Transcript 22 Aggression & Abuse -- Wilson 2006

Aggression & Abuse
Michael Wilson, PhD
University of Illinois Department of Psychology
and
University of Illinois College of Medicine
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:
A.
B.
C.
D.
E.
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
Outline
• Child maltreatment
– physical abuse covered in Rosengren lecture
• Domestic violence
• Rape
• Determinants of aggression & abuse
Child maltreatment
• Types of maltreatment
– physical abuse
– sexual abuse
– emotional/physical neglect
• Abuse-related injuries
– must be differentiated from injuries during normal
activity
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
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
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
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
slide courtesy of Dr. Karl Rosengren
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
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
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
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
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.
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
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
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
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
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
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.
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
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!
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.
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
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
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
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
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
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
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
DSM-IV definition of PTSD
A.
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
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.
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
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
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?
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
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
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:
A.
B.
C.
D.
E.
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