario for treatment for survivors of IPV may include three phases: safety and stabilization, processing traumatic material, reconnection and reintegration. Evidence-based treatments for IPV are listed in 

Although controversial, there is increasing awareness that a serious public health approach to the problem of IPV must include treatment of perpetrators as wells as victims.

 A wide range of mental health disorders is attributed to perpetration: PTSD, anger, anxiety, depression, suicidal behavior, personality disorders, alcoholism or problem gambling as well as high incidences of comorbidity. Furthermore, perpetrators have a high likelihood of having been exposed to violence in their childhood, which has led to adverse mental health outcomes.

Treatment for those who do harm is more limited than for victims. Overall, group treatments for IPV batterers have meagre effects on the cycle of violence. Most studies, regardless of intervention strategies, report that approximately one in three cases will have a new episode of IPV within 6 months.

Batterer intervention treatment programs (BIPs) serve as one of the primary societal responses to IPV, employing three primary modalities: psychoeducation (changing learned behavior), Duluth model (patriarchy and need for power and control as the root cause for violence), and ognitive behavioral therapy (deconstructing “dysfunctional” thinking). It is estimated that in the US at least half a million men enroll in approximately 2500 BIPs every year.

 However, BIPs in general have very high rates of participant attrition and poor results in preventing future violence. Few data exist concerning the mediators of BIP effects on IPV recidivism, and a variety of factors threaten to impede future design advancements, including turf battles regarding the causes of IPV and limited funding outlets.

A cultural shift has occurred and IPV is no longer defined as a family affair, but one that has lasting effects on the individual, the family, and the community. The mental health effects of IPV are paramount and require skilled clinicians to work alongside advocacy groups in providing much needed services. There is more work to be done, including understanding effective treatment for perpetrators within the context of family systems and becoming better attuned to crisis management especially when IPV is ongoing.

Given the prevalence of IPV within mental health settings, it is imperative for clinicians to be aware of risk factors, routine assessments, and effective interventions involved for both survivors and perpetrators.

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National Resources for Professionals and Patients

) One Family Justice Center in every state that provides a one-stop shop for social and legal services for victims of IPV

https://www.helpguide.org/articles/abuse/help-for-men-who-are-being-abused.htm

National Coalition Against Domestic Violence

National Resource Center on Domestic Violence

National Center on Domestic Violence, Trauma, and Mental Health

American Psychiatric Association Toolkit on IPV for Psychiatrists

https://www.psychiatry.org/psychiatrists/cultural-competency/education/intimate-partner-violence

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A cultural shift has occurred and intimate partner violence (IPV) is no longer defined as a family affair, but one that has lasting effects on the individual, the family, and the community.

[[{"type":"media","view_mode":"media_crop","fid":"39805","attributes":{"alt":"contraception and misconceptions","class":"media-image media-image-right","id":"media_crop_4070598942410","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4009","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"147","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The American Psychiatric Association is incorporating a statement into its practice guidelines advising psychiatrists to routinely inquire about pregnancy plans and discuss the risk of unplanned pregnancy and contraception.

 Although the majority of patients seen in general psychiatric practice are women, especially women of reproductive age, psychiatrists are often unlikely to inquire about and document discussions of contraception use and pregnancy planning.

In the US, 51% of pregnancies are unintended, and 40% of unintended pregnancies end in abortion.

 Most of these unintended pregnancies occur in women who were not using any form of contraception. Unintended pregnancies have a higher risk of adverse maternal and child health outcomes. In addition, these pregnancies are costly: in 2010, the total public expenditure on perinatal care for unintended pregnancies was $21 billion. Psychiatrists who treat women and adolescent girls may find it necessary to discuss with their patients reproductive planning and the role of contraception in setting comprehensive treatment goals.

Psychiatric knowledge about these issues is important for all patients; however, it is particularly important in the case of women with chronic mental illness, many of whom lack general knowledge about contraception and are less likely to use birth control, despite wishing to prevent pregnancy.

