Bellali N; Laboudi F; Ouanass A

Research Article

Austin J Psychiatry Behav Sci. 2019; 6(1): 1070.

Domestic Violence and Psychopathological Impact

Bellali N*, Laboudi F and Ouanass A

¹Arrazi University Psychiatric Hospital of Salé , Faculty of Medicine and Pharmacy, Mohammed V University of Rabat, Morocco

*Corresponding author: Bellali N, Arrazi University Psychiatric Hospital of Salé, Faculty of Medicine and Pharmacy, Mohammed V University of Rabat, Morocco

Received: December 13, 2018; Accepted: February 04, 2019; Published: February 11, 2019

Abstract

Context: Despite the seriousness of domestic violence and its consequences, it is largely underestimated, and many female victims cannot receive appropriate assistance.

Despite the psychological consequences of domestic violence, women who are victims of such violence are not primarily intended for the psychiatrist.

Objective: To study the profile of women who have been victims of domestic violence and to assess their psychopathological impact.

Methods: Cross-sectional study carried out for 76 women victims of domestic violence recruited in the ANNAJDA help center in Rabat during a period from March 2017 to May 2017. The instruments used were: a data collection sheet for socio-demographic, clinical and violence characteristics, the PCL-S scale was used to assess Post-Traumatic Stress Disorder (PTSD), the Hospital Anxiety and Depression (HAD) scale was used to assess anxiety and depression and the DSM 5 criteria were used to assess addiction.

Results: 76 female victims of domestic violence were included in the study. The average age of the mothers was 34.62 years. 47.3% have a low socioeconomic level. 63.2% of the victims were unemployed. All our victims have been subjected to psychological violence. 68.4% of our sample has a post-traumatic stress condition. 82.9% of victims show definite anxiety. 61.8% of women have a definite depressive disorder. 14.5% a dependence on a substance.

There was a significant association between sexual violence and anxiety and drug use, between financial violence and drug use, between physical violence and depression.

Keywords: Domestic violence; Women; Consequences; Psychopathological impact

Introduction

The issue of domestic violence is currently of real interest in the international medical literature, both epidemiologically and psychopathologically; this violence involves a constellation of social, legal and medical partners.

According to the World Health Organization, domestic violence is defined as the existence of violence within a heterosexual or homosexual couple [1].

According to the United Nations Organization (UN), violence against women is defined as “all acts of violence directed against women, and causing or potentially causing physical, sexual or psychological harm or suffering to women, including the threat of such acts, the compulsion or the arbitrary deprivation of liberty, whether in public life or in private life “ [2].

Domestic violence has serious health and social consequences. These consequences on women’s health (and their children) are as diverse as they are numerous and unspecific. This violence leads to three major types of medical disorders: traumatic, gynecological and psychological, but they often remain underestimated.

In Morocco, the scarcity of information indicates that domestic violence is not recognised as a serious human rights violation. It was only in the 1980’s that the women’s movement broke the silence.

According to the results of the National Survey on the Prevalence of Violence against Women (ENVEFF), conducted by the High Commission for Planning in 2009, 55% of married women suffer domestic violence in Morocco, of which psychological violence is the most widespread form [3].

Despite the psychological consequences of domestic violence, women victims of this violence are not primarily intended for the psychiatrist. They first consult the Somatician doctor to treat the after-effects of the physical abuse they have undergone, or to the forensic doctor to obtain a descriptive medical certificate.

Informing and referring the patient is one of the essential missions of the doctor and health professionals in general. The doctor can advise the woman to file a complaint and especially to contact psychiatrists and victim help associations for advice and assistance.

In this context, the objective of this work is to clarify our knowledge about the psychopathological impact of domestic violence.

In our practical study, we will investigate the psychopathological impact of domestic violence and assessing depression, anxiety, posttraumatic stress disorder and drug use.

Clinical Study

Objective of the work

The objective of the study is to study the profile of women victims of domestic violence and to assess their psychopathological impact.

Materials and Methods

Type of study: This is a descriptive cross-sectional study carried out in the help center for women victims of violence (ANNAJDA center) in Rabat between March 2017 and May 2017.

