Primary Care Update
Domestic violence: How to detect abuse in psychiatric patients
Identifying domestic abuse and its concurrence with psychiatric disorders is critical to treatment—and to possibly saving the patient’s life.
Victims of domestic abuse/violence often present with medical and psychiatric disorders (Box 1, Table 1). Identifying abuse—and encouraging the frightened or ashamed patient to seek help—is critical to evaluating presenting complaints, improving out-come, 7 and possibly saving the patient’s life.
This article will discuss ways to:
- detect signs of abuse
- determine whether a victim is in danger
- share information about crisis resources
- help those who are considering leaving an abusive partner to make a safety plan.
Medical complaints in victims of domestic violence/abuse
Domestic violence/abuse affects 1 of 4 women in the United States. Men also are victims, but the prevalence (1 of 14) and degree of injury is much lower. 1 Domestic violence/abuse occurs among all socioeconomic and ethnic groups. 1,2
- digestive problems (diarrhea, nausea, appetite loss, spastic colon, constipation, eating disorders,
- urinary problems and infections
- vaginal infections, sexually transmitted diseases, pelvic pain, menstrual problems
- sexual dysfunction
- chronic pain (headaches, pelvic, abdominal, back and neck)
- pregnancy problems (preterm labor, poor weight gain)
CASE REPORT: TWO YEARS OF HURT
Ms. W, age 26, is referred to a psychiatrist for treatment-resistant depression. Courses of fluoxetine, 20 mg/d titrated to 80 mg/d, and venlafaxine, 150 mg bid, failed to improve her symptoms. Her Beck Depression Inventory score at baseline is 18, suggesting borderline clinical depression.
Psychiatric disorders in victims of domestic abuse/violence
Weighted mean prevalence among abuse victims
Lifetime prevalence among general population
Alcohol abuse/dependence 4
5 to 8%
10% to 21%
Drug abuse disorder 4
5% to 6%
Posttraumatic stress disorder 4
1% to 12%
18% (ideation and attempts)
% of abused sample
% of non-abused sample
Anxiety symptoms 5
Generalized anxiety Disorder 6
Panic disorder 6
She has two children—ages 2 and 4—with her husband, a habitual crack cocaine user. She does not use drugs or alcohol.
When asked about her life at home, Ms. W laments that her husband is not helpful. When asked if her husband hurts her, she replies tearfully that he constantly yells at her and insults her, calling her “ugly” and “a lousy mom.” Upon further questioning, she reveals that her husband, when high on crack, sometimes hits her.
Ms. W does not work outside the home and did not finish high school. She is afraid to leave her husband because his mother helps care for the children and provides money, housing, and food. She constantly feels tearful and trapped.
The psychiatrist increases the venlafaxine to 375 mg/d and suggests that Ms. W call a domestic violence crisis center. She does not call the center, but agrees to see the psychiatrist monthly. Across 3 months her Beck score improves to 14.
SCREENING FOR ABUSE
The American Medical Association, American College of Physicians, and other physician and nursing organizations recommend routinely screening women for domestic abuse/violence. 8-10 Some patients will not disclose abuse to their physicians when asked, but most patients say they want doctors to ask them about domestic violence/abuse and to offer crisis phone numbers, pamphlets, and other resources. 11
Anyone who presents with complaints of fatigue, depression, anxiety, insomnia, hypervigilance, a treatment-resistant psychiatric disorder, or a visible physical injury (such as a black eye or bruises) should be screened for domestic abuse.
Written questionnaires—such as the Woman Abuse Screening Tool (WAST), WAST-short, and HITS—are another screening option.
WAST. The longer version of WAST has demonstrated 96% sensitivity in detecting physical or emotional abuse. 14 It includes the two WAST-short questions, plus five questions about whether:
- arguments with an intimate partner ever diminish the patient’s self-esteem
- such arguments ever result in kicking or hitting
- the patient ever feels frightened by the partner’s words or actions
- the patient has ever been physically or emotionally abused by his or her partner.
Because the additional questions are not scored, the longer WAST is not well suited to clinical practice. However, a patient who scores a 1 on the WAST-Short exam can provide more in-depth information on her troubled relationship by answering the extra questions.
HITS can be self-administered and its title is easy to remember, but the scoring system is cumbersome. The patient is asked: “How often does your partner:
- Hurt you physically?
- Insult you or talk down to you?
- Threaten you with harm?
- Scream or curse at you?”
Each answer is scored on a 1-to-5 scale—never, rarely, sometimes, fairly often, or frequently. A score ≥ 10.5 has demonstrated 96% sensitivity in identifying physical and verbal abuse. 15
Encouraging disclosure. Ask patients about domestic abuse when inquiring about smoking, alcohol use, or household makeup as part of the patient history. Your line of questioning might proceed as follows:
- “Do you live alone?”
