Clinical Picture of Abuse and Violence

Abuse: wrongful use, maltreatment of another Perpetrator typically someone the person knows Victims across lifespan: spouses, partners, children,

elders Evidence of physical injuries requiring medical attention Psychological injuries with broad range of responses

Characteristics of Violent Families

Family violence: spouse battering, neglect and physical,

emotional or sexual abuse of children, elder abuse, marital rape Common characteristics regardless of type of abuse (Box 11.1)
Social isolation Abuse of power, control Alcohol, other drug abuse Intergenerational transmission process

Cultural Considerations
Domestic violence spanning families of all ages and

from all ethnic, racial, religious, socioeconomic, sexual orientation backgrounds Battered immigrant women at particular risk
Facing increased legal, social, economic barriers

Intimate Partner Violence

Mistreatment or misuse of one person by another in

context of emotionally intimate relationship Emotional or psychological: name calling, belittling, screaming, yelling, destroying property, threatening, refusing to speak to or ignoring victim

Intimate Partner Violence (contd)

Physical: shoving, pushing, battering, choking
Sexual: assaults during sexual relations, rape Combination (common) Victims: primarily women (increased rates during

pregnancy)

Intimate Partner Violence (contd)

Prevalence in same-sex relationships as in

heterosexual relationships; victims with fewer protections Often perpetrated by husband against wife

Intimate Partner Violence (contd)

Clinical picture Abusers view of wife as belonging to him; strong feelings of inadequacy, low self-esteem; poor problem solving and social Increasing violence, abuse with any signs of independence Victim commonly dependent; viewed as unable to function without husband

Intimate Partner Violence (contd)

Cycle of abuse and violence Violent episode honeymoon phase tensionbuilding violent episode

Intimate Partner Violence (contd)

Identification important; victims commonly not

seeking direct help for problems Screening/assessment: SAFE (Box 11.2)

Stress/safety Afraid/abused Friends/family Emergency plan

Appropriate techniques (Table 11.1)

Question
Tell whether the following statement is true or false: The honeymoon phase of violence often occurs before the

first episode of violence.

Answer
False
The honeymoon phase occurs after an episode of

violence in which the abuser expresses regret, and then apologizes and promises it will never happen again.

Intimate Partner Violence (contd)

Treatment and interventions Laws related to domestic violence; arrest Restraining order/civil orders of protection Shelters Individual psychotherapy/counseling, group therapy, support and self-help groups Treatment for possible PTSD

Child Abuse
Intentional injury of a child Physical abuse or injuries Neglect or failure to prevent harm Failure to provide adequate physical or emotional care or supervision Abandonment Sexual assault or intrusion Overt torture or maiming

Child Abuse (contd)

Clinical picture of parents Minimal parenting knowledge, skills Emotionally immature, needy, incapable of meeting own needs View children as property Cycle of family violence: adults raising children in same way they were raised (adults as victims of abuse frequently abuse their own children)

Child Abuse (contd)

Identification important (Box 11.3)
Report suspected child abuse Treatment and intervention Child safety, well-being a priority Psychiatric evaluation/possible long-term therapy/play therapy (for very young child) Family therapy if reuniting feasible Psychiatric or substance abuse for parents Foster care (short- or long-term)

Elder Abuse
Maltreatment of older adults Physical, sexual, psychological abuse or neglect Self-neglect Financial exploitation Denial of adequate medical treatment 60% perpetrators spouses, 20% adult children, 20%

others

Elder Abuse (contd)

People who abuse elders almost always in caretaker

role or elders depend on them in some way Elders often reluctant to report abuse due to fear of alternative (nursing home) Clinical picture: variable depending on type of abuse

Elder Abuse (contd)

Assessment (potential indicators, Box 11.4)
Treatment and intervention Caregiver stress relief Additional resources Possible removal of elder or caregiver

Question
Tell whether the following statement is true or false:
Adults who were abused as children are more likely to

abuse their own children.

Answer
True
The tendency for adults to raise children in the same

way they were raised perpetrates the cycle of family violence. Adults who were victims of abuse as children frequently abuse their own children.

Rape and Sexual Assault

Crime of violence, humiliation of victim expressed

through sexual means Perpetration of act of sexual intercourse with female against her will and without consent
Whether will is overcome by force, fear of force, drugs,

or intoxicants

Rape and Sexual Assault (contd)

Also considered rape if woman incapable of exercising

rational judgment because of mental deficiency or when younger than age of consent
Only slight penetration of vulva needed (full

erection/ejaculation not necessary)

Rape and Sexual Assault (contd)

Strangers (approximately 50% of rapes),

acquaintances, married people, people of same sex Date rape (acquaintance rape) Highly underreported crime Most commonly occurring in womans neighborhood, often inside or near home

Rape and Sexual Assault (contd)

Most rapes premeditated
Male rape significantly underreported

Rape and Sexual Assault (contd)

