Nurses in all healthcare settings will encounter victims of violence.This chapter from A Practical Guide to Forensic Nursing examines the consequences of violence on physical and mental health and provides strategies and tools to identify survivors.
Violence is an ever-present threat in society. Every day, the news media is full of stories about crime, murder, abuse, and violence. With violence comes victimization. Nurses need to understand common responses in the aftermath of violence and crime to be able to serve their patients. The range and types of victims a nurse will encounter vary; however, the prevalence and health effects of violence means that nurses will encounter victims in their practices.
The Bureau of Justice Statistics reports that 6.1 million violent crime victimizations occurred in 2013 (Truman & Langton, 2014).
Nearly 700,000 young people ages 10 to 24 are treated in emergency departments (EDs) each year for injuries sustained due to violence-related assaults (Centers for Disease Control [CDC], 2009).
From 2006 to 2009, 112,664 visits made to United States EDs were for battering by a partner or spouse (Davidov, Larrabee, & Davis, 2014).
The U.S. Department of Justice reported that 37% of all women treated in hospital EDs for violence-related injuries were injured by a current or former spouse, boyfriend, or girlfriend (Rand, 1997).
In the National Violence Against Women Survey (NVAWS), only one-third of victims received healthcare (Tjaden & Thoennes, 2000). Further, individuals who reported the violence to the police were more likely to receive healthcare treatment than victims who did not report (Tjaden & Thoennes, 2000). Among 218 women presenting in a metropolitan emergency department with injuries due to violence, 28% required hospital admission and 13% required major medical treatment (Berrios & Grady, 1991). In general, victims of repeated violence experience more severe consequences than victims of one-time incidents experience (Johnson & Leone, 2005).
In the United States, costs for interpersonal violence (IPV) reach 3.3% of the gross domestic product (Waters, Hyder, Rajkotia, Basu, & Rehwinkel, 2004). In 2003, costs for interpersonal violence exceeded $8.3 billion, and the annual healthcare costs for victims of IPV can continue for as many as 15 years after the abuse ends (Centers for Disease Control and Prevention [CDC], 2003; Rivara et al., 2007).
These serious mental and physical health effects and the prevalence of violence suggest that nurses in all aspects of healthcare will encounter victims of violence. The purpose of this chapter is to present the consequences of violence. It includes a discussion of physical- and mental-health consequences as well as behavioral, interpersonal responses, and healthcare utilization patterns. Finally, strategies and tools to identify survivors and health consequences are discussed.
Overview of Victimization
Experiencing violence and crime creates a sense of turmoil for the survivor and her loved ones. Trauma is a personal and often horrific event that profoundly affects a person and redefines her life. The experience of trauma has the potential to change ones’ perceptions, worldview, and behavior. Trauma often leaves behind physical injury, emotional trauma, financial loss, and changes to the routines of daily life.
Violence and crime can also produce a crisis for the victim. Crisis is an intolerable situation in which one’s usual coping strategies are not effective. It upsets the usual order of one’s life, and often, after healing, a new sense of order and balance is created. Being unable to solve a problem can result in increased tension, anxiety, emotional unrest, and an inability to function (Caplan, 1964).
The two types of trauma one can experience are:
Acute trauma: Trauma precipitated by a stressor that occurs one time. A crime committed by a stranger is an example of an acute trauma.
Chronic trauma: Trauma that occurs over a period of time. Child, spousal, or elder abuse is considered a chronic stressor. These are also considered interpersonal violence as they occur within the context of a relationship. However, interpersonal violence can be both acute and chronic, as can trauma committed by a stranger.
Witnessing violence can also create a stress reaction and response (Reid-Quiñones et al., 2011). Chronic stressors continually upset one’s equilibrium, and neurobiological changes occur, as discussed in Chapter 3, “Neurobiology of Trauma.”
