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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 16-21

A cross-sectional study of intimate partner violence, adverse childhood experiences, and psychiatric morbidity in females with mental illness at a tertiary hospital


Department of Psychiatry, Institute of Mental Health, Osmania Medical College, Hyderabad, India

Date of Submission12-May-2021
Date of Acceptance13-May-2021
Date of Web Publication18-Jul-2021

Correspondence Address:
Dr. Sanchita Gour
Department of Psychiatry, Institute of Mental Health, Osmania Medical College, Hyderabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjp.tjp_21_21

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  Abstract 


Background: Intimate partner violence (IPV) has an adverse effect on the mental health of women. Sparse literature is available on IPV in women with mental illness.
Aims and Objectives: This study was carried out to assess the proportion of IPV, its correlation with sociodemographic factors, and its association with adverse childhood experiences.
Materials and Methods: The study was cross-sectional. Convenient sampling technique was used to collect the sample. Remitted female patients were assessed on the Abuse Assessment screen and Adverse Childhood Experiences Scale. Semi-structured intake pro forma was used to enter sociodemographic details and diagnosis (as per International classification of diseases-10). Data were analyzed using SPSS V.22.
Results: Proportion of IPV among female study subjects were found to be 67.14%. IPV was found to be more among subjects who were unmarried, single, divorced, those who had borderline, histrionic traits, and those whose partners were dependent on alcohol. IPV showed a positive correlation with adverse childhood experiences. Study subjects who showed more ACE showed a positive correlation with a family history of substance abuse, suicide attempts, and histrionic and borderline personality traits
Conclusion: IPV was high among patients with mental illness. Risk is high if the partner has alcohol dependence syndrome. Marriage was found to be protective against IPV. Prevention and intervention programs and marital counseling should be directed toward the assessment and treatment of IPV among females with psychiatric disorders.

Keywords: Adverse childhood experiences, intimate partner violence, prevalence


How to cite this article:
Gour S, Rao SS. A cross-sectional study of intimate partner violence, adverse childhood experiences, and psychiatric morbidity in females with mental illness at a tertiary hospital. Telangana J Psychiatry 2021;7:16-21

How to cite this URL:
Gour S, Rao SS. A cross-sectional study of intimate partner violence, adverse childhood experiences, and psychiatric morbidity in females with mental illness at a tertiary hospital. Telangana J Psychiatry [serial online] 2021 [cited 2021 Oct 23];7:16-21. Available from: http://www.:tjpipstsb.org/text.asp?2021/7/1/16/321769




  Introduction Top


Intimate partner violence (IPV)[1] is a big public health and social problem across both developed and developing countries. It includes physical, sexual, and emotional abuse and controlling behaviors causing harm by an intimate partner (WHO 2010). It covers violence by both current and former spouses and intimate partners. It is any behavior within an intimate relationship (married, unmarried, and live in). Several factors are known to increase the risk of IPV among women in the hands of their partners [Table 1].
Table 1: Risk factors for perpetuation of intimate partner violence[2],[3],[4],[5],[6],[7]

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On the contrary, there are some factors which appear to offer some protection against IPV [Table 2].
Table 2: Protective factors for intimate partner violence

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IPV needs to be differentiated from domestic violence.[8] Domestic violence refers to physical, sexual and emotional maltreatment of one family member by another (APA 1996). It includes all types of family violence, elder abuse, child abuse, and marital rape, whereas IPV is aggressive and limited to an intimate partner. There are substantial evidence and growing body of literature over the past two decades, suggesting that IPV may lead to a wide range of both short-term and long-term physical, mental, and sexual problems. Consequences[9],[10] of IPV include:

  1. Denial of fundamental human rights and undermining of development goals
  2. Health consequences – high levels of depression, anxiety, phobias, suicide risk, alcohol and drug abuse, eating and sleep disorders, physical inactivity, posttraumatic stress disorder (PTSD), smoking, self-harm, unsafe sexual behavior, physical injuries, and bruises. Sexual assaults lead to unwanted pregnancies, complications, and illegal abortions
  3. High incidence of stress and functional disorders – Inflammatory bowel disease, fibromyalgia, gastrointestinal symptoms, and chronic pain syndromes
  4. Impact on children – Children who witness violence, become victims, and perpetrators when they grow up. They have difficulty in forming trusting bonds, use violence as a legitimate method of resolving conflicts, and accept violence more easily
  5. Socioeconomic costs of violence – Included direct and indirect costs of medical, legal, and community system involved in prevention, detection, and management of IPV.


