علائم استرس و افسردگی پس از سانحه به عنوان ارتباط عمدی خودآسیبی در میان زنان جامعه با تجربه خشونت خانگی

Abstract Deliberate self-harm (DSH) among women in the general population is correlated separately with posttraumatic stress, depression, and abuse during childhood and adulthood. The prevalence of these DSH correlates is particularly high among women exposed to intimate partner violence (IPV), yet few studies have examined DSH among this high-risk population and none have examined these correlates simultaneously. Two hundred and twelve IPV-victimized women in the community participated in a 2-h retrospective interview. One-third reported current or past DSH. Discriminant analysis was used to examine which posttraumatic stress and depression symptoms and types of current IPV and childhood abuse were uniquely associated with current DSH. Findings show that women who currently use DSH reported greater severity of posttraumatic stress numbing symptoms and more severe sexual IPV compared to women who used DSH only in the past. Examining factors that are associated with women's current DSH in this population is critical so that a focus on DSH can be integrated into the treatment plans of women who are receiving mental health care, but also so that women who are not receiving such care can be referred to adequate mental health services.

Introduction Deliberate self-harm (DSH), whereby an individual deliberately causes tissue damage without suicidal intent (Gratz, 2001), is consistently and strongly associated with sexual victimization in both childhood (Gladstone et al., 2004, Mina and Gallop, 1998 and Noll et al., 2003) and adulthood (Campbell et al., 2007 and Gratz, 2006) and with mental health problems such as posttraumatic stress (Cloitre et al., 2002, Harned et al., 2006, Harned et al., 2010b and Nada-Raja and Skegg, 2011) and depression (Boudewyn and Liem, 1995 and Hawton et al., 1999). Despite the high prevalence of the aforementioned DSH correlates among women experiencing intimate partner violence (IPV; Caetano and Cunradi, 2003, Desai et al., 2002, Golding, 1999 and Sullivan et al., 2009) few studies have examined DSH in this high-risk population (Boyle et al., 2006, Levesque et al., 2010, Noll et al., 2003 and Sansone et al., 2007). DSH and IPV constitute critical health issues: according to recent data, 6% of women experience IPV annually (Black et al., 2011) and 4–8% of women in the general population use DSH (Brown et al., 2007). IPV-victimized women are up to three times more likely to present with DSH than non-victimized women (Boyle et al., 2006). Past research has taken different approaches to simultaneously examining DSH and IPV. In one instance, both constructs were examined as common consequences of childhood sexual abuse (Noll et al., 2003). In other research, their associations were examined in women psychiatric inpatients (Sansone et al., 2007), emergency medicine patients (Boyle et al., 2006), and university students (Levesque et al., 2010). No study to date, however, has examined the prevalence of DSH among IPV-victimized women in the community. Past studies are further limited in that they did not assess separately past and current DSH. Further, while some studies distinguished IPV types (Levesque et al., 2010 and Noll et al., 2003), no study simultaneously examined multiple types of IPV and types of childhood abuse. Failing to distinguish among psychological, physical, and sexual IPV or childhood emotional, physical, and sexual abuse as correlates of DSH is problematic since research indicates that types of abuse are differentially related to mental health outcomes (e.g., Clemmons et al., 2007, Dutton et al., 2006, Hedtke et al., 2008, Senn and Carey, 2010 and Sullivan et al., 2006). It is critical to examine factors that are associated with current use of DSH among IPV-victimized women so that (a)for women who already are receiving mental health care, a focus on DSH can be integrated into their treatment plans, and (b)for women who are not receiving such care but are in contact with other service providers, those providers can better identify the need for a referral to mental health services. Therefore, the purpose of this study is to determine the extent to which different posttraumatic stress and depression symptoms, and types of IPV and childhood abuse, differentiate women who are currently using DSH from those who used it only in the past or not atall. Research indicates that DSH, though maladaptive, is highly functional in the service of emotion regulation (Chapman et al., 2006 and Gratz and Tull, 2010). Theories of emotion regulation suggest that DSH can be understood as a way (a)to express or control unbearable or intense negative emotions including pain, fear, and anger; (b)to cope with the effects of dissociation that result from the intensity of such negative emotions; or (c)to mitigate the effects of posttraumatic stress reexperiencing and emotional numbing symptoms (Briere and Gil, 1998, Brown et al., 2007, Dyer et al., 2009 and Gratz, 2003). Compared to women who experience other types of traumatic life events, IPV-victimized women are at heightened risk for DSH since they often report experiencing an array of particularly intense negative emotions, including shame, guilt, and fear (Beck et al., 2011, JaquierPlease complete and update the reference given here (preferably with a DOI if the publication data are not known): Jaquier and Sullivan, in press. For references to articles that are to be included in the same (special) issue, please add the words ‘this issue’ wherever this occurs in the list and, if appropriate, in the text. and Sullivan, and JaquierPlease complete and update the reference given here (preferably with a DOI if the publication data are not known): Jaquier and Sullivan, in press. For references to articles that are to be included in the same (special) issue, please add the words ‘this issue’ wherever this occurs in the list and, if appropriate, in the text. and Sullivan,) and are at high risk for both posttraumatic stress and depression symptoms (Caetano and Cunradi, 2003, Desai et al., 2002, Golding, 1999 and Sullivan et al., 2009). These negative emotions and mental health problems, which are saliently related to DSH, tend to be more persistent and severe among individuals who experience interpersonal traumas such as IPV compared to impersonal traumas (Anders et al., 2011 and Forbes et al., 2012). Further, IPV-victimized women endure a high probability of repeat victimization, continued negative effects of IPV victimization, and a minimal likelihood of recovery over time compared to women who experience other traumatic life events (Beeble et al., 2009 and Blasco-Ros et al., 2010). IPV-victimized women are also at heightened risk for DSH because they are more likely than nonvictims to have experienced childhood sexual abuse (e.g., Golding, 1999 and McGuigan and Middlemiss, 2005), which also is often related to poor emotion regulation skills (e.g., Cloitre et al., 2005). Women with complex abuse histories often have similarly complex diagnostic profiles characterized by posttraumatic stress, depression, and DSH—which, in turn, are all characterized by emotion dysregulation (Chapman et al., 2006, Cloitre et al., 2005 and Gratz and Tull, 2012). Women with such complex issues often have limited adaptive emotion regulation skills and incur many obstacles to gaining access to and receiving appropriate mental health care (Briere and Gil, 1998, Johnson and Zlotnick, 2006 and Johnson et al., 2011). Few principles exist to guide clinical decision making for mental health care providers who treat these high-risk women (Forbes et al., 2007 and Harned et al., 2010a). Therefore, the first step toward improving providers' clinical decision making among IPV-victimized women in various settings is to understand how current and past DSH are differentially related to women's abuse histories and co-occurring mental health problems. This exploratory study addresses this gap in the literature by examining the severity of women's posttraumatic stress and depression symptoms and the severity of their types of IPV and childhood abuse to identify correlates unique to current DSH (vs. past or no DSH) among IPV-victimized women in the community.

