Severity of violence and quality of life of women with psychiatric disorders as compared to normal controls.

BACKGROUND: Despite the fact that violence against women is a significant public health problem, there is a paucity of research into this area, and little is known about the extent to which women with psychiatric disorders are affected. AIM: The aim of the study was to assess and compare the severity of violence and quality of life of women with psychiatric disorders and normal controls.
MATERIALS AND METHODS: Based on purposive sampling technique, a sample consisting of 120 participants was selected from in-patient (female section) and outpatient services of the Ranchi Institute of Neuro-Psychiatry and Allied Sciences and Kanke Area. Both groups were matched on sociodemographic details. Normal controls were screened using General Health Questionnaire-12. The severity of violence against women scale and the revised Conflict Tactics Scale were used to assess the severity of violence, and World Health Organization Quality of Life (WHOQOL)-BREF scale was used for the assessment of the quality of life. Scales were scored as per their test manuals. Results were tabulated and compared using appropriate statistical tests.
RESULTS: Women with psychiatric illness as well as normal controls faced various forms of symbolic violence equally. Women with psychiatric disorders faced significantly higher severity of physical assault, sexual coercion, and injury as compared to normal controls. Women with psychiatric disorders had significantly lower scores on WHOQOL BREF compared to normal participants.
CONCLUSION: Women with psychiatric disorders suffered significantly higher severity of both physical and sexual violence and had significantly worse quality of life compared to normal controls. Copyright:

“Violence against women is defined as any act of gender-based violence resulting in physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life.[1]” Interpersonal violence, institutional violence, and structural violence are the common varieties of violence faced by women. Interpersonal violence includes verbal abuse, threat, and intimidation, assault and battery, and rape and sexual assault. Institutional violence occurs in the family, workplace, and in the name of religious organization. Structural violence refers to at least two kinds of group violence that are socially motivated. One is for the purposes of establishing, defending, and/or extending hierarchy and inequality by the beating, exploiting, harassing, torturing, or killing individuals based on their age, class, ethnicity, gender, and/or sexual orientation. The other is for decreasing privilege and increasing liberty by resisting, protesting, and attacking those persons, symbols, or things that represent the established order.[2] A WHO multicenter study involving 11 countries reported that 15%–71% of women faced physical and sexual violence (SV) and 20%–75% emotional abuse in their lifetime.[3] Centre for Women's Studies and Development (CWSD) study found that women in India are subject to violence not only from husbands but also from members of both the natal and marital home.[4]

Violence is recognized as a significant contributor to ill health. Millions of women suffer from violence and its consequences because of their unequal status in society. Women who have experienced physical, sexual, or psychological violence suffer many health problems, often in silence. They have poor physical and mental health, suffer more injuries, but use less medical resources. Females of all ages are victims of violence, because of their limited social and economic power compared with men. Sometimes, men also are victims of violence, but violence against women is characterized by its high prevalence within the family; its acceptance by society; and its serious and long-term impact on women's health and quality of life.[56]

Violence has been recognized throughout as a significant health problem and a priority issue, but little attention has been given to its effects on the quality of life of female. Violence against women is worldwide phenomenon, and the fear of violence is an important factor in the lives of most women. Violence against mentally-ill women and their consequences can be more serious as these individuals may have more difficulty in protecting themselves due to impairment in various areas of their functioning. Hence, this population needs special attention and consideration, especially by mental health professionals. People living with mental illness are more likely to be the victims of all kinds of violence than those without mental illness. Studies reveal that the prevalence of physical violence against women with psychiatric disorders varies from 20.5% (in the past 12 months) to 82.1% (lifetime).[78910111213] Yet, all too frequently, women with serious mental illness fail to receive the treatment, services, protection, and support they need. It is in this background; the present study is significant because ignoring violence as a factor in women's health and well-being not only leads to misdiagnosis and inadequate treatment but also it ignores the personal and social consequences of violence. With this in mind, the present study was undertaken to assess the severity of violence and quality of life of women with psychiatric illness as compared to normal controls.

