Irritability
McKinlay et al. (1981) reported that 71% of a sample of TBI patients were described as irritable. Oddy et al. (1985) also found that irritability was the most common emotional change in patients who had sustained a TBI. Irritability has repeatedly been found to be a condition that occurs after a TBI in other studies as well (Hinkeldy & Corrigan, 1990; Dikman et al., 1989; Van Zomeren & van Den Berg, 1985).
Anhedonia and Depression
Anhedonia, or a loss of interest in activities that were once pleasurable, can be a reaction to a traumatic event such as a TBI, loss and/or failure, and can be an indication of depression (Prigatano et al., 1986; Hornung et al., 1981; Goldstein, 1952). Like batterers, a high frequency of depression has been reported among men who have sustained a TBI (Warnken & Rosenbaum, 1994). Brooks et al. (1987) found that 63% of a TBI population met criteria for depression within the first seven years after the injury occurred.
Perceived Helplessness and Depression
Patients who have sustained TBIs resulting in neuropsychological impairment may feel that they lack the skills and ability to exercise control over their lives. A negative attributional style, or a sense of a lack of control over life events may in turn, also lead to depression (Brown et al., 1988). Patients who are experiencing higher levels of depression and perceived helplessness, are often less active and discriminative in thinking tasks requiring action, initiation, and control (Kofta, 1993). This may potentiate even greater feelings of helplessness.
Research that has been conducted on helplessness has found that in uncontrollable situations people engage in intensive, yet unproductive cognitive problem-solving activities that do not yield positive results, despite their efforts. Sedek, Kofta, and Tyszka (1993) have hypothesized that prolonged exposure to such situations may lead to cognitive exhaustion, which can cause a generalized inhibition of the active processing of external stimuli. In such cases, there is tendency to oversimplify, or to rely on preconceived notions, which may cause impaired judgment and/or performance. Thus it would seem plausible that the decrease in abstract reasoning and concept formation, associated with the deficits in executive functioning seen in TBI patients may have an secondary environmental component that further exacerbates the biological injury.
Avoidance
Mikulincer (1989) observed that a tendency to turn inward increases the debilitating effects of unsolvable problems. Unsolvable problems have been found to be linked to the antecedent occurrence of “escape thoughts,” indicating an attempt on the part of the participant to distance themselves from the situation (Mikulincer, p. 133, 1989), a characteristic often noted in domestically violent men (Holtzworth-Monroe & Stuart, 1994; Waltz et al, 2000). Schontz (1975) and Klinger (1975) suggest that performance failure leads to task avoidance, which causes cognitive detachment that in turn impairs performance to an even greater extent. Over time this pattern may result in the development of cognitive helplessness, and a tendency to avoid discriminative reasoning (Sedek, 1993). It would appear that an avoidance of discriminate reasoning and greater cognitive detachment might lead toward a greater propensity of relying on physical force, as a means of problem-solving. This could result in an increase in marital aggression. It would appear that this could be especially true for TBI patients who have experienced performance failure as a result of their head injury.
Dependency Needs
The tendency of TBI victims to be more dependent on their spouses appears to be related to TBI victims’ higher levels of aggression post-injury. The head injured person’s increased dependency and likely feelings of increased helplessness may be a contributor to higher levels of aggression (Hamberger et al., 1996). Although West and Sheldon (1988) described compulsive care-seeking attachment within the context of battering, it appears likely that compulsive care-seeking attachment may also be a prominent feature in a person who has suffered impairment as the result of a head injury. Individuals who were once independent, often become limited in their ability to care for themselves after sustaining a TBI, and become more dependent –both physically and emotionally – on their partners and family members. Their increased dependency on others for care, along with feelings of increased vulnerability may result in a compulsive cake-seeking style of attachment which, as described earlier, can lead to violent behavior.
Self Esteem
Failure and a greater reliance on others may also threaten self-esteem, which increases both the likelihood of preoccupation with self-concerned thoughts and the person’s anxiety level (Snyder, Stephan, & Rosenfield, 1978). When a threat to self-esteem exists in such situations, there is a greater tendency to withdraw from active problem-solving and to assume a more defensive posture (Sedek et al., 1993). Patients who are unable to successfully complete problem-solving tasks have been observed to become anxious, depressed, irritable and apathetic on the basis of the psychosocial changes alone (Prigantano, Pepping, & Klonoff, 1986).
Saturday, July 12, 2008
Thursday, July 10, 2008
Agression and Traumatic Brain Injury
Frustration Tolerance, Anger and Aggression
Patients who have sustained a TBI have shown a lower tolerance level to frustration, greater degrees of sensitivity to stress and anxiety (Levin et al., 1989), and agitation, defined as constantly uninhibited movement (Reyes, Bhattacharyya, & Heller, 1981). These patients were prone to the expression of anger and if their movements became restricted (Reyes, Bhattacharyya, & Heller, 1981), they became subject to anger or violent behavior when their agitation continued over time (Prigatano et al., 1986).
Lack of Inhibition
As is the case with batterers, lack of inhibition and sudden mood change are often seen in patients with a TBI. (Brooks et al., 1987; Jarvie, 1954). In addition, TBI patients, like batterers, also frequently demonstrate poor social judgment and reduced verbal control (Prigatano, 1991; Struss & Benson, 1986; Lishman, 1978). Frontal lobe deficits lower a person’s ability to self-regulate, and have been hypothesized to be contributing factors to an increase in impulsive behavior (Westby & Ferraro, 1999). Grafman et al. (1996) have proposed that frontal lobe impairment causes higher levels of aggression, associated with reduced impulse and inhibitory control, because rules of social behavior are stored in the frontal lobes. When these areas are stimulated, the result is an inhibition of primitive reactions. If brain impairment has blocked access to this information, inappropriate kinds of social behavior, such as physically and verbally aggressive behavior may emerge in confrontational situations. Grafman et al. (1996) found that TBI patients scored higher on anger and hostility measures than the control group.
Perseveration
Perseveration is an abnormal repetition of specific behaviors that may include movements and verbalizations, and may be observed on drawings, sorting tests, and tracking tests. Perseverative behavior is an indication of frontal lobe impairment, and frequently occurs in individuals that engage in aggressive behaviors (Sedek et al., 1993). An example of common perseveration behavior would be to continue engaging in the same activity to solve a task even when the external variables have changed, resulting in unsuccessful outcomes. These kinds of situations can lead to feelings of helplessness and frustration (Sedek et al., 1993).
Patients who have sustained a TBI have shown a lower tolerance level to frustration, greater degrees of sensitivity to stress and anxiety (Levin et al., 1989), and agitation, defined as constantly uninhibited movement (Reyes, Bhattacharyya, & Heller, 1981). These patients were prone to the expression of anger and if their movements became restricted (Reyes, Bhattacharyya, & Heller, 1981), they became subject to anger or violent behavior when their agitation continued over time (Prigatano et al., 1986).
Lack of Inhibition
As is the case with batterers, lack of inhibition and sudden mood change are often seen in patients with a TBI. (Brooks et al., 1987; Jarvie, 1954). In addition, TBI patients, like batterers, also frequently demonstrate poor social judgment and reduced verbal control (Prigatano, 1991; Struss & Benson, 1986; Lishman, 1978). Frontal lobe deficits lower a person’s ability to self-regulate, and have been hypothesized to be contributing factors to an increase in impulsive behavior (Westby & Ferraro, 1999). Grafman et al. (1996) have proposed that frontal lobe impairment causes higher levels of aggression, associated with reduced impulse and inhibitory control, because rules of social behavior are stored in the frontal lobes. When these areas are stimulated, the result is an inhibition of primitive reactions. If brain impairment has blocked access to this information, inappropriate kinds of social behavior, such as physically and verbally aggressive behavior may emerge in confrontational situations. Grafman et al. (1996) found that TBI patients scored higher on anger and hostility measures than the control group.
