Bulimia / Anorexia

Not so long ago, doctors and therapists blamedanorexia,bulimia, and othereating disorderson overly controlling parents. When they first gained attention in the late 1970s and early 1980s, the diseases were often seen as psychosomatic -- the willful behavior of often-spoiled, privileged teenagers.

Today, a growing body of research indicates that you can indeed get anorexia from your parents, but not in the way previously thought. Eating disordersappear to be as strongly genetically linked as many other major psychiatric disorders, like schizophrenia,depression, bipolar disorder, or obsessive-compulsive disorder.

Anorexia Genes

In 1996, a private European foundation called the Price Foundation began to fund research into the genetics of anorexia and bulimia. During the next several years, an international group of scientists collected an astounding amount of data: first, on some 600 families with two or more members who have anorexia or bulimia, and later, on another group of 700 families with three members who have anorexia or bulimia along with 700 "control" women for comparison studies.

Their early results found a couple of "likely suspects": areas on chromosomes 1 and 10 that appear to be significantly linked with anorexia and bulimia. Follow-up studies of candidate genes have identified several genes that may increase a person's vulnerability to these disorders.

The research proved so promising that in 2002, the National Institute of Mental Health awarded a us$10 million grant to this group of investigators. This is the first-ever U.S. government-funded genetic study of anorexia. It aims to find regions of the human genome that contain genes influencing risk for anorexia. 

No one feels that we're going to find a single gene that will account for Anorexia Nervosa and Bulimia. We're convinced that instead there will be a number of genes that, to small effect, line up to create susceptibility.

Many people have theorized that the current obsessive cultural focus onweightand thinness, and on celebrities and their appearances, is likely to promote anorexia and bulimia. But that doesn't entirely explain the conundrum of eating disorders.

The overall prevalence of anorexia and bulimia, combined, is about 4%. But if they're largely caused by societal pressures, there should be alotmore of this.
-  In How many newsstand magazines can you read about someone'sweight loss?

Why can many girls go on a diet and walk away not dramatically affected, while four out of 100 wind up with psychiatric illnesses?

= The answer probably lies in neurochemistry and genetics.

The genetic research seems to indicate that some people, mostly, though not all, female, may have a latent vulnerability to eating disorders, which might never be turned on if they weren't exposed to particular influences, just as a predisposition toalcoholismcan remain latent unless the person takes a drink.

Since in our culture today,dietingbehaviors are more intense, it's exposing that latent vulnerability more now than in previous generations.

Treating Anorexia as a Genetic Disorder

Ultimately, of course, the investigators hope that this research might suggest new possibilities for treatment.

The long-term goal is to identify those aspects ofbrain related function that influence development, behavior, and personality, and help us refine the search for potentially more effective pharmacotherapy.

But while new medicines may help, anorexia and bulimia will ever be treated solely with medication. More effective new medications will be important, but a combination of approaches is essential. The importance of psychotherapy should never be minimized.

Drug treatments based on the new research are probably a long way off. But in the meantime, study results may help improve current treatment approaches. It potentially gives us a frame of reference for psychological treatment, allowing us to better target the therapeutic approaches that may help.

Information about the inheritability of anorexia and bulimia will also be important in prevention. For example, it could help parents and doctors to intervene early with young people whose family history and psychological profile may put them at particularly high risk. Studies have shown people at highest risk for anorexia or bulimia tend to have five personality traits:

Obsessive

Perfectionist

Anxious

Novelty-seeking

Impulsive

Many experts also hope that the growing evidence for a genetic component to anorexia and bulimia will help make the case for better access to treatment of these disorders, and improved insurance coverage of such treatment.

Whereas we have been developing treatments for eating disorders that are more and more effective, the majority of people still struggle to access them. There aren't enough clinicians trained to do this, and not enough funding for a process of treatment that often takes a very long time.

We need to understand the genetic influence involved in eating disorders, and its impact on psychological functioning. Bridging that gap of understanding will reduce stigma, inform the public, target the focus of therapy, and bring eating disorders rightly under the rubric of medical/psychological conditions as opposed to social phenomena.

Borderline (Emotionally Unstable) Personality Disorder is a condition characterized by rapid mood shift, impulsivity, hostility and chaotic social relationships. People with borderline personality disorder usually go from one emotional crisis to another.

In the general population, rapid mood shift, impulsivity, and hostility are normal in childhood and early adolescence, but disappear with maturity. However, in Borderline Personality Disorder, rapid mood shift, impulsivity, and hostility intensifies in adolescence and persists into adulthood. In early adulthood, individuals with this disorder have highly changeable moods and intense anger. Fortunately, in their 30's and 40's, the majority develop emotional stability and adequate coping skills. 

Borderline Personality Disorder is quite different from Bipolar I Disorder. The mood swings seen in Borderline Personality Disorder seldom last more than one day; whereas mood swings in Bipolar I Disorder last much longer. Borderline Personality Disorder doesn't exhibit the prolonged episodes of decreased need for sleep, hyperactivity, pressured speech, reckless over-involvement, and grandiosity that are characteristic of Bipolar I Disorder. 

The core features of this disorder are:

This disorder is only diagnosed if:

Socially, individuals with this disorder often form "love-hate" relationships that alternate between extremes of idealization and devaluation. They may make frantic efforts to avoid real or imagined abandonment. Frequently they feel that their life is empty and lacking in meaning and purpose. Many don't know "who they are" (i.e., identity confusion) or "where they are going in life" (i.e., goal confusion). 

Negative Emotion

• Emotions spiral out of control, leading to extremes of anxiety, sadness, rage
• Has extreme reactions to perceived slights or criticism
• Expresses emotion in exaggerated and theatrical ways.
• Emotions change rapidly and unpredictably.
• Feels unhappy, depressed, or despondent

Antagonism

• Intense anger,
• Often angry or hostile.

