Physical and Psychological Symptoms in Emotionally Abused and Non-abused Women
==============================================================================

* John H. Porcerelli
* Patricia A. West
* Juliann Binienda
* Rosemary Cogan

## Abstract

*Background:* This brief report compares emotionally abused and non-abused female family practice patients on physical and emotional symptoms, alcohol use problems, and social support problems.

*Methods:*We conducted a secondary analysis of data from a cross-sectional, multicenter study of victimization of family practice patients. Forty-seven adult women meeting criteria for emotional abuse (within the past year) and no physical abuse were matched demographically with 47 non-abused women. Each woman completed demographic and health history questionnaires, including questions about physical and emotional abuse.

*Results:*Emotionally abused women reported a greater number of physical (*P* < .001) and psychological (*P* < .0001) symptoms than non-abused controls. Emotionally abused women reported a significantly greater number of social support problems than non-abused women (*P* < .04).

*Conclusions:*This study supports a growing literature that demonstrates an association between emotional abuse and physical and emotional symptoms in women who are currently suffering emotional abuse at the hands of their partner or ex-partner. It is recommended that physicians inquire about emotional abuse in female patients with multiple psychosocial and physical symptoms.

The negative health consequences of physical abuse of women by their intimate partners are well documented throughout the health science literature. Less is known about the consequences of emotional abuse to women. Emotional abuse (also referred to as psychological abuse) can include any one of the following alone or in combination: threats of physical harm, physical and social isolation, extreme jealousy and controlling behavior, degradation, intimidation and other forms of chronic verbal harassment, withdrawal, destroying trust, and placing a partner in a dangerous situation.1 Although most women who suffer physical abuse at the hands of their partner also report being emotionally abused, there is a subset of women who report only emotional abuse. Longitudinal studies suggest that emotional abuse almost always precedes physical abuse.2 In studies of women who report both physical and emotional abuse, negative health outcomes are as strongly associated with emotional abuse as they are with physical abuse.3,4

The present study compared female family medicine patients reporting emotional abuse (and no physical abuse by a partner, ex-partner, or non-partner) with a group of non-abused women matched for age, race, income, employment, and education. We compared emotionally abused and non-abused women on self-reported physical symptoms and psychosocial variables. We hypothesized that emotionally abused women will have more physical and psychological symptoms, alcohol use problems, and social support problems than non-abused women.

## Methods

In this cross-sectional group comparison study design, participants were obtained from a multicenter prevalence study of violent victimization of male and female family practice patients.5 In the original study, 713 women and 350 men from 4 family practice clinics (1 urban and 2 suburban residency training sites and 1 suburban faculty practice) participated and were screened for physical and emotional abuse. Screening was conducted with consecutive female patients on 3 half-days per week in each of the clinic waiting rooms for a duration of ∼2 months. Only data on health correlates of physical victimization were reported in that study. Of the 713 women, 47 adult women (ages 18 to 64) reported being emotionally abused by their partner “within the past year” (not physically abused) and thus are the focus of this study. A comparison group included 47 women matched for age (±5 years), race (97% exact match), education (94% exact match), employment (89% exact match), and income (83% exact match). Non-exact matches were within one level of the standard demographic categories. Each emotionally abused woman was matched with one non-abused woman from our original sample. When more than one non-abused woman was eligible for matching to a woman in the emotionally abused group, one was randomly chosen using a random number generator.

Participants responded to a demographic questionnaire, the Brief Conflict Tactics Scale6 a single question with adequate validity for screening physical abuse in emergency department settings (*Have you been hit, kicked, punched or otherwise hurt by someone in the past year? If so, by whom?*), a face-valid question about emotional abuse developed by the investigators (*Have you felt controlled, threatened, or afraid of someone within the past year? If so, by whom?*), and a checklist of perpetrators (family member, friend, partner/ex-partner, stranger). If a patient checked the “yes” box for either abuse question, they were also requested to place a check mark next to the perpetrator(s).