Perseveration
Perseveration is an abnormal repetition of specific behaviors that may include movements and verbalizations, and may be observed on drawings, sorting tests, and tracking tests. Perseverative behavior is an indication of frontal lobe impairment, and frequently occurs in individuals that engage in aggressive behaviors (Sedek et al., 1993). An example of common perseveration behavior would be to continue engaging in the same activity to solve a task even when the external variables have changed, resulting in unsuccessful outcomes. These kinds of situations can lead to feelings of helplessness and frustration (Sedek et al., 1993).
Sunday, July 6, 2008
Traumatic Brain Injury
Description of TBI
Demographics of TBI Patients
About 1.9 million people in this country sustain a TBI annually, and within this group 50,000- 75,000 experience moderate to severe disability as a result. Most of these injuries occur in individuals between the ages of 15 and 24, and over the age of 75, and are 2-3 times more common in men than women. Primary causes of TBI include motor vehicle accidents, physical assaults, falls, and sports and other recreational related injuries (Rosenthal & Ricker, 2000).
Etiology of TBI
Harrison-Felix, Newton, Hall and Kreutzer (1996) have defined TBI as, “Damage to brain tissue caused by an external mechanical force, as evidenced by loss of consciousness due to brain trauma, posttraumatic amnesia, skull fracture, or objective neurological findings that can be reasonably attributed to TBI on physical examination or mental status examination (p.2).” The four primary types of TBI include: (1) contusions – bruising caused by direct impact, (2) compression – where the brain is forced against the skull as a result of direct impact, (3) rotational injuries and/or (4) pressure build up due to hemorrhaging (Stratton & Gregory, 1994).
In cases with contusions, damage occurs as the result of a blow at the immediate point of impact, and is referred to as the coup. The damage is often due to contusion and laceration, and can be either an open or a closed head injury. Open head injuries are due to the skull or brain being penetrated, often as the result of a gunshot wound or an assault to the head by a sharp object. Blunt traumas can also cause open head injuries as the result of a skill fracture that displaces bone into brain tissue. Closed head injuries are cases in which the skull is not fractured, which may occur in falls or other kinds of accidents involving direct impact (Stratton & Gregory, 1994).
Compression injuries are often referred to as a contrecoup. This kind of injury is the result of rapid acceleration and sudden deceleration, which forces the brain into motion. The brain impacts the skull opposite from the direction in which the force originated (Stratton & Gregory, 1994). These injuries frequently occur in car accidents, as a result of a sudden stop causing the brain tissue to come into abrupt contact with the internal surface of the skull.
Rotational acceleration of the brain, often the result of sustaining impact, as in the case of a car injury, can cause axonal shearing. Rotation injuries cause the brain to move quickly in one direction and then another. This movement produces a shearing force between the brain and the skull. Because the brain and the skull have different densities and characteristics of inertia, the brain moves and turns at a different speed than the skull. This shearing action may tear axons and veins attached to the surface of the brain (Stratton & Gregory, 1994).
Such an injury may cause hemorrhaging and will lead to the eventual deterioration of nerve fibers and a decrease in the cerebral white matter of the brain. Edema is a common secondary complication of a TBI. It occurs when there is an increase in water retention in brain tissue (Rosenthal & Ricker, 2000). Like hemorrhaging, edema can lead to the build up of increased intracranial pressure resulting in further brain damage.
The impairment that occurs from a TBI is frequently diffuse, and the frontal, temporal and occipital lobes of the cerebral cortex are especially prone to bruising. The cerebral cortex is the area of the brain responsible for higher levels of functioning (Brown & Miller, 1993; Lezak, 1995; Miller, L., 1999). Individuals that have sustained a TBI with damage to the frontal areas of the brain often demonstrate changes in cognition, personality and emotional responses (Lezak, 1995.)
Ovsiew and Yudofsky (1993) have stressed that it is important not to take the concept of specific brain centers or localization areas too literally, as it may be misleading. The location in which an injury disrupts a function is not necessarily the location of the function in a normal state, as brain functions are interrelated (Kennard & Swash, 1989). It is more accurate to view the brain in terms of “levels of organization,” with higher centers that involve executive functioning controlling and inhibiting the functions of lower centers. The lower centers are responsible for the more primitive and involuntary functions (Luria, 1973; Ovsiew & Yudofsky, 1993). Sequelae associated with frontal lobe impairment include disruption of the organization of the higher centers, and an inability to regulate the lower centers of the brain (Luria, 1973). LOC has been identified as a key factor in determining the degree of neuropsychological impairment. Generally the longer the duration of loss of consciousness from a head injury, the greater the severity of the brain damage. Recovery from a TBI is most dramatic within the first twelve months, and tapers off during the second year. Impairment that is still present after this period of time is generally considered to be permanent (Lezak, 1995).
Deficits in Executive Functioning
Executive functioning includes attention, concentration, abstract reasoning, formation of goals, concept formation, planning and initiation of purposeful actions, self-monitoring, self-awareness, third person perspective, frustration tolerance, impulse control, inhibition and ability to shift cues. Like batterers, individuals who have sustained a TBI often show impairment in executive functioning (Miller, 1999,Vermeiren, Clippele, Stone, Ruchin, & Deboutte, 2002; Elliot, 1989; Lezak, 1983).
Aspontaneity
Aspontaneity, defined as a lack of appropriate emotional response to external stimuli, has been noted in TBI patients (Lishman, 1968), and has been attributed to a lack of initiative, and impairment in the capacity for planning, goal setting, and anticipation (Struss & Benson, 1986). Patients with aspontaneity usually do not seek employment, and do not engage in rehabilitation programs (Prigatano, 1992). Kimberg and Farah (1993) observed that TBI patients appeared to disassociate between knowledge and behavior. On a test where higher scores could be achieved by following instructions, TBI patients did not follow the directions, even though they were able to describe the appropriate strategy post-test.
Demographics of TBI Patients
About 1.9 million people in this country sustain a TBI annually, and within this group 50,000- 75,000 experience moderate to severe disability as a result. Most of these injuries occur in individuals between the ages of 15 and 24, and over the age of 75, and are 2-3 times more common in men than women. Primary causes of TBI include motor vehicle accidents, physical assaults, falls, and sports and other recreational related injuries (Rosenthal & Ricker, 2000).
Etiology of TBI
Harrison-Felix, Newton, Hall and Kreutzer (1996) have defined TBI as, “Damage to brain tissue caused by an external mechanical force, as evidenced by loss of consciousness due to brain trauma, posttraumatic amnesia, skull fracture, or objective neurological findings that can be reasonably attributed to TBI on physical examination or mental status examination (p.2).” The four primary types of TBI include: (1) contusions – bruising caused by direct impact, (2) compression – where the brain is forced against the skull as a result of direct impact, (3) rotational injuries and/or (4) pressure build up due to hemorrhaging (Stratton & Gregory, 1994).
In cases with contusions, damage occurs as the result of a blow at the immediate point of impact, and is referred to as the coup. The damage is often due to contusion and laceration, and can be either an open or a closed head injury. Open head injuries are due to the skull or brain being penetrated, often as the result of a gunshot wound or an assault to the head by a sharp object. Blunt traumas can also cause open head injuries as the result of a skill fracture that displaces bone into brain tissue. Closed head injuries are cases in which the skull is not fractured, which may occur in falls or other kinds of accidents involving direct impact (Stratton & Gregory, 1994).
