Domestic Violence

Jane S. Sillman, MD
Harvard Medical School, Boston, MA

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

Describes relationships characterized by intentional controlling or violent behavior by someone who is in an intimate relationship with the victim
Abuser’s controlling behavior may take many forms including

Psychological abuse
Physical abuse
Sexual abuse
Economic control
Social isolation

Victims are usually women, but also include the disabled and elderly of both sexes
Elder abuse is associated with higher mortality and with increased chronic pain and depression
Victims are found among women of all ages, socioeconomic classes, and ethnicities
Frequency, National Violence Against Women Survey findings

Approximately 1.5 million women and 834,732 men in the U.S. are raped or physically assaulted by an intimate partner each year
Women living with female intimate partners experienced less physical abuse than women living with male intimate partners
Men living with a male intimate partner experienced more intimate partner violence than did men living with women
On average, women who were physically assaulted experienced more assaults and suffered more injuries than did the men who were victims

Risk Factors for Experiencing Violence

Having experienced childhood physical or sexual abuse
Younger than 35 years
Being single, divorced, or separated
Low socioeconomic status
Substance abuse (cigarette smoking and problem drinking)
Pregnancy
Physical disabilities
Increasing physical and mental frailty in the elderly

Risk Factors for Perpetrating Violence

Childhood exposure to violence and abuse
Violent behavior in other settings
Substance abuse
Unemployment
Psychological characteristics include

Antisocial personality
Borderline personality
Low self-esteem
Poor impulse control

Consequences of Abuse

Increased dependence on abuser for economic well-being and support after being isolated from family and friends
Develop anxiety, depression, or somatization
Turn to alcohol and drug abuse to numb pain
May develop posttraumatic stress disorder with dissociation, flashbacks, and even multiple-personality disorder
Physical abuse can lead to repeated injuries including

Soft tissue trauma
Lacerations
Fractures
Stroke, caused by attempts at strangulation

Ultimately, abuse may lead to the death of victim, either from suicide or from murder by abuser
Approximately 1,200 women in the U.S. die annually as a result of domestic violence

Differential Diagnosis

Anxiety
Depression
Alcohol and Substance Abuse
Posttraumatic stress disorder (PTSD)
Somatization

Best Tests

Initial treatment

Provide immediate emotional support
Ask about patient's emotional state and needs
Assess patient's immediate safety
Review options for help with patient

Refer to social worker
Refer to a domestic-violence hotline
Obtain a protection order against abuser
Provide information and help to find a place in a shelter

Massachusetts Medical Society's mnemonic RADAR summarizes the clinician's role as

R Routinely ask about domestic violenc
A Ask direct questions
D Document your findings
A Assess patient safety
R Review options

Reporting of abuse

Mandatory reporting of abuse required in three situations

Child abuse (i.e., involving a child younger than 18 years); must be reported to the Department of Social Services
Abuse of disabled persons, must be reported to the Disabled Persons Protection Commission
Elder abuse (i.e., involving a persons 60 years of age or older); must be reported to the physician's local Elder Abuse Hotline

Three states—California, Colorado, and Kentucky—require that physicians report all injuries from domestic violence
New Hampshire requires reporting if the victim suffered from a gunshot wound and consents to the reporting
Rhode Island requires reporting for medical-data-collection purposes only and does not include identification information

Follow-up treatment

Clinician needs to focus on four responsibilities:

Support
Safety
Safety plan
Ongoing assessment

Patient should have a safety plan of what to do in an emergency

If social worker is available, they will usually take on this responsibility
If the patient is not being followed by a social worker, the primary clinician can help the patient develop her safety plan

Key elements in safety plan include:

Plan for what to do in an emergency
A place to go in an emergency
Organization of resources that the patient will need if they have to leave home emergently

Intervention outcomes

Most victims of abuse are not ready to leave their abusers; their reasons for staying include:

Belief in abuser’s promises of change
Belief that abuse is their fault
Lack of money
Lack of a place to go
Fear of reprisal if they try to leave
Absence of intervention on their behalf

Limited data available on the outcomes of interventions; however, studies have shown that