In addition, a modified 88-item version of the Milcom Health History Update and Physical Examination form developed by Hollister, Inc. in cooperation with the Society of Teachers of Family Medicine was administered. The Milcom is made up of standard physical and emotional health items answered in a “yes-no” format. For this study, 17 physical symptoms included head, ears, eyes, nose, and throat (HEENT) items (headaches, dizziness, seizures, troubles with your ears, dental or other mouth problems, and nose bleeds), respiratory/cardiovascular items (palpitations and chest pain), gastrointestinal (abdominal discomfort and pain, nausea or vomiting, difficulty swallowing), genitourinary (menstrual changes, discomfort during intercourse, vaginal bleeding after intercourse, pelvic pain), skin (skin problems or changes in your skin), aching muscles or joints. Women reporting both physical and emotional abuse within the past year were excluded from this study. Psychological symptoms include 6 depression items (exhausted or fatigued most of the time, felt blue, lonely or depressed, more irritable than usual, frequent crying spells, suicidal ideation) and 2 anxiety items (difficulty trying to calm down or relax and overly anxious or worrying a lot). Alcohol use problems include the 4 CAGE7 questions and an additional item on quantity of daily use. Four social support items include (time well-balanced between work, family, and play; relationship with friends; relationship with partner; someone to discuss personal problems with).

Inclusion criteria for the emotional abuse group included women who reported being emotionally abused by their partner or ex-partner within the previous year and did not indicate physical abuse within the previous year by partner, ex-partner, or non-partner. Women in the control group did not report either physical or emotional abuse within the past year.

Because the groups in our study were matched on several demographic variables and thus were not considered as independent groups, paired-sample *t* tests were conducted comparing the emotionally abused group with the matched control group on each of the main dependent variables (physical symptoms, psychological symptoms, alcohol use problems, and social support problems).

## Results

Because the groups in this study were matched according to age, race, education, and income, overall scores are reported for the total sample: mean age = 35.72 (SD = 9.83; range 18 to 59); Caucasians = 52%, African Americans = 42%, other = 6%; 72% of patients had a family income less than $51,000, and 87% had at least a high school education.

The results of the analyses comparing emotionally abused and non-abused women on physical and psychological symptoms, alcohol use problems, and social support problems are reported in Table 1. The *t* values for physical symptoms (*P* = .001), psychological symptoms (*P* = .0001), and social support (*P* = .043) were statistically significant, thus supporting 3 of 4 hypotheses. Because statistical significance is affected by sample size, effect sizes were also used in this study to assess the strength of the differences between groups. According to Cohen’s criteria, an effect size of 0.20 is considered to be a small effect, 0.50 is considered a medium effect, and 0.80 is considered a large effect.8 In this study, differences in psychological symptoms between the matched groups evidenced a large effect (0.95), whereas the differences in physical symptoms approached a large effect (0.74), and social support problems (0.43) evidenced a moderate effect. Thus despite the small sample sizes of the groups, substantial differences, especially in physical and emotional symptoms, were obtained. Group differences approaching large effect sizes are likely to have clinical significance.

View this table:
[Table 1.](http://www.jabfm.org/content/19/2/201/T1)

Table 1. 
Physical and psychological symptoms, alcohol use problems and social support problems in emotionally abused and non-abused women.

Exploratory analyses were conducted to determine which specific physical symptom differed between the emotionally abused and non-abused groups. The *t* tests for each of the items revealed 8 of 18 physical symptoms were significantly greater in the emotionally abused group: HEENT items related to dizziness and seizures, cardiac items related to palpitations and chest tightness, gastrointestinal items related to abdominal discomfort and difficulty swallowing, and genitourinary items related to change in menstrual periods. Results of the analyses of specific psychological symptoms revealed differences on all items except for suicidal ideation. Only one of the social support problem items differed between the emotional and non-abuse groups: “Is your relationship with your spouse/partner as good as it was last year?”

## Discussion

This study supports a growing literature on the relationship between emotional abuse and physical and psychological symptoms.2–4 These studies showed symptoms in multiple systems including neurological, cardiovascular, abdominal, and genitourinary as well as in psychological (mostly depressive) symptoms. Women in the emotional abuse group also reported a greater number of negative social support items, ie, changes in their relationship with their partner within the past year.

We hypothesized that emotionally abused women have higher alcohol use problem scores than non-abused women (ie, emotionally abused women would turn to alcohol as a coping mechanism). This was not true in our study sample. In our original study,5 physically victimized women evidenced less alcohol use problems than physically victimized men. However, women who were physically victimized by more than one type of perpetrator (eg, partner and stranger) evidenced more alcohol use problems than women who were physically victimized by a single perpetrator or non-victimized.