Epidemiology

The prevalence of physical violence on females by partners was found to be 13%–16%, 6%–59% experienced sexual violence, and 20%–75% reported lifetime emotionally abusive act (WHO Multicentric Study).[11],[12],[13] The lifetime prevalence of IPV was 37.7% combined IPV and nonpartner sexual violence in South East Asia was 40.2%, Europe: 27.2%, and India: 42%. The prevalence of IPV varies depending on the setting. It was found to be the least in population studies – 0.98%–7.7%, it was 11.4%–44% in community, and 70.8% among UG students.[11]

Adverse childhood experiences

According to Centre for disease control (CDC), they are potentially traumatic events that occur in childhood (0–17 years) – experiencing or witnessing violence or abuse as a child in the home or community or having a family member attempt or die by suicide.[14]

Review of literature

Longitudinal studies on domestic violence have found a bidirectional relationship between IPV and psychiatric morbidity (This study found adolescents with psychiatric disorders were more likely to get involved in abusive relationships and vice versa).[14] Indian studies[15],[16] have found variable prevalence of IPV among females depending on setting – 16% (community sample), 50% (urban health centers), and 56% (rescue homes). Psychiatric morbidity among victims of IPV – 58% had depression and 12% PTSD. The sociodemographic correlates associated with increased risk of IPV were alcohol abuse among partner, family history of domestic violence, aggressive partner, unequal income, and unequal education among partners. Increased age of marriage and support from in-laws was found to be protective against IPV.[17],[18] Early adverse childhood experiences, current life stress, and low income of partners correlated with IPV among partners.[19]

  • Thus, we can see that women who have lived with violent partners or women who have experienced IPV are more likely to experience psychological problems suchas depression, PTSD, suicidal ideation, and physical symptoms than other women. According to a review,[20] there was a direct link between childhood trauma and adult onset of chronic diseases such as depression, suicide, being violent, and a victim of violence. Thus, this study was taken up to study the proportion of IPV and its correlates among a sample taken from a tertiary hospital.


Aims of the study

  • To estimate the proportion of IPV against female subjects in remission by intimate partners
  • To assess the association between IPV and psychiatric disorders and sociodemographic factors
  • To study the association between adverse childhood experiences and risk of IPV.


Procedure

Ethics committee approval was obtained before carrying out the study from Osmania Medical College, Institutional Ethics Committee. Permission was obtained from hospital authorities before carrying out the study. A cross-sectional study was done on 70 female patients with mental illness in a tertiary care center of Hyderabad. The study was carried out in between February 1 and March 31, 2020. A convenient sampling technique was used for the selection of study subjects. Written informed consent was obtained from all female patients before carrying out the study. Remitted subjects were taken up for study (CGI-S score less than or equal to 2). Abuse Assessment Screen (AAS) was used. Those who answered yes for one question were considered positive for IPV. Similarly, subjects who gave NO as the response for all five questions were considered negative for IPV. Both the groups were required to answer questions pertaining to their sociodemographic, educational, and personal details as part of the intake pro forma. The diagnosis was made and noted down according to the International classification of diseases-10 criteria. The Adverse Childhood Experiences Scale (ACES) was applied to both these groups. The results were computed and analyzed using the SPSS V 22 software.

Inclusion criteria

  • Female patients aged 18–45 years in remission stage who consented for the study
  • Those who were either married/divorced/separated/live-in relationship
  • Compulsorily have an attendant with them.


