Learn how IPV shapes mental health from pregnancy to adulthood, and how clinicians assess risk, plan safety, and treat victims and perpetrators.
The Centers for Disease Control and Prevention define intimate partner violence (IPV) as abuse or aggression that occurs in a romantic relationship and can be physical and/or sexual violence, stalking, and psychological aggression.1 Though psychiatrists may more frequently encounter individuals who have experienced IPV due to its sequelae impacting mental health, IPV is encountered by clinicians across several specialties, such as emergency medicine or primary care settings. Most recent data from the National Intimate Partner and Sexual Violence Survey show that nearly 34% of women and 17% of men have experienced contact sexual violence, physical violence, or stalking by an intimate partner during their lifetime.1 Over 38.6 million women and 27.3 million men have experienced aggression by an intimate partner in their lifetime.1 These individuals experienced a range of coercive control and entrapment tactics, but the most common include needing to know a victim’s whereabouts and current activity, as well as having a partner who keeps them from seeing or talking to family or friends.1
While women may engage in self-defense if experiencing IPV, they can also be primary aggressors, either perpetrating IPV or engaging in bi-directional relationship violence.2 Therefore, it is important to consider moving away from the assumption or stereotype that women are always the victims, or men the perpetrators. However, it has been shown that women with severe mental illness are at a heightened risk for victimization by their partners, largely attributed to impaired judgment, poor reality testing, and difficulties with social relationships, leading to increased vulnerability. Specifically, schizophrenia has been found across studies to increase the risk of being victimized by a partner.3 Aportion of these women also become the perpetrators of assault.3,4 This further becomes highlighted in mental health conditions such as bipolar disorder, where irritability associated with mania may lead to violence in either self-defense or mutual violence.3,4
The impacts of IPV are experienced by patients throughout the lifespan, beginning as early as in utero; it has been shown that IPV during pregnancy is associated with low birth weight, preterm birth, and even fetal injury.5 Emerging research shows that maternal exposure to IPV may lead their child to have developmental delays, behavioral difficulties, and chronic health conditions.5 In infancy, this is further highlighted by parenting dynamics. If positive interactions with primary caregivers are not present, a secure relationship or attachment is not cultivated, which negatively affects the infant’s stress response and the capacity for independent emotional regulation.6 Additionally, in children exposed to IPV, their risk for both experiencing and perpetrating IPV increases as adults.7 It has also been shown that exposure to IPV harms children's mental health in other ways, increasing their likelihood of developing anxiety and depression, as well as poor educational and behavioral outcomes when compared with peers who were not exposed to IPV.8
Adverse childhood experiences can include abuse, neglect, or household dysfunction and have been shown to be positively associated with IPV perpetration and victimization.9Growing up in a home with IPV may lead to externalization of behaviors, including aggression, disruptive behaviors, and other conduct problems, which in turn lead to changes in relationships between the child and their mother, such as increased spanking, and reduced warmth and connectedness.10 IPV affects an individual’s mental and physical well-being. Greater than 40% of women diagnosed with depression and/or anxiety report IPV history; when compared with the general population, victims of IPV have more than twice the risk for sleep disorders, chronic pain, anxiety disorders, and major psychiatric conditions.11
Safety planning is a primary aspect of evaluation and management across settings. In an outpatient setting, where a patient may disclose current or past IPV, it is imperative to engage these individuals in safety planning to increase a sense of control and collaboration.5 Recommendations generally align with treatment guidelines for trauma or anxiety/depression related to IPV, including cognitive behavioral therapy (CBT) to help patients attain safety while reducing trauma-related or posttraumatic stress disorder (PTSD) symptoms, or skills training in affective interpersonal regulation therapy, which is an evidence-based and skills-focused CBT for PTSD treatment. Additionally, other options, including cognitive processing therapy or eye movement desensitization and reprocessing therapy, may be considered. Regarding medication management, medications targeting major depressive disorder or PTSD associated with IPV, including SSRIs or other antidepressants, generally remain first-line options.5
In emergency department settings, risk assessment becomes key; both experiencing and perpetrating IPV are risk factors for suicide.5,12 Oftentimes, the emergency psychiatric evaluation becomes the gateway to ongoing mental health care, making suicide risk assessment and general safety assessment imperative.During these encounters, describing in detail the process of evaluations and what may happen will aid in giving the individual a sense of control and help to mitigate anxiety and fear.5 This will also allow mental health clinicians to begin targeting their presenting symptoms (pain, insomnia, trauma-related or depressive symptoms, etc) while engaging their natural supports and ensuring access to community resources upon discharge. IPV risk assessment commonly includes general questions surrounding a patient’s safety with their current romantic partner or whether they have ever experienced physical or emotional violence, leading to deeper questioning. In some settings, validated screening tools are used to further assess the danger of lethality or severe injury by an intimate partner.
