Aggression & Abuse

1. Aggression & Abuse Michael Wilson, PhD University of Illinois Department of Psychology and University of Illinois College of Medicine

2. A clinical vignette… A 21 year-old college student who has a 3 year-old child comes to the ED and reports that she was raped by a man she was on a date with 2 nights ago. The physical exam shows no physical evidence of rape (ie, no injuries, no semen). She appears anxious, disheveled, and “spacey” in general. She has restricted affect and a sense of a shortened future. It is most likely that this woman: • is delusional, and should be questioned about other paranoid thoughts • is malingering or “faking,” and should be warned about using hospital resources that could help other needy patients • is a hypochondriac, and should be referred to a psychiatrist • is suffering from a physical manifestation of a mental illness, and should be referred to a psychiatrist or a therapist • has been raped and that the rapist used a condom, and so should be referred to the rape crisis center

3. Outline • Child maltreatment • physical abuse covered in Rosengren lecture • Domestic violence • Rape • Determinants of aggression & abuse

4. Child maltreatment • Types of maltreatment • physical abuse • sexual abuse • emotional/physical neglect • Abuse-related injuries • must be differentiated from injuries during normal activity

5. Child maltreatment • neglect • = failure of caregiver to provide for needs adequately • may be physical or emotional • clothing, shelter, food, support • often harder to detect than abuse • may present in a variety of ways • dirty or improperly clothed • with injuries from inadequate supervision • with treatable medical conditions such as infections from diaper rash • with poor nutrition status

6. Child neglect • Markers of poor nutrition • little subcutaneous fat • protruding ribs • loose folds of skin, esp over buttocks • weight & length way below growth curve • BMI (weight in kg/height in meters2) < 5 %tile

7. Child neglect • Markers of environmental neglect • short stature more prominent than low weight • classic triad of short stature, bizarre voracious appetite (eating from trash cans), disturbed home situation • frequently hyperactive, unintelligible speech

8. Child neglect • If neglect suspected, children are admitted to hospital • weight gain in hospital with proper nutrition indicates neglect • also allows more in-depth assessment while in protected environment

9. slide courtesy of Dr. Karl Rosengren

10. Physical abuse in children • Worrisome signs • trauma inconsistent with story • belt marks when child “fell down stairs” • story that keeps changing • trauma inconsistent with developmental milestones • accidental poisoning in child who can’t sit up or walk

11. Physical abuse in children • Munchausen syndrome by proxy • first named in 1977 • relatively uncommon type of factitious disorder • factitious disorder = condition where patient induces illness to be in sick role • by proxy, parents (usually mom) fakes child’s illness • parents may travel from hospital to hospital • on presentation, symptoms may be various • but result from administration of drugs or toxins

12. Physical abuse in children • Munchausen syndrome by proxy • most common induced conditions are vomiting, diarrhea, respiratory arrest, asthma, CNS dysfunction (such as seizures) • hardly ever, simulation of mental disorders • kids are commonly preschool age • cases have atypical clinical course & inconsistent lab results

13. Physical abuse in children • Munchausen syndrome by proxy • named in the DSM-IV-TR as “factitious disorder by proxy” • under “criteria for further study” • although “Munchausen variant” is most severe of factitious disorders • MSBP commonly mentioned in textbooks • but controversial

14. Physical abuse in children • Problems with MSBP • hard to define • on closer investigation, many kids harmed more by doctors than parents • who makes the diagnosis? • Psychiatrist dealing with mom? Or pediatrician dealing with kid? Pankratz (2006) “Persistent problems with the munchausen syndrome by proxy label.” Journal of American Academy of Psychiatry and Law.

15. Sexual abuse in children • Signs • STDs, anal trauma, specific knowledge about intimate acts • may have no signs at all • ~15% in ED have unrelated complaints such as abdominal pain, asthma, sore throat • Self-report • rarely disclose abuse until much later • questioning is usually best done by trained worker

16. Domestic partner abuse • Domestic violence is difficult to define • Roughly, use of a pattern of assaultive & coercive behaviors, including physical, sexual, & psychological attacks, as well as economic coercion, used against an intimate partner • May include force, emotional/psychological abuse, intimidation, deprivation, isolation, stalking, assault/battery

17. Domestic partner abuse • Occurrence • Since difficult to define, difficult to measure prevalence • However defined, male = female • Female > male in younger age groups • Male > female in older age groups • in both observational studies & self-reports from women

18. Domestic partner abuse • Occurrence in hospital setting • Hx of abuse common in ED setting • ~14% of women in ED have history of physical/sexual abuse in last year • 30%-54% have history of physical/sexual abuse in lifetime • does not reflect just family violence • ED presentations of abuse vary • direct trauma, depression, anxiety, substance abuse, substance intoxication, suicide attempts • may present with vague psychiatric complaints

19. Domestic partner abuse • Subtle signs of violence • injuries inconsistent with story • glass fragments when “fell down stairs” • central pattern of injury • overattentive & guarded significant other • delay between injury & medical attention • uncommon injuries • fingernail scratches, bite marks, cigarette burns, rope burns

20. Domestic partner abuse • Injury rate • 2-4 million women are battered each year in the US • Injury rates ~equal for men • Arrest rates: male >> female • does this indicate that battery by males is more serious? • or are females more likely to report & seek medical attention? Tolan et al. (2006). “Family Violence.” Annual Review of Psychology.