Four categories of male rapists Sexual sadists (aroused by victims pain) Exploitive predators (impulsive use of victims for own gratification) Inadequate men (belief that no woman would voluntarily have sexual relations with them; obsessed with fantasies about sex) Men for whom rape is displaced expression of anger, rage

Rape and Sexual Assault (contd)

Feminist theory: women historically objects for

aggression Severe physical, psychological trauma

Medical problems

Rape and Sexual Assault (contd)

Severe physical, psychological trauma Psychological problems

Fear, helplessness, shock, disbelief, guilt, humiliation, embarrassment Avoidance of places or circumstances of rape; loss of previously pleasurable activities Depression, anxiety, PTSD, sexual dysfunction, insomnia, impaired memory, suicidal thoughts

Myths, misunderstandings (Box 11.5)

Rape and Sexual Assault (contd)

Assessment: Physical examination; preservation of evidence (rape kit/rape protocol) Description of what happened Treatment and intervention Immediate support Education (Box 11.6) Prophylactic treatment of STIs, pregnancy Therapy to restore victims sense of control

Community Violence
School violence (homicides, suicides, theft, violent

crimes) Bullying Hazing Effects on children, young adults Violence on larger scale (i.e., terrorism) Early intervention, treatment for victims

Question
Which of the following statements about rape is most

accurate? A.It is a highly reported crime. B.Most rapes are premeditated. C.Rape requires ejaculation. D.Provocative dress invites rape.

Answer
B. Most rapes are premeditated.

Most rapes are premeditated.

Rape, an underreported crime, requires only slight

penetration of the vulva. Full erection or ejaculation are not necessary. Provocative dress leading to rape is a myth.

Psychiatric Disorders Related to Abuse and Violence

Posttraumatic stress disorder (PTSD) Dissociative disorders

PTSD
Disturbing behavior due to exposure to traumatic

event (natural disaster, combat, assault) at least 3 months after trauma occurred Three clusters of symptoms
Reliving event
Avoiding reminders of event Being on guard or experiencing hyperarousal

PTSD (contd)
Occurrence at any age Severity, duration of trauma and proximity of person to

event as most important factors

Dissociative Disorders
Dissociation: subconscious defense mechanism used

to protect emotional self from recognizing full impact of some horrific or traumatic event by allowing mind to forget or remove itself from painful situation or memory Occurrence both during and after event
Easier with repeated use

Dissociative Disorders (contd)

Dissociative disorders: disruption in usually integrated

functions of consciousness, memory, identity, environmental perception

Dissociative amnesia

Dissociative fugue
Dissociative identity disorder ([DID] formerly multiple

personality disorder) Depersonalization disorder

PTSD and Dissociative Disorders

Treatment and intervention Community-based group or individual therapy Cognitive behavioral therapy Pharmacologic treatment

Paroxetine, sertraline for PTSD Symptomatic treatment for dissociative disorders (antianxiety agents, antidepressants)

The Nursing Process: Assessment

History of trauma or abuse
General appearance, motor behavior Hyperalertness, anxiety, agitation Mood, affect Wide-ranging emotions from passivity to anger Thought processes, content Nightmare, flashbacks, destructive thoughts or impulses

The Nursing Process: Assessment (contd)

Sensorium, intellectual processes Disorientation [during flashbacks], memory gaps Judgment, insight Impaired decision-making, problem-solving abilities Self-concept Low self-esteem

The Nursing Process: Assessment (contd)

Roles, relationships Problems with relationships, work, authority figures Physiologic considerations Difficulty sleeping, under- or overeating, use of alcohol or drugs for self-medication

Question
Tell whether the following statement is true or false: For the diagnosis of PTSD, the symptoms occur usually

within 1 month of the trauma.

Answer
False
For the diagnosis of PTSD, the symptoms occur at least

3 months after the trauma.

A diagnosis of acute stress disorder is appropriate when

the symptoms appear within the first month after the trauma and do not persist for more than 4 weeks.

The Nursing Process: Data Analysis

Common nursing diagnoses Risk for self-mutilation Ineffective coping Posttrauma response Chronic low self-esteem Powerlessness

The Nursing Process: Outcome Identification

The client will Be physically safe Distinguish between self-harm ideas and taking action on those ideas Learn healthy ways to deal with stress Express emotions nondestructively Establish social support network in community

The Nursing Process: Intervention

Promoting clients safety
Helping client cope with stress, emotions using

grounding techniques Helping promote clients self-esteem Establishing social support

The Nursing Process: Evaluation

Outcomes possibly taking years to achieve Protection of self Ability to manage stress, emotions Ability to function in daily life

Self-Awareness Issues
Becoming comfortable asking all women about abuse

(SAFE questions) Listening to accounts of abuse from clients, families Recognizing clients strengths, not just problems Working with perpetrators of abuse; dealing with own feelings about abuse, violence