Disinhibition

• Need for stimulation/proneness to boredom
• Impulsivity
• Promiscuous sexual behavior
• Irresponsibility

Like all personality disorders, Borderline Personality Disorder is a deeply ingrained and enduring behavior pattern, manifesting as an inflexible response to a broad range of personal and social situations. This behavior represents an extreme or significant deviation from the way in which the average individual in a given culture relates to others. This behavior pattern tends to be stable. It causes significant distress/disability. 

Warning: Self-diagnosis of this disorder is usually inaccurate.

Accurate diagnosis of this disorder requires assessment by a qualified practitioner   trained in psychiatric diagnosis and evidence-based treatment.

Course

The course of Borderline Personality Disorder is quite variable. Borderline personality disorder is likely to remit (50% by 2 years, and 85% by 10 years), and once it remits, it usually does not relapse. Unfortunately, after 10 years, only about 20% have stable relationships or full-time employment.

Complications

Completed suicide occurs in 8%-10% of individuals with Borderline Personality Disorder. Self-mutilation (e.g., cutting or burning), suicide threats and attempts are very common. Recurrent job losses, interrupted education, and broken marriages are common. 

Comorbidity

Personality disorders are an overlooked and underappreciated source of psychiatric morbidity. Comorbid personality disorders may, in fact, account for much of the morbidity attributed to axis I disorders in research and clinical practice. 

impairment or poor, or worse, functioning in at least one area.

Some other disorders frequently occur with this disorder.

Non-Personality Disorders

        Bipolar and Related Disorders:

• Bipolar I or II disorder
• (15%) Cyclothymic disorder

        Depressive Disorders:

• Major depressive disorder
• (60%) Persistent depressive disorder (dysthmia)
• (70%) Substance/medication-induced depressive disorder

        Trauma- and Stressor-Related Disorders:

• Post-traumatique stress disorder

        Feeding and Eating Disorders:

• (25%) Bulimia Nervosa

        Substance-Related and Addictive Disorders:

• (35%) Substance use disorders

        Neurocognitive Disorders:

• Attention-deficit/hyperactivity disorder
• Personality Disorders

        Antagonistic Cluster:

• Histrionic personality disorders,
• (25%) Narcissistic
• (25%) Antisocial

Note: Antisocial, narcissistic, borderline, and histrionic personality disorders are all closely related since they all share the same core feature of antagonism. 
This core feature is an exaggerated sense of self-importance, insensitivity towards the feelings and needs of others, and callous exploitation of others. These antagonistic behaviors put the individual at odds with other people. If an individual has one of these antagonistic personality disorders, they are very likely to have another.

Familial Pattern

If individuals have Borderline Personality Disorder; their first-degree biological relatives are 5 times more likely to have this disorder. These relatives also have an increased risk of having Substance Use Disorders, Antisocial Personality Disorder, and Depressive or Bipolar Disorders. 

Effective Therapies

Psychotherapy

Psychotherapy represents the primary, or core, treatment for this disorder and adjunctive, symptom-targeted pharmacotherapy can be helpful. Research has shown that Dialectical Behavior Therapy (DBT) is helpful in decreasing inappropriate anger and self-harm, and in improving general functioning.

There are too few studies to allow firm conclusions to be drawn about the value of the other kinds of psychotherapeutic interventions for this disorder.

Dialectical behavior therapy and general psychiatric management have been shown to be equally effective. Individuals with this disorder usually suffer from 2 or more psychiatric disorders. Two years after therapy, even though two-thirds achieve diagnostic remission and significant improvement in quality of life, 53% is neither employed nor in school and 39% still receiving psychiatric disability financial support. Research has shown that individuals with this disorder need long-term therapy that teaches less emotional, aggressive and impulsive ways of coping.

Pharmacotherapy

Although there are currently no medications approved by the FDA to treat this disorder, some medications can exert a modest beneficial effect on some core traits of borderline personality disorder. Research has shown second-generation – atypical, antipsychotics, mood stabilisers, and omega-3 fatty acids offer a modest benefit. However, first-generation – typical, antipsychotics and antidepressants are only marginally effective.

One randomized clinic trial that compared female patients receiving fluvoxamine with a control group showed robust, long-lasting reduction in rapid mood shifts only in the treatment group.

Another randomized clinic trial that compared olanzapine with placebo in borderline patients showed improvement in global functioning in the medication group compared with the placebo group.

Another randomized clinic trial studied three groups of BPD patients - one group receiving fluoxetine, a second group receiving olanzapine, and a third receiving a combination of both; all three interventions led to substantial improvement, though a significantly greater rate of improvement in clinician-rated depression and impulsive aggression was seen in the olanzapine and the combination groups.

Also, double-blind - placebo-controlled trials demonstrated benefit of divalproex sodium for patients with BPD and for patients with cluster B personality disorders who demonstrate impulsive aggression.

Ineffective therapies

Vitamins, nutritional supplements, and special diets are all ineffective in the treatment of personality disorders.

Intra family violence, abuse, battering

Domestic violence, also known as domestic abuse, spousal abuse, battering, family violence, and intimate partner violence (IPV), is broadly defined as a pattern of abusive behaviors by one or both partners in an intimate relationship such as marriage, dating, family, or cohabitation. Domestic violence, so defined, has many forms, including physical aggression or assault (hitting, kicking, biting, shoving, restraining, slapping, throwing objects), or threats thereof; sexual abuse; emotional abuse; controlling or domineering; intimidation; stalking; passive/covert abuse (e.g. neglect); and economic deprivation. Alcohol consumption and mental illness can be co-morbid with abuse, and present additional challenges in eliminating domestic violence.

Awareness, perception, definition and documentation of domestic violence differs widely from country to country, and from era to era. Domestic violence and abuse is isn't limited to the usual tactics. Contrasting from general abuse, a person can also suffer from endangerment, criminal coercion, kidnapping, unlawful imprisonment, trespassing, harassment, as well as stalking. 