This also introduces the challenging decision, at times, of holding a patient with a history of perpetrating IPV in observation due to concern for dangerousness if released in the community. While states vary in their approach regarding duty to third parties, clinicians should consider the depth of perpetration history, assess the patient’s violence risk towards a partner, and if that risk is due to a mental illness before releasing them. This risk may also be elevated if the patient presents with suicidal ideation or previous suicide attempts. In a study conducted by Vignola-Lévesque and Léveillée (2021), 13 men who were (1) perpetrators of IPV, (2) classified into the profile of being homicidal, and (3) were left by their partners, had all attempted suicide at least once.13 Nearly 1 in 5 victims of homicide are killed by an intimate partner, and over half of female homicide victims are killed by a former or current male intimate partner, according to US crime reports.1 Homicide risk is highest in the period immediately before and following a breakup, and it is therefore essential to ask specific questions regarding the status of a patient’s romantic relationship if IPV is suspected.13 Additionally, while protective orders seem to increase safety on the whole, the risk of them acting as a catalyst for violence in the form of retaliation from the perpetrator must be considered on a case-by-case basis.
It is established that patients experiencing IPV may suffer from resulting depressive and anxiety-related disorders with suicidal ideation and/or previous suicide attempts. However, the impact on the perpetrator and what may predispose these individuals to behave in violent ways is less frequently emphasized. For adolescent IPV, it has been hypothesized that risk factors for perpetration include a history of experiencing or witnessing abuse, childhood trauma with physical/emotional abuse or neglect, and early alcohol or substance use initiation.14,15Additionally, these individuals may not have developed effective interpersonal communication or frustration-tolerance skills, which can lead to challenges with attachment, as it is displayed as hostility, anger, and aggression.15 In adulthood, several personality types have been examined regarding their relationship with IPV perpetration, including openness and neuroticism being positively correlated with perpetration.16 Personality pathologies are encountered frequently in inpatient psychiatry, and in a study conducted by Collison and Lynam (2021), it was found that antisocial and borderline personality disorders demonstrated the largest effect sizes for IPV perpetration and victimization.17Most IPV perpetrators have a history of criminal offenses (both violent and non-violent), which increases their risk of re-offending.13
Two case examples observed on an inpatient psychiatry unit illustrate these points.
Case 1: “Angela,” a pregnant woman presents with acute mania and a recent arrest related to IPV. This first case illustrates previously discussed associations with bipolar disorder and IPV perpetration.3,4
Case 2:“John,” a 40-year-old, man presents with suicidal ideation and a history of IPV. He is suspected of evading an impending arrest due to IPV re-offending. This second case demonstrates the link between suicidality and violence/perpetration risk.5,12,13
A commonality between these 2 cases is our duty to our patients, with a focus on acute stabilization of current symptoms and maintaining support for them as individuals. A history of IPV may not be as overt – this can often present with someone admitted with agitation and aggression-related behaviors, with a history of violence being revealed later. It is imperative to dive into the actual symptoms these patients are experiencing in order to tailor interventions. Once the patient is psychiatrically optimized, safety planning and assessing ongoing dangerousness are pertinent not only for their own safety, but also for the victims of IPV. This also includes evaluation of the victim’s recovery environment upon discharge; for example, if a patient is experiencing verbal aggression from their partner despite having physical safety with them, they may struggle to recover the environment does not change. Many IPV perpetrators also utilize coercive control. When this is no longer effective, their threats may escalate to physical violence, and they are at higher risk for violent outcomes if suicidal ideation is also present, likely due to “last resort” thinking. For some perpetrators, losing their relationships may be viewed as a significant identity loss with resulting impulsivity and acting out.
Across settings in psychiatry, including outpatient clinics, emergency departments, and inpatient units, we may encounter patients who are suspected or confirmed perpetrators or victims of IPV.In either case, risk assessment and safety planning remain essential. The risk of intimate partner homicide requires particular attention in risk assessment and mitigation. A history of trauma or ongoing IPV may account for current mood symptoms, and in patients with suspected personality pathologies or aggression, evaluating for a history of IPV perpetration or victimization will be key in establishing appropriate treatment planning. Effectively treating patients who perpetrate indirectly supports victims. By engaging in the duality of IPV through identifying and supporting not only the victims but also the perpetrators, we can begin to help break the cycle of IPV.
Dr Taylor is a PGY-2 resident in the Department of Psychiatry at Carolinas Medical Center - Atrium Health Wake Forest Baptist.
Dr Rachal is associate professor and chair of psychiatry at Wake Forest University School of Medicine and medical director for behavioral health at Advocate Health Charlotte.
Dr Soliman is an assistant professor of psychiatry at the Wake Forest School of Medicine and is affiliated with Advocate Health.
References
1. The National Intimate Partner and Sexual Violence Survey 2023/2024 Intimate Partner Violence Data Brief. CDC. February 2026. Accessed September 17, 2026.
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