Further Outpatient Care
If screening is to be effective, established protocols for making appropriate referrals must be in place. ED staff should have working knowledge of community resources that provide safety, treatment, advocacy, and support, and they should make appropriate referrals for physical, psychological, and substance abuse problems.
Family therapy generally is contraindicated in the presence of domestic violence.
Patients who are victims of chronic domestic violence are at high risk even after ending the abusive relationship and are most likely to be in need of immediate and intensive intervention services.
Men presenting with injuries resulting from domestic violence may be true victims, or they may have been injured by a partner’s justifiable efforts at self-defense. In one study, 51% of male patients identified by the ICD-9 code of “adult maltreatment syndrome” had prior arrests for domestic violence versus 20% of control patients. Based on the history obtained, consideration should be directed as to the most appropriate referral: domestic violence patient support group or abuser treatment program.
Inform the patient that local programs for abused women provide free confidential services and that representatives from these agencies frequently can provide information concerning legal rights, police and court proceedings for protective orders, and referral to shelters, support groups, and other services.
If the patient is willing, assist her or him in calling a domestic violence hotline or local crisis intervention center during the ED visit.
The patient should receive a list of emergency numbers, including the name and telephone number of the local crisis intervention center.
General referral cards that have several emergency telephone numbers not limited to agencies dealing with abuse may be kept more safely by the patient.
Offer a written list of resources each visit.
Place informational brochures in the women's bathroom, out of sight of an abusive (male) partner.
The toll-free number of the National Domestic Violence Hotline is 1-800-799-7233
Refer victims of cyberstalking to the local police or sheriff's department, the district or state attorney, and/or the FBI. The following organizations also offer help for victims of cyberstalking:
Further Inpatient Care
See the list below:
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Consider admission if the patient has no safe place to go.
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If the patient is suicidal or homicidal, discuss the need for hospitalization and consultation with a psychiatrist.
Inpatient & Outpatient Medications
See the list below:
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Do not prescribe tranquilizers or other sedating medications, because such medications may impair victims' ability to flee or to defend themselves.
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Clinicians may contribute to the overuse or abuse of psychoactive or sedating medications by prescribing them for anxiety, panic symptoms, or chronic pain syndromes that are actually psychiatric or somatic manifestations of abuse.
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The use or abuse of alcohol and other drugs appears to increase after physical abuse begins; in most people probably as a consequence of abuse rather than a cause.
Deterrence/Prevention
See the list below:
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Reportedly, at least 40% of domestic violence victims never contact the police. Of female victims of domestic violence homicide, 44% had visited an ED within 2 years of their murder.
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The ED staff may represent the only opportunity for victims of domestic violence to obtain professional help for their life situation, reinforcing the need for a high index of suspicion and routine screening for domestic violence.
Complications
See the list below:
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Undiagnosed abuse may compound the patient's sense of entrapment, thereby continuing the victimization.
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Missing a diagnosis of domestic violence may result in inappropriate and potentially harmful treatment.
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Different backgrounds may influence how an abuse victim responds to the abuse.
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Intentional violence results in many short- and long-term effects, including acute injury, injury-related long-term disability, chronic pain syndromes, abuse of alcohol and other drugs, depression, suicidal behavior, panic disorder, and other mental health conditions to include PTSD.
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Women with a history of domestic violence have a 60% higher rate of physical health problems than do women in the general population, and these women are 4-6 times more likely to have depression.
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A study of patients in a general practice found PTSD in 35% of patients who had experienced domestic violence; a rate approximately twice as high as in the general population. In this study, PTSD was often comorbid with major depression. While life-threatening traumatic events are not uncommon, PTSD resulting therefrom is usually acute and short-term, whereas in victims experiencing the severe end of the domestic violence spectrum, PTSD may be chronic.
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Abused women have a 16-times higher risk of abusing alcohol and a 9-times higher risk of drug abuse when compared with nonabused women.
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One study of women presenting to the ED with psychiatric symptoms revealed that 25% were battered.
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Misdiagnosing the sequelae of domestic violence as mental illness may lead to inappropriate use of psychoactive medications and hospitalization for nonexistent psychiatric illness.
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Murder or suicide ultimately may result from escalating domestic violence.
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Factors that increase the risk of homicide in domestic violence include the presence of a firearm in the home, use of alcohol or other drugs by the abuser, increasing frequency of battering, increasing severity of injuries, sexual abuse, and threats of homicide or suicide.
Prognosis
Domestic violence typically recurs and progressively escalates in both frequency and severity.
Of persons first injured by domestic violence, 75% continue to experience abuse.
Half of battered women who attempt suicide try again.
Brookoff reported a study of 62 episodes of domestic assault, in which 68% involved the use or display of weapons (5 handguns, 1 shotgun, 17 knives, and 19 blunt instruments such as hammers or baseball bats), and 15% resulted in serious injury. [18] Eighty-nine percent of victims reported previous assaults by their current assailants, with 35% experiencing violence on a daily basis.
The ultimate result of domestic violence may be death from suicide or homicide.
Patient Education
Basic knowledge about domestic violence may help promote the willingness of the victim to seek help.
The patient should know the following:
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Domestic violence occurs often in our society.
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It continues over time and increases in frequency and severity.
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It may well have damaging long-term effects on children who are hurt or who witness violence.
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Domestic violence is a crime.
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Resources are available to help.
For excellent patient education resources, see eMedicineHealth's patient education article Domestic Violence.