MATERIALS AND METHODS

This cross-sectional study was undertaken at Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS) and Kanke area, Ranchi, during the period from September 2009 to November 2011. The study protocol was approved by the institutional ethical committee. Informed consent was obtained from all participants, and the purpose of the study was clearly explained to the participants.

The participants were selected using purposive sampling technique from inpatient (female ward) and outpatient services of RINPAS and Kanke area meeting the following inclusion and exclusion criteria. An equal number of age- and sex-matched normal controls were included with the following inclusion and exclusion criteria.

Inclusion criteria for women with psychiatric illness

Diagnosis of psychiatric disorders according to the International Statistical Classification of Diseases and Related Health Problems-10 Diagnostic Criteria for Research.[14]

Patients who gave consent to participate

Patients whose acute symptoms had subsided by treatment and were communicative

Married patients in the age range of 18–50 years

Patients who were educated up to primary level.

Exclusion criteria for women with psychiatric illness

Patients who were not cooperative.

Patients with any comorbid neurological disorder and severe physical illness.

Inclusion criteria for the normal controls

Participants who gave consent to participate.

Married participants in the age range of 18–50 years

Participants who were educated up to primary level.

Exclusion criteria for the normal controls

Participants who scored above the cutoff point of General Health Questionnaire-12 (GHQ-12)

Participants with a past history of psychiatric disorders.

Tools of measurement

Sociodemographic datasheet

It is a semi-structured Pro forma, especially designed to obtain information about sociodemographic variables such as age, sex, education, marital status, religion, and family type.

General Health Questionnaire-12

The GHQ12 is a measure of current mental health. It focuses on two major areas – the inability to carry out normal functions and the appearance of new and distressing experiences. It is sensitive to the presence of psychiatric disorders in individuals presenting in primary care settings and nonpsychiatric clinical settings.[15]

Severity of violence against women scale

This 46-item scale assesses the occurrence of and provides normative severity ratings for, nine dimensions of aggression from a male toward a female partner. Items were rationally derived based on the family violence literature. The scale assesses nine dimensions of threats of violence or actual violent behavior. In the student sample, alpha coefficients of severity ratings ranged from 0.92 to 0.96 across the nine dimensions. Alphas ranged from 0.89 to 0.96 in the community sample including excellent internal consistency in both samples. Initial construct validity is supported by the scale development procedures, which provide empirical support for dimensions through item impact ratings, factor analysis, and scale intercorrelations.[16]

The Revised Conflict Tactics Scale 2

The Conflict Tactics Scale 2 (CTS2) is the most widely used research and clinical instrument for obtaining data on physical violence on a partner. For the present study, the version which measures violence against the spouse was used. The 39-item victimization scale of CTS2 comprises five subscales that measure the frequency of physical assault, psychological aggression, sexual coercion, negotiation, and injury between partners. Construct validity of the CTS has been demonstrated in a number of studies. The scale has good internal consistency. Reliability ranges from 0.79 to 0.95.[1718]

Quality of life scale (World Health Organization Quality of Life-BREF)

Hindi version of the World Health Organization Quality of Life (WHOQOL)-BREF contains 26 questions in four major domains: physical health, psychological health, social relationships, and environment. This scale emphasizes the subjective experiences of the respondents rather than their objective life conditions. The alpha score of all domain ranges from 0.59 to 0.87; the factor loadings of the item range from 0.52 to 0.84. WHOQOL-BREF is highly valid across cultures.[19]

Procedure

The participants were selected using purposive sampling technique from inpatient (female ward) and outpatient services of the Ranchi Institute of Neuro-Psychiatry and Allied Sciences and Kanke area following the inclusion and exclusion criteria. Normal controls were screened using GHQ-12. Informed consent was obtained from all participants, and the purpose of the study was clearly explained to the participants. After collecting sociodemographic information, the Severity of Violence Against Women Scale, The revised CTS, and WHO Quality of Life-BREF scale were administered, respectively. The tests were scored as per the manual and results tabulated.

