Ethnicity and race do not appear to be factors in the prevalence of IPV when controlling for demographic, interpersonal, and sociocultural factors (Cho, 2012; Lipsky, Caetano, Field, & Bazargan, 2005). Although there are wide ranges of prevalence rates for various types of violence and abuse, studies show that they occur frequently. Those working in primary care should routinely assess all patients for signs and symptoms of abuse, including psychological abuse, and also look for victimization in men as well as in women and children.

CONTRIBUTING FACTORS IN ADULTS WHO ARE VIOLENT

History of Childhood Exposure to Violence

Current research points to a number of possible experiential and biological causes of violence. A correlation appears to exist between having a history of victimization as a child and being a perpetrator of child abuse. In one study, children being monitored by child protective services (CPS) were approximately three times more likely to have a parent reporting a childhood history of abuse or neglect (Folsom, Christensen, Avery, & Moore, 2003). Even in the absence of victimization, it appears that childhood exposure to violence between others is also a predictor of violent behavior in that individual.

Substance Abuse

In general, alcohol abuse is frequently related to various types of violent behaviors (Lipton et al., 2013). Alcohol use appears to have the effect of disinhibiting emotional control in some people and seems to be a contributing factor in IPA. The frequency of alcohol intoxication has been shown to be correlated with the rate of abusive episodes of intimate partners by men (Ames, Cunradi, Duke, Todd, & Chen, 2013). Alcohol abuse can also be the result of being the victim in an abusive relationship. It has been noted that high rates of IPA victimization are associated with women who abuse substances. In one study, nearly 50% of women entering substance use disorder (SUD) treatment were identified as having a lifetime history of victimization from IPA (Schneider, Burnette, Ilgen, & Timko, 2009).

Psychiatric Illness

Psychiatric illness may be both a contributing factor in the perpetration of violence and a result of victimization from violence. The individuals with psychiatric illness who appear to be at highest risk of perpetrating violence seem to be (1) older males with diagnoses of schizophrenia; or (2) individuals with personality disorders and either a substance abuse disorder or PTSD (Flannery, Farley, Tierney, & Walker, 2011). In addition, a diagnosis of psychiatric illness seems to contribute to the risk of becoming a victim of violence (Honkonen, Henriksson, Koivisto, Stengård, & Salokangas, 2004). It is possible that this may be a reaction by others to the aggressive behavior displayed by people with psychiatric symptoms, or that people with psychiatric disorders are vulnerable to abuse by others due to psychological symptoms that can leave them defenseless.

There is also some evidence that psychiatric disorders may be triggered by exposure to violence and abuse. It has been reported that adverse childhood experiences have been associated with as much as 32% of the diagnoses of psychiatric disorders and 50% of reported suicide attempts (Afifi et al., 2008). In addition, postpartum depression has been found to be correlated with the combination of IPA and alcohol abuse (Lobato, Moraes, Dias, & Reichenheim, 2012).

With respect to violence, it is important to note that suicide is an act of aggression. In addition to the self-destruction that results from suicide, it also can be associated with murder. Overall, it is estimated that 13% of murders result in suicide of the perpetrator (Panczak et al., 2013). The rate appears to double (25%) when focusing on murder–suicides within intimate relationships (Galta, Olsen, & Wik, 2010).

Neurological Disorders (Brain Injury, Intellectual Disabilities, Seizure Disorders, and Dementia)

Research suggests that the rate of violence is higher among individuals with traumatic brain injury (Fazel, Lichtenstein, Grann, & Långström, 2011). People who have been the victims of head trauma and stroke appear to fall into this risk category. Anecdotally, violence has also been observed with respect to epilepsy during the post-ictal phase of a seizure (Yankovsky, Veilleux, Dubeau, & Andermann, 2005). However, the relationship between epilepsy and violence does not appear to be significant when controlling for behaviors found in siblings. This suggests that heredity and environment play a more significant role in the causation of the violent behavior than does epilepsy (Fazel et al., 2011).

Chronic Pain

The literature indicates that people in chronic pain are at greater risk of perpetrating violence toward others. A study of chronic pain patients found that approximately 30% of participants reported perpetrating low-level aggression; 12% reported injuring their partner; and 5% reported engaging in sexual coercion. SUDs were also found to be associated with violence in this population (Taft, Schwartz, & Liebschutz, 2010). It appears that the abuse of prescription narcotics or other frequently prescribed pain medications for individuals in chronic pain may have the effect of disinhibiting impulse control and lead to violence.

Gang Violence

Youth who are members of gangs are at greater risk of violence by the very nature of gang activity. People who live and work in neighborhoods where gangs are active, as well as staff in emergency departments and hospital wards that service those neighborhoods, are at risk of being victims of this type of violence. It is important to observe patients in the hospital or outpatient setting for signs of gang membership. These may involve colors of clothing, types of clothing, the use of hand signs and gestures, and unique tattoos. The local police precincts can be informative about such signs of gang membership and ways to avoid victimization.

When approaching a person who is a member of a gang, it is important to realize that he or she is likely in possession of a weapon. Health professionals who work in neighborhoods where gangs are active will not be able to avoid contact with gang members, due to the fact that gang members are frequently the victims of violence by rival gang members and will be in need of various kinds of health care (Sanders, Schneiderman, Loken, Lankenau, & Bloom, 2009).

Pregnancy

IPA is not uncommon during pregnancy (Daoud et al., 2012), but pregnancy does not appear to increase the risk of IPA. In fact, the rate of IPA in women who are in an abusive relationship appears to decline during the period of time when they are pregnant: 3% to 17% of pregnant women experience IPA (McMahon & Armstrong, 2012). After the birth of the child, the rate of IPA appears to return to the prepregnancy rate (Daoud et al., 2012). This suggests that screening for IPA may be most effective prior to pregnancy and after delivery of the baby. Despite the rate of abuse being lower during pregnancy, it is of significant concern due to the potential for life-threatening harm to both the mother and fetus.