Definitions

According to the Merriam-Webster dictionary definition, domestic violence is: "the inflicting of physical injury by one family or household member on another; also: a repeated or habitual pattern of such behavior".

The term "intimate partner violence" (IPV) is often used synonymously with domestic abuse/domestic violence. Family violence is a broader definition, often used to include child abuse, elder abuse, and other violent acts between family members. Wife abuse, wife beating, and battering are descriptive terms that have lost popularity recently for at least two reasons:

-There is acknowledgment that many victims are not actually married to the abuser, but rather cohabiting or in other arrangements.

 -Abuse can take other forms than physical abuse. Other forms of abuse may be constantly occurring, while physical abuse happens    occasionally.

-Males as well as females are victims of domestic violence.

-These other forms of abuse have the potential to lead to mental illness, self-harm, and even attempts at suicide.

Classification

All forms of domestic abuse have one purpose: to gain and maintain control over the victim. Abusers use many tactics to exert power over their spouse or partner: dominance, humiliation, isolation, threats, intimidation, denial and blame.
The form and characteristics of domestic violence and abuse may vary in other ways. Michael P. Johnson argues for three major types of intimate partner violence. The typology is supported by subsequent research and evaluation by Johnson and his colleagues, as well as independent researchers.

Distinctions need to be made regarding types of violence, motives of perpetrators, and the social and cultural context. Violence by a person against their intimate partner is often done as a way for controlling "their partner", even if this kind of violence is not the most frequent. Other types of intimate partner violence also occur, including violence between gay and lesbian couples, and by women against their male partners.

Distinctions are not based on single incidents, but rather on patterns across numerous incidents and motives of the perpetrator. Types of violence identified by Johnson:

-Common couple violence (CCV) is not connected to general control behavior, but arises in a single argument where one or both partners physically lash out at the other. Intimate terrorism is one element in a general pattern of control by one partner over the other. Intimate terrorism is more common than common couple violence, more likely to escalate over time, not as likely to be mutual, and more likely to involve serious injury.

-Intimate terrorism (IT) may also involve emotional and psychological abuse.

-Violent resistance (VR), sometimes thought of as "self-defense", is violence perpetrated by victims against their abusive partners.

-Mutual violent control (MVC) is rare type of intimate partner violence occurs when both partners act in a violent manner, battling for control.

-Another type is situational couple violence, which arises out of conflicts that escalate to arguments and then to violence. It is not connected to a general pattern of control. Although it occurs less frequently in relationships and is less serious than intimate terrorism, in some cases it can be frequent and/or quite serious, even life-threatening. This is probably the most common type of intimate partner violence and dominates general surveys, student samples, and even marriage counseling samples.

-Types of male batterers include "family-only", which primarily fall into the CCV type, who are generally less violent and less likely to perpetrate psychological and sexual abuse. IT batterers include two types: "Generally-violent-antisocial" and "dysphoric-borderline".

-The first type includes men with general psychopathic and violent tendencies. The second type are men who are emotionally dependent on the relationship. Support for this typology has been found in subsequent evaluations.

-Others divide domestic violence into two types: reciprocal violence, in which both partners are violent, and non-reciprocal violence, in which one partner is violent.

Physical

Physical abuse is abuse involving contact intended to cause feelings of intimidation, pain, injury, or other physical suffering or bodily harm. Physical abuse includes hitting, slapping, punching, choking, pushing, burning and other types of contact that result in physical injury to the victim. Physical abuse can also include behaviors such as denying the victim of medical care when needed, depriving the victim of sleep or other functions necessary to live, or forcing the victim to engage in drug/alcohol use against his/her will. If a person is suffering from any physical harm then they are experiencing physical abuse. This pain can be experienced on any level. It can also include inflicting physical injury onto other targets, such as children or pets, in order to cause psychological harm to the victim.

Sexual

Sexual abuse is any situation in which force or threat is used to obtain participation in unwanted sexual activity. Coercing a person to engage in sex, against their will, even if that person is a spouse or intimate partner with whom consensual sex has occurred, is an act of aggression and violence.

Sexual violence is defined by World Health Organization as: "any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work."

Marital rape, also known as spousal rape, is non-consensual sex in which the perpetrator is the victim's spouse. As such, it is a form of partner rape, of domestic violence, and of sexual abuse.

Categories of sexual abuse include:

-Use of physical force to compel a person to engage in a sexual act against his or her will, whether or not the act is completed;

-Attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, unable to decline participation, or unable to communicate unwillingness to engage in the sexual act, e.g., because of underage immaturity, illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure.

Emotional

Emotional abuse (also called psychological abuse or mental abuse) can include humiliating the victim privately or publicly, controlling what the victim can and cannot do, withholding information from the victim, deliberately doing something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, implicitly blackmailing the victim by harming others when the victim expresses independence or happiness, or denying the victim access to money or other basic resources and necessities. Degradation in any form can be considered psychological abuse.

Emotional abuse can include verbal abuse and is defined as any behavior that threatens, intimidates, undermines the victim’s self-worth or self-esteem, or controls the victim’s freedom. This can include threatening the victim with injury or harm, telling the victim that they will be killed if they ever leave the relationship, and public humiliation. Constant criticism, name-calling, and making statements that damage the victim’s self-esteem are also common verbal forms of emotional abuse. Often perpetrators will use children to engage in emotional abuse by teaching them to harshly criticize the victim as well. Emotional abuse includes conflicting actions or statements which are designed to confuse and create insecurity in the victim. These behaviors also lead the victim to question themselves, causing them to believe that they are making up the abuse or that the abuse is their fault.

Emotional abuse includes forceful efforts to isolate the victim, keeping them from contacting friends or family. This is intended to eliminate those who might try to help the victim leave the relationship and to create a lack of resources for them to rely on if they were to leave. Isolation results in damaging the victim’s sense of internal strength, leaving them feeling helpless and unable to escape from the situation.

