OR WAIT null SECS
The 1994 death of Nicole Brown Simpson and the subsequent highly publicized murder trial of her ex-husband, O.J. Simpson, brought increasing national attention to the problems of domestic violence and intimate partner murder. In 2000, there were 1247 female victims of intimate partner murder in the United States.1 Fully one third of female murder victims were killed by an intimate partner.1 On the positive side, rates of female victimization by intimate partner violence and murder appear to have decreased in the recent past.
The term "intimate partner violence" (IPV) is defined as physical or sexual violence between spouses and former spouses, and violence within heterosexual and homosexual dating relationships. IPV is broader and better encompasses the issue than the former term, "domestic violence."Recent national statistics indicate that 20% of violent crimes committed against women were by intimate partners.1 The estimated US lifetime prevalence of assault by an intimate partner ranges from 9% to 30%.2-7
The association between IPV and posttraumatic stress disorder (PTSD), depression, and substance use disorders is well established.8-10 Although primary care, obstetrics, and emergency department physicians should also look for signs,11-14 IPV is particularly relevant to psychiatric practice.
Scope of the problem Women with severe mental illness, including mood and psychotic disorders, appear to have elevated risks of being both victims and perpetrators of IPV. Pregnancy is already a potentially difficult time in the context of mental illness and may put women at increased risk for becoming vic-tims of IPV.15 A history of childhood abuse, which is relatively common in this population, may further elevate this risk. Risk of victimization may be mediated by concomitant impairments in judgment, reality testing, and planning.16
In addition, women may have difficulty in determining whether physical closeness is assaultiveness or intimacy.17 Studies indicate that as many as half of married female psychiatric inpatients who have severe mental illnesses are victims of IPV; outpa-tient rates are similar.18-20 One fifth to more than half of female psychiatric patients may be victims of marital rape.21,22Psychiatrists and IPV
Symptoms of mental illness may worsen with victimization.23 Physical abuse may even precipitate a suicide attempt.24-26 Women who are victims of IPV may appear paranoid to clinicians, and Minnesota Multiphasic Personality Inventory-2 profiles of abused women are similar to profiles of inpatients with schizophrenia and borderline personality disorder.27 PTSD in women who have serious mental illnesses often remains undetected by psychiatrists.
Obtaining information on the existence, nature, and extent of abuse is important, not only for proper diagnosis but also for safety planning, medication management, and discharge planning. However, many women do not report victimization to clinicians.28,29 Although IPV victimization is more common than the presentation of many psychiatric symptoms about which psychiatrists ask, it often goes undetected by psychiatrists.30,31
It is thus critical that clinicians ascertain the existence of partner abuse. A discussion about decision making within relationships can be used to broach this topic,29 or normalizing statements about the frequency of victimization can be used to open a discussion.18 Women can be asked about fears of being hurt by their partners, or they can be asked directly about abuse. Abuse screening measures have also been developed.32
Knowledge of IPV can aid in making choices within both pharmacotherapy and psychotherapy. For example, certain medications could decrease a woman's ability to respond in dangerous situations or to escape.33 Issues in psychotherapy may include mistrust, emotional isolation, and self-esteem impairments28; role-playing may be useful in eliciting these issues.34IPV, psychiatrists, and the law
Psychiatrists should have some knowledge about shelters, services, and legal options, or have someone to whom they can refer patients for those issues. A woman's decision about leaving a relationship is not to be made lightly. Separation represents the point of greatest risk of harm.35 The victim may be ambivalent, fear for her children, fear retaliation, or have financial difficulties. Civil protection orders (also known as restraining orders) are violated in approximately 40% of cases and may not be an appropriate remedy.36 Fewer than half of IPV incidents are reported, and IPV offenders are arrested in only 5% to 36% of cases.35 Furthermore, more than a quarter of offenders who are arrested re-assault before trial.35
Women with mental illnesses may exhibit violent behavior toward their partners. One fifth of women in an inpatient sample had engaged in IPV against their partners.20 More research is needed on risk and protective factors, as well as underlying motives, which can range from paranoia to anger to self-defense.
"Battered women's syndrome" (BWS) is a term used in the legal arena, specifically for women who kill their abusers. However, it is not a syndrome in DSM. Scholars have criticized BWS as a legal construct that is used only in self-defense partner-murder cases rather than to describe a medical syndrome. In addition, the label suggests pathology in the victim. Finally, since there is no agreed-on definition of BWS, it may be falsely implied that a diagnosis of PTSD is required for a woman to have killed her abuser in self-defense.37
Expert testimony on battered women has been allowed in courtrooms in the United States since Ibn-Tamas v United States in 1979,38 and it is also used in Canada, Australia, New Zealand, and the United Kingdom.39,40 The expert may be helpful in providing a context for the woman's violence; the impact of the abusive relationship; the learned helplessness model; the patterns or cyclicity of violence, including the potential contrition phase; the use of excessive force; and the woman's belief in the reasonableness of her actions.37,39 However, the expert must use caution not to mislead the court, because these are not the only patterns of violence or profiles of victims.
In conclusion, as psychiatrists, we are in a potentially opportune position to be aware of IPV among women with mental illnesses and to make a difference in their lives.
Intimate Partner Violence, 1993-2001.
