|Dr. Doenlen’s Qualifications
Board Certifications (A.B.M.E.)
- General Psychiatry
- Child Psychiatry
- Forensic Psychiatry
Office at Psychological Associates, P.A.
(as required by Florida Statutes)
At the conclusion, the participant should
be able to:
- estimate the number of patients likely
to be victims or perpetrators
- perform screening procedures for
- Know where to refer victims of domestic
- use resources in the community
Highlights in Today’s Presentation
- Domestic Violence Statistics, Screening,
- Post Traumatic Stress Disorder
- Treatment Considerations
Every 15 seconds, a woman is
(American Medical Association. 1991.
"Five Issues in American Health." Chicago, IL.)
Two to four million women are beaten by
their partners each year.
(Council on Scientific Affairs, 1992,
"Violence Against Women: Relevance for Medical Practitioners."
Journal of the American Medical Society 267(23): pp.3184-3189.)
Thirty-four percent of Americans say they
have witnessed an incident of domestic violence, compared with only 19
percent who report witnessing a robbery or mugging.
(Family Violence Prevention Fund and EDK
Associates, 1993, "National Survey on Domestic Violence," San
Studies on the prevalence of domestic
violence suggest that from one-fifth to one-third of all women will be
physically assaulted by a partner or ex-partner during their lifetime.
(Council on Scientific Affairs, American
Medical Association. 1991. "Violence Against Women: Relevance for
Medical Practitioners." Journal of the American Medical Association
Battering is the greatest single cause of
injury among U.S. women, accounting for more emergency room visits than
auto accidents, muggings and rapes combined.
(Stark, Evan D. and Anne Flitcraft. 1989.
"Violence Among Intimates: An Epidemiological Review." In Handbook
of Family Violence. Van Hasselt, ed. pp. 293-318. New York: Plenum
Twenty-two to 35 percent of women who
visit emergency departments in the United States are there for symptoms
related to on-going abuse.
(Randall, T. 1992. "Domestic
Violence Intervention Calls for More than Treating Injuries."
Journal of the American Medical Association 264(8): p. 939.)
In 1991, 28 percent of all female murder
victims were slain by their husbands or partners.
(Federal Bureau of Investigation.
1991. "Crime in the United States, 1991." Washington, D.C.)
In 1992, abuse by husbands and partners
was ranked by the U.S. Surgeon General as the leading cause of injuries
to women aged 15 to 44.
(Novello, Antonia, as reported in
"Newsweek", July 4, 1994.)
Women are more likely to be victims of
homicide when they are estranged from their husbands than when they live
with their husbands. The risk of homicide is higher in the first two
months after separation.
(Wilson, M.., and Daly, M., 1993, Violence
and Victims, "Spousal Homicide Risk and Estrangement,"
Victimization by Intimate Partner
Physical Assaults by Intimate Partner
Offender Risk Characteristics
Extensive prior records.
Do not share the justice system's view that what they
did was wrong, much less criminal. They rationalize or minimize their
Alcohol and/or drug abusers.
Lack strong ties to family, employment or the
community, as measured by family disruption, high unemployment, and
frequency of residency changes.
Easy access to their victims. Also, easy access to
Characteristics of Victims
Blames herself for the violence.
Exhibits low self esteem (which is
magnified by the batterer's confirmation that she is
Fears leaving or staying.
Minimizes or denies that a problem
Is often isolated from family, friends,
and any support systems.
Characteristics of Victims
Feels shame and guilt.
Uses sexual relations as a way to
Often believes she can change the
Often believes she can help herself
without outside intervention.
Why do men rape?
1 out of 12 males commit rape.
Believe in sexual entitlement
usually marital or date rape
War rape (revenge against enemy)
Rape Trauma Syndrome
Not a DSM-IV diagnosis, often used in
First Phase - Acute
- extremely controlled
- various physical symptoms
Rape Trauma Syndrome
Second Phase - Period
of Apparent Readjustment
- rationalizes the rape
- has "forgotten" it
- appears to have resolved the issue
- represents another step toward true
Rape Trauma Syndrome
Third Phase - Reorganization
- reemergence of previous troubling
- suicidal thoughts
- appears to "be getting worse
instead of better"
- relationships under greatest stress
- begins to grapple with deep-seated
feelings about rape
Cycle of Violence
- Tension Building Phase
- Acute Battering Incident
- Calm, Loving Respite
PTSD – Traumatic Event
The person has been exposed to a
traumatic event in which both of the following were present:
The person experienced, witnessed, or
was confronted with an event or events that involved actual or
threatened death or serious injury, or a threat to the physical
integrity of self or others
PTSD – Extreme Stress
- Serious accident or natural disaster
- Rape or criminal assault
- Combat exposure
- Child sexual or physical abuse or severe
- Witnessing a traumatic event
- Sudden unexpected death of a loved one
PTSD – Response
The person's response involved intense
fear, helplessness, or horror.