Compression injuries are often referred to as a contrecoup. This kind of injury is the result of rapid acceleration and sudden deceleration, which forces the brain into motion. The brain impacts the skull opposite from the direction in which the force originated (Stratton & Gregory, 1994). These injuries frequently occur in car accidents, as a result of a sudden stop causing the brain tissue to come into abrupt contact with the internal surface of the skull.
Rotational acceleration of the brain, often the result of sustaining impact, as in the case of a car injury, can cause axonal shearing. Rotation injuries cause the brain to move quickly in one direction and then another. This movement produces a shearing force between the brain and the skull. Because the brain and the skull have different densities and characteristics of inertia, the brain moves and turns at a different speed than the skull. This shearing action may tear axons and veins attached to the surface of the brain (Stratton & Gregory, 1994).
Such an injury may cause hemorrhaging and will lead to the eventual deterioration of nerve fibers and a decrease in the cerebral white matter of the brain. Edema is a common secondary complication of a TBI. It occurs when there is an increase in water retention in brain tissue (Rosenthal & Ricker, 2000). Like hemorrhaging, edema can lead to the build up of increased intracranial pressure resulting in further brain damage.
The impairment that occurs from a TBI is frequently diffuse, and the frontal, temporal and occipital lobes of the cerebral cortex are especially prone to bruising. The cerebral cortex is the area of the brain responsible for higher levels of functioning (Brown & Miller, 1993; Lezak, 1995; Miller, L., 1999). Individuals that have sustained a TBI with damage to the frontal areas of the brain often demonstrate changes in cognition, personality and emotional responses (Lezak, 1995.)
Ovsiew and Yudofsky (1993) have stressed that it is important not to take the concept of specific brain centers or localization areas too literally, as it may be misleading. The location in which an injury disrupts a function is not necessarily the location of the function in a normal state, as brain functions are interrelated (Kennard & Swash, 1989). It is more accurate to view the brain in terms of “levels of organization,” with higher centers that involve executive functioning controlling and inhibiting the functions of lower centers. The lower centers are responsible for the more primitive and involuntary functions (Luria, 1973; Ovsiew & Yudofsky, 1993). Sequelae associated with frontal lobe impairment include disruption of the organization of the higher centers, and an inability to regulate the lower centers of the brain (Luria, 1973). LOC has been identified as a key factor in determining the degree of neuropsychological impairment. Generally the longer the duration of loss of consciousness from a head injury, the greater the severity of the brain damage. Recovery from a TBI is most dramatic within the first twelve months, and tapers off during the second year. Impairment that is still present after this period of time is generally considered to be permanent (Lezak, 1995).
Deficits in Executive Functioning
Executive functioning includes attention, concentration, abstract reasoning, formation of goals, concept formation, planning and initiation of purposeful actions, self-monitoring, self-awareness, third person perspective, frustration tolerance, impulse control, inhibition and ability to shift cues. Like batterers, individuals who have sustained a TBI often show impairment in executive functioning (Miller, 1999,Vermeiren, Clippele, Stone, Ruchin, & Deboutte, 2002; Elliot, 1989; Lezak, 1983).
Aspontaneity
Aspontaneity, defined as a lack of appropriate emotional response to external stimuli, has been noted in TBI patients (Lishman, 1968), and has been attributed to a lack of initiative, and impairment in the capacity for planning, goal setting, and anticipation (Struss & Benson, 1986). Patients with aspontaneity usually do not seek employment, and do not engage in rehabilitation programs (Prigatano, 1992). Kimberg and Farah (1993) observed that TBI patients appeared to disassociate between knowledge and behavior. On a test where higher scores could be achieved by following instructions, TBI patients did not follow the directions, even though they were able to describe the appropriate strategy post-test.
Friday, July 4, 2008
Traumatic Brain Injury (TBI) and Battering
Individuals with neuropsychological impairment as the result of a head injury are considered to be among those at greatest risk for developing violent and aggressive behavior. Sustaining a TBI has been found to be a significant predictor of becoming a batterer. In a comparison study, prior history of TBI was found to be more highly correlated with domestic battering than any other medical, psychosocial, and psychiatric variables measured (Cohen et al., 1999). Men with a history of brain injury are six times more likely to engage in spousal aggression, and in 93.1% of a group of batters who sustained TBIs, the injury occurred prior to the first episode of domestic violence (Westby & Ferraro, 1999).
Both verbal and physical forms of aggression are common post-injury symptoms described by TBI patients (Warnken et al., 1994). Rosenbaum and Hoge (1989) evaluated the occurrence of significant head injury among batterers, and found that 61% of the sample they studied had sustained a TBI involving loss of consciousness (LOC) in the past. Rosenbaum et al. (1994) conducted a study that compared men who battered, nonviolent men who were reportedly dissatisfied in their marriages, and satisfied married men. A significantly greater number of men who battered had sustained a TBI. Fifty three percent of the men who battered had a history of TBI as compared to 25% of the dissatisfied married men, and 16% of the satisfied married men.
Both verbal and physical forms of aggression are common post-injury symptoms described by TBI patients (Warnken et al., 1994). Rosenbaum and Hoge (1989) evaluated the occurrence of significant head injury among batterers, and found that 61% of the sample they studied had sustained a TBI involving loss of consciousness (LOC) in the past. Rosenbaum et al. (1994) conducted a study that compared men who battered, nonviolent men who were reportedly dissatisfied in their marriages, and satisfied married men. A significantly greater number of men who battered had sustained a TBI. Fifty three percent of the men who battered had a history of TBI as compared to 25% of the dissatisfied married men, and 16% of the satisfied married men.
Thursday, July 3, 2008
Intermittent Explosive Disorder and Agression
One of the organic syndromes, considered to be hereditary, that has been linked to pathological aggression is Episodic Dyscontrol Syndrome, now referred to in the DSM-IV (APA, 2000) as Intermittent Explosive Disorder (Valavka, 1995). Results of neurological batteries given to marital aggressors who have been diagnosed with Intermittent Explosive Disorder indicate impairment in the frontal and temporal lobes, which are areas of the brain involving self-regulation. Damage in this region has been associated with increased aggression (Lezak, 1983) and permanent changes in the control and expression of emotional response (Macchi, 1989).
Intermittent Explosive Disorder has been found to occur in individuals with borderline and antisocial personality disorders, ADHD, as well as other organic brain syndromes (Elliot, 1988, 1998). Elliott described the neurological factors contributing to this syndrome as falling into two categories: (a) those that arise early in life and are attributed to hereditary and early prenatal and infant development, and (b) those that develop during adolescence or later (Elliot, 1988, 1998).
Elliott’s original description of this disorder, which included TBI as a possible cause, is different from what is now listed in the DSM-IV (APA, 2000), which specifically states that Intermittent Explosive Disorder is not the result of a head injury. Although it is considered not to be the result of a head injury, the DSM IV (APA, 2000) states,
“A history of neurological conditions (e.g. head injury, episodes of unconscious, or febrile seizures in childhood) may be present. However, if the clinician judges that the aggressive behavior is a consequence of the direct physiological effects of a diagnosable general medical condition, the appropriate Mental Disorder Due to a General Medical Condition should be used instead (p.610).”
The DSM-IV (APA, 2000) has given the following diagnostic criteria for Intermittent Explosive Disorder:
(a) Several discrete episodes of loss of control of aggressive impulses resulting in serious assaultive acts or destruction of property.
(b) The degree of aggressiveness during episodes is out of proportion to the precipitating stress.
