13. Adult abuse/Intimate partner abuse

Question 1

Describe: Domestic violence (6)

Answer 1

• Domestic violence = intentional controlling or violent behavior (physical, sexual, or emotional abuse, economic control, or social isolation of the victim) by a person who is/was in an intimate relationship with the victim
• The victim lives in a state of constant fear and is terrified about when the next episode of abuse will occur.
• Despite this, abuse frequently remains hidden and undiagnosed because patients often conceal that they are in abusive relationships.
• Abuse of power in a relationship involving domination, coercion, intimidation, and the victimization of one person by another
• Most spouse abuse: wife abuse (some abuse of husbands has been reported) 10% of women in a relationship with a man have experienced abuse.
• Of women presenting to a primary care clinic, almost one-third reported physical and verbal abuse.

Question 2

Name examples: Physical abuse (7)

Answer 2

• Pushing
• hitting
• biting
• burning
• locking out
• abandoning in an unsafe place
• resulting in pain, injury, sleep deprivation, disablement, and murder

Question 3

Name examples: Sexual abuse (6)

Answer 3

Forced unwanted sexual activity such as rape; sex with objects, friends, or animals. May also include demands to wear more provocative clothing, etc.

• Rape of wives
• Rape of women (may be associated with other crimes or nonsexual abuse)
• Sexual sadists
• Exploitive predators
• Men dealing with feelings of inadequacy
• Men with displaced expression of anger and rage

Question 4

Name examples: Emotional or Psychological abuse (6)

Answer 4

• Constant criticism
• threats to hurt, kill
• extreme jealousy
• denying friendships
• outside interests, or activities
• time accounting, etc.

Question 5

Name examples: Economic abuse (3)

Answer 5

• Not allowing money
• denying improvement in earning capacity
• detailed accounting of spending, etc.

Question 6

Name Preexisting vulnerabilities for abuse (5)

Answer 6

• Women/pregnant (trauma victims, chronic abdominal pain/headaches)
• Elders with injuries
• Children with injuries
• Head injuries
• Others (past violence, former victim of abuse, intellectual functioning, family and cultural influences, impulsivity)

Question 7

Name Psychiatric/Medical Disorders associated with abuse (14)

Answer 7

• Psychosis (e.g., delusions of persecutory or jealous types, command hallucinations)
• Substance-related (e.g., abuse/dependence, intoxication, withdrawal, substance induced–psychotic/mood/anxiety/cognitive disorders)
• PD (e.g., antisocial, borderline, narcissistic, paranoid)
• Mood disorders (e.g., manic phase of BP, agitated depression)
• Cognitive disorders (e.g., delirium, dementia)
• Attention Deficits (ADs) (e.g., OCD, generalized AD, social phobia)
• Attention-deficit and disruptive behavior disorders (e.g., ADH D, oppositional defiant disorder, conduct disorder)
• Pervasive developmental disorders/autistic spectrum disorders
• Developmental disability/mental retardation
• Impulse control disorders (e.g., intermittent explosive disorder)
• Medication-induced (e.g., akathisia)
• Other General Medical Condition (GMC) related (e.g., Huntington, neuropsychiatric SLE)
• Socioeconomic cultural factors
• Chronic medical conditions/disability

Question 8

Describe approach: Abuse (2)

Answer 8

• History of hyperalertness, sleeping or eating disturbances, fatigue, mood swings, phobias, somatization, exaggerated startle response
• Past experiences of sexual assault, family violence, or child sexual abuse

Question 9

Name general observations and physical exam: Abuse (5)

Answer 9

• Partner refuses to leave exam room and answers questions for the patients.
• Signs of imminent violence in partner: threats, paranoid ideas, yelling, pacing, agitated behavior
• Mental status exam: avoidance of eye contact/ fearfulness, evasive behavior, hostility, appears in distress/ psychomotor retardation, agitation (fidgeting, moving about, hand-wringing, nail biting, hair pulling, lip biting), restlessness/ depressed mood and flat restricted effect/ suicidal and or homicidal ideation, intent, plan
• Examine vital signs (tachycardia), pupils (drug-related), and skin for scars/wounds/ bruises, stigmata of drug and/or alcohol use, and weight loss (chronic suffering)
• Examine location of injuries (usually central, breasts, abdomen, genitals), forearm defensive wounds, bruises of different ages

Question 10

Name Investigations in violence (9)

Answer 10

• CBC: R/O anemia and/or infection
• Electrolytes: R/O electrolyte imbalance, dehydration, starvation
• Thyroid (TSH): R/O hyper- or hypothyroidism
• INR, PTT, coagulation status: R/O coagulopathy
• Toxicology/drug screen: Alcohol, Cannabis, Opioid, Amphetamine , Cocaine, Other stimulants
• Urinalysis: Drugs
• CXR: R/O fx
• Other x-ray: R/O limb fx
• CT: Headache to rule out brain lesions, masses, or hemorrhage

Question 11

Describe the management of violence (8)

Answer 11

• Determine immediate and short-term risk to victim
• Provide validation, support, and counseling
• Offer referral (e.g., hospital social worker, local domestic hotline, domestic violence advocates, institutional and community resources, specialists such as psychiatrists) to discuss options and safety issues and plans
• Educate patient about what to do in case of emergency and range of support services available
• Leave the room and obtain assistance from security or police if partner is violent
• Physician’s legal responsibility to report potential victims of violent patients only with patient’s consent because of patient–physician confidentiality
• Diagnose wife/husband abuse and assess the role in etiology of other health concerns; assess immediate and short-term risk to victim
• Determine whether the husband/wife comes from a violent home or was abused himself or herself, feels threatened at home, work, or with peers