One of the earliest studies of victims of violence was that of Burgess and Holmstrom (1974) on rape survivors. Prior research on rape focused on perpetrators and specifically on identifying typologies of rapists. After interviewing numerous rape survivors at a Boston hospital, Rape Trauma Syndrome (RTS) was identified (Burgess & Holmstrom, 1974). RTS is a cluster of symptoms and reactions commonly experienced by rape survivors. Burgess and Holmstrom’s definition of Rape Trauma Syndrome also outlines a process or phases that rape survivors go through toward reorganization. A key contribution of RTS is in identifying a range of responses and emotions experienced by survivors. Survivors may express their reactions in an expressed or controlled manner:
The expressed style is the expected reaction and includes overt behaviors such as crying, hysteria, tenseness, confusion, and volatility. The response can be seen often as emotional and indicating a lack of control. Response to trauma can also be expressed in nontraditional ways such as laughing.
The controlled style involves more ambiguous behaviors that are not frequently associated with trauma survivors. Controlled behaviors include calmness, shock, and subdued appearance. Some survivors appear distraught; others are quiet and reserved.
Individuals who dissociate during the attack may present as distant and withdrawn and may not be able to recall details related to the event. Immediate reactions to trauma are more dependent on individual coping styles than on the trauma experienced. The emotions of fear and anxiety begin during the assault; survivors’ fear of rape and of being killed or hurt can continue for years after the assault. Scholars have built on the work of Burgess and Holmstrom and continue to identify health-related consequences of multiple types of violence. The next sections review physical and mental health consequences along with information about other indices of health.
Identifying Responses to Violence
Violence is an assault on the body, and the body reacts in a variety of ways. The most common consequence or response to victimization is injury, both physical and psychological.
Physical reactions include immediate consequences, such as injuries, and longer-term consequences, such as headaches, sleep disturbances, stomach pains, nausea, vaginal pain, or discomfort. The physical injury incurred depends on the type of violence:
- Sexual violence can result in vaginal, rectal, or perineal trauma. Common injuries include bruises, lacerations, abrasions, burns, fractured bones, and head injuries.
- Strangulation by an intimate partner is a particularly lethal form of violence that is also a risk factor for future violence (Glass et al., 2008). A person can become unconscious in seconds and death can occur in minutes.
Strangulation is associated with substantial health consequences. These include physical symptoms such as dizziness, nausea, sore throat, voice changes, throat and neck injuries, breathing problems, ringing in ears, and vision change; neurological issues such as eyelid droop, facial droop, left or right side weakness, loss of sensation, loss of memory, and paralysis; and psychological symptoms such as PTSD, depression, suicidal ideation, and insomnia (McClane, Strack, & Hawley, 2001).
- Injuries from physical attacks can lead to long-term health consequences. For example, being hit in the head can result in hearing loss, vision impairment, and brain damage. Childhood abuse has been linked to health problems in adults, including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease, and health risk behaviors such as smoking, substance use, and risky sexual behavior (Felitti et al., 1998).
- Sexual health concerns that are associated with victimization include repeated sexually transmitted diseases (STDs) and unwanted pregnancy (World Health Organization [WHO], 2013). Forced sex is associated with increased incidence of developing pelvic inflammatory disease and reoccurrence of STDs (Champion, Foley, Sigmon-Smith, Sutfin, & DuRant, 2008; Upchurch & Kusunoki, 2004). Fear of contracting a sexually transmitted disease is a factor that prompts individuals to seek healthcare after rape. Limited research documents occurrence of STDs; however, as many as 2% of women report contracting an STD as a consequence of sexual violence (Masho, Odor, & Adera, 2005).
Chapter 6, “Assessment of Wounds and Injury,” provides a complete description of the types of injuries seen after violence.
Linking Behavioral Health Consequences to Violence
Behavioral responses to violence include aggressive and antisocial behavior, suicidal behavior, and substance abuse. Self-destructive behavior is the most frequent behavioral response to violence. For example, children may dart into traffic and take physical risks; adolescents and adults may eat, drink, or smoke excessively.
Self-destructive behaviors also include self-mutilation, suicide attempts, chronic suicidality, unprotected sex, reckless driving, and eating disorders. Abuse in any form affects the self-concept of the survivor. Emotional abuse often accompanies physical and sexual abuse. Harsh criticism, rejection, intimidation, and degradation can markedly alter or diminish the victim’s self-worth.