- “Do you have a significant other?”
- “How is your relationship going?”
- “Is your partner supportive?”
- “What happens when you and your partner disagree?”
Woman Abuse Screening Tool-Short version
1. In general, how would you describe your relationship?
□ a lot of tension
□ some tension
□ no tension
2. Do you and your partner work out arguments with:
□ great difficulty
□ some difficulty
□ no difficulty
Answers are scored on a 1-to-3 scale, with 1 meaning “a lot of tension” or “great difficulty.” A score of 1 on either question indicates possible domestic abuse/violence.
Source: Reference 14
Be empathic. Explain the association between domestic abuse/violence and mental and physical disorders. Tell the patient that domestic abuse is common and help is readily available. Share information about crisis services even if the patient does not immediately disclose suspected abuse. Victims generally feel tremendous shame from living with the abuse, so disclosure takes time and trust.
Most states do not require physicians to report domestic abuse to the police unless injuries are caused by a weapon (knife or gun). However, physicians in California, Colorado, Kentucky, and New York must report any injuries resulting from domestic abuse—even if not caused by a weapon. 16 In these states, clinicians should disclose their reporting obligation at the start of the patient interview.
Warning signs of danger to a domestic abuse victim
Assess danger to any patient who reports being a victim of domestic abuse/violence. Consider danger imminent if the patient acknowledges any one of the following:
- Homicide or suicide threats from partner
- Weapons in the home
- Excessive substance use by partner or victim
- Escalating abuse or threats
- Physical/verbal abuse of children
- Harm to pets
- Fear of the partner
Source: Reference 17
Possessions a victim needs in case of emergency
Advise a patient who reports domestic abuse/violence to pack important belongings in case she needs to immediately leave an abusive partner.
The emergency bag should contain:
- Identification for self and children (birth certificates, driver’s license)
- Important documents (school and health records, insurance cards, car title, marriage license, mortgage or rental papers, protective orders, custody papers, divorce papers)
- Medications (for victim and children)
- Keys (auto, home, safe deposit box)
- Phone numbers
- Clothing (for victim and children)
- Comfort items, such as toys and blankets for children.
Source: Reference 17
WHEN A PATIENT CONFIRMS ABUSE
Affirm the difficulty of sharing this information and reassure the patient that she is not alone. Tell her, for example, “I know this is difficult to talk about. No one deserves to be treated this way.”
Reaffirm confidentiality. Victims fear harm to themselves or their children if their abusers find out they have discussed the abuse.
Refer the patient to a local domestic violence crisis agency or to a therapist knowledgeable about domestic abuse. A patient who reports being threatened at gunpoint or who fears for her safety should be urged to call police.
Do not refer the victim and partner to couples counseling. Such therapy is contraindicated because of the relationship’s power imbalance and the risk that the abuser will retaliate when alone with the victim.
DEVELOPING A SAFETY PLAN
Patients who have decided to leave an abusive partner need help forming a safety plan. Assistance from a domestic violence crisis agency is invaluable, but some patients prefer to work with their physicians. Safety planning involves helping the victim identify options and needs upon leaving the relationship.
Start by asking the patient:
- “If you leave home, where will you go?
- Is there an alternative if you cannot stay where you planned?
- Do you have an emergency bag?” (Box 3) 17
Remind the patient to keep her emergency bag, purse, and keys handy in case she needs to leave quickly.
Instruct the patient to:
- Tell a neighbor about the violence and ask him or her to call police if he or she hears suspicious noises from the victim’s residence.
- Teach children to dial 911 or 0 or to make a collect call to a relative, friend, minister, or other trusted person in an emergency. Also teach children addresses of close relatives and friends.
- Learn the local domestic violence hotline number. 17
IF A PATIENT DENIES ABUSE
If a suspected victim denies she is being abused, schedule regular visits and let her know you are concerned. Ask how the relationship is progressing at the next monthly visit. If you fear the patient is in danger, schedule weekly or biweekly visits.
Above all, do not tell the victim what to do. Some patients are not ready to act, while others may call the local agency from your office.
- National Domestic Violence Hotline (24-hour). 1-800-799-SAFE (7233). Translation services available.
- National Resource Center on Domestic Violence. (800) 537-2238 or www.ndvh.org
- American Medical Association Domestic Violence Resources. www.ama-assn.org/ama/pub/article/3216-6827.html
- American Medical Women’s Association online CME course educates physicians about domestic violence. Physicians can earn two CME credits at no charge. www.dvcme.org
Drug brand names
- Fluoxetine • Prozac
- Venlafaxine • Effexor
The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.
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