Population: A sample of 76 female victims of domestic violence who contacted the victim help center

Inclusion criteria: Women who are victims of domestic violence and who have visited the help center for victims of violence and who are willing

Exclusion criteria:

• Women victims of violence other than conjugal violence.

• No consent.

Measuring instruments:

Sociodemographic and clinical data collection sheet: Variables concerning the victims’ characteristics: socio-demographic and clinical data.

Scale of post-traumatic stress disorder: In order to assess the presence of post-traumatic stress disorder, we used the PCLS / Post traumatic stress disorder Checklist Scale (Post-traumatic stress disorder scale).

The PCLS was created in 1993 by Weathers FW, et al. based on the diagnostic criteria of DSM IV. This self-questionnaire, translated into French, was validated in 2003 for the screening and follow-up of PTSD by Cottraux J, et al. and then by the army health service in 2011 [4].

The scale is composed of 17 items that assess the intensity of the 17 symptoms of PTSD presented in DSM IV

Each question is scored between 1 and 5 depending on the intensity and frequency of symptoms in the previous month.

The 17 items can be grouped into 3 scales corresponding to the 3 main syndromes of the PTSD:

• The intrusion (items 1 to 5);

• Avoidance (items 6 to 12);

• Hyperstimulation (items 13 to 17).

With a threshold score of 44 for PTSD diagnosis, sensitivity is of 97% and specificity 87%. With a threshold of 34, the PCLS scale allows with a sensitivity of 78% and a specificity of 94% to identify subjects requiring psychiatric or psychotherapeutic management beyond the presence or absence of PTSD.

During the first psychological interview, the patient with a suspected PTSD is assessed with the PCLS scale (Post traumatic stress disorder Check List Scale). Patients with a PCLS score above 34 are referred for psychotherapy (hypnotherapy and/or CBT, EMDR).

Patients with insignificant scores (‹34) receive information on post-traumatic psychological disorders that may appear later, their treatment and management modalities. They are regularly reviewed in interviews and reassessed with the PCLS scale.

HAD scale (Hospital Anxiety and Depression scale): This is a self-administered questionnaire completed by the patient [5,6]. The HAD scale is an instrument for detecting anxiety and depressive disorders. It comprises 14 items rated from 0 to 3. Seven questions relate to anxiety (total A) and seven others to the depressive dimension (total D), thus allowing two scores to be obtained (maximum mark of each score = 21).

To detect anxious and depressive symptoms, the following interpretation can be proposed for each of the scores (A and D):

• 7 or less: absence of symptomatology;

• 8 to 10: doubtful symptomatology;

• 11 and above: definite symptomatology.

Addiction evaluation DSM-5: Inadequate use of a product leading to clinically significant impairment or suffering, characterized by the presence of two (or more) of 11 criteria at any time during a continuous twelve-month period

• Presence of 2 to 3 criteria: slight addiction

• Presence of 4 to 5 criteria: moderate addiction

• Presence of 6 or more criteria: severe addiction

Statistical analyses: The data were analyzed with the SPSS20 software.

Descriptive results

Population: The study included 76 women who were victims of domestic violence, and who requested assistance from the Victims’ help Centre in Rabat.

The socio-demographic and clinical characteristics of the victims of domestic violence: The average age of women who participated in the research is 34.62 years (range: 17-56 years). Regarding marital status, they are all married. 43.4% live with their spouses, 40.8% with their families, and 15.8% live alone. They have an average of 2.60 children. 6.6% of women have a high socio-economic level and 47.3% have a low socio-economic level. 93.4% of women live in urban areas. 63.2% of victims do not work. 30.3% of our sample are illiterate and 30.3% have a university degree.

Regarding clinical characteristics, 26.3% of victims were followed for a depressive disorder, 15.8% have already made a suicide attempt. 23.7% of our sample have a medical history. 5.3% of women victims of domestic violence had a miscarriage and 2.6% had a fetal death in utero.

The Characteristics of the violence suffered:

Types of domestic violence: 100% of our sample have been subjected to psychological violence.