Responses to Interpersonal Violence
Exposure to interpersonal violence, both as victim and as a witness, increases the risk of substance abuse/dependence disorders (Kilpatrick et al., 2003). In situations of ongoing abuse, survivors may begin to use substances because their partners use or as a way to escape the reality of the abusive situation (Campbell, 2002). A study of adolescents in Belgium, Russia, and the United States found that exposure to violence was related to increased smoking, alcohol use, and marijuana use (Vermeiren, Schwab-Stone, Deboutte, Leckman, & Ruchkin, 2003).
Responses to interpersonal violence also include problems with intimacy, inability to trust, difficulties in interpersonal relationships, and revictimization. A history of abuse can create a disruption in the ability to form longstanding and healthy attachments (Anda et al., 2006). An abused person experiences abandonment, devaluation, and pain in the relationship with the abuser. This can make it difficult to trust and form intimate relationships.
Responses to Sexual Abuse
Sexually abused children are more likely to exhibit sexualized behavior than those who were not. Sexualized behavior includes developmentally inappropriate or intrusive, coercive sexual behavior. Children who were abused at an early age, by a family member, and involving penetration are at greater risk of sexualized behavior (Kellogg, 2010). Sometimes, they may exhibit promiscuous behavior. Individuals who experience chronic sexual abuse may be conditioned to think that the only thing they are good for is sex.
Incest, rape, and sexual assault can create feelings of repulsion and a lack of enjoyment of sex. Children, adolescents, and adults who are abused sexually may feel dirty or different. They often feel that they are the only ones this is happening to. Sexual dysfunction can include lack of sexual desire, lack of orgasm, aversion to sexual contact, pain associated with sex, and difficulty with lubrication (Campbell, Lichty, Sturza, & Raja, 2006; Turchik & Hassija, 2014).
Revictimization is common among survivors of violence. For more information on this topic, see “The Cycle of Revictimization” later in this chapter.
Cataloguing Mental Health Responses to Violence
Mental health responses are all too common after experiencing violence. The experience of violence triggers the onset of intense emotions that can have a disintegrating effect on the mind. Each individual shows or conceals his emotional state using his unique response pattern.
to violence include depression, anxiety and fear, lowered self-esteem, anger, and guilt. Referrals to mental health or psychiatric services on an in- or out-patient basis may be necessary to facilitate healing and recovery from trauma. Depression is the most common emotional response in the aftermath of trauma and victimization. Individuals with abuse histories often have thoughts of suicide and feelings of guilt and blame. Members of society often promote victim blaming that can lead to lowered self-esteem and guilt. Perpetrators may tell survivors that the abuse is their fault or is because of the victim’s perceived inadequacies. Blaming one’s self for the incident can lead to lowered self-esteem. Survivors often feel anger against the perpetrator, fate, and society. This anger is unexpressed during the assault and may be expressed inappropriately or turned inwardly. Working through rage can be a critical factor in healing from trauma.
Psychiatric disorders common after victimization include depression, post-traumatic stress disorder, acute stress disorder, anxiety, somatoform, and dissociative identity disorder. Depression is a common mental disorder, and it is a common consequence of violence. Symptoms of depression include significant weight loss or gain, sleep disturbances, increased or decreased motor activity, loss of energy, loss of pleasure in activities of life, decreased concentration, feelings of worthlessness, depressed mood most of the day, and recurrent thoughts of death or suicidal ideation (American Psychiatric Association [APA], 2013). Suicidal thoughts, plans, and behaviors are common in survivors (Campbell, 2002; Norman et al., 2012). Symptoms of anxiety, such as restlessness, fear of going crazy, and panic, are common responses to victimization.
The emotional trauma of victimization is often expressed through somatic disturbance. Common stress or anxiety related symptoms include sleep disorders, gastrointestinal concerns, muscle tension, headaches, palpitations, and chronic pain at an injury site. Unexplained chronic pain or conditions, such as pelvic pain, sexual problems, gastrointestinal problems, kidney or bladder infections, and headache, could give the clinician reason to suspect violence (WHO, n.d.).