The need for identifying physical abuse of women in primary care is well established. However, the findings from this and other recent studies,2–4 indicate that physicians should inquire about emotional abuse in women who present with multiple physical and psychological symptoms. Except for the HITS (hurt, insulted, threatened, screamed),9 instruments used for identifying partner abuse in primary care settings include physical victimization items and rarely include an item about emotional abuse. For example, the Patient Health Questionnaire,10 a valid self-report psychiatric diagnostic instrument designed for primary care settings, includes one domestic violence item having to do with physical abuse only. It is recommended that both physical and emotional abuse items be included in standard assessment scales. Both self-report and patient-centered interviewing can aid primary care physicians in providing comprehensive preventive health care to their female patients as it relates to interpersonal violence.

Limitations of the study include a cross-sectional design which limits our ability to indicate a causal link between emotional abuse and physical and psychological symptoms. Longitudinal studies comparing pre- and post-abuse physical and psychological status are needed with primary care patients. Additional limitations of the study include a small sample size, lack of statistical adjustment of common confounding variables (eg, degree of somatization, history of childhood abuse/neglect, etc), a reliance on self-reported physical symptoms, and the use of a single (global) emotional abuse screening item for the determination of emotional abuse. However, the success of this single item in the present study warrants further study of its convergent and predictive validity with other known scales of emotional abuse.

## Notes

*   *Funding:* This work was supported by grants from the Oakland Health Education Program (OHEP) Center for Medical Education (Southfield, MI) and St. John Hospital and Medical Center Research Fund (St. Clair Shores, MI).
    
    *Conflict of interest:* none declared.

*   Received for publication May 3, 2005.
*   Revision received July 26, 2005.
*   Accepted for publication July 29, 2005.

## References

1.  Eyler AE, Cohen M, Kershaw MO. Domestic violence and abuse. In: Knesper DJ, Riba MB, Schwenk TL, editors. Primary care psychiatry. Philadelphia (PA): WB Saunders; 1997. p. 387–68.
    
    

2.  O’Leary DK. Psychological abuse: a variable deserving critical attention in domestic violence. Violence Vict 1999; 14: 3–23.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10397623&link_type=MED&atom=%2Fjabfp%2F19%2F2%2F201.atom) 

3.  Coker AL, Smith PH, Bethea L, King MR, McNeown RE. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med 2000; 9: 451–7.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1001/archfami.9.5.451&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10810951&link_type=MED&atom=%2Fjabfp%2F19%2F2%2F201.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000086954100010&link_type=ISI) 

4.  Coker AL, Davis KE, Arias I, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med 2002; 23: 260–8.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/S0749-3797(02)00514-7&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=12406480&link_type=MED&atom=%2Fjabfp%2F19%2F2%2F201.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000178871200004&link_type=ISI) 

5.  Porcerelli JH, Cogan R, West PP, et al. Violent victimization of women and men: physical and psychiatric symptoms. J Am Board Fam Pract 2003; 16: 32–9.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=12583648&link_type=MED&atom=%2Fjabfp%2F19%2F2%2F201.atom) 

6.  Feldhaus KM, Kozio-McLain J, Amsbury HL, Norton IM, Lowensein SR, Abott JT. Accuracy of three brief screening questions for detecting partner violence in the emergency department. JAMA 1997; 277: 1357–61.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1001/jama.1997.03540410035027&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=9134940&link_type=MED&atom=%2Fjabfp%2F19%2F2%2F201.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1997WW26100024&link_type=ISI) 

7.  Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984; 252: 1905–7.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1001/jama.1984.03350140051025&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=6471323&link_type=MED&atom=%2Fjabfp%2F19%2F2%2F201.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1984TN44700023&link_type=ISI) 

8.  Cohen J. Statistical power analysis for the behavioral sciences. 2nd Ed. Hillsdale (NJ): Lawrence Erlbaum Associates, Inc; 1988.
    
    

9.  Sherin KM, Sinacore JM, Li X, Zitter RE, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med 1998; 30: 508–12.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=9669164&link_type=MED&atom=%2Fjabfp%2F19%2F2%2F201.atom) 

10. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. JAMA 1999; 282: 1737–44.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1001/jama.282.18.1737&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=10568646&link_type=MED&atom=%2Fjabfp%2F19%2F2%2F201.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000083471400028&link_type=ISI)