People who are being emotionally abused often feel as if they do not own themselves; rather, they may feel that their significant other has nearly total control over them. Women or men undergoing emotional abuse often suffer from depression, which puts them at increased risk for suicide, eating disorders, and drug and alcohol abuse.

Verbal

Verbal abuse is a form of emotionally abusive behavior involving the use of language. Verbal abuse can also be referred to as the act of threatening. Through threatening a person can blatantly say they will harm you in any way and will also be considered as abuse. It may include profanity but can occur with or without the use of expletives.

Verbal abuse may include aggressive actions such as name-calling, blaming, ridicule, disrespect, and criticism, but there are also less obviously aggressive forms of verbal abuse. Statements that may seem benign on the surface can be thinly veiled attempts to humiliate; falsely accuse; or manipulate others to submit to undesirable behavior; make others feel unwanted and unloved; threaten others economically; or isolate victims from support systems.

The abuser may fluctuate between sudden rages and false joviality toward the victim; or may simply show a very different "face" to the outside world than to the victim. While oral communication is the most common form of verbal abuse, it includes abusive communication in written form.

Economic

Economic abuse is a form of abuse when one intimate partner has control over the other partner's access to economic resources. Economic abuse may involve preventing a spouse from resource acquisition, limiting the amount of resources to use by the victim, or by exploiting economic resources of the victim. The motive behind preventing a spouse from acquiring resources is to diminish victim's capacity to support him/herself, thus forcing him/her to depend on the perpetrator financially, which includes preventing the victim from obtaining education, finding employment, maintaining or advancing their careers, and acquiring assets. In addition, the abuser may also put the victim on an allowance, closely monitor how the victim spends money, spend victim's money without his/her consent and creating debt, or completely spend victim's savings to limit available resources.

Effects

On children

There has been an increase in acknowledgment that a child who is exposed to domestic abuse during their upbringing will suffer in their developmental and psychological welfare. Due to the awareness of domestic violence that some children have to face, it also generally impacts how the child develops emotionally, socially, behaviorally as well as cognitively. Some emotional and behavioral problems that can result due to domestic violence include increased aggressiveness, anxiety, and changes in how a child socializes with friends, family, and authorities. Depression, as well as self-esteem issues, can follow due to traumatic experiences. Problems with attitude and cognition in schools can start developing, along with a lack of skills such as problem-solving. Correlation has been found between the experience of abuse and neglect in childhood and perpetrating domestic violence and sexual abuse in adulthood. Additionally, in some cases the abuser will purposely abuse the mother in front of the child to cause a ripple effect, hurting not one but two of his victims. It has been found that children who witness mother-assault are more likely to exhibit symptoms of posttraumatic stress disorder (PTSD).

Physical

Bruises, broken bones, head injuries, lacerations, and internal bleeding are some of the acute effects of a domestic violence incident that require medical attention and hospitalization. Some chronic health conditions that have been linked to victims of domestic violence are arthritis, irritable bowel syndrome, chronic pain, pelvic pain, ulcers, and migraines. Victims who are pregnant during a domestic violence relationship experience greater risk of miscarriage, pre-term labor, and injury to or death of the fetus.

Psychological

Among victims who are still living with their perpetrators, high amounts of stress, fear, and anxiety are commonly reported. Depression is also common, as victims are made to feel guilty for ‘provoking’ the abuse and are frequently subjected to intense criticism. It is reported that 60% of victims meet the diagnostic criteria for depression, either during or after termination of the relationship, and have a greatly increased risk of suicidality. In addition to depression, victims of domestic violence also commonly experience long-term anxiety and panic, and are likely to meet the diagnostic criteria for Generalized Anxiety Disorder and Panic Disorder. The most commonly referenced psychological effect of domestic violence is Post-Traumatic Stress Disorder (PTSD). PTSD (as experienced by victims) is characterized by flashbacks, intrusive images, exaggerated startle response, nightmares, and avoidance of triggers that are associated with the abuse. These symptoms are generally experienced for a long span of time after the victim has left the dangerous situation. Many researchers state that PTSD is possibly the best diagnosis for those suffering from psychological effects of domestic violence, as it accounts for the variety of symptoms commonly experienced by victims of trauma.

Financial

Once victims leave their perpetrator, they can be stunned with the reality of the extent to which the abuse has taken away their autonomy. Due to economic abuse and isolation, the victim usually has very little money of their own and few people on whom they can rely when seeking help. This has been shown to be one of the greatest obstacles facing victims of DV, and the strongest factor that can discourage them from leaving their perpetrators. In addition to lacking financial resources, victims of DV often lack specialized skills, education, and training that are necessary to find gainful employment, and also may have several children to support.. If a victim is able to secure rental housing, it is likely that her apartment complex will have "zero tolerance" policies for crime; these policies can cause them to face eviction even if they are the victim (not the perpetrator) of violence.

Long-term

Domestic violence can trigger many different responses in victims, all of which are very relevant for any professional working with a victim. Major consequences of domestic violence victimization include psychological/mental health issues and chronic physical health problems. A victim’s overwhelming lack of resources can lead to homelessness and poverty.

On responders

Vicarious trauma

Due to the gravity and intensity of hearing victims’ stories of abuse, professionals (police, counselors, therapists, advocates, medical professionals) are at risk themselves for secondary or vicarious trauma (VT), which causes the responder to experience trauma symptoms similar to the original victim after hearing about the victim’s experiences with abuse. Research has demonstrated that professionals who experience vicarious trauma show signs of exaggerated startle response, hyper-vigilance, nightmares, and intrusive thoughts although they have not experienced a trauma personally and do not qualify for a clinical diagnosis of PTSD. Researchers concluded that although clinicians have professional training and are equipped with the necessary clinical skills to assist victims of domestic violence, they may still be personally affected by the emotional impact of hearing about a victim’s traumatic experiences.