(c) The episodes of loss of control are not better accounted for by antisocial or borderline personality disorders, psychosis, or ADHD, and they are not due to the direct effects of a substance or general medical condition (e.g. a personality change due to head injury).
In his article,” The Neurology of Explosive Rage: The Dyscontrol Syndrome,” Elliot (1977) stated that unprovoked explosive rage, as manifested in either verbal or physical aggression, may be psychogenic or organic in origin. These outbursts of uncontrollable anger associated with this syndrome can vary in severity and form. More severe forms of Intermittent Explosive Disorder according to Miller (1994),
“Can appear as sudden, often unprovoked outbursts, primitive and poorly organized in nature – flailing, spitting, scratching, etc. – and usually directed at the nearest available object or person. The act itself can be quite destructive to furniture, pets, or people who happen to get in the way, but human injury is usually the result of misguided efforts on the part of observers to subdue the patient during an episode. In such cases, the wild thrashing that inflicts the injurious blows probably represents a desperate attempt to escape restraint rather than a directed assault against a particular individual – although sudden, directed but usually unsustained attacks may occur. The outbursts are typically short-lived and may be followed by feelings of regret and remorse when the individual becomes aware what he/she has done (p.92).”
Intermittent Explosive Disorder has been found to be intergenerational, although a number of confounding variables, such as parental conflict or separation, trauma and neglect, are also often present. This overlap makes it difficult to tease out heredity from environmental factors. Intermittent explosive disorder is listed in the DSM-IV (APA, 2000) under the category of Impulse-Control Not Elsewhere Classified, and information available on Intermittent Explosive Disorder is limited.
Intermittent Explosive Disorder has been found to occur in individuals with borderline and antisocial personality disorders, ADHD, as well as other organic brain syndromes (Elliot, 1988, 1998). Elliott described the neurological factors contributing to this syndrome as falling into two categories: (a) those that arise early in life and are attributed to hereditary and early prenatal and infant development, and (b) those that develop during adolescence or later (Elliot, 1988, 1998).
Elliott’s original description of this disorder, which included TBI as a possible cause, is different from what is now listed in the DSM-IV (APA, 2000), which specifically states that Intermittent Explosive Disorder is not the result of a head injury. Although it is considered not to be the result of a head injury, the DSM IV (APA, 2000) states,
“A history of neurological conditions (e.g. head injury, episodes of unconscious, or febrile seizures in childhood) may be present. However, if the clinician judges that the aggressive behavior is a consequence of the direct physiological effects of a diagnosable general medical condition, the appropriate Mental Disorder Due to a General Medical Condition should be used instead (p.610).”
The DSM-IV (APA, 2000) has given the following diagnostic criteria for Intermittent Explosive Disorder:
(a) Several discrete episodes of loss of control of aggressive impulses resulting in serious assaultive acts or destruction of property.
(b) The degree of aggressiveness during episodes is out of proportion to the precipitating stress.
(c) The episodes of loss of control are not better accounted for by antisocial or borderline personality disorders, psychosis, or ADHD, and they are not due to the direct effects of a substance or general medical condition (e.g. a personality change due to head injury).
In his article,” The Neurology of Explosive Rage: The Dyscontrol Syndrome,” Elliot (1977) stated that unprovoked explosive rage, as manifested in either verbal or physical aggression, may be psychogenic or organic in origin. These outbursts of uncontrollable anger associated with this syndrome can vary in severity and form. More severe forms of Intermittent Explosive Disorder according to Miller (1994),
“Can appear as sudden, often unprovoked outbursts, primitive and poorly organized in nature – flailing, spitting, scratching, etc. – and usually directed at the nearest available object or person. The act itself can be quite destructive to furniture, pets, or people who happen to get in the way, but human injury is usually the result of misguided efforts on the part of observers to subdue the patient during an episode. In such cases, the wild thrashing that inflicts the injurious blows probably represents a desperate attempt to escape restraint rather than a directed assault against a particular individual – although sudden, directed but usually unsustained attacks may occur. The outbursts are typically short-lived and may be followed by feelings of regret and remorse when the individual becomes aware what he/she has done (p.92).”
Intermittent Explosive Disorder has been found to be intergenerational, although a number of confounding variables, such as parental conflict or separation, trauma and neglect, are also often present. This overlap makes it difficult to tease out heredity from environmental factors. Intermittent explosive disorder is listed in the DSM-IV (APA, 2000) under the category of Impulse-Control Not Elsewhere Classified, and information available on Intermittent Explosive Disorder is limited.
Wednesday, July 2, 2008
Characteristics of Domestic Violence
The research conducted by Mungas (1983) indicates that violent behavior is not a “homogeneous phenomenon” and that to try to conceptualize all violent behaviors as being qualitatively similar is misleading. He stressed that violent behavior can be best understood by attempting to identify specific patterns of behavior. Elliott (1986) proposed a biosocial model, which views aggression as the result of an interaction between the brain and the environment. Likewise, Warnken and Rosenbaum (1994) have argued that marital aggression cannot be understood by examining a single precipitating event or factor. They have approached the topic from the following areas: (a) sociocultural – environmental stressors, racial and status differences, and family interaction, (b) interpersonal – the pattern of marital and family interaction, (c) intrapersonal – personal history, personality characteristics, pathology and organic dysfunction. Raine et al. (1994) determined that the presence of a combination of contributing factors, such as described by Warnken and Rosenbaum, more than doubled the rate of violent offending in a sample that included data from over 4,000 subjects.
Demographic and Sociocultural Factors Associated with Aggression Factors
Domestic violence has been found to occur across racial and ethnic groups (Bureau of Justice, 1995). In a study conducted through the University of Texas with a sample of 555 Caucasian, 358 African American, and 527 Hispanic couples living in the United States, the frequency rate of domestic violence was reported to be 53% among African American couples, 38% among Hispanic couples, and 28% among Caucasian couples (Caetano et al., 2000). When norms regarding violence approval, age, and economic stressors were held constant, no significant differences in the likelihood of partner assault between Hispanic and Caucasian populations were detected (Kantor et al., 1994). Rates of domestic violence were found to be comparable between urban and rural locations within similar economic classes (Lee et al., 2000). Findings of a study conducted by Kantor et al. (1994) indicated that being born in the United States increases the risk of wife assault among Mexican American and Puerto Rican American husbands. A survey of Los Angeles households that included responses from 1,243 Mexican Americans and 1,149 Caucasians, reported that 21.2% of the respondents said they had been martially aggressive at least once (Sorenson, 1991). The findings of this study yielded results similar to the study conducted by Kantor et al. (1994). Spousal violence rates for Mexican Americans born in Mexico and Caucasians born in the United States were equivalent (20% and 21.6% respectively) while the frequency of marital aggression was highest (30.9%) for Mexican-Americans born in the United States (Sorenson, 1991). Police reports involving episodes of domestic violence, made between 1996 and 1997, show that Hispanics were more likely to be injured than non-Hispanics, with the likelihood of injury decreasing with each additional year of age (Duncan et al., 1999). Research conducted by Lee et al. (2002) found that African American women experience higher rates of intimate partner homicide than Caucasian women, yet the total frequency for nonfatal partner battering was similar.
Cultural Values
Risk of violence was found to be highest in groups where violence is socially acceptable (Jewkes, 2002). The southern and western areas of the United States, associated with a greater degree of “honor related” norms that endorse violence, were found to have a higher frequency of argument-related homicide rates. These regional groups also had higher levels of violent TV viewership, violent magazine subscription rates, hunting licenses per capita and rates of execution. In addition, the laws and social policies were more favorable towards violence with looser gun control regulations, state and Congressional representatives who vote for more aggressive foreign policies and self-defense laws that are more lenient in allowing people to use violence to defend themselves and their property (Cohen, 1998).