3. Results Among IPV-victimized women, 13.7% (n=29) reported current DSH, 16% (n=34) reported past DSH only, and 70.3% (n=149) reported no DSH. Overall, the mean scores of posttraumatic stress and depression symptoms were higher among women who reported current DSH; women who reported current DSH also had higher mean scores for each type of IPV and childhood abuse ( Table 1). The prevalence of posttraumatic stress disorder was higher among women reporting current DSH, as was the proportion of women scoring above the depression threshold. All but two correlations among study variables were significant; childhood sexual abuse was not correlated with posttraumatic stress avoidance symptoms or physicalIPV. The MANOVA revealed differences between the three DSH groups on a linear composite of mental health problems and IPV and childhood abuse variables, F(22, 398)=2.79, p<0.001, Wilks' Lambda=0.75. Follow-up one-way ANOVAs with Bonferroni correction (p<0.004) indicated significant differences of severity among the three DSH groups for posttraumatic stress re-experiencing, numbing, and hyperarousal symptoms, and for depression symptoms. Both sexual IPV and childhood emotional abuse were significantly different across groups. Next, to identify which variables best differentiated the three DSH groups, a stepwise DDA was conducted that calculated two statistically significant discriminant functions ( Table 2). Three variables were retained: childhood emotional abuse, posttraumatic stress numbing symptoms, and sexual IPV ( Table 3). Correlations of predictor variables with both discriminant functions (i.e., function structure matrix) are presented in Table 4. These findings combined with the examination of the group centroids ( Table 5) suggested that Function 1discriminated between women reporting no DSH and women reporting past or current DSH. All independent variables were positively related to Function 1, but childhood emotional abuse and posttraumatic stress numbing symptoms contributed most strongly to group discrimination. Function 2discriminated between women reporting DSH currently and in the past, with the former group displaying greater severity of both sexual IPV and posttraumatic stress numbing symptoms and lower scores of childhood emotionalabuse. Table 2. Wilks' lambda and canonical correlation for deliberate self-harm groups. Function Wilks' lambda χ2 d.f. p Rc 1–2 0.79 48.77 6 0.000 0.43 2 0.97 6.89 2 0.032 0.18 Note: Rc=Canonical correlations. Table options Table 3. Predictor variables in stepwise discriminant function analysis. Step Predictor variable Variables in discriminant function Wilks' lambda Exact F p 1 Childhood emotional abuse 1 0.87 16.29a 0.000 2 Posttraumatic stress numbing 2 0.81 11.50b 0.000 3 Sexual intimate partner violence 3 0.79 8.58c 0.000 a d.f.1=2, d.f.2=209. b d.f.1=4, d.f.2=416. c d.f.1=6, d.f.2=414. Table options Table 4. Correlation of predictor variables with discriminant functions (function structure matrix). Variable Function 1 Function 2 Symptom severity for mental health problems Posttraumatic stress re-experiencing 0.507 0.243 Posttraumatic stress avoidance 0.489 0.193 Posttraumatic stress numbing 0.742 0.360 Posttraumatic stress hyperarousal 0.541 0.174 Depression 0.566 0.238 Current intimate partner violence Psychological 0.395 0.249 Physicala 0.323 0.252 Sexuala 0.469 0.623 Childhood abuse Emotionalb 0.808 −0.551 Physicalb 0.560 −0.312 Sexualb 0.348 −0.086 Note: Statistical analyses were runwith: a Log10-transformed scores. b Squared scores. Table options Table 5. Group centroids. Function 1 Function 2 Current deliberate self-harm 0.945 0.273 Past deliberate self-harm only 0.480 −0.373 No deliberate self-harm −0.294 0.032 Table options Consistent with the DDA, planned contrasts comparing women reporting current versus past DSH indicated that the two groups significantly differed on the severity of their posttraumatic stress numbing symptoms (p=0.02) and the severity of their sexual IPV (p=0.02). Women with current DSH reported greater severity of numbing symptoms and sexual IPV compared to women with past DSH only. No other variables demonstrated a significant difference between these two groups.