Caring for Abused Persons

Chapter 35

Self-esteem: how one feels about oneself. Its components are self-

acceptance, self-worth, self-love and self-nurturing.

Abuse

• Most abuse of women, children and elderly is intimate violence (perpetrator loved and trusted person).

• World is no longer safe.

• Empowerment is foreign.

• Empowerment is the promotion of the continued growth and development of strength, power and personal excellence.

Woman Abuse

• Significant health problem crossing all racial, ethnic and SES lines

• 2-4 million women abused each year

• Single, divorce separated women at highest risk

• Violence begins early in dating relationship

• Dynamics of intimate relationships– Chronic syndrome characterized by emotional abuse, degradation,

restrictions on freedom, abuse, threats, stalking and isolation from family

– Core pattern of coercive control

Battering, Rape and Sexual Assault

• Single greatest cause of injury to women• Women are aware that they are in danger of being killed.• Sexual assault occurs once every 6.4 minutes.• Types of rapists:

– Power (55%)• Attack people own age, using intimidation and minimal physical force• Premeditated

– Anger (40%)• Target either very young or old• May use extreme force resulting in injury

– Sadistic (5%)• Most dangerous• Premeditated, often torture or kill victims• Derive erotic gratification

Child Abuse• Can take several forms, varies from state to state• Prevalence unknown• Child neglect most common

– Failure to protect child– Physical neglect– Medical neglect

• Physical - severe spanking, kicking, shoving or any other type of physical action

• Sexual abuse - ranges from mild (covert) to severe (overt)– Incest– Sexual abuse by a non-family member– Pedophilia

Child Abuse (cont.)• Emotional abuse

• Acts of omission, co-mission that psychologically damage the child

• Types– Rejecting

– Isolating

– Terrorizing

– Ignoring

– Corrupting

• Munchausen’s by proxy (factitious disorder)

• Children of battered women

Elder Abuse• Estimated at 1.5 million cases

• Neglect (58.5%)

• Physical abuse (15.7%)

• Financial/material mismanagement (12.3%)

• Emotional (7.3%)

• Sexual (.04%)

• Risks• Older age

• Impairment in ADL

• Dependency on caregiver

• Isolation, stressful events

• History of intergenerational conflict

Biologic Theories

• Neurologic problems– Traumatic brain injury, seizure disorder (post-

ictal), dementia

– Orbitofrontal cortex damage

– Disruption of neurotransmitter system

• Links with substance abuse

Psychosocial Theories• Psychopathology theory

– Type I - antisocial and violent in many situations– Type II - antisocial and abuse family members– Type III - dysphoric-borderline, only family

• Social learning theory– Men who view violence as children become violent as adults.

• Social– Acceptance of violence as normal– Family stress theory

Dynamics of Woman Abuse

• Feminist theories• Men perpetuating control over women

• Patriarchal society

• Power inequity

• Borderline personality organization • Consistent with cycle of violence

• Why women stay in relationships• Economic

• Responsible for maintenance of marriage, family

Dynamics of Woman Abuse (cont.)

• Traumatic bonding• Explains why women stay in relationship

• Emotional attachments formed because of intermittent abuse

• Structural components of relationship– Power imbalance

– Intermittency in abuse

• Cycle of violence

Biologic Responses

• Depression

• Acute stress disorder (ASD)• New disorder in updated DSM-IV

• Barrage of stress-related events persists for two days

• If lasts longer, becomes PTSD

• Post-traumatic stress disorder (PTSD)

• Dissociative identity disorder (DID)

Post-traumatic Stress Disorder

• Lifetime prevalence: 1 to14%

• More prevalent in women than men

• 30% of women develop PTSD after exposure to a traumatic event, 15% of men

• May develop anytime after trauma

• Young and elderly more sensitive

PTSD

• Hyperarousal– Stress system goes on permanent alert– Dopamine hyperactivity– Behavioral sensitization

• Intrusion– Re-live as if it were continually recurring– Flashbacks, nightmare vivid– Amygdala involved in memory

• Avoidance and numbing– Develop periods of dissociation

Dissociative Identity Disorder

• Formerly multiple personality disorder• Two or more distinct identities with unique

personality characteristics and inability to recall important information about self

• Prevalence unknown

Dissociative Identity Disorder

• Etiology unknown, but causative factors include:

– A traumatic event

– A psychological or genetic vulnerability

– Formative environmental factors

– Absence of external support

Substance Abuse and Dependence

• Association between childhood abuse, PTSD and substance abuse is well-established.

• Survivors who experience PTSD, depression and other forms of hyperarousal or emotional distress often abuse substances that inhibit noradrenergic activity and lessen stress.

Psychological Responses• Low self-esteem

• Alienation from self (painful feelings that go to the core)

• Alienation from others (painful feelings from being disconnected to others)

• Guilt and shame• Blame self for abuse

• Prevent victims from seeking medical care and reporting abuse

• Anger• Chronic irritability, unexpected or uncontrollable feelings of anger

Social and Interpersonal Responses

• Problems with intimacy– Difficulty forming trusting relationships

– Sexual problems common

• Revictimization– Victims usually become victims again

– High risk for dissociative disorders

– Alexithymia may add risk for revictimization

Assessing for Abuse

• Health care providers often miss abuse or re-victimize the patient by blaming.

• Establishing a nurse-patient relationship is the most important step.

• Lethality assessment first

• Assessment questions

Biologic Assessment

• Past seven present medical history, ADLS

• Document injuries.

• Observe for:• Elevated pulse and BP

• Sleep and appetite disturbances

• Nightmares

• Memory difficulties

• Substance abuse

Psychological Assessment

• Mental status evaluation• Suicide assessment• Observe for:

– Anhedonia– Difficulty concentrating– Feelings of worthlessness or guilt– Thoughts of suicide or death

Social Assessment

• Social networks and support

• Daily activities

• Financial support

• Assess restriction of freedom

• Degree of dependency in relationship

Sexual Assault

• Assess for injuries.

• Collect evidence for forensic evaluation.

• Someone specially trained should conduct it.

Nursing Management: Children• Careful physical assessment• Safety of child• Breaking the silence• Increasing self-esteem• Dealing with loss• Learning to trust• Learning to protect oneself• Assertive conflict resolution• Empowerment

Nursing Management: Elderly• Accurate assessment

• Determining danger

• Interventions depend on acceptance

• Included in mandatory reporting

• Improving functional level

• Involving other family members

Biologic Interventions

• Restoring physical health• Teaching sleep hygiene, promoting exercise• Administering and monitoring medications

• PTSD -benzodiazepine, -blockers and antidepressants (SSRIs- Zoloft)

• Referring to treatment center for substance abuse

Psychological Interventions

• Assisting with psychotherapy or counseling

• Providing education

• Behavioral interventions– Anxiety management

– Measuring gains in small steps

Social Interventions

• Family interventions– Parenting skills

– Leisure skills

– Household organization

• Working in the community– Assistance in developing support networks

– Home visits

Special Considerations in Sexual Assault

• Early treatment crucial• Diminish survivor distress• Supportive, caring, non-judgmental• Unwanted pregnancies• STD, HIV• Interventions

– Education– Counseling– Emotional support

Evaluation and Treatment Outcomes

• Depends on the setting• Follow-up important• Referral for treatment of disorders

resulting from abuse (ASD, PTSD and other anxiety disorders, DID, major depression, substance abuse)