Educational and Occupational Characteristics of Batterers
Numerous studies have been conducted with regard to battering that have found an inverse relationship between income and education. Men who engage in domestic battering are often unemployed, in a low status job, and tend to be less educated than the majority of the population (Hotaling & Sugarman, 1986). Lester (1999) has suggested that whether a person chooses internally directed aggression versus externally directed aggression might be related to their level of education. Less educated men may have a tendency to express outwardly, whereas men with higher levels of education may inhibit the outward expression of emotion and internalize aggression in an attempt to conform to the laws of society.
Straus, Gelles, and Steinmetz (1980) found that abusers often experience higher levels of job-related stress and tend to be more dissatisfied with their occupation overall. In regard to place of residence, a relationship was found between domestic violence and residence in an impoverished neighborhood, especially among African American couples (Cunradi, 2000).
In addition to frequently being at a lower socioeconomic status than the majority of the population, Bernard and Bernard (1984) reported that batterers were frequently found to be at lower levels of social status, education and financial security than their wives. Pillemer (1985) found that 64% of a group of male aggressors were financially dependent on their victims, and 55% need housing from their victims. Men who battered also were found to have significantly less education and were of a lower occupational status than men who didn’t batter (Rosenbaum et al., 1994).
Cumulatively, the results of these studies suggest that being: (1) a member of second generation racial and ethnic minority, (2) from the southern or western regions of the United States, (3) at a lower socioeconomic status, (4) financially dependent upon a partner, (5) less educated, and/or (6) from an impoverished neighborhood, increases the likelihood of becoming a batterer.
Interpersonal Aspects of Aggression
Intergenerational Factors
In the majority of theories of human development, both environmental factors and early childhood experience have been found to play an important role in the development of aggressive adult behavior. Fitch and Papantonio (1983) found that 60% to 80% of batterers had been physically abused by their parents, and 33% witnessed domestic violence between their parents growing up (Kalmuss, 1984). These studies support what has been referred to as the intergenerational theory, which proposes that adults often engage in behaviors that were modeled in the home by parental figures when they were children, and generalize them to other situations (Elliott, 1988; Kalmuss, 1984). Rosenbaum and O’Leary (1981) also found, in a comparison study between abusive and nonabusive husbands that abusive husbands were more likely to have been abused as children, and were more likely to have witnessed spousal abuse in their family of origin. Children often emulate the family member that they perceive to have the most power (Bandura, 1977). Violent behavior modeled by the father has been found to be particularly detrimental because the father often has the greatest power and status in traditional, more patriarchal families, and is often the primary male role model (Avakame, 1998).
Even though there is a great deal of evidence to support the premise of an intergenerational theory (Elliott 1988; Mungas, 1983; Warnken and Rosenbaum, 1994), this theory fails to explain all cases of domestic violence. Stacey and Shupe (1983) conducted a study that consisted of a sample of over 500 male spouse batterers. They reported that 40% of the participants did not witness physical violence between their parents, 60% had not been physically abused as a child, 60% had not been neglected by their parents, and 50% did not have an alcoholic father. These results suggest that there are other factors besides experiencing or witness domestic violence in the home that are responsible for the development of battering behavior.
Discrepancies in Values, Power, and Autonomy in Couples of Domestic Violence
Couples of marital violence often experience greater differences in their values, an imbalance of power within their relationship, and tend to have more dependency issues than other couples. Dissonance has often been noted between the beliefs of batters and their spouses. Hotaling and Sugarman (1986) observed that greater degrees of discrepancy in the involvement of religious activities and/or incompatibility in religious background between batterers and their wives, were associated with higher levels of marital violence (Gelles, 1974; Rosenbaum & O’Leary, 1981). Traditional men paired with nontraditional women have been found to increase marital dissatisfaction and has been associated with couple violence (Walker, 1984).
One study comparing maritally aggressive and nonaggressive men, discovered marital discord to be the strongest indicator of marital aggression (Rosenbaum & O’Leary, 1981). An imbalance of power between partners has been observed in relationships in which marital discord and domestic violence occurs. The cumulative research in this area is somewhat inconsistent, as some studies have observed that men tend to be more dominant in violent relationships, while other studies have found that women who are battered are the more assertive partners. It appears that an inequality of power, in either direction, between husbands and wives is associated with higher levels of aggression. The common ingredient among couples of marital violence seems to be an imbalance within the relationship in one or more of these areas.
Abused wives have been described as being overly passive and traditional (Lishman, 1978), and/or extremely domineering in their interactions with their abusive husbands (Snell et al., 1964). Hornung, McCullough and Sugimoto (1981) found that housewives were less likely to be in a physically violent marital relationship than women who were working, and that occupational overachievement in men was associated with a lower prevalence of spousal violence. However, they also reported that women, whose level of educational attainment was low, relative to their husbands, were at greater risk for spousal violence, especially in the form of life-threatening violence (Hornung, McCullough, & Sugimoto, 1981). Multiple studies have found that wife abuse was three times as likely when the husband dominated decision-making than when the wife dominated decision-making and about eight times more frequent than in marriages with equal power structures (Murphy & Meyer, 1991; Straus et al., 1980). Other studies have observed that in marriages of high marital conflict, female dominant relationships had the highest percentage of husband to wife violence (Coleman & Straus, 1986), and aggressors were found to be less appropriately assertive with their spouses (Rosenbaum & O’Leary, 1981).
The degree of perceived autonomy and desire for power within the relationship are also factors linked to marital violence. In a study conducted by Hotaling and Sugarman (1986), domestic violence offenders were found to be more dependent on their spouses than other men perceived differences in status by offenders in regard to their wives were found to be linked to higher levels of marital aggression. Offenders’ use of aggression was interpreted as being an attempt to enforce male dominance. Dutton and Strachan (1987) observed that maritally aggressive men scored higher on the need for power as measured by the Thematic Apperception Test, than did a group of non-batterers. Dobash and Dobash (1992) have suggested that the male aggressor’s use of marital violence is often a tactic used to maintain power, which grows out of a sense of inequality in the spousal relationship. Rosenbaum, Cohen and Forsstrom-Cohen (1991) have argued that disparities in education, income, and social status are factors that negatively impact a marital aggressor’s self-esteem. In summary, it appears that status inconsistency due to an imbalance of power and autonomy, and conflicting values within a relationship are all predictors of marital aggression (Hornung, McCullough, & Sugimoto, 1981).
Personality Characteristics of Batterers
Typologies of Batterers
Marital aggression occurs on a continuum of frequency and severity, ranging from domestic violence exclusively, to marital aggression with other violent/criminal activities. Results from research studies on batterers indicate that domestic aggression is rarely linked to chronic, generalized or severe mental disorders, but instead is linked to problematic psychological patterns that lead to violent reactions under stress (Faulk, 1974). These behavior patterns have been associated with specific personality types, or clinical profiles.
For example, Margolin and Gleberman (1988) found that batterers show narcissistic/antisocial, compulsive, and asocial/borderline features. Holtzworth-Munroe and Stuart (1994) have conceptualized three “typologies” that can be used to describe batterers. These typologies differ in several different ways, including genetic/prenatal factors, exposure to violence in the home, deviant peer relations and attitudes towards violence, impulsivity, poor social skills, attachment problems, and character disorders.
