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Skip Navigation Linksראשי > רשימת כתבי עת > Israeli Journal of Family Practice - גליון מס' 129 > Difficulties in the Diagnosis of Domestic Violence in Family Medicine. Three Case Presentations
יוני 2006 June | גיליון מס' 129 .No
צור קשר
חברי מערכת
רשימת גליונות קודמים
שער הגליון
מאמר מקורי
Difficulties in the Diagnosis of Domestic Violence in Family Medicine. Three Case Presentations


Biderman Aya MD Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev and Clalit Health Services, Beer-Sheva, Israel Yeheskel Ayala PhD MSW Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev and Clalit Health Services, Beer-Sheva, Israel Amitai Simi BSW Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev and Clalit Health Services, Beer-Sheva, Israel

Biderman Aya MD, Yeheskel Ayala PhD MSW, Amitai Simi BSW
Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev and Clalit Health Services, Beer-Sheva, Israel
Correspondence to: Dr A. Biderman, P.O.Box 543, Meitar 85025, Israel, Fax: 972-8-6477636, Tel: 972-8-6477436, E-mail: sbider@netvision.net.il

 

Abstract
Screening programs for the detection of domestic violence among women who visit their family physicians have been described in many countries. The Israeli Ministry of Health has also developed such a program. In this paper, we describe three case presentations, in which a longer physician-patient relationship was required for the patient to disclose her secret. We emphasize the important role of the social worker in the clinic setting, both as a resource person for the abused woman and for the clinic staff.
Keywords: Domestic violence, Family medicine, Medical social work.
 

Background
Domestic violence is a prevalent problem among women who attend primary care clinics (1). It is estimated that one in 6 women has been abused during her lifetime and one of 3-4 women presenting in the health care system has undergone such an experience. One of every seven women experienced domestic violence in the previous year (2,3).
Although these figures have been reported in the medical literature, there is still a lack of awareness by physicians of the extent to which abused women utilize the health care system, thus making it a prime area in which domestic life problems are medicalized, and a challenge for accurate diagnosis and treatment. Many of the abused women visit the clinic regularly with various somatic and psychiatric complaints, seldom disclosing the real problem (4,5).
In the past few years there has been a growing call for physicians to take an active role in screening female patients for domestic violence (6).
In Israel, the Ministry of Health has recently issued regulations which require medical staff to offer information to female patients about existing resources for abused women, and that this activity be documented in the patient's medical chart.
This article describes three women who presented at a primary care clinic in Israel with somatic complaints and were later diagnosed as being abused. All three cases demonstrate the need for a strong and standing relationship between physician and patient and for a longer visit-time to enable detection of such problems, as well as the need for a multi-professional practice team to respond appropriately. The place of a social worker in the clinic is essential for detection and treatment of these women. A systematic approach to detection and diagnosis of abused women in the primary care setting is discussed.

Case presentations
Case 1:
N, a 60 year old mother of two, a child survivor of the Holocaust, who immigrated to Israel from Russia 10 years earlier, came to her family physician complaining of pains in the chest, high blood pressure and anxiety. She requested medication to reduce her symptoms and was given a selective serotonin reuptake inhibitor. The physician knew that the husband and wife had conflict relations: for example, the wife worked as a house cleaner without her husband’s "permission", while he stayed at home. The family physician referred N to the social worker for further evaluation. At the beginning of her sessions with the social worker, N said that when she feels anxious she takes medications and finds them helpful. She did not think she needed psychotherapy. The social worker asked directly about violence at home and learned that the patient has been abused physically, psychologically and economically. Her husband also threatened to kill her. During the sessions, N told the social worker about her childhood during the Holocaust and about her father's death from starvation. She also related that her husband was very jealous of her and demanded that the house be kept in perfect order and that the children be quiet. He was an only child and N had to take care of her mother-in-law until she died in Russia, after which the family immigrated to Israel.
All the meetings with the social worker took place without the husband’s approval. The physician and social worker paid the couple a house call, in the course of which the husband was very polite, acting as if there was no problem at all. The patient was informed of the available resources for abused women in the area and her daughters’ telephone numbers were written in her chart. N decided to remain with her husband, refusing to have him examined by a psychiatrist. She never approached any of the centers for abused women and stopped visiting the social worker. She still complains of various symptoms but is able now to share her secrets and her fears with her physician, and is not as lonely as before.
This case demonstrates the difficulties physicians and social workers face and their helplessness in working with abused women, as part of “traumatic counter-transference” (7).