General health effects abound following victimization. Survivors have been found to be disproportionately frequent users of healthcare services due to the acute and chronic physical, somatic, and psychological consequences of assault (Dichter, Cerulli, & Bossarte, 2011; Elhai, North, & Frueh, 2005; Schnurr & Green, 2004). Survivors have been found to have increased medical service usage even when perceptions of health and somatic symptoms are no longer elevated, reflecting the insidious and long-term effects of violence. Post-traumatic stress disorder (PTSD) appears to be a mediator that increases utilization of medical and mental health services after trauma (Rosendal, Mortensen, Andersen, & Heir, 2013). Survivors of trauma often report lower health-related quality of life (Schnurr & Green, 2004) and poorer physical and mental health outcomes (Coker et al., 2002; Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008). Sleep and appetite disturbances are common in violence survivors.
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) may be an immediate or chronic response to physical or sexual violence. PTSD is diagnosed in individuals who have experienced, witnessed, or were confronted with a traumatic event and have characteristic resulting symptoms. Resulting symptoms include persistent re-experiencing of the event, persistent avoidance of stimuli associated with the trauma, and symptoms of increased arousal (APA, 2013). The persistent re-living of the event creates an intrusion to daily functioning. Survivors may experience flashbacks, nightmares, or some experience in which the traumatic event is reenacted. They may also feel the need for safety rituals, such as extensive checking of locks.
Many people who experience traumatic events do not develop PTSD. Lifetime prevalence estimates suggest that about 8% of the general population have PTSD, with women being twice as likely as men to have PTSD at some point during their lifetimes (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). A systematic review suggests that individuals who are exposed to intentional trauma are more likely than those exposed to unintentional trauma to be diagnosed with PTSD (Santiago et al., 2013).
Avoidance behaviors are efforts to avoid anything associated with the traumatic event. This can include efforts to avoid feelings, thoughts, activities, places, and people. Numbing behaviors, such as difficulty expressing feelings, lack of interest in pleasurable activities, or isolating from others, are another way to avoid the traumatic event. The restrictions may interfere with normal life functioning. Avoidance and numbing can lend itself to periods of dissociation. Dissociation provides a separation of feelings and thoughts and allows the person to disappear and feel as if the traumatic event did not happen to him. The person feels complete powerlessness and escapes the situation by dissociating. Alterations in memory after a traumatic event can be associated with dissociative symptoms. Other survivors may have symptoms of increased arousal. Hyperarousal symptoms include being extremely watchful of the environment, insomnia, anger, and rage. Individuals with arousal are constantly alert and on guard for signs of danger or trauma. Exposure to severe and uncontrollable stressors desensitizes a person to trauma. That is, the person is so used to being on edge that he may react to milder stressors with a major stress response. Intrusions, avoidance, and hyperarousal symptoms may persist for as long as 2 years, or longer, after the attack and usually cause some disruption in the individual’s interpersonal, social, or occupational functioning.
Symptoms of PTSD often occur within 3 months of the stressor. However, symptoms may not emerge until years after an event. Acute Stress Disorder (ASD) is a more immediate response to a traumatic event. ASD usually occurs within 1 month after the traumatic event. The symptom profile of ASD is similar to PTSD. The main difference is that ASD has a shorter time of the onset of symptoms than does PTSD. Individuals with ASD may experience dissociative symptoms, persistent re-experiencing of the event, marked avoidance, and marked arousal (APA, 2013). Dissociative symptoms may occur during and after the trauma. They include numbing, detachment, reduced awareness of surroundings, depersonalization (feeling of lost identity), derealization (false perception that the environment is changed), and amnesia for important aspects of the trauma. These cognitive symptoms, during and after the trauma, provide an escape from the traumatic event by altering one’s state of consciousness. The dissociative symptoms are not necessary for a diagnosis of PTSD. For a diagnosis of ASD to be given, the symptoms must cause significant distress or impair functioning. Most people recover from Acute Stress Disorder within a month; however, it is a significant predictor of PTSD (Brewin, Andrews, Rose, & Kirk, 1999). If the symptoms are unresolved, then the diagnosis is changed to PTSD.