The first typology proposed by Holtzworth-Munroe and Stuart (1994) is: (a) Generally violent/antisocial batterers (generally violent), who engage in moderate to severe domestic violence, and are the most involved in extra-familial violence and criminal activity. Bernard and Bernard (1984) reported that persons like this have a strong tendency to externalize blame. They are likely to have substance abuse problems and to demonstrate antisocial and narcissistic personality patterns (Else et al., 1993; Flournoy & Wilson, 1991). The second type of batterer is: (b) Dysphoric/borderline (pathological), who engages in moderate to severe domestic violence, are the most depressed, psychologically distressed, and emotionally volatile. They are also likely to have substance abuse problems, and show borderline and schizotypal personality patterns. The third type is: (c) Family only batterers who engage in the least frequency and severity of domestic violence, and are most likely to have a passive, dependent personality pattern.
Aggression and Personality Disorders
Holtzworth-Munroe and Stuart (1994) have defined Antisocial Personality Disorder as the most severe batterer typology. Antisocial Personality Disorder includes several dimensional and categorical aspects of personality: (a) novelty seeking (b) harm avoidance, and (c) reward dependence (Cloninger, 1987). Studies with psychopaths and individuals with asocial tendencies indicate that these groups have decreased levels of arousal and decreased ability to filter stimuli, which results in stimulus deprivation, sensation seeking behaviors, and a greater desire to experience stimulating events (Raine, Lenez, & Scerbo, 1995). Volavka’s (1990) research has also uncovered a link between violent behavior and an abnormal processing of sensory input.
A second category of battering typology using the model presented by Holtzworth-Munroe and Stuart (1994) is the category associated with Borderline Personality Disorder (BPD). BPD has been defined in part as including impulsivity and frequent episodes of anger with out-of-control behavior (Valavka, 1990). Interestingly, McWilliams (1994) stated that compared to other personality disorders, individuals diagnosed with BPD tend to be extremely sensitive to rejection from others. Walker (1984) reported that about one half of all batterers threaten suicide during violent episodes with their wives, although it is unclear as to the frequency of actual attempts or completion rates (Warnken & Rosenbaum, 1994).
The third typology of battering proposed by Holtzworth-Munroe and Stuart (1994) is the family-only typology. Many of the batterers that have this typology frequently have characteristics associated with a dependent personality profile. A study conducted by Hamberger et al., 1996) found that 85% of the participants in their study fell into a passive dependent personality pattern, and that this type actually had the highest frequency of spousal violence. Based the premise that batterers often are dependent upon their spouses and strive to gain power, Waltz et al., (2000) conducted an empirical study that tested the validity of Holtzworth-Munroe and Stuart’s family-only typology (1994). The results of the study were that generally violent men tended to be more dismissing and avoidant, whereas pathologically dependent men, diagnosed with a personality disorder, were more preoccupied, ambivalent and prone to feelings of jealousy. Family-only type batterers were different from nonviolent men in that they demonstrated a compulsive care-seeking attachment style, or an anxious and ambivalent way of relating to their spouses (Waltz et al., 2000).
Dependency Issues and Styles of Attachment
West and Sheldon (1988) have described compulsive care-seeking attachment as being comprised of the three factors which are: (a) perceiving life in terms of difficulties that require help from others to resolve, (b) organizing relationships based on receiving nurturing and support, and (c) assuming that others will be responsible for one’s own needs and
decisions. Men who become domestically violent may have experienced the threat of loss of a significant attachment figure. Bowlby’s (1980) research indicates that an anger response frequently occurs in individuals threatened with loss as an attempt to prevent further separation. Ganley and Harris (1978) proposed that anger may be a critical factor in domestically violent men as feelings of hurt, fear and jealousy often appear to be immediately transformed into feelings of anger. The anger may then manifest in acts of domestic violence as a reaction against the perceived loss of an attachment figure that they are dependent upon to fulfill their needs.
Self-Esteem, Depression and Aggression
As suggested by Holtzworth-Munroe and Stuart (1994), many marital aggressors suffer from depression, in addition to Axis II disorders (Warnken & Rosenbaum, 1994). Maiuro (1988) reported that domestically violent men were more likely to be significantly depressed than generally assaultive and nonviolent men, as measured by the Beck Depression Inventory.
A number of symptoms associated with depression have been noted in batterers in various studies. Gelles (1972) found that male aggressors tend to isolate themselves, and have difficulty establishing and maintaining support systems. Goldstein and Rosenbaum (1985) reported that males who engage in marital aggression have been found to have low self-esteem and poor self-images. In addition, domestically violent men showed significantly higher levels of hostility and anger than nonviolent men (Maiuro, 1988). Rosenbaum and Bennett (1986) have proposed that depression may be linked to a sense of personal injury and anger that may lead to outbursts of temper and violence.
Other Intrapersonal Factors Associated with Aggression
Impaired Perception
Violent men were observed to misinterpret responses from their spouses more frequently, and to believe that aggressive responses would be more effective as a means to accomplishing their goals. They were found to generate less competent responses in situations with conflicts involving rejection, challenges and betrayal in the areas of communication and finance (Anglin & Holtzworth 1997).
Holtzworth-Monroe (1992) has argued that unrealistic expectations, irrational beliefs, misperceptions and processing distortions in taking in and interpreting external stimuli may lead to faulty conclusions. Erroneous interpretations may result in hostile attributions that negatively effect decision-making, which may contribute to the initiation of an aggressive response (Holtzworth-Monroe, 1992). This is supported by the results of a study conducted by Giancola and Zeichner (1994). They found that aggression was significantly related to performance on the Conditional Association Task, which measures the ability to learn a series of conditional associations between unrelated stimuli.
Coping and Anger Management Skill Deficits
In her research, Holtzworth-Monroe (1992) has identified deficits in sequential information processing in maritally violent men, linked to interpersonal interaction. Batterers often demonstrate a lack of ability in expressing themselves (LaViolette, Barnett, & Miller, 1984). In one study, maritally aggressive men, as defined by the Modified Conflict Tactics Scale (MTCS; Pan, Neidig, & O’Leary, 1994) and the Short Marital Adjustment Scale (SMAT; Locke & Wallace, 1959), were found to share the following characteristics: (a) fewer number of competent responses in spousal conflicts, (b) less likelihood of using coping skills involving reasoning, and (c) greater reliance on physical aggression. Anglin and Holtzworth (1997) found that physically aggressive spouses are less skilled in terms of problem-solving than nonviolent spouses, and appeared to have both marital and general skill deficits.
Impulsivity
Impulsivity may refer to an abrupt inclination towards an unpremeditated action, or action without conscious and deliberate judgment (Valavka, 1995). Impulsivity has been defined to include the three following aspects: (a) Motor impulsiveness, which refers to physical activity without forethought, or acting without thinking (a primary symptom of attention-deficit/hyperactivity disorder, (ADHD), (b) Cognitive impulsiveness, which refers to acts of rapid and careless decision-making, and (c) Non-planning impulsiveness, which is a lack of planning for the future. People who demonstrate non-planning impulsivity pay most attention to events in the here and now, and tend to “discount” time in the future (Valavka, 1995).
Impulsive behavior is often associated with people who are considered to be “sensation-seeking” (Valavka, 1995), often seen in conjunction with substance abuse. Male batterers have been found to demonstrate poor impulse control and an inability to control anger (Rosenbaum & O’Leary, 1981). Fedora and Fedora (1983) found that both psychopathic and nonpsychopathic criminals with violent behavior demonstrated greater performance deficits on tasks involving executive functioning and impulse control as measured by the Trail Making Test Part B (Reitan & Wolfson, 1985) as compared to a control group. Lueger and Gill (1990) conducted a comparison study between adolescent males with and without conduct disorder (CD), which is considered to be a precursor to adult antisocial behavior. Both groups were matched on age, education, substance abuse, and socioeconomic status. They found that the CD group scored lower on the Wisconsin Card Sorting Test, which is a measure of executive functioning in disinhibition and perseveration.