Statistical analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS 16.0, IBM). To determine whether there were any baseline differences in sociodemographic characteristics of participant's Chi-square analysis was done. For comparison of severity and frequency of violence between women with psychiatric illness and normal controls, Mann–Whitney U test (for ordinal variables) was used.

RESULTS

The sample consisted of sixty women with psychiatric disorders (34 patients of bipolar affective disorder, 22 having schizophrenia, 2 diagnosed as psychotic disorder not otherwise specified, and 2 suffering from obsessive–compulsive disorder) and an equal number of age-matched normal controls. The majority of the participating women were Hindus, in the age range of 18–35 years, educated up to primary level, and were not employed. Most of the women were from joint family, rural area, had more than two children and belonged to low socioeconomic status with monthly family income between Rs. 3000 and 5000. No significant difference was found between these groups in any of the sociodemographic characteristics [Table 1]. Comparison of scores on severity of violence against women scale and CTS between women with psychiatric disorder and normal controls is shown in Tables 2 and 3, respectively. Comparison of type and level of severity of conflict tactics in women with psychiatric disorder and normal controls is given in Table 4. Women with psychiatric disorder had significantly lower scores on all the subscales of WHO QOL BREF compared to normal controls [Table 5].

Table 1

The sociodemographic details of women with psychiatric illness and normal controls

Variables	Women with psychiatric illness	Normal controls	χ2 (df)	Significance
Age (years)
18-35	40	35	0.889 (1)	NS
36-50	20	25
Education
Primary	13	12	0.204 (4)	NS
Matriculation	18	19
Intermediate	20	19
Other qualification	9	10
Occupation
Working	18	20	0.577NS (1)	NS
Nonworking	42	40
Type of family
Nuclear	15	10	1.263NS (2)	NS
Joint	45	50
Number of children
None	5	9	1.833NS (2)	NS, NS
One	10	12
Two	20	16
>Two	25	23	1.014NS (1)	NS
Family income (Rs.)
3000-5000	35	34
6000-8000	15	12
>8000	10	14
Religion
Hindu	20	20	0.373NS (2)	NS
Muslim	10	9
Christian	18	21
Sikh	12	10
Domicile
Urban	20	25	1.269NS (1)	NS
Rural	40	35
Socioeconomic status
Low	30	32	4.032NS (2)	NS
Middle	20	22
High	10	6

NS - Not significant

Table 2

Comparison of severity of violence against women between women with psychiatric illness and normal controls

Severity of violence against women scale	Mean±SD			Mann-Whitney U-test
	Women with psychiatric illness	Normal controls	Mean rank		U	Z-score
			Women with psychiatric illness	Normal controls
Symbolic violence	2.967±1.053	2.900±1.052	64.18	62.82	1579.00	−1.212NS
Threat of mild violence	2.633±1.288	2.267±0.999	63.13	57.87	1642.00	−0.857*
Threat of moderate violence	2.950±1.099	2.917±0.962	68.21	62.79	1662.50	−0.752NS
Threat of serious violence	2.817±0.962	2.867±0.947	60.46	59.54	1742.50	−0.316NS
Mild violence	2.4667±0.747	2.2000±1.269	64.08	60.92	1775.00	−0.136*
Minor violence	3.1667±0.905	2.4833±1.127	70.75	50.25	1185.00	−3.368**
Moderate violence	2.4667±1.112	1.8333±0.905	70.17	50.83	1220.00	−3.138**
Serious violence	3.0833±0.869	1.9167±0.869	79.67	41.33	650.00	−6.251**
Sexual violence	3.1667±0.994	2.2500±0.932	75.29	45.71	912.500	−4.830**

*P<0.05, **P<0.01. NS - Not significant; SD - Standard deviation

Table 3

Comparison of Conflict Tactics Scale scores between women with psychiatric illness and normal controls

