The Faces of Domestic Violence

Understanding Post Traumatic Stress Disorder

by Henry A. Doenlen, M.D.

Power point presentation and outline about domestic violence, with special emphasis on Post Traumatic Stress Syndrome. This instructs physicians on what they need to know to understand and provide assistance for victims of domestic violence. 

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© 2001, Henry A. Doenlen, M.D. All rights reserved.

Dr. Doenlen’s Qualifications

Board Certifications (A.B.M.E.)

  • General Psychiatry
  • Child Psychiatry
  • Forensic Psychiatry

Office at Psychological Associates, P.A.

Objectives
(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 domestic violence
  • Know where to refer victims of domestic violence
  • use resources in the community

Highlights in Today’s Presentation

  1. Domestic Violence Statistics, Screening, and Referrals
  2. Post Traumatic Stress Disorder
  3. Treatment Considerations

Domestic Violence

Every 15 seconds, a woman is battered.

(American Medical Association. 1991. "Five Issues in American Health." Chicago, IL.)

Domestic Violence

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.)

Domestic Violence

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 Francisco, CA)

Domestic Violence

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 267(23): 1992.)

Domestic Violence

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 Publishing Corp.)

Domestic Violence

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.)

Domestic Violence

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.)

Domestic Violence

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.)

Domestic Violence

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," 8:3-16)

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 behavior.

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 weapons.

Characteristics of Victims

Blames herself for the violence.

Exhibits low self esteem (which is magnified by the batterer's confirmation that she is "worthless").

Fears leaving or staying.

Minimizes or denies that a problem exists.

Is often isolated from family, friends, and any support systems.

Characteristics of Victims

Feels shame and guilt.

Uses sexual relations as a way to establish intimacy.

Often believes she can change the batterer's behavior.

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

Criminal fantasy

Serial rapists

Group process

Gang rape

War rape (revenge against enemy)

Darwinian argument

Rape Trauma Syndrome

Not a DSM-IV diagnosis, often used in court.

First Phase - Acute Distress

  • immediate
  • shock
  • disbelief
  • confusion
  • anxiety
  • crying
  • 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 resolution

Rape Trauma Syndrome

Third Phase - Reorganization or Integration

  • reemergence of previous troubling responses
  • 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 neglect
  • Hostage/imprisonment/torture/displacement as refugee
  • 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 traumatic event

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 following:

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 from others

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 span)

PTSD – Increased Arousal

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

  • 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

Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

Specify if:

With Delayed Onset: if onset of symptoms is at least 6 months after the stressor

Associated Features

  • Depressed Mood
  • Somatic/Sexual Dysfunction
  • Guilt/Obsession
  • Addiction

PTSD – Initial Treatment

Psychotherapy alone (milder acute case)

Medication and Psychotherapy (chronic, more severe case, or co-morbid conditions)

Individual Psychotherapy

  • Anxiety management, relaxation
  • Assertiveness
  • Cognitive therapy
  • Exposure therapy
  • Play therapy
  • Psycho-education

PTSD - Medication

SSRI’s

Nefazodone (Serzone)

Venlafaxine (Effexor)

Trazodone (Desyrel) for insomnia

Adequate initial trial

6 weeks if no response

8 weeks if partial response

Screening Questions

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?

Interviewing

Victim may not recognize herself as "battered"

Women may not bring up subject on their own

Victim may discuss when asked direct questions

Interview alone

"Because abuse and violence are so common in women's lives, I've begun to ask about it routinely."

Documentation

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 assault

Use victims own words

Document that victim was asked about domestic violence, and victim's response

Complete medical history

Complete social history

More Documentation

Detailed description of the injuries

Color photographs and imaging studies

Victims explanation of cause of the injuries

Examiner's opinion on whether the injuries were adequately explained

Results of lab tests, diagnostic procedures

If police are called, name and badge number of investigating officer

Any other actions taken

Abuse Registry

Suspected physical abuse, sexual abuse, neglect, exploitation

Children, elderly, and disabled

1-800-962-2873

Listed in back of front cover of phone book

"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

Favor House

Certified domestic violence center

Escambia County

Santa Rosa County

Counseling Center

2001 W. Blount St., 32501

434-1177

Other services

  • 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 further injuries

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 report

if report, unlikely to be accused of not acting in good faith

 

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Copyright © 2001, Psychological Associates, P.A., All rights reserved.

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July, 2001