Violence and abuse

Definitions:

nFighting: physical or psychological aggression between presumably equally matched people

nAbuse: physical or psychological aggression or neglect of weaker or vulnerable people

§Children

§Elderly

nPredictive factors to be an abuser:

§Repeated school/ household changes as child

§ His parents frequently have history of

–criminal behavior

–Drug /alcohol abuse

§The abuser also was physically/sexually abused

§ As child was notorious of harming animals

§Low intelligence

§Trouble delaying gratification

§Neglectful parenting

§Previous display of aggression

§Poverty

nViolence is

§2^nd leading death cause in 15-24 year old group American whites

§1^st leading death cause in same age group Afro-Americans

nAggression

§Males display more aggressive behavior

§Higher level of androgens

§More man perpetrator and victim of crime

§Women homicide

§36 % murder the partner

§7 % only of all felony murder (crime)

§History of head injury

§EEG abnormalities

§Temporal lobe, frontal lobe, hypothalamus, prepiriform area, amygdala might be involved in aggressive behavior

nAggression – Neurochemistry

§Dopamine = increase

§GABA; serotonine = decrease

§Low serotonine and 5-HIAA level (deficit) in

–Violent people

–Violent suicide

§Substance abuse:

–Reduced aggression:

pOpiate/heroine users

pLSD users

pBZD & barbiturates: increase GABA – tend to decrease aggression

–Increased aggression

pCocaine: increase DA availability, precipitate combative behavior

pPhencyclidine (PCP)

nImpulse control disorders

nChronic and lifelong problem

n Subjectively increased tension before and relief or pleasure after the activity

Classification:

1.      Intermittent explosive disorder (IED)

2.      Pyromania

3.      Kleptomania (often associated with bulimia)

4.      Pathological gambling

5.      Trichotillomania

nIED (Inremittent Explosive Disorder):

–Attacks without adequate cause

–Not loss of touch with reality

–‘Soft’ neurological signs

–Differential diagnosis:

pSubstance abuse

pConduct disorder

pAntisocial PD

pDissociative disorder

n Probably present in every culture. If happens in conjunction with dissociative symptoms in different part of the world called:

·         Fugue

·         Amok (Southeast Asia)

·         Cathard (Polynesia)

·         Mal de pelea (Puerto Rico)

·         Caffard (North Africa)

·         Iich’s (Navajo)

n Recommended therapy of impulse control and aggressive disorders:  SSRI

Abuse & neglect

Types:

1.      Physical abuse

2.      Emotional and physical neglect

3.      Sexual abuse

A. Child abuse:

n“Typical” abused child has history of:

§Premature or low birth weight

§Hyperactivity

§Mild physical disability

§Colicky

n“Typical” abuser:

§ History of Substance abuse

§Poverty

§History of victimization

§Usually the mother or closest family member is the abuser

nTypical child abuse injuries:

§Shaken baby syndrome: Brain + eye hemorrhages

§Hidden surfaces by clothes

§Areas unlikely to be bruised in play

pButtock, lower back

pBruises NOT over bony surfaces

pBruises on an infant

pBelt or buckle shaped bruises

§Cigarette burns,

§burns by immersion into hot water with clear border

§Fractures

pMultiple fractures at different stages of healing

pSpiral fractures (twisting)

pBucket handle fractures (edge between meta & epiphysis)

§Ruptured spleen

§Wrist rope burns (tied)

§Petechiae (forced pressure)

§Neglect:

pMalnutrition, diaper rash, dirt

nSexual abuse of children

nEvidences of child sexual abuse

§Any type of STD

§Genital or anal trauma

§Recurrent urinary infections

§Specific knowledge about sexual act

§Excessive initiation of sexual games (doctor)

nPsychological sequelae

§Dissociative disorder

§Borderline personality disorder

§PTSD

§GAD

§Substance abuse

§Dyspareunia, vaginismus

§Violent, abusive behavior

–Most victims 8 – 13 y old

–25% younger than 8 y

–70 – 90 % committed by well known person

–Half committed by relatives, other half by other family acquaintances

–90 % of abusers are men

–Abused children do not report because fear of

–Withdrawal of affection

–Retribution

–Shame

–Inappropriate guilt

B. Abuse of elderly and sick

§  The “typical” abused elder

§Some degree of dementia

§Physical dependence on others

§Incontinent

§Does not report abuse; says “she felt down”

§  The “typical” abuser of an elder

§Has history of substance abuse

§Poverty

§Social isolation

§Usually the closest family member

§  Typical elder abuse injuries:

§Neglect

§Malnutrition, urine odor, lack of medication, dentures, eyeglasses

§Bilateral bruises on inner surface of arms (grabbed)

§Soft tissue bruises not above bony surfaces

§Cigarette and other burns

§Fractures @ different stages of healing

§Spiral fractures

§Internal injuries – ruptured spleen

§Rope burns

nDomestic violence:

§25% of women in EA visit are battered

§Dissimulation

§Irrational explanation for the injury

§Delay seeking treatment

§Depression

§If partner there, he might be overtly hostile and interfering with the doctor

§Occurs in cycles

§Spouse abuser likely to be child abuser

§Failure to report or leave the abusing partner

§Pregnant women at higher risk being abused

§Frequent history of miscarriage and pre-term labor

§Injuries on breast and abdomen

§Low self esteem or blames herself

nDuties of the physician:

§Suspected child and elder abuse MUST be reported

§No need to tell the victim he suspect abuse

§NO need for family consent to hospitalize abused person for care and protection

§In domestic abuse

§The abused person considered as competent

§The abused shall report to law enforcement officials

nRape

§Always crime never passion

§Victim shall NOT prove that she resisted

§Not admissible evidences

§Seductive clothing, previous sex activities, etc.