Case 2:
M, a 50-year-old woman, complained of genito-urinary symptoms which caused her increasing disability. She suffered from urinary incontinence and dyspareunia. At the time of the initial visit M was married to F for 30 years and had two grown children. She was working as an accountant, earning a good salary. F had been a bank clerk but retired early due to a heart problem.
M’s symptoms were becoming more serious. She described herself as depressed, hopeless and considering suicide. These reactions to her physical symptoms struck her physician as disproportionately severe, arousing the suspicion that there were other issues involved.
When M was asked to relate what was going on in her life at the time, she reported that her 16-year-old son had stopped going out of the house, did not have any friends and was very attached to her. She also said that this might be related to her problematic relations with her husband, who used to stalk her, believing that she was unfaithful to him. He became very jealous of her and demanded sexual intercourse much more often than she would have liked. At that time she did not recognize his attitudes as abusive.
Both M and F were referred to the social worker and were also seen by a consultant psychiatrist in the family medicine clinic. F was diagnosed as suffering from pathological jealousy and was given medication. M was treated by the social worker, who listened to the story of her life as an abused woman and used behavioral techniques to improve her urinary symptoms. M decided that, in spite of her suffering, she would not leave her sick husband, the father of her children. Their daughter is married with two children. These grandchildren made M and F very happy and kept both of them busy after retirement.
In the past five years M's symptoms became unbearable and she was seen by a gynecologist, who diagnosed her condition as “non-neurogenic neurogenic bladder” and treated her accordingly. The gynecologist suggested that M undergo an operation, which she refused. Recently, the couple agreed to begin joint therapy with the social worker, hoping to improve their communication as an older couple and to enable their grown son to leave home. 
This second case describes stalking as an abusive behavior (8), pathological jealousy (9,10) as contributing to abuse and some of the typical physical symptoms related to chronic abuse (1,2).

Case 3:
L is a twenty one year old woman, born in Ethiopia, who immigrated with her family to Israel in 1990 . She presented with dizziness, palpitations and malaise during the past few months. At the time she was working as a cleaning woman in a large store. She was forced to quit her job when she developed chest pain, radiating to her left arm. She went through a number of investigative procedures, some of them invasive. L told her family physician that the symptoms started after her cousin committed suicide. The physician recommended medications for anxiety and depression but L preferred not to take them. Finally, she was referred by her family physician to the clinic social worker.
L is the seventh of nine children, three of whom still lived at home at the time. Her parents, were old and sick, could not speak Hebrew and needed her to serve as a bridge between themselves and the strange environment. There was a lot of tension between her parents, and L often saw her mother beaten by her father. She would have liked to be her mother’s protector, but felt helpless. She was very close to her mother and had a bad relationship with her father, who preferred her younger sister to her. When asked about the sleeping arrangements at home, L started to cry and spoke of her fear of getting out of bed at night. After several sessions she was, at last, able to talk about the problems with her brother. He is three years older than her and lives in another city. He is an alcoholic and used to visit his parents’ home several times a year. During these visits, he would get drunk and become aggressive towards his parents and towards L. She was very frightened of him and very aware of her parents’ helplessness during his visits. This was a secret kept within the family.
The social worker suggested a family conference but the mother refused to participate, fearing that this might worsen the situation. During the sessions, L began to understand that her symptoms, especially the dizziness, were related to the family situation. In a later stage of the therapy, L received occupational counseling and successfully completed a course for kindergarten teacher assistants. She is now working and married.
 As a result of L’s meetings with the social worker, L's symptoms resolved, the number of visits to the clinic declined and she was able to talk about her “secrets” openly.
This case demonstrates the health issues that may result from the traumatic experience of witnessing domestic violence (11). It also expresses the trans-generational pattern often found in domestic violence.