Bureau of Justice Statistics: Crime Data Brief. Washington, DC: US Department of Justice; February 2003. NCJ 197838. Available at: www.ojp.usdoj.gov/ bjs/ pub/pdf/ipv01.pdf. Accessed July 11, 2007.
Tjaden P, Thoennes N.
Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey
. Washington, DC: US Department of Justice; November 2000. NCJ 183781. Available at: www.ncjrs.gov/pdffiles1/nij/183781.pdf. Accessed July 11, 2007.
Bureau of Justice Statistics.
Bureau of Justice Statistics Sourcebook of Criminal Justice Statistics--1997
. Washington, DC: US Department of Justice; 1998.
Nisonoff L, Bittman I. Spouse abuse: incidence and relationship to selected demographic variables.
Peterson R. Social class, social learning, and wife abuse.
Soc Serv Rev
A Survey of Spousal Violence Against Women in Kentucky.
Study No. 792701. Washington, DC: US Department of Justice; 1979.
Teske RHC, Parker ML.
Spouse Abuse in Texas: A Study of Women's Attitudes and Experiences
. Huntsville, Tex: Survey Research Program, Criminal Justice Center, Sam Houston State University; 1983.
El-Bassel N, Gilbert L, Witte S, et al. Intimate partner violence and substance abuse among minority women receiving care from an inner-city emergency department.
Women's Health Issues
Coker AL, Weston R, Creson DL, et al. PTSD symptoms among men and women survivors of intimate partner violence: the role of risk and protective factors.
Houry D, Kaslow NJ, Thompson MP. Depressive symptoms in women experiencing intimate partner violence.
J Interpers Violence
Kimberg L. Addressing intimate partner violence in primary care practice.
Medscape Womens Health
. 2001; 6:E1.
Ernst AA, Weiss SJ. Intimate partner violence from the emergency medicine perspective.
McCloskey LA, Lichter E, Ganz ML, et al. Intimate partner violence and patient screening across medical specialties.
Acad Emerg Med
Parsons L, Goodwin MM, Petersen R. Violence against women and reproductive health: toward defining a role for reproductive health care services.
Matern Child Health J
Miller LJ, Finnerty M. Sexuality, pregnancy, and childbearing among women with schizophrenia-spectrum disorders.
Goodman LA, Rosenberg SD, Mueser KT, Drake RE. Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions.
DeNiro DA. Perceived alienation in individuals with residual-type schizophrenia.
Issues Ment Health Nurs.
Friedman SH, Loue S. Incidence and prevalence of intimate partner violence by and against women with severe mental illness.
J Womens Health.
Carlile JB. Spouse assault on mentally disordered wives.
Can J Psychiatry
Post RD, Willett AB, Franks RD, et al. A preliminary report on the prevalence of domestic violence among psychiatric inpatients.
Am J Psychiatry
. 1980;137: 974-975.
Cole C. Routine comprehensive inquiry for abuse: a justifiable clinical assessment procedure?
Clin Soc Work J
Weingourt R. Wife rape in a sample of psychiatric patients.
IMAGE J Nurs Sch
. 1990;22: 144-147.
Campbell JC. Health consequences of intimate partner violence.
Stark E, Flitcraft A. Killing the beast within: woman battering and female suicidality.
Int J Health Serv
. 1995; 25:43-64.
Dienemann J, Boyle E, Baker D, et al. Intimate partner abuse among women diagnosed with depression.
Issues Ment Health Nurs
Kaplan ML, Asnis GM, Lipschitz DS, Chorney P. Suicidal behavior and abuse in psychiatric outpatients.
Khan FI, Welch TL, Zillmer EA. MMPI-2 profiles of battered women in transition.
J Pers Assess.
Hilberman E, Munson K. Sixty battered women.
Jacobson A, Richardson B. Assault experiences of 100 psychiatric inpatients: evidence of the need for routine inquiry.
Am J Psychiatry
Carmen EH, Rieker PP, Mills T. Victims of violence and psychiatric illness.
Am J Psychiatry
. 1984;141: 378-383.
Sahay S, Piran N, Maddocks S. Sexual victimization and clinical challenges in women receiving hospital treatment for depression.
Can J Commun Ment Health.
Soeken KL, McFarlane J, Parker B, Lominack MC. The abuse assessment screen. In: Campbell JC, ed.
Empowering Survivors of Abuse: Health Care for Battered Women and Their Children.
Thousand Oaks, Calif: Sage; 1998:195-203.
Fischbach, RL, Herbert B. Domestic violence and mental health: correlates and conundrums within and across cultures.
Soc Sci Med.
Gearon JS, Bellack AS. Women with schizophrenia and co-occurring substance use disorders: an increased risk for violent victimization and HIV.
Community Ment Health J
Jordan CE. Intimate partner violence and the justice system.
J Interpers Violence
Spitzberg BH. The tactical topography of stalking victimization and management.
Trauma Violence Abuse
Dutton MA. Intimate partner violence: 25 years of expert testimony. Presented at: the American Academy of Psychiatry and the Law annual meeting; October 27, 2006; Chicago.
Ibn-Tamas v United States,
407 Atl Rpt 2d 626 (DC 1979).
Schuller RA, Rzepa S. Expert testimony pertaining to battered women's syndrome: its impact on jurors' decisions.
Law Hum Behavior.
Tang KL. Battered woman syndrome testimony in Canada: its development and lingering issues.
Int J Offender Ther Comp Criminol