§Legal consideration:

§Sexual assault / aggravated sexual assault

§Sodomy

§Not necessary the presence of semen

§Even husband can be prosecuted raping his wife

§Date rape

§Statutory rape

§The victim younger tan 16 or 18 y (depending on state law) even if consensual the sex

§Mentally or physically disabled

§Sequels

§PTSD

§Most rape NOT reported

§Doctors role

§Detailed patient history and examination

§Doctor shall not report the case, but encourage the patient to report the case, because

§Patient considered competent

Case Studies

v  A 3-year-old girl with moderate mental retardation is brought to the clinic by her mother because she has been complaining that her arm hurts. On physical examination, the girl has several bruises on her thorax and a tender right forearm. On laboratory examination, you discover a normocytic, normochromic anemia and basophilic stippling. On x-ray, you find signs of multiple fractures of different ages and increased density at the metaphyseal plate of the growing long bones.

1. Which of the following is the most appropriatetreatment?

(A) edetate calcium disodium (CaEDTA)

(B) flumazenil (Romazicon)

(C) naloxone (Narcan)

(D) deferoxamine (Desferal)

(E) acetylcysteine (Mucomyst)

2. Which of the following is the most likely cause of this girl’s bruises?

(A) Thrombocytopenia

(B) Developmental coordination disorder

(C) Malnutrition

(D) Physical abuse

(E) Hepatic failure

1. (A) CaEDTA is a chelating agent used to treat lead toxicity. Flumazenil is used to reverse the sedating effects of excess benzodiazepines, and naloxone is used to reverse the effects of excess opiates. Deferoxamine is a chelating agent used to treat iron toxicity. Acetylcysteine is used to treat acetaminophen toxicity.

2. (D) The girl’s bruises are most likely the result of physical abuse, which is strongly suggested by the presence of multiple fractures of different ages. Thrombocytopenia and malnutrition are rare in the United States. In developmental coordination disorder, there is a delay in achieving major milestones and clumsiness, but there is not typically a pattern of repeated injury. Hepatic failure is extremely rare in a 3-year-old child.

v  A 6-year-old boy is brought to the emergency department by his mother, who reports that he was playing on some steps in front of the house when he slipped and fell. She tells you that she is concerned that he might have broken his arm. An x-ray of the boy’s arm shows a fracture of the ulna, as well as signs of several old fractures of varying ages. Which of the following is the most appropriate action?

(A) Refer the boy to an orthopedist for further evaluation.

(B) Tell the mother that you notice that the boy has had multiple broken bones and recommend that she limit the boy’s sports activities.

(C) Set the current broken bone in a cast and recommend that the boy see his pediatrician for follow-up care.

(D) Recommend calcium supplements and a multiple vitamin daily.

(E) Tell the boy that you notice that he has had multiple broken bones and ask him how each of these fractures happened.

(E) The finding of multiple fractures especially when they are of different ages is a red flag for physical abuse. Even though the boy may be scared to report what happened for fear of punishment, it is important to try to talk with him alone and find out as much as possible. It is not appropriate to refer the boy to an orthopedist or his pediatrician prior to investigating the possibility of physical abuse. Recommending limited sports or extra vitamins does not address the question of whether the boy is safe at home.

v  A38-year-old male refugee presents to the mental health clinic at the urging of his family members. While lived in his former hometown, he had witnessed a friend killed during an explosion. Since that time, he has had chronic insomnia with ongoing nightmares of the event as well as occasional flashbacks. He describes always being “on edge,” avoiding crowds, and becoming easily startled with loud noises. He admits to regular khat use, especially when his symptoms are worse. Which of the following is the most appropriate treatment to begin for this patient?

(A) atypical antipsychotic

(B) benzodiazepine

(C) lithium

(D) serotonin-specific reuptake inhibitor

(E) valproic acid

(D) This patient is suffering from symptoms of posttraumatic stress disorder (PTSD), an anxiety disorder consisting of reexperiencing symptoms (e.g., nightmares, flashbacks, intrusive thoughts), increased arousal (e.g., hyperstartle, hypervigilence, irritability), and avoidance/ numbing. The best studied and most efficacious medications are considered to be the SSRIs. Antipsychotics, including the atypicals, should not be used as monotherapy, although may be used in conjunction, especially if there are associated psychotic symptoms. Benzodiazepines should be avoided in this patient population not only because of the significant comorbidity with substance addiction but also as they have not been found to be particularly effective.

Mood stabilizers, such as lithium and valproic acid, occasionally are used in addition to SSRIs in order to target the mood lability or aggression sometimes seen in PTSD.