The Cycle of Revictimization
Secondary revictimization occurs when survivors encounter victim-blaming attitudes in providers and other individuals whom they turn to for help. The experience of trauma results in a loss of control for survivors. They often turn to helpers looking for support and validation. When professionals or authorities respond in a distant manner, survivors feel rejected and not supported. This results in additional trauma. The treatment of victims of sexual assault is often found to be negative and upsetting to victims (Campbell, Wasco, Ahrens, Sefl, & Barnes, 2001).
As a society, we hold biases regarding victimization, victims, and certain crimes. For example, male rape survivors report negative treatment from authorities. Misbeliefs include that men cannot be raped or that men should be able to fight off rape. LGBT individuals face multiple levels of victimization and are likely to experience indifference, rejection, and stigmatization from police, healthcare personnel, and often family and friends.
Revictimization is common among survivors of violence. Multiple studies have identified prior victimization as a strong predictor of future victimization (Finkelhor, Ormrod, & Turner, 2007). Many survivors who were abused as children are revictimized later in life and sometimes on multiple occasions. It is thought that being abused negatively affects the ability to protect oneself. As discussed in Chapter 3, trauma can alter the development and function of the child and adolescent brain, which can elicit other consequences. Symptoms of PTSD, such as numbing and hyperarousal, may play a role in revictimization (Ullman, Najdowski, & Filipas, 2009). Increased levels of arousal can make the autonomic nervous system lose the ability to warn of impending danger. A lack of risk recognition predicts revictimization (Bockers, Roepke, Michael, Renneberg, & Knaevelsrud, 2014). In a study of victims of violence, exaggerated startle response, irritability, and outbursts of anger are related to revictimization (Kunst & Winkel, 2013). However, another study found that numbing symptoms and problem drinking are independent risk factors for revictimization (Ullman et al., 2009). Decreased self-esteem can create difficulty in setting boundaries, which can place survivors at risk for abuse and exploitation.
Gender Concerns With Violence
Much of the research on partner violence and rape has been conducted using primarily female samples, often middle class and white samples. Men and boys are also victims of partner violence and rape at the hands of female and male perpetrators. However, in studies conducted by the Justice Department and Centers for Disease Control, the sample size of male survivors is too small to conduct meaningful analyses (Black et al., 2011; Tjaden & Thoennes, 2000, 2006). Despite this, on average, annually, 9,040 male victims experience completed rapes, and 10,270 male victims experience attempted rape (Rennison, 2001). More than 35% of women and 28% of men experience rape, physical violence, and/or stalking by an intimate partner in their lifetime (Black et al., 2011). Both men and women who experienced physical and sexual violence reported similar health effects (Black et al., 2011).
Society conceptualizes partner violence and rape as events that happen only to female victims. Societal perceptions can influence male responses to violence, causing them not to report partner or sexual violence to the police or seek healthcare due to fear of a negative reaction or of not being believed or taken seriously. Men who experienced rape reported psychological disturbance in response to being raped, specifically anxiety, depression, increased feelings of anger and vulnerability, loss of self-image, emotional distancing, self-blame, and self-harming behaviors (Walker, Archer, & Davies, 2005). Research specific to consequences of violence for men is limited.
Cultural Implications Regarding Violence
One’s cultural background exerts a strong influence on acceptable thoughts, behaviors, and attitudes. Culture also determines the values that a group uses to guide actions and decisions. Cultural values and norms provide a framework for roles, responsibilities, and behaviors related to behavior and relationships. Culture, race, and ethnicity can also affect the presentation of symptoms to a provider. For example, Italians often use words for drama to convey the emotional intensity of an experience. This is in contrast to Chinese culture, which avoids talking about problems, or Irish culture, in which it is embarrassing to discuss feelings with anyone (McGoldrick, Giordano, & Garcia-Preto, 2005).
Clearly, survivors will be best helped when the provider is able to provide culturally sensitive care. Cultural sensitivity would include behaviors that are open to diversity among individuals. It is important for you to recognize that there is no standard cookbook approach. There can be much diversity among members of the same ethnic or racial background. Assessment or intake tools can incorporate questions that uncover the cultural significance of events for clients. By asking clients about the meaning that this event may hold for their family, church, or social group, the healthcare or social service provider gains insight into the perspective of the survivor and may then implement a culturally sensitive plan of action.
