Domestic Abuse Victims Bring Complex Issues to Treatment

Though there has been limited focus on the problem of domestic violence by the field of psychiatry, there is a high prevalence of domestic violence in mental health settings, according to psychiatrists who are experts in treating domestic violence.

At APA's annual meeting in New York City last month, they discussed how best to address the mental health needs of patients who are victims of domestic violence.

Domestic violence and mental health problems are often intertwined, according to Carole Warshaw, M.D., director of the Domestic Violence and Mental Health Policy Initiative in Chicago and a member of APA's Committee on Family Violence and Abuse. For example, studies show that from 42 percent to 46 percent of women in outpatient mental health settings have experienced physical abuse, and 29 percent to 38 percent have experienced sexual abuse as adults.

For women patients with serious mental illnesses, these rates are twice as high. Further, studies of women enrolled in domestic violence programs have shown high prevalence rates of mental illness, according Warshaw.

In 2000, researcher Jacqueline Golding, Ph.D., found that mean prevalence rates of posttraumatic stress disorder (PTSD) among women in these settings is 61 percent. About 50 percent of these women experienced depression symptoms, and 20 percent exhibited suicidal behavior.

Complicating matters is the fact that women with severe mental illness who reveal that they are victims of domestic violence may not be taken seriously by the medical community.

“Not infrequently, reports of abuse are attributed to delusions,” Warshaw said, adding, “but we know that an episode of abuse often precipitates psychotic decompensation.”

Warshaw also pointed out that “the symptoms and stigma associated with mental illness can increase women's vulnerability to being controlled by an abusive partner.”

The partner may tell the woman and others that she is crazy, for instance, or have her committed to a psychiatric hospital and then speak on her behalf, Warshaw noted. After an episode of violence, it is not uncommon for abusers to rationalize their behavior by saying they were just trying to restrain a partner who was “out of control,” Warshaw pointed out.

Psychiatrists should be aware that symptoms related to trauma resulting from domestic violence may look similar to symptoms of serious mental illness, Warshaw said. For instance, flashbacks may be confused with hallucinations, and emotional lability and affect dysregulation associated with complex trauma may be mistaken for symptoms of bipolar disorder. Some women may have symptoms related to ongoing trauma plus one or two comorbid psychiatric disorders,“ but there has not been much written about how these conditions intersect,” she said.

Some symptoms of PTSD—avoidance and dissociation, for example—can hinder an abused woman's ability to get out of a dangerous situation, Warshaw pointed out. The symptoms “can prevent women from mobilizing the resources they need to stay safe or to protect their children from danger,” she said, by increasing a woman's chance of being isolated and controlled by an abusive partner.