Conflict Tactics Scale-2	Mean±SD		Mann-Whitney U test
	Women with psychiatric illness	Normal controls	Mean rank		U	Z-score
			Women with psychiatric illness	Normal controls
Negotiation	1.833±0.905	2.517±0.651	48.17	72.83	1060.00	−4.189**
Psychological aggression	2.667±0.629	2.500±0.651	65.08	55.92	1525.00	−1.741NS
Physical assault	2.633±0.551	1.583±0.766	80.50	40.50	600.00	−6.723**
Sexual coercion	2.250±0.795	1.583±0.766	73.42	47.58	1025.00	−4.332**
Injury	2.083±0.829	1.750±0.836	67.00	54.00	1410.00	−2.180**

**P<0.01. NS - Not significant; SD - Standard deviation

Table 4

Comparison of type and level of severity of conflict tactics in women with psychiatric illness and normal controls

Conflict Tactics Scale-2	Type and level of severity	Women with psychiatric illness	Normal controls	χ2 (df)
Negotiation	Never	30	5	42.712** (2)
	Cognitive	7	40
	Emotional	23	15
Psychological aggression	Never	5	5	0.276NS (2)
	Minor	32	40
	Severe	23	15
Physical assault	Never	5	35	42.696** (2)
	Minor	23	10
	Severe	32	15
Sexual coercion	Never	12	35	18.635** (2)
	Minor	17	10
	Severe	31	15
Injury	Never	18	30	27.676** (2)
	Minor	10	25
	Severe	32	5

**P<0.01. NS - Not significant

Table 5

Comparison of quality of life between women with psychiatric illness and normal controls

WHO-quality of life scale BREF	Mean±SD		Mann-Whitney U test
	Women with psychiatric illness	Normal controls	Mean rank		U	Z-score
			Women with psychiatric illness	Normal controls
Physical health	2.333±1.189	3.250±1.099	47.38	73.62	1012.50	−4.251**
Psychological health	2.333±1.189	3.333±1.258	47.79	73.21	1037.50	−4.130**
Social relation	2.250±1.019	3.583±1.453	45.08	75.92	875.00	−5.000**
Environment	2.333±1.189	3.750±1.373	44.46	76.54	837.50	−5.187**

**P<0.01. SD - Standard deviation; WHO - World Health Organization

DISCUSSION

Violence against women is often not looked for in mental health clinical settings and is also a low priority in research into mental health issues. Moreover, there are many barriers to disclosure by patients and enquiry about violence against women by health professionals.[20] The past research on violence and psychiatric disorders has concentrated on violence perpetrated by patients with psychoses.[2122] However, it is increasingly evident that it is the psychiatric patients who are more often the victims of domestic and SV. A systematic review of 42 studies revealed that the median prevalence of domestic violence among female psychiatric patients was 30%. Unfortunately, none of the studies included control populations, and there was little information on emotional abuse and violence perpetrated by family members (other than partners).[23] The inclusion of a matched control group in the present study is a step forward and gives a better picture of the present conditions of women in society.

Comparison of severity of violence against women with psychiatric disorder and normal controls

A major finding of this study was that symbolic violence was equally faced by both the groups which is consistent with the findings of an earlier study.[24] In the early stages of an abusive relationship, the escalating tension can be implied rather than overt violence. The abusive partner may hit, kick, or break furniture or other inanimate objects, while the abused partner watches. Displays of violence such as this are prophetic – the woman watching knows that even though the violence is directed at a piece of furniture this time, it may be her next time.[24] With regard to threat of mild violence, it was observed that women with psychiatric disorder faced significantly more threats of mild violence as compared to normal controls. On the other hand, threat of moderate violence was equally faced by both the groups. Social psychology research suggests that threats of violence are generally a typical tactic used to coerce compliance.[25] Women are more prone to suffer repeat victimization, a longer history of violence, and violence and stalking after separation from a partner. Women are also more likely to experience fear, threats, intimidation, and assaults during stalking, and fear that they or someone close to them would be harmed or killed.[26] Abusive partners may also use a woman's children to coerce her into staying in the relationship. The abusive partner may threaten to harm the children, take them away, or physically hurt the children in front of their mother to maintain control of her.[27] In the present study, the threat of serious violence was equally faced by women with psychiatric disorder and normal controls. However, the findings indicate that women with psychiatric disorder have faced more mild and minor violence as compared to normal controls. National Family Health Survey-3 also reported similar findings in that most women said their husband had pulled their hair or twisted their arms followed by having something thrown at them, being pushed, or shaken.[28]

