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
Domestic violence/abuse impairs victims’ physical and mental health.2 Injuries and ailments more prevalent among domestic abuse victims than among the general population include:2,3
- 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
- hypertension
- fainting
- 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.
Table 1
Psychiatric disorders in victims of domestic abuse/violence
| Disorder | Weighted mean prevalence among abuse victims | Lifetime prevalence among general population |
|---|---|---|
| Alcohol abuse/dependence 4 | 19% | 5 to 8% |
| Depression 4 | 48% | 10% to 21% |
| Drug abuse disorder 4 | 9% | 5% to 6% |
| Posttraumatic stress disorder 4 | 64% | 1% to 12% |
| Suicidality 4 | 18% (ideation and attempts) | Ideation 1-16% Attempts <1-4% |
| % of abused sample | % of non-abused sample | |
| Anxiety symptoms 5 | 26% | 8% |
| Generalized anxiety Disorder 6 | 10% | 4% |
| Panic disorder 6 | 13% | <1% |
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.
Prevention and treatment guidelines for physicians9,12,13 recommend interviewing the patient—without the partner or children—in a nonjudgmental and empathic fashion.11
Written questionnaires—such as the Woman Abuse Screening Tool (WAST), WAST-short, and HITS—are another screening option.
WAST-Short has demonstrated 92% sensitivity in identifying emotional or physical abuse (Table 2).14
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?”