The association of psychological, physical and financial violence was the most frequent among our population with a prevalence of 31.6% (Table 1).

Table 1: Types of domestic violence.




  
    Types of domestic violence
    %
  
  
    psychological
    14.5
  
  
    psychological + physical
    26.3
  
  
    psychological + financial
    9.2
  
  
    psychological + physical +    financial
    31.6
  
  
    psychological + sexual
    9.2
  
  
    psychological + physical + sexual
    3.9
  
  
    psychological + sexual + financial
    5.3



Table 1: Types of domestic violence.

Types of psychological violence: The victims of domestic violence in this study describe different forms of psychological violence summarized in (Table 2).

Table 2: Typology of domestic violence.




  
    Variables
    N (%)
  
  
    Emotional blackmail
    3 (3.9)
  
  
    Psychological pressures
    8 (10.5)
  
  
    Control of exits and visits
    2 (2.6)
  
  
    Threat of death
    2 (2.6)
  
  
    Moral harassment
    6 (7.9)
  
  
    Emotional blackmail+threat of death
    2 (2.6)
  
  
    Psychological pressures + death threat
    6 (7.9)
  
  
    Psychological pressures + moral harassment
    31 (40.8)
  
  
    Psychological pressure + death threat + moral    harassment
    4 (5.3)
  
  
    Psychological pressures + emotional blackmail +    moral harassment
    10 (13.2)
  
  
    Psychological pressures + control of outings and    visits
    2 (2.6)



Table 2: Typology of domestic violence.

Filing complaints after violence: 43% of victims reported that they filed a complaint against their spouses as a result of the violence.

The assessment of the psychopathological impact of domestic violence:

We studied the psychopathological consequences of domestic violence on victims. Using the PCLS, HAD scales and DSM 5 addiction criteria.

All the women in our sample experienced domestic violence as a stressful event.19.7% of them have PTSD symptoms, and 68.4% have post-traumatic stress disorder.

82.9% of victims present a certain anxiety according to the HAD scale, and 11.8% have a questionable symptomatology.

61.8% of women have a definite depressive disorder according to the HAD scale and 30.3% have a questionable symptomatology.

14.5% are addicted to a substance.

13.2% of our sample have a severe addiction.

6.6 % of women consume tobacco alone, 2.6% consume tobacco and alcohol and 5.3% have polyaddiction.

2.6% started using substances after domestic violence.

6.6 % of women consume tobacco alone, 2.6% consume tobacco and alcohol and 5.3% have polyaddiction.

2.6% started using substances after domestic violence.

Analytical results

The psychopathological impact according to the different types of violence:

We investigated whether there was a significant relationship between the type of violence and the existence of post-traumatic stress, depression, anxiety or addiction.

The victims have suffered from different forms of violence, psychological, physical, financial and sexual.

Physical violence: 47 women in our sample (61.8%) were victims of physical violence.

The results are summarized in (Table 3).

Table 3: Psychiatric disorders and physical violence.




  
     
    physical violence
    P
  
  
    PTSD
    33 (70.2%)
    NS
  
  
    Anxiety
    40 (85.1%)
    NS
  
  
    Depression
    25 (53.2%)
    0.048
  
  
    Drug use
    5 (10.6%)
    NS



Table 3: Psychiatric disorders and physical violence.

Based on these results, it can be seen that the presence of depression in victims of physical violence is the only parameter that was statistically significant with a P of less than 0.05.

Financial violence: 35 women in our sample (46.1%) were victims of financial violence.

The results are summarized in (Table 4).

Table 4: Psychiatric disorders and financial violence.




  
     
    financial violence
    p
  
  
    PTSD
    20 (57.1%)
    NS
  
  
    Anxiety
    29 (82.9%)
    NS
  
  
    Depression
    22 (62.9%)
    NS
  
  
    Drug use
    1 (2.9%)
    0.008



Table 4: Psychiatric disorders and financial violence.

Based on these results, it can be seen that the presence of addictive behaviours among victims of financial violence is the only parameter that was statistically significant with a P below 0.05.

Sexual violence: 14 women in our sample (18.4%) were victims of sexual violence.