21. Domestic partner abuse • Characteristics of abuser • from all religious, racial, cultural, demographic backgrounds • no particular DSM diagnosis is more common • but much more common in patients with DSM diagnosis • most share the desire to use force to control partner • have higher rates of denial • Risk factors for abuse • Hx prior aggression, hx of being violent victim • low impulse control, low self-esteem • relationship with lots of conflict

22. Domestic partner abuse • Characteristics of battered women • more commonly reported by women of color, poor women • occurs in all SES classes • women generally cut off from family & friends, money • may also stay to protect children or pets • If not diagnosed • typically leads to multiple visits to clinicians • however, reluctant to tell • so, can result in misleading psych diagnoses • or unneeded psych meds!

23. Role of the physician • Interventions • assess safety at home before discharge • assess potential for suicide/homicide • if not safe, separation into shelters is common first step • education about community resources is key • law enforcement not always helpful • especially if abuser arrested only for short while • if victim presses charges, more likely to be safe from further violence than arrest without warrant Tintinalli, et al. (2000). Emergency medicine: A comprehensive study guide.

24. Role of the physician • Treatment goals • safety of patient should be first priority • education is next priority • patient herself must make the decision to leave • if “getting her to a shelter” or “having him arrested” is goal, you will become frustrated • instead assure patient that help is available & she is not alone • couples/marital counseling often extremely effective

25. Rape • Definition • considered by much of the public to be a grown man overpowering an adult woman for sex • legal definition: nonconsensual penetration of a body orifice • often has more to do with power than sex • defined in Illinois as “Criminal Sexual Assault” • includes unwanted sexual touching, with degrees according to the amount of force used • makes no reference to gender • can be any mode of touching

26. Rape • Legal considerations • not required to prove that woman resisted • just that sex was nonconsensual • “state of mind” therefore becomes area of interest • previous sexual activity is not admissible (“rape shield” laws) • consenting to go on a date ≠ sexual consent

27. Rape • Prevalence • women aged 16-24 are at greatest risk of rape • in anonymous surveys, up to 50% of college women report some sort of unwanted activity • 15-27% report history of rape • 74%-95% committed by someone known to victim • often associated with alcohol

28. Rape • Characteristics • rapists are usually males < 25 years • usually known to victim • often use alcohol or other substances • have a desire to use power against a woman • are not primarily motivated by sex

29. Rape • Sequelae for rape victim • commonly involve emotional problems • commonly involve blaming the victim • DSM disorders include PTSD • perhaps as consequence, ~25% of rapes are reported to police • less in date rape

30. PTSD • Characteristic symptoms following exposure to traumatic event • involves actual or threatened death or serious injury • patient’s response must involve intense fear & horror • include military combat, assault, kidnapping, terrorist attack, being taken hostage, civil war, catastrophic disasters, etc. • lifetime prevalence ~8% • highest rates (33%-50%) found among rape survivors, military combat & captivity, genocide

31. DSM-IV definition of PTSD • The person has been exposed to a traumatic event in which both of the following were present: 1. person experienced an event that involved actual or threatened death or serious injury; 2. person’s response involved intense fear, helplessness, or horror. B. The traumatic event is continually reexperienced in one or more ways: 1. distressing recollections of the event 2. distressing dreams of the event 3. reliving the event 4. distress at exposure to cues that symbolize an aspect of the event 5. physiologic reactivity on exposure to such cues

32. DSM-IV definition of PTSD C. Persistent avoidance of stimuli associated with the event includes: efforts to avoid thoughts & feelings of the event; efforts to avoid activities that arouse recollections of the event; inability to recall an aspect of the trauma; diminished interest in significant activities; feeling of detachment from others; restricted range of affect; sense of shortened future. D. Persistent symptoms of increased arousal includes: difficulty falling or staying asleep; irritability; difficulty concentrating; hypervigilance; exaggerated startle response E. Duration of symptoms in B, C, D is > 1 month F. Disturbance causes distress or impairment in social, occupational, or important area of functioning.

33. Rape • Role of physician • conduct sensitive but thorough exam • must be supportive, not question patient’s judgment or truthfulness • must look for signs of injury • generally treat prophylactically for STDs

34. Determinants of aggression & abuse • Biologic • androgens associated with violence • males > females in aggression • homicide of strangers is almost exclusively men • Androgenic steroids taken by bodybuilders can cause increased aggression • other brain abnormalities also associated with violence • include high epinephrine, low serotonin • brain injury

35. Determinants of aggression & abuse • Psychological • Substance abuse/dependence is related to increased violence • Presence of one form of abuse in household increases risk for others • Across studies, 41% co-occurrence of child maltreatment & domestic violence • Maltreatment in childhood = powerful predictor of domestic violence • modeling?

36. Determinants of aggression & abuse • Psychological determinants of child abuse (from Dr. Rosengren’s lecture) • Abusers generally have unrealistic expectations, low self-esteem, low empathy towards child, poor impulse control, social isolation • Child may be perceived as “slow” or “different,” be fussy, premature

37. Determinants of aggression & abuse • Sociological • Child maltreatment & domestic violence more prevalent in low SES • may reflect limited personal/community resources • Child maltreatment & domestic violence more prevalent in social isolation • adequate social support lowers risk

38. A clinical vignette… A 21 year-old college student who has a 3 year-old child comes to the ED and reports that she was raped by a man she was on a date with 2 nights ago. The physical exam shows no physical evidence of rape (ie, no injuries, no semen). She appears anxious, disheveled, and “spacey” in general. She has restricted affect and a sense of a shortened future. It is most likely that this woman: • is delusional, and should be questioned about other paranoid thoughts • is malingering or “faking,” and should be warned about using hospital resources that could help other needy patients • is a hypochondriac, and should be referred to a psychiatrist • is suffering from a physical manifestation of a mental illness, and should be referred to a psychiatrist or a therapist • has been raped and that the rapist used a condom, and so should be referred to the rape crisis center