In the comparison of moderate and serious violence, the finding suggests that women with psychiatric disorder have faced more moderate and serious violence as compared to normal controls. The findings are similar to those reported by the WHO (2005) who found in their multicountry study that the most common act of violence experienced by women was being slapped by their partner. More women reported severe physical violence having occurred over a year ago than in the past 12 months. More than half of women who had suffered a violent act in the past 1 year had faced that act more than once.[3] The CWSD study also reported that most women experienced beating frequently. Beating followed by kicking was rated as the first and second most common mode of physical violence.[4]

An important finding of the present study was that women with psychiatric disorder faced more SV as compared to normal controls. The finding of increased SV faced by psychiatric patients is in agreement with the results of few earlier studies. Jennings found that 50%–70% of female psychiatric inpatients had histories of physical or sexual abuse.[29] Three groups of female substance abusers: with schizophrenia, with nonpsychotic affective disorders (e.g., depression), and without comorbid psychiatric disorders were asked about physical and sexual abuse. Results revealed elevated rates of violent sexual and physical abuse in the previous year. The risks were significantly higher in women with schizophrenia.[30] A meta-analysis of studies of physical and SV faced by adults with disabilities included 17 studies with data on mentally ill individuals. They reported that 21% of the mentally ill had experienced physical violence, and 6% had experienced SV within the previous 12 months.[31]

In a UK study of 303 randomly selected psychiatric outpatients and 22,606 general population controls interviewed using the British Crime Survey domestic/SV questionnaire, SV in the past year was reported by 10% and 2%, respectively (adjusted odds ratio 2.9, 95% confidence interval 1.4–5.8).[32] CWSD study also reported that 1.6% of women mentioned forced sex as the most frequent mode of violence they had to suffer.[4] In an Australian study involving 230 adult general practice outpatients, it was found that 45.2% had experienced at least one incident of SV in adulthood, while 26.9% reported child sexual abuse. Most reported unwanted caresses, being fondled or groped, and being forced to have sex due to pressure and coercion by the partner.[33]

Comparison of conflict tactics and its level of severity in women with psychiatric disorder and normal controls

Negotiation

Comparison of conflict tactics revealed a significant difference in negotiation, which indicates that negotiation was more used by normal controls in conflict resolution as compared to women with psychiatric disorder. Further, the results indicate that cognitive negotiation was significantly more used by normal controls, whereas emotional negotiation was significantly more used by women with psychiatric disorder in conflict resolution. Similarly, Gilson et al.[34] reported that people with disabilities being more likely to experience violence and abuse. Another study also reported that symptoms associated with serious mental illness, such as impaired reality testing, disorganized thought processes, impulsivity, and poor planning and problem-solving, can compromise one's ability to perceive risks and protect oneself from violence.[35]

Psychological aggression

With regard to psychological aggression, the results indicate that minor psychological aggression as well as severe psychological aggression was almost equally faced by both the groups. In agreement with the findings of the present study, CWSD study also reported that psychological torture was rampant in domestic violence. Excluding a minor percentage, all others had suffered mental strain of one form or the other. Almost half of women had to suffer the psychological strain on a frequent and occasional basis. The majority of the victims (55.9%) had to bear the pain of psychological strain either frequently or occasionally.[4] Another study also observed that all categories of women reported either psychological or physical abuse at incidence levels ranging from 60% to 75%.[36]

Physical assault

In the comparison of physical assault, the findings indicate that both minor and severe physical assault was faced more by women with psychiatric disorder as compared to normal controls. Many studies are in agreement with the findings of the present study. CWSD study found that 81.6% of the victims suffered physical violence. The victims also reported that, in addition to the multiple forms, they experienced violence not once but several times in their life. The frequency with which they experienced the torture varied from daily to rarely.[4] Similarly, Goodman et al. concluded that a large proportion of women with a serious mental disorder are victimized repeatedly in the course of their lives.[37] Coverdale et al. reported that, during adulthood, female patients were significantly more likely to be sexually and physically abused than male patients, and those sexually abused were significantly more likely to report a history of sexual abuse during childhood.[38] A WHO study reported that 49% of ever-partnered women experienced physical violence by a partner at some point in their lives and 35% of all ever-partnered women experienced at least one severe form of physical violence.[3]

