Assessment and Evaluation of Violence

Primary care physicians may encounter situations in which family, domestic, or societal violence is discovered or suspected. Such an awareness can carry legal and moral obligations; many state laws mandate reporting of child, spousal, and elder abuse. Physicians are frequently the first point of contact for both victim and abuser.

Between 1 and 2 million older Americans and 1.5 million U.S. children are thought to experience some form of physical maltreatment each year. Spousal abuse is thought to be even more prevalent. One survey of internal medicine practices found that 5.5% of all female patients had experienced domestic violence in the previous year, and that these individuals were more likely to suffer from depression, anxiety, somatization disorder, and substance abuse and to have attempted suicide.

When domestic violence is suspected, direct but nonjudgmental questioning should be pursued with each party separately - "Do you feel safe at home?" and "If there's a disagreement or a conflict between the two of you, how is it worked out?" Individuals who are abused may have signs of obvious or suspected physical injury; in addition, abused individuals frequently express low self-esteem, vague somatic symptomatology, social isolation, and a passive feeling of loss of control.

Although it is essential to treat these elements in the victim, the first obligation is to ensure that the perpetrator has taken responsibility for preventing any further violence. Substance abuse and/or dependence and serious mental illness in the abuser may contribute to the risk of harm and require direct intervention. Depending on the situation, law enforcement agencies, community resources such as support groups and shelters, and individual and family counseling can be appropriate components of a treatment plan.

A safety plan should be formulated with the victim, in addition to providing information about abuse, its likelihood of recurrence, and its tendency to increase in severity and frequency. Antianxiety and antidepressant medications may sometimes be useful in treating the acute symptoms, but only if independent evidence for an appropriate psychiatric diagnosis exists.

Antidepressants are generally not indicated when the diagnosis is linked to the social situation, such as an adjustment disorder with depressed mood.

The most important element in treatment is the development of a supportive doctor-patient relationship that avoids further blame of the victim. In certain circumstances, a significant potential for societal violence may be discovered. Sympathetic, but direct, questioning about potential violent impulses, access to weapons, recreational drug use, and specific homicidal ideation is necessary and is sometimes therapeutic in its own right. The existence and possible contribution of such medical conditions as delirium and/or intoxication should be evaluated. Available disposition options for potentially violent patients include police custody, psychiatric hospitalization, and referral to home care, with involvement of family, friends, and caregivers. In deciding which treatment option is most appropriate, clinicians should endeavor to establish an empathic interaction with the patient, while avoiding interventions or stimuli that might precipitate or increase the risk of violent behavior.