Substance Abuse and Aggression
Another frequent characteristic of male batterers, also often found in people who are both impulsive and/or depressed, is a history of substance abuse. A high rate of alcoholism was reported in abusive men by their wives (Goldstein & Rosenbaum, 1985), and heavy drinkers tend to become more abusive towards their wives than moderate drinkers (Kanter & Straus, 1986). Alcohol abuse has been reported for 20% to 80% of males who engage in marital aggression, and 18% to 35% of domestic violence offenders have reported problems with drug abuse. The disinhibitory effects of drugs and alcohol can exacerbate an emotionally charged situation and increase the potential for violence (Kantor & Straus, 1987).
Intelligence and Aggression
Adult violent offenders were found to have lower Full Scale Intelligence Quotients (FSIQ) than nonviolent offenders (Spellacy, 1978). A different study found that violent offenders tended to have lower Verbal IQs as compared to Performance IQs (Yeudall, 1977). Mutschler (1997) has proposed that lower Verbal IQ scores indicate a lack of resources and planning skills necessary to process emotional states, which results in an increase in tendencies towards aggressive behaviors.
Biological Factors Associated with Aggression
As mentioned earlier, aggressive behavior patterns have been found in families for several generations with the likelihood of affecting 50% of the offspring (Elliott, 1988). Although intergenerational aggression in families may be higher due to the effects of learning through environmental exposure, this cannot be the only reason. If aggression were solely due to environmental factors, then 100% of the children raised in aggressive families would be aggressive (Elliott, 1988). Aggression is also considered to be linked to a variety of biological factors. Some of the biological factors that have been associated with aggression include hormones, organic syndromes, epilepsy, perinatal insults, birth traumas, anoxia, post-natal brain infections and diseases, exposure to toxins and genetic disorders, and sustaining a brain injury (Elliott, 1988; Kandel & Mednick, 1991; Lezak, 1995; Miller, 1999; Pennington, 1991).
Hormone Theories
Higher levels of testosterone have been considered to be a cause of increased male aggression (Elliott, 1988a). Although a positive relationship exists between testosterone levels and aggression in males (Dabbs et al., 1987). Correlation does not necessarily mean causation (Carlson, 2002). A person’s environment has also been found to directly affect their level of testosterone (Carlson, 2002). Thus, a person’s environment may cause an increase in both testosterone and aggression levels simultaneously in a parallel fashion, without the testosterone directly causing the increased aggression levels.
Genetics and Heredity Factors
Over a decade ago an argument was made that attributed violent and criminal behavior to a XXY chromosomal abnormality; however, findings were inconsistent and inconclusive (Elliott, 1988a). Although chromosomal abnormality is not present in the majority of batterers, a structural abnormality with the X chromosome and the presence of the fragile X chromosome have been found to be tied to mental impairment, which has been correlated with aggression (Elliott, 1988a).
Both the hormone and the chromosome theories illustrate the problems that can occur when trying to determine the nature of the existing relationship between hereditary factors and aggression. Pennington (2002) describes some hypotheses to explain this kind of comorbidity which include: “ (1) The two conditions share a common risk factor that is consequently not specific to either disorder; (2) One disorder may cause the symptoms of the other disorder; (3) There is an etiological subtype in which a shared risk factor produces both disorders, but that other cases of each disorder do not share risk factors; and (4) there is a nonrandom mating such that individuals with transmissible risk factors (either genetic or environmental for one disorder are more likely to have children with individuals with transmissible risk factors for the other disorder (p. 22).” The fact that we are unable to study these factors within the framework of an experimental design using random selection and assignment limits our ability to determine the exact nature of the relationship between biological factors and aggressive behavior. Because of this, current research in this area is frequently a description of common themes and shared characteristics, rather than definite causal relationships.
Demographic and Sociocultural Factors Associated with Aggression Factors
Domestic violence has been found to occur across racial and ethnic groups (Bureau of Justice, 1995). In a study conducted through the University of Texas with a sample of 555 Caucasian, 358 African American, and 527 Hispanic couples living in the United States, the frequency rate of domestic violence was reported to be 53% among African American couples, 38% among Hispanic couples, and 28% among Caucasian couples (Caetano et al., 2000). When norms regarding violence approval, age, and economic stressors were held constant, no significant differences in the likelihood of partner assault between Hispanic and Caucasian populations were detected (Kantor et al., 1994). Rates of domestic violence were found to be comparable between urban and rural locations within similar economic classes (Lee et al., 2000). Findings of a study conducted by Kantor et al. (1994) indicated that being born in the United States increases the risk of wife assault among Mexican American and Puerto Rican American husbands. A survey of Los Angeles households that included responses from 1,243 Mexican Americans and 1,149 Caucasians, reported that 21.2% of the respondents said they had been martially aggressive at least once (Sorenson, 1991). The findings of this study yielded results similar to the study conducted by Kantor et al. (1994). Spousal violence rates for Mexican Americans born in Mexico and Caucasians born in the United States were equivalent (20% and 21.6% respectively) while the frequency of marital aggression was highest (30.9%) for Mexican-Americans born in the United States (Sorenson, 1991). Police reports involving episodes of domestic violence, made between 1996 and 1997, show that Hispanics were more likely to be injured than non-Hispanics, with the likelihood of injury decreasing with each additional year of age (Duncan et al., 1999). Research conducted by Lee et al. (2002) found that African American women experience higher rates of intimate partner homicide than Caucasian women, yet the total frequency for nonfatal partner battering was similar.
Cultural Values
Risk of violence was found to be highest in groups where violence is socially acceptable (Jewkes, 2002). The southern and western areas of the United States, associated with a greater degree of “honor related” norms that endorse violence, were found to have a higher frequency of argument-related homicide rates. These regional groups also had higher levels of violent TV viewership, violent magazine subscription rates, hunting licenses per capita and rates of execution. In addition, the laws and social policies were more favorable towards violence with looser gun control regulations, state and Congressional representatives who vote for more aggressive foreign policies and self-defense laws that are more lenient in allowing people to use violence to defend themselves and their property (Cohen, 1998).
Educational and Occupational Characteristics of Batterers
Numerous studies have been conducted with regard to battering that have found an inverse relationship between income and education. Men who engage in domestic battering are often unemployed, in a low status job, and tend to be less educated than the majority of the population (Hotaling & Sugarman, 1986). Lester (1999) has suggested that whether a person chooses internally directed aggression versus externally directed aggression might be related to their level of education. Less educated men may have a tendency to express outwardly, whereas men with higher levels of education may inhibit the outward expression of emotion and internalize aggression in an attempt to conform to the laws of society.
Straus, Gelles, and Steinmetz (1980) found that abusers often experience higher levels of job-related stress and tend to be more dissatisfied with their occupation overall. In regard to place of residence, a relationship was found between domestic violence and residence in an impoverished neighborhood, especially among African American couples (Cunradi, 2000).
In addition to frequently being at a lower socioeconomic status than the majority of the population, Bernard and Bernard (1984) reported that batterers were frequently found to be at lower levels of social status, education and financial security than their wives. Pillemer (1985) found that 64% of a group of male aggressors were financially dependent on their victims, and 55% need housing from their victims. Men who battered also were found to have significantly less education and were of a lower occupational status than men who didn’t batter (Rosenbaum et al., 1994).
Cumulatively, the results of these studies suggest that being: (1) a member of second generation racial and ethnic minority, (2) from the southern or western regions of the United States, (3) at a lower socioeconomic status, (4) financially dependent upon a partner, (5) less educated, and/or (6) from an impoverished neighborhood, increases the likelihood of becoming a batterer.
