Intimate Partner Violence Among Women With Severe Mental Illness

The term "intimate partner violence" (IPV) is defined as physical or sexual violence between spouses and former spouses, and violence within heterosexual and homosexual dating relationships. IPV is broader and better encompasses the issue than the former term, "domestic violence."Recent national statistics indicate that 20% of violent crimes committed against women were by intimate partners.¹ The estimated US lifetime prevalence of assault by an intimate partner ranges from 9% to 30%.^2-7

The association between IPV and posttraumatic stress disorder (PTSD), depression, and substance use disorders is well established.^8-10 Although primary care, obstetrics, and emergency department physicians should also look for signs,^11-14 IPV is particularly relevant to psychiatric practice.

Scope of the problem Women with severe mental illness, including mood and psychotic disorders, appear to have elevated risks of being both victims and perpetrators of IPV. Pregnancy is already a potentially difficult time in the context of mental illness and may put women at increased risk for becoming vic-tims of IPV.¹⁵ A history of childhood abuse, which is relatively common in this population, may further elevate this risk. Risk of victimization may be mediated by concomitant impairments in judgment, reality testing, and planning.¹⁶

In addition, women may have difficulty in determining whether physical closeness is assaultiveness or intimacy.¹⁷ Studies indicate that as many as half of married female psychiatric inpatients who have severe mental illnesses are victims of IPV; outpa-tient rates are similar.^18-20 One fifth to more than half of female psychiatric patients may be victims of marital rape.^21,22

Psychiatrists and IPV
Symptoms of mental illness may worsen with victimization.²³ Physical abuse may even precipitate a suicide attempt.^24-26 Women who are victims of IPV may appear paranoid to clinicians, and Minnesota Multiphasic Personality Inventory-2 profiles of abused women are similar to profiles of inpatients with schizophrenia and borderline personality disorder.²⁷ PTSD in women who have serious mental illnesses often remains undetected by psychiatrists.

Obtaining information on the existence, nature, and extent of abuse is important, not only for proper diagnosis but also for safety planning, medication management, and discharge planning. However, many women do not report victimization to clinicians.^28,29 Although IPV victimization is more common than the presentation of many psychiatric symptoms about which psychiatrists ask, it often goes undetected by psychiatrists.^30,31

It is thus critical that clinicians ascertain the existence of partner abuse. A discussion about decision making within relationships can be used to broach this topic,²⁹ or normalizing statements about the frequency of victimization can be used to open a discussion.¹⁸ Women can be asked about fears of being hurt by their partners, or they can be asked directly about abuse. Abuse screening measures have also been developed.³²

Knowledge of IPV can aid in making choices within both pharmacotherapy and psychotherapy. For example, certain medications could decrease a woman's ability to respond in dangerous situations or to escape.³³ Issues in psychotherapy may include mistrust, emotional isolation, and self-esteem impairments²⁸; role-playing may be useful in eliciting these issues.³⁴

IPV, psychiatrists, and the law
Psychiatrists should have some knowledge about shelters, services, and legal options, or have someone to whom they can refer patients for those issues. A woman's decision about leaving a relationship is not to be made lightly. Separation represents the point of greatest risk of harm.³⁵ The victim may be ambivalent, fear for her children, fear retaliation, or have financial difficulties. Civil protection orders (also known as restraining orders) are violated in approximately 40% of cases and may not be an appropriate remedy.³⁶ Fewer than half of IPV incidents are reported, and IPV offenders are arrested in only 5% to 36% of cases.³⁵ Furthermore, more than a quarter of offenders who are arrested re-assault before trial.³⁵

Women with mental illnesses may exhibit violent behavior toward their partners. One fifth of women in an inpatient sample had engaged in IPV against their partners.²⁰ More research is needed on risk and protective factors, as well as underlying motives, which can range from paranoia to anger to self-defense.

"Battered women's syndrome" (BWS) is a term used in the legal arena, specifically for women who kill their abusers. However, it is not a syndrome in DSM. Scholars have criticized BWS as a legal construct that is used only in self-defense partner-murder cases rather than to describe a medical syndrome. In addition, the label suggests pathology in the victim. Finally, since there is no agreed-on definition of BWS, it may be falsely implied that a diagnosis of PTSD is required for a woman to have killed her abuser in self-defense.³⁷

Expert testimony on battered women has been allowed in courtrooms in the United States since Ibn-Tamas v United States in 1979,³⁸ and it is also used in Canada, Australia, New Zealand, and the United Kingdom.^39,40 The expert may be helpful in providing a context for the woman's violence; the impact of the abusive relationship; the learned helplessness model; the patterns or cyclicity of violence, including the potential contrition phase; the use of excessive force; and the woman's belief in the reasonableness of her actions.^37,39 However, the expert must use caution not to mislead the court, because these are not the only patterns of violence or profiles of victims.

In conclusion, as psychiatrists, we are in a potentially opportune position to be aware of IPV among women with mental illnesses and to make a difference in their lives.