The results are summarized in (Table 5).

Table 5: Psychiatric disorders and sexual violence.




  
     
    physical violence
    P
  
  
    PTSD
    9 (64.3%)
    NS
  
  
    Anxiety
    8 (57.1%)
    0.01
  
  
    Depression
    9 (64.3%)
    NS
  
  
    Drug use
    5(35.7%)
    0.025



Table 5: Psychiatric disorders and sexual violence.

Based on these results, it can be seen that the presence of addictive behaviours and anxiety in victims of sexual violence are the parameters that were statistically significant with P below 0.05.

Psychological violence: Indeed, it was not possible to identify the presence of psychiatric disorders and psychological violence because this parameter is considered as a statistical constant.

File a complaint:

The different types of violence versus filing a complaint: We examined whether there was a significant relationship between the type of violence and the filing of a complaint.

The results are summarized in (Table 6).

Table 6: The types of violence and the complaint.




  
     
    complaint
    P
  
  
    Psychological violence
    No statistics are calculated because    psychological
    violence is a constant
  
  
    Physical violence
    26 (55.3%)
    0.008
  
  
    Financial violence
    18 (51.4%)
    NS
  
  
    Sexual violence
    4 (28.6%)
    NS



Table 6: The types of violence and the complaint.

We found a statically significant association between physical violence and filing a complaint (p‹0,05).

Socio-demographic characteristics versus filing a complaint: We found a statically significant association between school level and filing a complaint against a spouse with a p at 0.001.

Regarding the function, we did not find a significant association between working or not with the filing of a complaint, also we did not find a significant association between the socio-economic level and the complaint filed by the victims.

1) Psychiatric history versus psychiatric disorders found:

The results are summarized in (Table 7).

Table 7: Psychiatric disorders versus psychiatric history.




  
     
    Psychiatric history
    p
  
  
    PTSD
    16 (80%)
    NS
  
  
    Anxiety
    17 (85%)
    NS
  
  
    Depression
    12 (60%)
    NS
  
  
    Drug use
    6 (30%)
    0.031



Table 7: Psychiatric disorders versus psychiatric history.

We found a significant association between having a psychiatric history and the presence of addictive behaviour with a P less than 0.05.

Discussion

The profile of victims of domestic violence

Our work is carried out in a female population. Indeed, women are more likely to be victims of violence than men and essentially physical, sometimes fatal. Domestic violence against men exists and is not anecdotal; however, the subject is still taboo and very little studied. Thus, the literature provides almost exclusively data on domestic violence against women.

The average age of our sample is 34.62 years (extended: 17-56 years). In 2000, the National Survey of Violence Against Women in France (ENVEFF) revealed that 1 in 10 women aged 20 to 59 living in a couple had been victims of domestic violence over the last 12 months (20 ). In the majority of studies, 20 to 30% of women aged 18 to 60 report having experienced domestic violence in their lifetime [7,8].

Young women (20 to 24 years old) are twice as affected (15.3% versus 8% over 45 years old). The decrease in the overall rate of conjugal violence with advancing age, is linked by the authors to a phenomenon of “habituation” of women living the situation for a long time [8].

In our population, 6.6% of women have a high socio-economic level, 47.3% have a low socio-economic level and 46.1% have a medium socio-economic level and 46.1% have a medium socioeconomic level.

In our work, no standard profile can be described, but there are predominant characteristics: the majority of women are unemployed, with a low level of education and a low or medium socio-economic level. These characteristics are not specific to women victims of violence, but the public received in these listening centers have the same characteristics.

According to the National Survey of Violence Against Women in France, domestic violence is prevalent in all social classes, even if some associated factors may appear: unemployment, social precariousness, low socio-economic level would multiply by 3 the risk of physical or sexual domestic violence.

From a sociological point of view, the analysis of the available data highlights some of the characteristics of the victims’ public: young women and women without a diploma are three times more likely to be victims of domestic violence [9].

In our sample 26.3% of victims have at least a psychiatric history.