Exclusion criteria

Those with epilepsy, mental retardation, significant head injury, and those in delirium or agitated state.

Scales

  • Abuse Assessment Scale (AAS)[21] – This scale was developed by Judith McFarlene in 1992. It consists of five items to assess the frequency and perpetrator of physical, sexual, and emotional abuse. It is a clinician-administered scale. If any question is answered affirmatively, the AAS is considered positive for abuse
  • ACES[22] – Developed in 1985 by Dr Vincenti Felitti to help identify childhood abuse, neglect, and family dysfunction. Possible scores were 0–10. With ACE score of 4 or more increases the likelihood of chronic diseases, suicide and depression enormously
  • CGI-S Scale[23] – Clinical Global Improvement Scale (Severity) used to assess the severity of illness. Clinician-rated scale based on how ill the patient is at the time of interview on a seven-point scale. Rating is based upon the observed and reported symptoms, behavior within the past 7 days.



  Results Top


Statistical analysis was done using SPSS V22. Descriptive data were analyzed using percentage and means. Analytical data were analyzed using Kendall's tau coefficient. P value was set at 0.05.

A total of 70 female subjects [Figure 1] participated in our study, out of which 47 (67.14%) study subjects experienced IPV. Majority (80%) of the study subjects were in the age group of 14–24 years, 48.6% of them were employed, 31.4% were educated up to school, and 40% up to college. The mean age at marriage of study subjects was 22.46 years ± 7.182 standard deviation. Sixty-eight percent of study subjects belonged to low socioeconomic status, 48.57% were married, 45% hailing from rural background, and 51.4% were housewives.
Figure 1: IPV and Psychiatric Diagnosis

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IPV was found to be more among separated, divorced, live-in relationships, and unmarried status than in those who were married [Table 3]. The association was statistically significant (P = 0.006). About 68.75% of study subjects facing IPV belonged to low socioeconomic status.
Table 3: Association between intimate partner violence and marital status

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IPV was associated with a number of suicide attempts [Table 4] (74.5% of subjects with IPV had a suicide attempt), the association between IPV and suicide attempts was statistically significant (P = 0.005).
Table 4: Association between intimate partner violence and number of suicide attempts

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Partners of study subjects who were addicted to alcohol were more likely to inflict IPV. Seventy-seven percent of those who suffered from IPV had partners who were dependent on alcohol (P = ‒0.084). Proportion of alcohol dependence among partners was 44% (31 out of 70). Eighty-three percent of study subjects had habit of consuming alcohol, 17% were addicted to alcohol. About 48.93% of study subjects facing IPV had a family history of substance abuse, the association was not statistically significant.

A statistically significant correlation (Kendall tau b coefficient = 0.235; significant at 0.001 level 2 tailed).

A statistically significant correlation was found between ACES and number of suicide attempts (Kendall tau b coefficient = 0.389; significant at 0.01 level (two tailed).

A statistically significant correlation was found between ACES and personality traits was found to be significant at 0.001 level (two tailed); Kendall tau b coefficient = 0.343.

A statistically significant correlation was found between IPV and ACES (Kendall tau b = 0.450; significant at 0.01 level) [Table 5].
Table 5: Correlation between Adverse Childhood Experiences Scale and intimate partner violence

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  Discussion Top


Lifetime IPV of female study subjects as per our study was found to be 67.14%. Indian studies (Ramadugu study) done in community sample found that 16% of women experienced IPV in the past year. Our study found a higher prevalence as it was done on psychiatric patients at a tertiary centere hailing from rural and urban background. Another Indian study (Kevi Fernandez, 17) of patients attending the outpatient department (OPD) of an urban health training center found the prevalence of IPV to be 50%. Another reason for the high prevalence of IPV in our sample could be due to the fact that we assessed lifetime prevalence. Most of the partners confess that reasons for inflicting violence on their partners were because of their psychopathology, resisting treatment, poor personal care, or disruptive behavior. Our study is in line with a study done in NIMHANS[18] OPD, which found that 56% of women reported IPV.