Sexual coersion

In the present study, the findings suggest that sexual coercion was frequently faced by women with psychiatric disorder as compared to normal controls. In the level of severity of sexual coercion, the finding suggests that minor as well as severe sexual coercion was more faced by women with psychiatric disorder as compared to normal controls. Consistent with the above findings, Eckert et al. concluded in their study that sexual assaults in women with a major psychiatric disorder were common and more violent than in women without such diagnoses.[39] The findings of the present study are also in agreement with the previous study of Chandra et al., who found that sexual coercion is a serious and prevalent concern among female Indian psychiatric patients.[40]

Injury

In the comparison of injury, the finding suggests that women with psychiatric disorder were more injured due to physical assault or sexual coercion as compared to normal controls. In the level of severity of injury, the findings indicate that women with psychiatric disorder faced more minor as well as severe injuries as compared to normal controls. Similarly, the CWSD study reported that most of the respondents in their study were physically injured by the attacks on them, and half of them were very seriously injured.[4] The findings of the present study are also consistent with the findings of Trevillion et al., who reported that both men and women with all types of mental disorders report a high prevalence and increased risk of domestic violence compared to people without mental disorder, with women more likely to experience abuse than men.[41]

Comparison of quality of life of women with psychiatric disorder and normal controls

In physical health, the finding suggests that normal controls were more satisfied with their physical health as compared to women with psychiatric disorder. Laffaye et al. also found in his study that female victims of intimate partner violence were significantly more impaired than the nonabused control group. Victims were significantly more impaired in their physical functioning, mental health, vitality, role limitations due to emotional health, and social functioning.[42] Alsaker reported in a cross-sectional study that women experienced a multitude of threats and actual physical and psychological violence during their partnership. Their health-related quality of life was low and significantly below the norm for the female population of Norway in all dimensions.[43]

In psychological health, the finding suggests that normal controls were more satisfied with their psychological health as compared to normal controls. Heise also stated that violence against women can result in long-term mental, physical, and sexual health problems.[44] An official German report also concluded that all forms of violence can contribute extensively to psychological, psychosocial, and health problems for those women affected.[45] Violent victimization can influence women's overall perception of health, which can reflect women's general health status.[46]

In social relationships, the finding indicates that normal controls were significantly more satisfied with their social relation as compared to women with psychiatric disorder. Similarly, Greenan concluded that violence against women has a significant impact on the lives of individual women, their health, their safety, their self-esteem, and their ability to participate in society.[47] A German review found that violence seems to be a factor for many women, leading to cutting all ties to former personal and professional relationships and in the case of every third to seventh women, seem to end in therapy.[45]

In environment also, the findings indicate that normal controls were significantly more satisfied with their environment as compared to women with psychiatric disorder. A German review also found in their study that the social environment seems to play a major role in the support of women affected by violence, in a positive as well as in a negative sense.[45] The results of the present study are in agreement with an earlier study which established that, along with the proximate physical and emotional impacts of violence, women's overall QOL may be adversely impacted over an entire lifetime, which can, in turn, affect their participation and engagement in various aspects of life and society.[48]

Limitations

The sample size of the study was small, and hence the generalization of the result remains doubtful. Second, the samples were selected using purposive sampling technique. The samples were not selected disorder wise. Illiterate patients were also not included in the study due to problem in administering the scales.

CONCLUSION

Women with psychiatric disorders suffered significantly higher severity of both physical and SV and had significantly worse quality of life compared to normal controls.

The findings suggest the immediate need for action and for more support of women experiencing violence. It also indicates the necessity for more efforts in the direction of early identification, intervention, and prevention, especially for women with a psychiatric disorder.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.