The National Survey of Violence Against Women in France objectively shows that 35% of victim female have a psychiatric or psychological care history. And that 68% of women victims of physical or sexual domestic violence report a history of physical abuse in their lives. In addition, children who have been witnessed domestic violence are reported to be 4 times more likely to be victims of sexual or physical abuse in their relationships [8].

The types of domestic violence

In our study, domestic violence is of multiple types, very often repeated, with a predominance of physical and psychological violence. The most frequent association is psychological, physical and financial violence with 31.6%, and 85.5% of our sample reports at least 2 types of violence always associating the psychological component. All these data are consistent with the data of the National Survey of Violence Against Women in France.

The National Survey of Violence Against Women in France also objected that repeated physical abuse is prevalent: 71% of women abused by their partners report an assault “more than once” and 24.4% report “more than 10 times”.

The National Survey of Violence Against Women in France also reveals that psychological violence is preponderant within the violent couple (>50% in total) compared to physical or sexual violence, and may even be the only mode of expression.

In our study the prevalence of sexual violence is 18.4%.

Literature data shows that sexual assaults also appear to be significant in relationships where the spouse or ex-spouse represents 46.9% of forced sexual relations (compared to 30% in public spaces) and 7% for touching. Marriage is far from protecting against violence, particularly sexual violence within the couple, despite its status as a legal institution.

Consequences of domestic violence

The consequences for the victims’ health are multiple; there are no symptoms specific to domestic violence. The repercussions are somatic as well as psychological; the most severe injuries lead to death [8,10].

In France, a woman dies every 3 days as a result of this violence.

For European women aged 16 to 44, brutality in the home is the leading cause of death before road accidents, cancer and even war [11]. A woman suffering from domestic violence loses 1 to 4 years of a healthy life [12].

The health status of the couple’s children can also be seriously affected [13].

In our sample 5.3% of women victims of domestic violence had a miscarriage, 2.6% had a fetal death in utero and 2.6% had a voluntary termination of pregnancy (ABORTION).

Cécile Sarafis, in her study of 2009 on 100 women seeking abortion [14], reported that 23% of them request an abortion as a result of violence, and 14% in the context of domestic violence. Two women do this at the request of the violent husband only, which represents 14% of abortions due to domestic violence.

In another study, 18% of pregnancies ended with miscarriage. The Henrion report shows that the risk of miscarriage is increased in the event of violence during pregnancy [15].

The National Survey of Violence Against Women in France reports 1.6 times more women giving birth prematurely among those who reported experiencing violence [16], and Silverman’s study shows a 1.37 times greater risk of prematurity in cases of domestic violence during pregnancy [17].

All the women in our sample experienced domestic violence as a stressful event and 68.4% had post-traumatic stress. 82.9% of our victims had definite anxiety according to the HAD scale. And it was statistically significant when it is about sexual violence.

In a study Denis Ferroul confirmed the high prevalence of PTSD among victims of domestic violence (12%). This anxiety disorder is prevalent in women and is frequently associated with other anxiety and depressive disorders.

The prevalence of PTSD appears to vary according to the traumatism and, for each traumatism, according to an individual’s vulnerability.

The prevalence of PTSD in our population justifies the presence of domestic violence among the triggering events. [18].

The impact of psychological violence on the risk of PTSD is statistically stronger than sexual violence and then physical violence [19-21].

It has been shown that the higher the level of psychological violence is, and the more severe and marked the post-traumatic symptoms are. The increased risk of developing PTSD symptoms would depend on the duration, frequency, severity but also on the type of violence experienced [22].

61.8% of our population has a definite depressive disorder according to the HAD scale. And it was statistically significant when it was a case of physical violence, which is consistent with the literature.

In cases of physical or sexual violence, depression is common and affects 38 to 83% of women according to studies by Cascardi, O Leary [23]. Being involved in a violent conjugal relationship increases the risk of a major depressive episode: having experienced a violent relationship, for example between 24 and 26 years, would double the risk of a major depressive episode at 30 years [24]. These depressions are characterized by loss of self-esteem, excessive caution, withdrawal, sleep and eating disorders, suicidal ideation, and suicide attempts.