There are several common initial responses that are found in clinicians who work with victims: loss of confidence in their ability to help the client, taking personal responsibility for ensuring the client’s safety, and remaining supportive of the client’s autonomy if they makes the decision to return to their perpetrator. It has also been shown that clinicians who work with a large number of victims may alter their former perceptions of the world, and begin to doubt the basic goodness of others. Clinicians who work with victims tend to feel less secure in the world, become "acutely aware" of power and control issues both in society and in their own personal relationships, have difficulty trusting others, and experience an increased awareness of gender-based power differences in society.

The best way for a clinician to avoid developing VT is to engage in good self-care practices. These can include exercise, relaxation techniques, debriefing with colleagues, and seeking support from supervisors. Additionally, it is recommended that clinicians make the positive and rewarding aspects of working with domestic violence victims the primary focus of thought and energy, such as being part of the healing process or helping society as a whole. Clinicians should also continually evaluate their empathic responses to victims, in order to avoid feelings of being drawn in to the trauma that the victim experienced. It is recommended that clinicians practice good boundaries, and find a balance in expressing empathic responses to the victim while still maintaining personal detachment from their traumatic experiences.

Burnout

Vicarious trauma can lead directly to burnout, which is defined as "emotional exhaustion resulting from excessive demands on energy, strength, and personal resources in the work setting". The physical warning signs of burnout include headaches, fatigue, lowered immune function, and irritability. A clinician experiencing burnout may begin to lose interest in the welfare of clients, be unable to empathize or feel compassion for clients, and may even begin to feel aversion toward the client. If the clinician experiencing burnout is working with victims of domestic violence, the clinician risks causing further great harm through re-victimization of the client. It should be noted, however, that vicarious trauma does not always directly lead to burnout and that burnout can occur in clinicians who work with any difficult population – not only those who work with domestic violence victims.

Cause

There are many different theories as to the causes of domestic violence. These include psychological theories that consider personality traits and mental characteristics of the perpetrator, as well as social theories which consider external factors in the perpetrator's environment, such as family structure, stress, social learning. As with many phenomena regarding human experience, no single approach appears to cover all cases.

Whilst there are many theories regarding what causes one individual to act violently towards an intimate partner or family member there is also growing concern around apparent intergenerational cycles of domestic violence. Responses that focus on children suggest that experiences throughout life influence an individuals' propensity to engage in family violence (either as a victim or as a perpetrator). Researchers supporting this theory suggest it is useful to think of three sources of domestic violence: childhood socialization, previous experiences in couple relationships during adolescence, and levels of strain in a person's current life. People who observe their parents abusing each other, or who were themselves abused may incorporate abuse into their behavior within relationships that they establish as adults.

Psychological

Psychological theories focus on personality traits and mental characteristics of the offender. Personality traits include sudden bursts of anger, poor impulse control, and poor self-esteem. Various theories suggest that psychopathology and other personality disorders are factors, and that abuse experienced as a child leads some people to be more violent as adults. Correlation has been found between juvenile delinquency and domestic violence in adulthood. Studies have found high incidence of psychopathy among abusers.

For instance, some research suggests that about 80% of both court-referred and self-referred men in these domestic violence studies exhibited diagnosable psychopathology, typically personality disorders. "The estimate of personality disorders in the general population would be more in the 15-20% range [...] As violence becomes more severe and chronic in the relationship, the likelihood of psychopathology in these men approaches 100%." Psychological profile of men who abuse their wives, arguing that they have borderline personalities that are developed early in life.

Jealousy

Many cases of domestic violence against women occur due to jealousy when the woman is either suspected of being unfaithful or is planning to leave the relationship. An evolutionary psychology explanation such cases of domestic violence against women are that they represent to male attempts to control female reproduction and ensure sexual exclusivity for himself through violence or the threat of violence.

Behavioral

Behavioral theories draw on the work of behavior analysts. Applied behavior analysis uses the basic principles of learning theory to change behavior. Behavioral theories of domestic violence focus on the use of functional assessment with the goal of reducing episodes of violence to zero rates. This program leads to behavior therapy. Often by identifying the antecedents and consequences of violent action, the abusers can be taught self control. Recently more focus has been placed on prevention and a behavioral prevention theory.

Social theories

Looks at external factors in the offender's environment, such as family structure, stress, social learning, and includes rational choice theories.

Resource theory

Women who are most dependent on the spouse for economic well being (e.g. homemakers/housewives, women with handicaps, the unemployed), and are the primary caregiver to their children, fear the increased financial burden if they leave their marriage. Dependency means that they have fewer options and few resources to help them cope with or change their spouse's behavior.

Couples that share power equally experience lower incidence of conflict, and when conflict does arise, are less likely to resort to violence. If one spouse desires control and power in the relationship, the spouse may resort to abuse. This may include coercion and threats, intimidation, emotional abuse, economic abuse, isolation, making light of the situation and blaming the spouse, using children (threatening to take them away), and behaving as "master of the castle".

Social stress

Stress may be increased when a person is living in a family situation, with increased pressures. Social stresses, due to inadequate or other such problems in a family may further increase tensions. Violence is not always caused by stress, but may be one way that some people respond to stress. Families and couples in poverty may be more likely to experience domestic violence, due to increased stress and conflicts about and other aspects. Some speculate that poverty may hinder a man's ability to live up to his idea of "successful manhood", thus he fears losing honor and respect. Theory suggests that when he is unable to economically support his wife, and maintain control, he may turn to misogyny, substance abuse, and crime as ways to express masculinity.

Social learning theory

Social learning theory suggests that people learn from observing and modeling after others' behavior. With positive reinforcement, the behavior continues. If one observes violent behavior, one is more likely to imitate it. If there are no negative consequences (e. g. victim accepts the violence, with submission), then the behavior will likely continue. Often, violence is transmitted from generation to generation in a cyclical manner.

Power and control

In some relationships, violence is posited to arise out of a perceived need for power and control, a form of bullying and social learning of abuse.