Discussion
The three cases presented here demonstrate different aspects of dealing with domestic violence in the family practice setting. In most cases, abuse is a family secret, concealed even from the physician and the practice nurse. It takes a long time to win the patient’s trust and enable her to discuss her problems. On the other hand, abused women usually attend the primary care clinics frequently and are high utilizers of medical resources, presenting with physical and psychological symptoms (1,2,12). A primary care clinic is, therefore, an ideal place for identifying abuse.
Victims of abuse may present in different ways, with varied symptoms and physical findings (2). Some of these symptoms are directly related to abuse, but others may be ambiguous: chronic pain; chronic gynecological symptoms; irritable bowel syndrome; depression; anxiety; panic disorder; post traumatic stress disorder, etc..
Because of its high prevalence, screening for domestic violence for all female patients over 14 has been recommended (2,6). A suitable questionnaire may facilitate a woman's openness to the doctor, nurse or social worker about her secret. Direct inquiry about domestic violence seems to be essential in communication with patients about abuse (13). Screening, however, is not enough. Clinic doctors and nurses should be aware of domestic violence and its clinical implications, of the legal aspects of domestic violence and of women’s rights in this regard. Primary physicians and nurses may have to overcome their own barriers and inhibitions relating to the issue of domestic violence. They need to learn how to ask screening questions, the importance of consent and of documentation, and how to assess their patients' safety. To accomplish these goals, medical staff should have extensive training, and be familiar with the resources for abused women existing locally, both inside and outside of the clinic. In our setting, a social worker is part of the clinic staff, to whom women can turn directly or be referred by the clinic physicians and nurses. The social worker is the central person within the clinic to deal with matters related to domestic violence and also serves as a consultant to medical personnel regarding abused women.
The social worker can refer the woman to resources outside the clinic, including shelters for abused women and their children, centers for the treatment of domestic violence, other services run by voluntary organizations and legal services such as the family court. Our experience with abused women is that only the minority turn to these treatment centers. In many cases, the clinic is their only place to get help. Our mandate, as clinic staff, is therefore not only to cure, but to care for the victim of abuse, to open the door for her, to hear her in a safe environment, to be her confidant (7). We may encounter her at a stage in her life when she does not yet want to take action regarding the situation but is relieved to share her secret. This is a healing relationship which can be a start to further treatment.
 Another aim in the diagnosis of domestic abuse is to prevent somatic fixation (14) among abused women who translate their suffering into physical symptoms. By diagnosing the problem correctly, a physician can avoid an excessive workup, which, in turn, often causes more somatic fixation.
Family physicians are trained to be patient-centered in their approach (14,15), to know their patients in their family context. The central role the family physician takes, in the front line of the medical system, makes him/her an important resource for a variety of life's problems.  Domestic violence is a severe family issue that presents itself to physicians in the form of physical symptoms and thus is being turned into a medical problem. We believe this can be avoided by training physicians and other health care professionals in the diagnosis and treatment of problems related to domestic violence.
This paper adds to the discussion regarding the difficulties of screening for domestic violence in a family practice setting. It also emphasizes the central place of a medical social worker in the primary care clinic regarding the issue of domestic violence.
Policy implications of this paper relate to the need for extensive education of the clinic staff regarding domestic violence, and the importance of a multi-disciplinary team to address the needs of abused women in the clinic.

References
1. McCauley J, Kern DE, Kolodner K, Dill L, Schroeder AF, DeChant HK, Ryden J, Bass E, Derogatis KLR. The “battering syndrome”: Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995;123:737-746
2. Eisenstat SA, Bancroft L. Domestic violence. New Eng J Med 1999;341:886-892
3. Grynbaum M, Biderman A, Levy A, Petasne-Weinstock S. Domestic Violence: Prevalence among Women in a Primary Care Center - A Pilot Study. Isr Med Assoc J 2001;907-910
4. Hamberger, LK. Saunders, DG. Hovey, M. Prevalence of domestic violence in community practices and rate of physician inquiry.  Fam Med 1992;24:283-287
5. Martins, R. Holzapfel, S. Baker, P. Wife abuse: are we detecting it? J Women’s Health 1992;1:77-80
6. US Department of Health and Human Services. US Department of Justice. Surgeon General’s workshop on violence and public health: report. Washington, DC: Public Health Service. 1986
7. Herman, JL. Trauma and Recovery. Basic Books, New York. 1992
8. Kurt JL. Stalking as a variant of domestic violence. Bull Am Acad Psychiatry Law 1995;23:219-230
9. Brainerd EG, Hunter PA, Moore D, Thompson TR. Jealousy induction as a predictor of power and the use of other control methods in heterosexual relationships. Psychol Rep 1996;79:1319-1325
10. Pines MA. Romantic jealousy. Understanding and conquering the shadow of love. Tel-Aviv, Cherikover. 1993
11. Kilpatrick KL,Williams LM. Post-traumatic stress disorder in child witnesses to domestic violence. Am J Orthopsychiatry 1997;67:639-664
12. Marais A, de Villiers PJ, Moller AT, Stein DJ. Domestic violence in patients visiting general practitioners-prevalence, phenomenology, and association with psychopathology. S Afr Med J 1999;89:635-640
13. Rodriguez MA, Sheldon WR, Bauer HM, Perez-Stable EJ. The factors associated with disclosure of intimate partner abuse to clinicians. J Fam Pract 2001;50:338-344
14. Mc Daniel, S. Campbell, TL. Seaburn, DB. Family-Oriented Primary Care: A Manual for Medical  Providers. Springer-Verlag. New York, Berlin 1989
15. Stuart, M. Brown, JB. Weston, WW. McWhinney, IR. McWilliam, CL. Freeman, TR. Patient-Centered Medicine. Transforming the Clinical Method. Thousand Oaks, CA, Sage Publications 1995

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