14.5% of our victims use drugs, and this was statistically significant in relation to sexual and physical domestic violence, as well as the presence of psychiatric history.

Abuse of psychoactive substances and drugs (prescribed by the doctors consulted) is frequent among victims of domestic violence [25].

Psychotropic drug use among these women is 4 to 5 times higher than in the general population: 30% when they report several violent episodes, 20% when they declare one against 10% when they do not report (The National Survey of Violence Against Women in France) [25,26].

In our sample 14.5% consume tobacco and 7.9% consume alcohol.

The association between physical violence and addiction was statistically significant, which is consistent with the literature.

The results of a study showed that 45% of women consumers were found in a group of women who were victims of physical violence [27].

In a community sample of 406 married women, Ratner found that those who reported being physically abused were 8.1 times more likely to be addicted to alcohol than those who had not been abused [28].

Profile of women who filed complaints

In our results, 43.4% of victims filed a complaint against their spouses. A significant association was found between filing a complaint and physical violence (P=0.008), and between filing a complaint and school level (P=0.001).

In terms of management, women who filed a complaint more often consulted a health professional and obtained a medical certificate than those who did not file a complaint [29].

In 2000, the emergency department of Hôpital-Dieu of Paris studied the situation of victims of aggressions. In a population of 116 patients, victims of domestic violence represent 7% of cases; only one in eleven women filed a complaint. It is therefore necessary to improve the links between the general emergency services and the UMJ, to provide support in relation to the associations, to develop the training of caregivers and information of patients, in particular by distributing a technical sheet [30].

Limits

Since our sample is relatively small (76), we cannot afford to generalize our statistical results.

Addiction was assessed according to the DSM V criteria, while the PCLS scale, which is based on DSM IV, was used to search for PTSD.

The victims of domestic violence have been recruited within a listening association “ANNAJDA” in Rabat and this sample will not be very representative of all women who suffer domestic violence, particularly those who do not receive any management.

Conflicts of Interest

The authors do not declare any conflict of interest.

Conclusion

This study is cross-sectional and descriptive. Its objective is to strengthen our knowledge on the psychopathological impact of women victims of domestic violence.

However, given the small size of our sample, it is difficult to generalize our results.

We will therefore consider our study as an introduction for future work on the consequences of this violence on children who attend this violence and the modalities of management of the whole family (author, victim and child).

The results of this study show the importance of the psychological consequences of domestic violence and their severity, hence the need to systematically look for them in any woman victim of domestic violence to complete the management that is global.

References

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Citation: Bellali N, Laboudi F and Ouanass A. Domestic Violence and Psychopathological Impact. Austin J Psychiatry Behav Sci. 2019; 6(1): 1070.

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Types of domestic violence	%
psychological	14.5
psychological + physical	26.3
psychological + financial	9.2
psychological + physical + financial	31.6
psychological + sexual	9.2
psychological + physical + sexual	3.9
psychological + sexual + financial	5.3

Variables	N (%)
Emotional blackmail	3 (3.9)
Psychological pressures	8 (10.5)
Control of exits and visits	2 (2.6)
Threat of death	2 (2.6)
Moral harassment	6 (7.9)
Emotional blackmail+threat of death	2 (2.6)
Psychological pressures + death threat	6 (7.9)
Psychological pressures + moral harassment	31 (40.8)
Psychological pressure + death threat + moral harassment	4 (5.3)
Psychological pressures + emotional blackmail + moral harassment	10 (13.2)
Psychological pressures + control of outings and visits	2 (2.6)

	physical violence	P
PTSD	33 (70.2%)	NS
Anxiety	40 (85.1%)	NS
Depression	25 (53.2%)	0.048
Drug use	5 (10.6%)	NS

	financial violence	p
PTSD	20 (57.1%)	NS
Anxiety	29 (82.9%)	NS
Depression	22 (62.9%)	NS
Drug use	1 (2.9%)	0.008

	physical violence	P
PTSD	9 (64.3%)	NS
Anxiety	8 (57.1%)	0.01
Depression	9 (64.3%)	NS
Drug use	5(35.7%)	0.025