With counseling, victims experience gradual increases in self-esteem
Advocacy programs have been shown to decrease abuse
Act of seeking a protection order decreases intimate partner violence, even if the order is not granted
Completion of batterer intervention program correlated with a decrease in arrests

Prevention programs

Boston Dating Violence Intervention Project, focused on high-school students

Offered school assemblies that educate students about the characteristics of abusive relationships
Training for school staff on how to identify students who may be in abusive relationships
Students felt that the sessions were helpful in teaching them how to identify and get out of abusive relationships

Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) program created by CDC

To facilitate primary prevention of intimate partner violence at the community level
Funds state-level domestic-violence coalitions to provide

Prevention-focused training
Technical assistance
Funding to local Coordinated Community Responses (CCRs)
Data on the efficacy of these community-based primary prevention interventions will be helpful

Best Therapy*

Initial treatment

Provide immediate emotional support
Ask about patient's emotional state and needs
Assess patient's immediate safety
Review options for help with patient

Refer to social worker
Refer to a domestic-violence hotline
Obtain a protection order against abuser
Provide information and help to find a place in a shelter

Massachusetts Medical Society's mnemonic RADAR summarizes the clinician's role as

R Routinely ask about domestic violenc
A Ask direct questions
D Document your findings
A Assess patient safety
R Review options

Reporting of abuse

Mandatory reporting of abuse required in three situations

Child abuse (i.e., involving a child younger than 18 years); must be reported to the Department of Social Services
Abuse of disabled persons, must be reported to the Disabled Persons Protection Commission
Elder abuse (i.e., involving a persons 60 years of age or older); must be reported to the physician’s local Elder Abuse Hotline

Three states—California, Colorado, and Kentucky—-require that physicians report all injuries from domestic violence
New Hampshire requires reporting if the victim suffered from a gunshot wound and consents to the reporting
Rhode Island requires reporting for medical-data-collection purposes only and does not include identification information

Follow-up treatment

Clinician needs to focus on four responsibilities:

Support
Safety
Safety plan
Ongoing assessment

Patient should have a safety plan of what to do in an emergency

If social worker is available, they will usually take on this responsibility
If the patient is not being followed by a social worker, the primary clinician can help the patient develop her safety plan

Key elements in safety plan include:

Plan for what to do in an emergency
A place to go in an emergency
Organization of resources that the patient will need if they have to leave home emergently

Intervention outcomes

Most victims of abuse are not ready to leave their abusers; their reasons for staying include:

Belief in abuser’s promises of change
Belief that abuse is their fault
Lack of money
Lack of a place to go
Fear of reprisal if they try to leave
Absence of intervention on their behalf

Limited data available on the outcomes of interventions; however, studies have shown that

With counseling, victims experience gradual increases in self-esteem
Advocacy programs have been shown to decrease abuse
Act of seeking a protection order decreases intimate partner violence, even if the order is not granted
Completion of batterer intervention program correlated with a decrease in arrests

Prevention programs

Boston Dating Violence Intervention Project, focused on high-school students

Offered school assemblies that educate students about the characteristics of abusive relationships
Training for school staff on how to identify students who may be in abusive relationships
Students felt that the sessions were helpful in teaching them how to identify and get out of abusive relationships

Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) program created by CDC

To facilitate primary prevention of intimate partner violence at the community level
Funds state-level domestic-violence coalitions to provide

Prevention-focused training
Technical assistance
Funding to local Coordinated Community Responses (CCRs)
Data on the efficacy of these community-based primary prevention interventions will be helpful

Best References

Bonomi AE, Anderson ML, Rivara FP, et al: J Womens Health (Larchmt) 16:987, 2007 [PMID 17903075]

Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA). National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, 2007 http://www.cdc.gov/ncipc/DELTA

Gerber MR, Ganz ML, Lichter E, et al: Arch Intern Med 165:1016, 2005 [PMID 15883240]

MacMillan HL, Wathen CN, Jamieson E, et al: JAMA 296:530, 2006 [PMID 16882959]

The author has no commercial relationships with manufacturers of products or providers of services discussed in this module.

* To obtain additional drug information, click on the DrugInfo tab in the left column, or click on the following link: http://search.medscape.com/drug-reference-search?queryText=

September 2011