Various psychiatric disorders have their own specific risks. In bipolar disorder, unplanned pregnancy is common. In one observational study that compared women with bipolar disorder with healthy controls, the bipolar women reported more frequent unplanned pregnancies (32.8% of pregnancies were planned among the bipolar women compared with 78.1% of pregnancies among healthy controls without mental illness).

 Women with primary psychotic disorders, such as schizophrenia, are at greater risk for coerced sex, risky sexual behavior, and unplanned/unwanted pregnancy.

 Among women with borderline personality disorder, those with more severe symptoms are at greater risk for unplanned pregnancy and teen-age pregnancy than are women who have Axis 1 disorders.

Women with substance use disorders are also at higher risk for unplanned pregnancy, which increases the risk of fetal exposure to illicit substances, alcohol, and tobacco, particularly during organogenesis in early pregnancy. In a survey of women attending outpatient drug treatment programs, high rates of pregnancy were reported, and 70.5% of pregnancies were unplanned.

 In addition, women with substance use disorders are at risk for risky sexual behaviors, including prostitution.

 In a growing number of states, instead of receiving treatment, women with substance use disorders and concomitant pregnancy are at risk for criminal prosecution.

Because of these risks, good psychiatric practice should include questions about contraception, pregnancy planning, and counseling about reproductive safety of the patient’s specific drug regimen in order to prevent unintended pregnancy and plan for a healthy pregnancy when desired.

Polypharmacy should be kept to a minimum and known teratogens, such as valproic acid and carbamazepine, should be avoided if possible in women not using reliable contraception. The psychiatrist should understand the interactions between psychotropics and hormonal contraceptives. Drugs such as carbamazepine, oxcarbazepine, topiramate, and modafinil can decrease the effectiveness of hormonal contraceptives, while oral contraceptives can decrease serum levels of valproate and lamotrigine.

 The safety of psychotropic drugs during pregnancy and the risk of untreated illness should be discussed so that if a woman becomes pregnant, she will not immediately discontinue her medication.

Psychiatrists should be prepared to ask basic questions about contraceptive use and pregnancy wishes and, if necessary, refer to a reproductive psychiatric specialist or collaborate with the patient’s primary care physician or gynecologist to establish an appropriate treatment plan.

The authors are members of the Committee on Gender and Mental Health, the Group for Advancement of Psychiatry. The authors report no conflicts of interest concerning the subject matter of this article.

 Robinson GE. Contraceptive care for women with chronic, serious mental illness. American Psychiatric Association Action Paper ADMNOV1212F; 2012. For a copy of this paper, please e-mail Dr Robinson at gail.robinson@utoronto.ca.

 Blehar MC, Oren DA. Women’s increased vulnerability to mood disorders: integrating psychobiology and epidemiology. 

Unintended Pregnancy in the United States.

http://www. guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html

 Miller LJ. Sexuality, reproduction, and family planning in women with schizophrenia. 

 Marengo E, Martino DJ, Igoa A, et al. Unplanned pregnancies and reproductive health among women with bipolar disorder. 

 De Genna NM, Feske U, Larkby C, et al. Pregnancies, abortions, and births among women with and without borderline personality disorder. 

 Black KI, Stephens C, Haber PS, Lintzeris N. Unplanned pregnancy and contraceptive use in women attending drug treatment services. 

 Heil SH, Jones HE, Arria A, et al. Unintended pregnancy in opioid-abusing women. 

 ACOG Committee on Ethics. ACOG Committee Opinion #321: Maternal decision making, ethics, and the law. 

 Joffe H. Reproductive biology and psychotropic treatments in premenopausal women with bipolar disorder. 

 Oesterheld JR, Cozza K, Sandson NB. Oral contraceptives. 

Psychiatrists who treat women and adolescent girls may find it necessary to discuss with their patients reproductive planning and the role of contraception in setting comprehensive treatment goals. Here's why.

Author | Elizabeth Fitelson, MD

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