The most recent Indian Survey NFHS 4[24] Report has been released in December 2019, a nationally representative survey of women of Telangana state estimated that 42.7% of women had experienced physical violence by current and former spouses (lifetime) and 34% experienced it in the past 1 year. Studies from Turkey and China[25] on the general population reported in a nationally represented sample found the prevalence of IPV as 15%–16%.

Of all sociodemographic factors, our study found a statistically significant association between marital status and IPV. Our study findings showed that being married or involved in formal marriage had a protective effect, whereas divorce, unmarried and in live-in, multiple marriages, and separated were associated with risk of IPV, in line with the WHO Multi-centric study.[10]

IPV was more prevalent among schizophrenic subjects (27.65%). IPV may be a cause or consequence of schizophrenia; as many times, partners claim to have abused patients in view of ignorance. Mental disorders among women study subjects and substance abuse disorder among their partner are associated with increased risk of IPV. About 10.63% (5 out of 47) of subjects in IPV group were found to have depression in our study. A Chinese study done on abused women showed 74.5% reported severe depression. In an Indian study done on consecutive women attending adult psychiatry OPD of NIMHANS (105 sample), 59 (56%) reported with a history of IPV, 14% showed PTSD. Majority of those reporting IPV showed depressive features. Our study is not in line with existing literature, as ours is a tertiary care hospital, schizophrenia is the most prevalent condition at our center. Our study found that 74.5% of study subjects with IPV had a history of suicide attempt in the past.

Our study also found a statistically significant correlation between IPV and personality traits (Borderline, Histrionic).

Adverse Childhood Experiences and IPV – Our study found a positive correlation between ACE and IPV [Table 4], presence of ACE increased the risk of IPV. Female subjects who experienced adverse childhood experiences were more likely to place themselves in vulnerable positions and allow their partners to abuse them. Among ACE, being brought up in a background where domestic violence was highly prevalent, study subjects might have thought, and their partners abusing them is justified. In NMHS study, Telangana community sample found 44% of married women, 40% of unmarried women thought their husbands are justified in beating and hitting them.

ACE and personality traits – Our study found that as the number of adverse childhood experiences increases, it was more associated with psychological problems like personality issues and suicide attempts. Our study is in line with an ACE study[20] which concluded that ACE score increases the risk of depression, adult alcohol abuse, domestic violence, suicide, and emotional problems.


  Conclusion Top


Proportion of IPV among female study subjects was found to be 67.14%.

IPV was found to be more among subjects who were unmarried, single, divorced, or in live-in relationships. Unstable marital relationship was found to be a risk factor for IPV as per our study.

Subjects who had borderline, histrionic personality traits were associated with an increased risk of IPV.

Study subjects who had partners who were habituated to alcohol were more likely to inflict IPV (association was not statistically significant).

IPV showed a positive correlation with adverse childhood experiences.

Study subjects who faced more ACE during their childhood showed a positive correlation with a family history of substance abuse [Table 6], suicide attempts [Table 7], and histrionic and borderline personality traits [Table 8] (higher the ACES, more is the risk of psychological problems).
Table 6: Correlation between Adverse Childhood Experiences Scale and family history of substance abuse

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Table 7: Correlation between Adverse Childhood Experiences Scale and no of suicide attempts

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Table 8: Correlation between Adverse Childhood Experiences Scale and personality traits

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Drawbacks

  • No control group
  • Size of the sample was small (70)
  • Study was cross-sectional in design. Whether IPV is a cause or consequence of mental illness could not be established.


Implications

  • We found that borderline and histrionic personality traits, several mental disorders among study subjects were associated with increased risk of IPV. The risk is also elevated if there are substance use disorders among their partners
  • Prevention and intervention programs should be directed toward assessment and treatment of IPV among individuals with psychiatric disorders – marital counseling, early diagnosis, and management of psychiatric disorders and follow-up
  • To reduce IPV against women, modifiable risk factors need to be addressed.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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