Assessing Injuries That Occur Through Violence
Trauma assessment typically involves conducting a thorough history to identify all forms of traumatic events experienced directly or witnessed by the client. This background data is used to inform the choice of intervention. This history can be supplemented with trauma-specific standardized clinical measures. These measures help the nurse to identify the type and severity of symptoms the individual is experiencing. The National Center for PTSD has lists of surveys to measure traumatic exposure. The Trauma History Questionnaire, shown in Table 4.1, is a commonly used self-report measure that has 24 items and takes about 10 to 15 minutes to complete. The survey is established as a reliable and valid measure (Hooper, Stockton, Krupnick, & Green, 2011). Not all individuals who have experienced trauma need trauma-specific interventions.
TABLE 4.1 THE TRAUMA HISTORY QUESTIONNAIRE
to access larger version of Table 4.1, The Trauma History Questionnaire
Unfortunately, many individuals exposed to trauma lack natural support systems and need the help of trauma-informed care systems. Many people who do not meet the full criteria for PTSD still suffer significant post-traumatic symptoms that can strongly affect behavior, judgment, education/work performance, and ability to connect with family/caregivers. These individuals may benefit from a comprehensive trauma assessment to determine the most effective interventions.
Nurses can use screening tools that are covered in the following sections to assess and describe the violence.
The Abuse Assessment Screen (AAS)
The Abuse Assessment Screen (AAS) was developed and tested by nurses and has proven to be a reliable method of assessing violence (Laughon, Renker, Glass, & Parker, 2008). Its five items inquire about physical, sexual, and emotional abuse, in addition to asking about abuse during pregnancy. Male and female body maps are provided to document injuries. Respondents also identify the perpetrator. Direct questions and word choices are important to gather this information. While individuals may respond affirmatively to questions about kicking, punching, or hitting, they might not see themselves as battered, abused, or a victim. Similarly, individuals may respond affirmatively that someone made them have sex against their wishes but not see themselves as having been raped. It is important to frame violence assessment questions using behavioral terms rather than making judgments.
The Beck Depression Inventory (BDI) is a widely used, self-report survey containing 21 items (Beck, Steer, & Carbin, 1988). It takes about 5 to 10 minutes to complete. The items are consistent with the diagnostic criteria for depression. Higher scores indicate higher levels of depression.
A shorter option is the Patient Health Questionnaire-9 (PHQ9). The nine-item assessment tool is also consistent with the diagnostic criteria for depression and takes less than 2 minutes to complete. The scores are interpreted into ranges or levels of depression (Kroenke, Spitzer, & Williams, 2001).
Anxiety is often measured using the Hamilton Anxiety Scale. This 14-item scale is widely used by clinicians to determine the level of anxiety. Higher scores indicate more severe levels of anxiety (Maier, Buller, Philipp, & Heuser, 1988). The Beck Anxiety Inventory–Primary Care is a seven-item scale that measures anxiety and depression and screens for PTSD (Mori et al., 2003). The Impact of Events is a widely used, though longer measure of PTSD. The 22-item scale measures symptoms of intrusion, avoidance, and hyperarousal (Horowitz, Wilner, & Alvarez, 1979). Further information about these scales and others can be found at the National Center for PTSD website (http://www.ptsd.va.gov/index.asp
This chapter explained how experiencing violence can lead to short- and long-term physical- and mental-health symptoms and disorders, how nurses interact with patients who’ve experienced violence, and how to accurately assess injuries using verifiable scales of measurement.
The experience of violence can have profound effects on psychological and physical health and wellbeing of patients, as well as health utilization. Nurses routinely interact with individuals whose lives have been touched by violence. Each encounter represents an opportunity to provide teaching, referrals, and access to resources that can help individuals to manage and alleviate the consequences of violence. An understanding of the myriad ways that individuals respond to violence helps the nurse to identify individuals who have experienced violence and connect them to appropriate resources.
Angela F. Amar, PhD, RN, FAAN, is an associate professor and assistant dean for BSN education in the Nell Hodgson Woodruff School of Nursing at Emory University.
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