Abusers' efforts to dominate their partners have been attributed to low self-esteem or feelings of inadequacy, unresolved childhood conflicts, the stress of poverty, hostility and resentment toward women (misogyny), hostility and resentment toward men (misandry), personality disorders, genetic tendencies and socio-cultural influences, among other possible causative factors. Most authorities seem to agree that abusive personalities result from a combination of several factors, to varying degrees.

A causalist view of domestic violence is that it is a strategy to gain or maintain power and control over the victim. This view is in alignment with "cost-benefit" theory that abuse rewards the perpetrator in ways other than, or in addition to, simply exercising power over his or her target(s). In most cases, abusers are quite capable of exercising control over themselves, but choose not to do so for various reasons.

An alternative view is that abuse arises from powerlessness and externalizing/projecting this and attempting to exercise control of the victim. It is an attempt to 'gain or maintain power and control over the victim' but even in achieving this it cannot resolve the powerlessness driving it. Such behaviors have addictive aspects leading to a cycle of abuse or violence. Mutual cycles develop when each party attempts to resolve their own powerlessness in attempting to assert control.

Questions of power and control are integral to the titles of which include: coercion and threats, intimidation, emotional abuse, isolation, minimizing, denying and blaming, using children, economic abuse, male privilege.

Mental illness

Psychiatric disorders are sometimes associated with domestic violence, such as borderline personality disorder, antisocial personality disorder, bipolar disorder, schizophrenia, drug abuse, and alcoholism. It is estimated that at least one-third of all abusers have some type of mental illness.

Gender aspects of abuse

The relationship between gender and domestic violence is a controversial topic. There continues to be debate about the rates at which each gender is subjected to domestic violence and whether abused men should be provided the same resources and shelters that exist for women victims. In particular, men are less likely to report being victims of domestic violence due to social stigmas. However, argue that the rate of domestic violence against men is often inflated due to the practice of including self-defense as a form of domestic violence.

Some sources conclude that women are subjected to domestic violence more often and more severely than are men. Women are more likely than men to be murdered by an intimate partner. Of those killed by an intimate partner about three quarters are female and about a quarter are male.

The UN Declaration on the Elimination of Violence against Women (1993) states that "violence against women is a manifestation of historically unequal power relations between men and women, which has led to domination over and discrimination against women by men and to the prevention of the full advancement of women, and that violence against women is one of the crucial social mechanisms by which women are forced into a subordinate position compared with men."

The frequency of violent acts is not as crucial as the impact of the violence and its function, when trying to understand spousal abuse; specifically, they state that the purpose of domestic violence is typically to control and intimidate, rather than just to injure.

Both men and women have been arrested and convicted of assaulting their partners in both heterosexual and homosexual relationships. The bulk of these arrests have been men being arrested for assaulting women. However, in the case of reciprocal violence, frequently only the male perpetrator is arrested. Determining how many instances of domestic violence actually involve male victims is difficult. Male domestic violence victims may be reluctant to get help for a number of reasons.

Some researchers have found a relationship between the availability of domestic violence services, improved laws and enforcement regarding domestic violence, increased access to divorce, and higher earnings for women with declines in intimate partner homicide by women. Murders of female intimate partners by men have dropped, but not nearly as dramatically. Men kill their female intimate partners at about four times the rate that women kill their male intimate partners. At least two thirds of women killed by their intimate partners were battered by those men prior to the murder. When males are killed by female intimates, the women in those relationships had been abused by their male partner about 75 percent of the time.

A problem in conducting studies that seek to describe violence in terms of gender is the amount of silence, fear and shame that results from abuse within families and relationships. Another is that abusive patterns can tend to seem normal to those who have lived in them for a length of time. Similarly, subtle forms of abuse can be quite transparent even as they set the stage for further abuse seeming normal. Finally, inconsistent definition of what constitutes domestic violence makes definite conclusions difficult to reach when compiling the available studies.

Theories that women are as violent as men have been dubbed "gender symmetry" theories.

The simple tally of physical acts is similar in both directions, but some studies show that male violence may be more serious. Male violence may do more damage than female violence; women are more likely to be injured and/or hospitalized. Wives are more likely to be killed by their husbands than the reverse (59 percent to 41 percent), and women in general are more likely to be killed by their spouses than by all other types of assailants combined.

Women are far more likely to use weapons in their domestic violence, whether throwing a plate or firing a gun.

Men are among those who are likely to be on the receiving end of acts of physical aggression. The extent to which this involves mutual combat or the male equivalent to "battered women" is at present unresolved. Both situations are causes for concern. The dangers involved-especially for women-when physical aggression becomes a routine response to relationship conflict. "Battered men"-those subjected to systematic and prolonged violence-are likely to suffer physical and psychological consequences, together with specific problems associated with a lack of recognition of their plight. Seeking to address these problems need not detract from continuing to address the problem of “battered women."

Gender roles and expectations can and do play a role in abusive situations, and exploring these roles and expectations can be helpful in addressing abusive situations. Likewise, it can be helpful to explore factors such as race, class, religion, sexuality and philosophy.

More men than women do not disclose the identity of their attacker. There is no evidence that male victims are more likely to under-report than female victims. In fact, men tend to over-estimate their partner’s violence and under-estimate their own, while women do the reverse.

Same-sex relationships

Domestic violence also occurs in same-sex relationships. Gay or bisexual relationships have been identified as a risk factor for abuse in certain populations. In an effort to be more inclusive, many organizations have made an effort to use gender-neutral terms when referring to perpetratorship and victimhood.