Women in the Military

Violence against women in the military is gaining public attention. As many as 55% of female military personnel report being harassed, and 23% report being sexually abused by associates (Skinner et al., 2000). These high rates of victimization indicate the need to include military service by women as a risk factor when screening for violence and abuse.

Violence Toward Groups

Recently, the media have reported numerous gun shootings at schools, movie theaters, shopping centers, and other public areas where innocent people have been indiscriminately murdered. Much attention is being focused on the identification of potential perpetrators of this type of behavior and whether or not health professionals and educators may be able to anticipate the warning signs. A study in which the characteristics of 64 mass murderers were analyzed found a series of similarities. Perpetrators commonly had (1) a variety of psychiatric disorders; (2) a fascination with weapons and a warrior-like identity; (3) a history of violence against people or animals; and (4) a recent loss or rejection (Meloy et al., 2004). People who display this constellation of symptoms require referral to mental health professionals for further evaluation.

SEQUELAE OF VIOLENCE

Aside from the obvious results of violence, such as injury, disability, and death, a variety of psychological and somatic symptoms may occur. Exposure to violence can cause internalized psychological symptoms such as PTSD, anxiety, and depression. It can also cause externalized psychological symptoms such as somatic pain and discomforts, exacerbation of asthma, and risky health-related behaviors including unsafe sex.

PTSD, Anxiety, and Depression (Internalized Psychological Symptoms)

Individuals who witness violence between others are at risk of developing internalized psychological symptoms as well. A study found that PTSD and major depressive disorder were able to be predicted in children exposed to IPA between their parents (Zinzow et al., 2009). Witnessing the abuse of others appears to be related to a variety of health issues. Abuse witnessed during childhood has been correlated with overall poor health status, depression, higher prevalence of IPA, and greater use of health care services (Cannon, Bonomi, Anderson, Rivara, & Thompson, 2010). The relationship between exposure to violence between others and internalized psychological symptoms also extends beyond violence in the home. Chronic exposure to violence in the community is associated with a 2½-fold increase in the odds of having a lifetime experience of depressive symptoms (Clark et al., 2007).

Emotional abuse can have negative health effects that are similar to those of physical abuse. Emotional abuse such as experiencing frequent degrading and critical comments and manipulation has been found to be associated with depression and anxiety symptoms in victims (Lawrence, Yoon, Langer, & Ro, 2009). In addition, emotional abuse as a child appears to carry over into parenting abilities. A study found that being a victim of emotional child abuse was correlated with a risk of depression and suicide in the victim’s children (McFarlane, Groff, O’Brien, & Watson, 2003).

Somatic Symptoms

Somatic symptoms involving physical complaints of discomfort or pain subsequent to exposure to physical violence may be an indication that there is a relationship between the two issues. A significant increase in the prevalence of somatic symptoms has been found in women exposed to physical and sexual violence as compared to women who were not exposed (Eberhard-Gran, Schei, & Eskild, 2007). Similarly, children with asthma who have been exposed to violence reported more nighttime symptoms of their disease than those who were not (Walker, Lewis-Land, Kub, Tsoukleris, & Butz, 2008). Since there are no laboratory tests or procedures to determine somatic origin of pain or other physical symptoms, it is necessary to rule out all other possible causes of the symptoms before concluding that they are somatic in origin. This usually requires psychiatric consultation as well.

Exposure to violence may also lead to greater risk-taking within various spheres of people’s lives. A study found that a history of IPA in women was related to high-risk sexual behaviors. Victims of IPA reported higher exposure to HIV risk factors, that is, sex without a condom, sex with a man they knew or suspected of IV drug use, and a history of sexually transmitted infection (Sormanti & Shibusawa, 2008).

ASSESSMENT

Intimate Partner Abuse

Within IPA, certain things to look for are injuries to the face that may be due to slaps or punches; bruises on the arms due to punches; bruises on the wrists from pulling or restraining the arms; scratches on the back; and bite marks on shoulders or other areas of the body. Patterns of bruises that appear like marks left by fingers from a slap or that had a tight grip on the victim are clearly a cause for concern. Nervousness and evasiveness when questioned about the injuries may be indicative of the patient trying to avoid the issue of abuse.

Characteristics of Elder Abuse

Elder abuse is most likely to occur in people who are physically dependent on others for their care or require assistance to effectively provide self-care. It can take the form of emotional or physical abuse. The injuries in the context of elder abuse may appear similar to those observed in IPA. In addition, bruises on the wrists or ankles may be indicative of being restrained to a bed or chair. Pressure injuries or bruises on the buttocks or sacral area in a person who is ambulatory may also suggest that the elder has been restrained to a bed or chair. In an elder who is nonambulatory, these injuries may be signs of neglect, that is, being left for long periods in the same position in a bed or chair. Poor hygiene or attire in a cooperative individual can be a sign of neglect.

When elders with financial assets are dependent on children or other family members, a situation described as financial abuse appears to be common (Gibson & Greene, 2013). This involves withholding an individual’s money, and depriving him or her of the ability to make necessary expenditures for clothing, household help, food, and the like. Often, this is perpetrated by the children for the purpose of preserving an inheritance or to financially exploit the elder in other ways. Signs of financial abuse are clothing that is old or excessively worn, and poor hygiene or nutrition related to financial concerns despite possessing adequate financial assets to purchase or obtain assistance to maintain a more appropriate lifestyle. All types of elder abuse should be reported to the appropriate government agency. Consult your local government’s website for the telephone number for reporting.

Posttraumatic Stress Disorder