Note: In children, this may be
expressed instead by disorganized or agitated behavior
PTSD – Recollections
The traumatic event is persistently
re-experienced in one (or more) of the following ways:
recurrent and intrusive distressing
recollections of the event, including images, thoughts, or
perceptions. Note: In young children, repetitive play may occur
in which themes or aspects of the trauma are expressed.
PTSD - Dreams
recurrent distressing dreams of the
event. Note: In children, there may be frightening dreams
without recognizable content.
PTSD - Flashbacks
acting or feeling as if the traumatic
event were recurring (includes a sense of reliving the experience,
illusions, hallucinations, and dissociative flashback episodes,
including those that occur on awakening or when intoxicated).
Note: In young children,
trauma-specific reenactment may occur.
PTSD – Distress & Reactivity
intense psychological distress at
exposure to internal or external cues that symbolize or resemble an
aspect of the traumatic event
physiological reactivity on exposure to
internal or external cues that symbolize or resemble an aspect of the
PTSD - Avoidance
Persistent avoidance of stimuli
associated with the trauma and numbing of general responsiveness (not
present before the trauma), as indicated by three (or more) of the
efforts to avoid activities, places, or
people that arouse recollections of the trauma
PTSD – Memory Impairment
efforts to avoid thoughts, feelings, or
conversations associated with the trauma
inability to recall an important aspect
of the trauma
PTSD – Disinterest & Detachment
markedly diminished interest or
participation in significant activities
feeling of detachment or estrangement
restricted range of affect (e.g.,
unable to have loving feelings)
PTSD – Foreshortened Future
sense of a foreshortened future (e.g.,
does not expect to have a career, marriage, children, or a normal life
PTSD – Increased Arousal
Persistent symptoms of increased arousal
(not present before the trauma), as indicated by two (or more) of the
- difficulty falling or staying asleep
- irritability or outbursts of anger
- difficulty concentrating
- hyper vigilance
- exaggerated startle response
PTSD – Impairment
Duration of the disturbance (symptoms in
Criteria B, C, and D) is more than 1 month.
The disturbance causes clinically
significant distress or impairment in social, occupational, or other
important areas of functioning
PTSD – Onset & Duration
if duration of symptoms is less than 3 months
if duration of symptoms is 3 months or more
With Delayed Onset:
if onset of symptoms is at least 6 months after the stressor
- Depressed Mood
- Somatic/Sexual Dysfunction
PTSD – Initial Treatment
Psychotherapy alone (milder acute case)
Medication and Psychotherapy (chronic, more severe
case, or co-morbid conditions)
- Anxiety management, relaxation
- Cognitive therapy
- Exposure therapy
- Play therapy
PTSD - Medication
Trazodone (Desyrel) for insomnia
Adequate initial trial
6 weeks if no response
8 weeks if partial response
Written Health Assessment
Are you in a relationship where you
have been physically hurt?
Has your partner ever harmed or
threatened to harm you or some one you love?
Victim may not recognize herself as
Women may not bring up subject on their
Victim may discuss when asked direct
"Because abuse and violence are so
common in women's lives, I've begun to ask about it routinely."
Date and time of arrival and examination
Name, address and phone number of any one
accompanying the victim
Name of alleged perpetrator
Chief complaint and description of the
Use victims own words
Document that victim was asked about
domestic violence, and victim's response
Complete medical history
Complete social history
Detailed description of the injuries
Color photographs and imaging studies
Victims explanation of cause of the
Examiner's opinion on whether the
injuries were adequately explained
Results of lab tests, diagnostic
If police are called, name and badge
number of investigating officer
Any other actions taken
Suspected physical abuse, sexual abuse,
Children, elderly, and disabled
Listed in back of front cover of phone
"It may be a few minutes before we
can answer your call..."
May leave a message in voice mail
Should report a suspected abuse, even
if it was previously reported by some one else
Faxing an Abuse Report
FAX : 1-800-914-0004
Victim's (and caretaker's) name, birth
date, address, phone, whereabouts
Alleged perpetrator's name, relationship
to victim, address, phone, whereabouts
Description of the suspected abuse
Actions taken by the reporter
Reporter's name, address, phone,
relationship to victim
Certified domestic violence center
Santa Rosa County
2001 W. Blount St., 32501
- Education programs
- Counseling, support groups
Favor House Shelter
24 hour crises line 434-6600
- May call collect
- Listed in front cover of phone book, and in
bushiness section under Favor House
Location not known to public
Transportation arranged at time of referral
Eligibility for admission to the shelter
- Victim of physical abuse by spouse
- Able to look after self and children
- Free of alcohol and drug addiction
Shelter - Entrance
Shelter - Security
Shelter - Kitchen
Shelter - Outside
Shelter living room
Shelter play room
Risk - Inquire & Referral
Inquire about the abuse
A physician who does not inquire about
abuse or accepts an unlikely explanation of the injuries may be found
liable for if the women returns to the abuse situation and sustains
Conduct interview and examination apart
from the suspected victim's spouse or partner
Make appropriate referrals for help
Risk - Mandatory Reporting
Abuse of children, elderly, disabled
Abuse Registry Hot Line
second degree misdemeanor if don't
if report, unlikely to be accused of
not acting in good faith