Historically, domestic violence has been seen as a family issue and little interest has been directed at violence in same-sex relationships. It has not been until recently, as the gay rights movement has brought the issues of gay and lesbian people into public attention, when research has been conducted on same-sex relationships. Lesbians and gay men are just as likely to abuse their partners as heterosexual men," Gays and lesbians, however, face special obstacles in dealing with the issues "the double closet". Similarities include frequency (approximately one in every four couples); manifestations (emotional, physical, financial, etc.); co-existent situations (unemployment, substance abuse, low self-esteem); victims' reactions (fear, feelings of helplessness, hyper-vigilance); and reasons for staying (love, can work it out, things will change, denial). At the same time, significant differences, unique issues and deceptive myths are typically present. Added discrimination and fear gays and lesbians can face; dismissal by police and some social services; a lack of support from peers who would rather keep quiet about the problem in order not to attract negative attention toward the gay community; the impacts of HIV status or AIDS in keeping partners together, due to health care insurance/access, or guilt; outing used as a weapon; and encountering supportive services that are targeted and/or structured for the needs of heterosexual women and which may not meet the needs of gay men or lesbians.

Marital conflict disorder

Marital Conflict Disorder Without Violence or Marital Abuse Disorder (Marital Conflict Disorder With Violence). Couples with marital disorders sometimes come to clinical attention because the couple recognize long-standing dissatisfaction with their marriage and come to the clinician on their own initiative or are referred by an astute health care professional. Secondly, there is serious violence in the marriage which is -"usually the husband battering the wife".

In these cases the emergency room or a legal authority often is the first to notify the clinician. Most importantly, marital violence is a major risk factor for serious injury and even death and women in violent marriages are at much greater risk of being seriously injured or killed. There is current considerable controversy over whether male-to-female marital violence is best regarded as a reflection of male psychopathology and control or whether there is an empirical base and clinical utility for conceptualizing these patterns as relational."

Recommendations for clinicians making a diagnosis of Marital Relational Disorder should include the assessment of actual or "potential" male violence as regularly as they assess the potential for suicide in depressed patients. Further, "clinicians should not relax their vigilance after a battered wife leaves her husband, because some data suggest that the period immediately following a marital separation is the period of greatest risk for the women. Many men will stalk and batter their wives in an effort to get them to return or punish them for leaving. Initial assessments of the potential for violence in a marriage can be supplemented by standardized interviews and questionnaires, which have been reliable and valid aids in exploring marital violence more systematically."
"Very recent information" on the course of violent marriages which suggests that "over time a husband's battering may abate somewhat, but perhaps because he has successfully intimidated his wife. The risk of violence remains strong in a marriage in which it has been a feature in the past. Thus, treatment is essential here; the clinician cannot just wait and watch." The most urgent clinical priority is the protection of the wife because she is the one most frequently at risk, and clinicians must be aware that supporting assertiveness by a battered wife may lead to more beatings or even death.

Cycle of abuse

Frequently, domestic violence is used to describe specific violent and overtly abusive incidents, and legal definitions will tend to take this perspective. However, when violent and abusive behaviors happen within a relationship, the effects of those behaviors continue after these overt incidents are over. Advocates and counselors will refer to domestic violence as a pattern of behaviors, including those listed above.

Cycle of abuse consists of three basic phases:

-Tension Building Phase Characterized by poor communication, tension, fear of causing outbursts. During this stage the victims try to calm the abuser down, to avoid any major violent confrontations.

-Violent Episode Characterized by outbursts of violent, abusive incidents. During this stage the abuser attempts to dominate his/her partner (victim), with the use of domestic violence.

-Honeymoon Phase Characterized by affection, apology, and apparent end of violence. During this stage the abuser feels overwhelming feelings of remorse and sadness. Some abusers walk away from the situation, while others shower their victims with love and affection.

Although it is easy to see the outbursts of the Acting-out Phase as abuse, even the more pleasant behaviors of the Honeymoon Phase serve to perpetuate the abuse.

Many domestic violence advocates believe that the cycle of abuse theory is limited and does not reflect the realities of many men and women experiencing domestic violence.

Management

The response to domestic violence is typically a combined effort between law enforcement, social services, and health care. The role of each has evolved as domestic violence has been brought more into public view.

Domestic violence historically has been viewed as a private family matter that need not involve the government or criminal justice. Police officers were often reluctant to intervene by making an arrest, and often chose instead to simply counsel the couple and/or ask one of the parties to leave the residence for a period of time. The courts were reluctant to impose any significant sanctions on those convicted of domestic violence, largely because it was viewed as a misdemeanor offense.

Medical response

Medical professionals can make a difference in the lives of those who experience abuse. Many cases of spousal abuse are handled solely by physicians and do not involve the police. Sometimes cases of domestic violence are brought into the emergency room, while many other cases are handled by family physician or other primary care provider. Subspecialist physicians are also increasingly playing an important role. For example, HIV physicians are ideally suited to play an important role in managing abuse given the association between abuse and HIV infection as well as their often life-long relationships with patients.

Medical professionals are in position to empower people, give advice, and refer them to appropriate services. The health care professional has not always met this role, with uneven quality of care, and in some cases misunderstandings about domestic violence.

Many doctors prefer not to get involved in people's "private" lives. Training for general practitioners about domestic violence was very limited or they had no training. Knowledge and understanding of domestic violence was very limited among health care professionals and they do not see themselves as being able to play a major role in helping women in regards to domestic violence. Injuries are often just treated and diagnosed, without regard for the causes. As well, there is substantial reluctance for victims to come forward and broach the issue with their physicians. On average, women experience 35 incidents of domestic violence before seeking treatment.

Health professionals have an ethical responsibility to recognize and address exposure to abuse in their patients, in the health care setting. "Due to the prevalence and medical consequences of family violence, physicians should routinely inquire about physical, sexual, and psychological abuse as part of the medical history. Physicians must also consider abuse in the differential diagnosis for a number of medical complaints, particularly when treating women."

Counseling for person affected

Due to the extent and prevalence of violence in relationships, counselors and therapists should assess every client for domestic violence (both experienced and perpetrated). If the clinician is seeing a couple for couple’s counseling, this assessment should be conducted with each individual privately during the initial interview, in order to increase the victim’s sense of safety in disclosing DV in the relationship. In addition to determining whether DV is present, counselors and therapists should also make the distinction between situations where battering may have been a single, isolated incident or an ongoing pattern of control. The therapist must, however, consider that domestic violence may be present even when there has been only a single physical incident as emotional/verbal, economic, and sexual abuse may be more insidious.

Another important issue in assessing clients for DV lies in differing definitions of abuse – the therapist’s definition may differ from that of the client, and paying close attention to the way the client describes their experiences is crucial in developing effective treatment plans. The therapist must determine if it is in the best interest of the client to explain that some behaviors (such as emotional abuse) are considered domestic violence, even if the client did not previously consider them as such.

If it becomes apparent to the therapist that domestic violence is taking place in a client’s relationship, there are several statements the clinician can make that have been shown to be effective in rapport-building and immediate crisis intervention with clients. Firstly, it is essential that the therapist believe the victim’s story and validate their feelings. It is recommended that the therapist acknowledge them for taking a risk in disclosing this information, and assure them that any ambivalent feelings they may be having are normal. The therapist should emphasize that the abuse they have experienced is not their fault, but should keep their feelings of ambivalence in mind and refrain from blaming their partner or telling them what to do. It is unreasonable for the therapist to expect that a victim will leave their perpetrator solely because they disclosed the abuse, and the therapist should respect the victim’s autonomy and allow them to make their own decisions regarding termination of the relationship. Finally, the therapist must explore options with the client (such as emergency housing in shelters, police involvement, etc.) in order to uphold their obligation to protect the welfare of the client.

Lethality assessment

A lethality assessment is a tool that can assist in determining the best course of treatment for a client, as well as helping the client to recognize dangerous behaviors and more subtle abuse in their relationship. In a study of victims of attempted domestic violence-related homicide, only about one-half of the participants recognized that their perpetrator was capable of killing them, as many domestic violence victims minimize the true seriousness of their situation. Thus, lethality assessment is an essential first step in assessing the severity of a victim’s situation.

Safety planning

Safety planning allows the victim to plan for dangerous situations they may encounter, and is effective regardless of their decision on whether remain with their perpetrator. Safety planning usually begins with determining a course of action if another acute incident occurs in the home. The victim should be given strategies for their own safety, such as avoiding confrontations in rooms where there is only one exit and avoiding certain rooms that contain many potential weapons (such as kitchens, bathrooms, etc.).

Counseling for offenders

The main goal for treatment for offenders of domestic violence is to minimize the offender’s risk of future domestic violence, whether within the same relationship or a new one. Treatment for offenders should emphasize minimizing risk to the victim, and should be modified depending on the offender’s history, risk of reoffending, and criminogenic needs. The majority of offender treatment programs are 24–36 weeks in length and are conducted in a group setting with groups not exceeding 12 participants. Groups are also standardized to be gender specific (male offenders only or female offenders only). It has been demonstrated that domestic violence offenders maintain a socially acceptable façade to hide abusive behavior, and therefore accountability is the recommended focus of offender treatment programs. Successful completion of treatment is generally associated with old age, higher levels of education, lower reported drug use, non-violent criminal histories, and longer intimate relationships. Anger management alone has not been shown to be effective in treating domestic violence offenders, as domestic violence is based on power and control and not on problems with regulating anger responses. Anger management is recommended as a part of an offender treatment curriculum that is based on accountability, along with topics such as recognizing abusive patterns of behavior and re-framing communication skills. Treatment of offenders involves more than the cessation of abusive behavior; it also requires a great deal of personal change and the construction of a self-image that is separate from former behavior while still being held accountable for it. Any corresponding problems should also be addressed as part of domestic violence offender treatment, such as problems with substance abuse or other mental illness.

Prevention and Intervention

There are many community organizations which work to prevent domestic violence by offering safe shelter, crisis intervention, advocacy, and education and prevention programs. Community screening for domestic violence can be more systematic in cases of animal abuse, healthcare settings, emergency departments, behavioral health settings and court systems. Tools are being developed to facilitate domestic violence screening.

Domestic violence and pregnancy

Pregnancy, when coupled with Domestic violence, may amplify health risks. Abuse during pregnancy, whether physical, verbal or emotional, produces adverse effects for both the mother and fetus. Domestic violence during pregnancy is categorized as abusive behavior towards a pregnant woman, where the pattern of abuse can often change in terms of severity and frequency of violence. Abuse may be a long-standing problem in a relationship that continues after a woman becomes pregnant or it may commence in pregnancy. Although female-to-male partner violence occurs in these settings, the overwhelming form of domestic violence is perpetrated by men against women.

Domestic abuse can be triggered by pregnancy for a number of reasons. Pregnancy itself can be used a form of coercion and the phenomenon of preventing one’s reproductive choice is referred to as birth control sabotage, or reproductive coercion. Studies on the birth control sabotage performed by males against female partners have indicated a strong correlation between domestic violence and birth control sabotage. Pregnancy can also lead to a hiatus of domestic violence when the abuser does not want to harm the unborn child. The risk of domestic violence for pregnant women is greatest immediately after childbirth.

Prognosis

There are strong associations between exposure to domestic violence and abuse in all their forms and higher rates of many chronic conditions. The strongest evidence comes from the Adverse Childhood Experiences' series of studies which show correlations between exposure to abuse or neglect and higher rates in adulthood of chronic conditions, high risk health behaviors and shortened life span. Evidence of the association between physical health and violence against women has been accumulating. Moreover, it is important to consider the effect of domestic violence and its psycho-physiologic sequelae on women who are mothers of infants and young children. Several studies have shown that maternal interpersonal violence-related posttraumatic stress disorder (PTSD) can, despite traumatized mother's best efforts, interfere with their child's response to the domestic violence and other traumatic events. Thus, practitioners and service agencies addressing the needs of domestic violence victims should assess the victim-as-parent and evaluate the safety and well-being of children in the home.

Epidemiology

Domestic violence occurs across the world, in various cultures, and affects people of all economic statuses. According to one study, the percentage of women who have reported being physically abused by an intimate partner vary from 69% to 10% depending on the country