Interpersonal Aspects of Aggression
Intergenerational Factors
In the majority of theories of human development, both environmental factors and early childhood experience have been found to play an important role in the development of aggressive adult behavior. Fitch and Papantonio (1983) found that 60% to 80% of batterers had been physically abused by their parents, and 33% witnessed domestic violence between their parents growing up (Kalmuss, 1984). These studies support what has been referred to as the intergenerational theory, which proposes that adults often engage in behaviors that were modeled in the home by parental figures when they were children, and generalize them to other situations (Elliott, 1988; Kalmuss, 1984). Rosenbaum and O’Leary (1981) also found, in a comparison study between abusive and nonabusive husbands that abusive husbands were more likely to have been abused as children, and were more likely to have witnessed spousal abuse in their family of origin. Children often emulate the family member that they perceive to have the most power (Bandura, 1977). Violent behavior modeled by the father has been found to be particularly detrimental because the father often has the greatest power and status in traditional, more patriarchal families, and is often the primary male role model (Avakame, 1998).
Even though there is a great deal of evidence to support the premise of an intergenerational theory (Elliott 1988; Mungas, 1983; Warnken and Rosenbaum, 1994), this theory fails to explain all cases of domestic violence. Stacey and Shupe (1983) conducted a study that consisted of a sample of over 500 male spouse batterers. They reported that 40% of the participants did not witness physical violence between their parents, 60% had not been physically abused as a child, 60% had not been neglected by their parents, and 50% did not have an alcoholic father. These results suggest that there are other factors besides experiencing or witness domestic violence in the home that are responsible for the development of battering behavior.
Discrepancies in Values, Power, and Autonomy in Couples of Domestic Violence
Couples of marital violence often experience greater differences in their values, an imbalance of power within their relationship, and tend to have more dependency issues than other couples. Dissonance has often been noted between the beliefs of batters and their spouses. Hotaling and Sugarman (1986) observed that greater degrees of discrepancy in the involvement of religious activities and/or incompatibility in religious background between batterers and their wives, were associated with higher levels of marital violence (Gelles, 1974; Rosenbaum & O’Leary, 1981). Traditional men paired with nontraditional women have been found to increase marital dissatisfaction and has been associated with couple violence (Walker, 1984).
One study comparing maritally aggressive and nonaggressive men, discovered marital discord to be the strongest indicator of marital aggression (Rosenbaum & O’Leary, 1981). An imbalance of power between partners has been observed in relationships in which marital discord and domestic violence occurs. The cumulative research in this area is somewhat inconsistent, as some studies have observed that men tend to be more dominant in violent relationships, while other studies have found that women who are battered are the more assertive partners. It appears that an inequality of power, in either direction, between husbands and wives is associated with higher levels of aggression. The common ingredient among couples of marital violence seems to be an imbalance within the relationship in one or more of these areas.
Abused wives have been described as being overly passive and traditional (Lishman, 1978), and/or extremely domineering in their interactions with their abusive husbands (Snell et al., 1964). Hornung, McCullough and Sugimoto (1981) found that housewives were less likely to be in a physically violent marital relationship than women who were working, and that occupational overachievement in men was associated with a lower prevalence of spousal violence. However, they also reported that women, whose level of educational attainment was low, relative to their husbands, were at greater risk for spousal violence, especially in the form of life-threatening violence (Hornung, McCullough, & Sugimoto, 1981). Multiple studies have found that wife abuse was three times as likely when the husband dominated decision-making than when the wife dominated decision-making and about eight times more frequent than in marriages with equal power structures (Murphy & Meyer, 1991; Straus et al., 1980). Other studies have observed that in marriages of high marital conflict, female dominant relationships had the highest percentage of husband to wife violence (Coleman & Straus, 1986), and aggressors were found to be less appropriately assertive with their spouses (Rosenbaum & O’Leary, 1981).
The degree of perceived autonomy and desire for power within the relationship are also factors linked to marital violence. In a study conducted by Hotaling and Sugarman (1986), domestic violence offenders were found to be more dependent on their spouses than other men perceived differences in status by offenders in regard to their wives were found to be linked to higher levels of marital aggression. Offenders’ use of aggression was interpreted as being an attempt to enforce male dominance. Dutton and Strachan (1987) observed that maritally aggressive men scored higher on the need for power as measured by the Thematic Apperception Test, than did a group of non-batterers. Dobash and Dobash (1992) have suggested that the male aggressor’s use of marital violence is often a tactic used to maintain power, which grows out of a sense of inequality in the spousal relationship. Rosenbaum, Cohen and Forsstrom-Cohen (1991) have argued that disparities in education, income, and social status are factors that negatively impact a marital aggressor’s self-esteem. In summary, it appears that status inconsistency due to an imbalance of power and autonomy, and conflicting values within a relationship are all predictors of marital aggression (Hornung, McCullough, & Sugimoto, 1981).
Personality Characteristics of Batterers
Typologies of Batterers
Marital aggression occurs on a continuum of frequency and severity, ranging from domestic violence exclusively, to marital aggression with other violent/criminal activities. Results from research studies on batterers indicate that domestic aggression is rarely linked to chronic, generalized or severe mental disorders, but instead is linked to problematic psychological patterns that lead to violent reactions under stress (Faulk, 1974). These behavior patterns have been associated with specific personality types, or clinical profiles.
For example, Margolin and Gleberman (1988) found that batterers show narcissistic/antisocial, compulsive, and asocial/borderline features. Holtzworth-Munroe and Stuart (1994) have conceptualized three “typologies” that can be used to describe batterers. These typologies differ in several different ways, including genetic/prenatal factors, exposure to violence in the home, deviant peer relations and attitudes towards violence, impulsivity, poor social skills, attachment problems, and character disorders.
The first typology proposed by Holtzworth-Munroe and Stuart (1994) is: (a) Generally violent/antisocial batterers (generally violent), who engage in moderate to severe domestic violence, and are the most involved in extra-familial violence and criminal activity. Bernard and Bernard (1984) reported that persons like this have a strong tendency to externalize blame. They are likely to have substance abuse problems and to demonstrate antisocial and narcissistic personality patterns (Else et al., 1993; Flournoy & Wilson, 1991). The second type of batterer is: (b) Dysphoric/borderline (pathological), who engages in moderate to severe domestic violence, are the most depressed, psychologically distressed, and emotionally volatile. They are also likely to have substance abuse problems, and show borderline and schizotypal personality patterns. The third type is: (c) Family only batterers who engage in the least frequency and severity of domestic violence, and are most likely to have a passive, dependent personality pattern.
Aggression and Personality Disorders
Holtzworth-Munroe and Stuart (1994) have defined Antisocial Personality Disorder as the most severe batterer typology. Antisocial Personality Disorder includes several dimensional and categorical aspects of personality: (a) novelty seeking (b) harm avoidance, and (c) reward dependence (Cloninger, 1987). Studies with psychopaths and individuals with asocial tendencies indicate that these groups have decreased levels of arousal and decreased ability to filter stimuli, which results in stimulus deprivation, sensation seeking behaviors, and a greater desire to experience stimulating events (Raine, Lenez, & Scerbo, 1995). Volavka’s (1990) research has also uncovered a link between violent behavior and an abnormal processing of sensory input.
A second category of battering typology using the model presented by Holtzworth-Munroe and Stuart (1994) is the category associated with Borderline Personality Disorder (BPD). BPD has been defined in part as including impulsivity and frequent episodes of anger with out-of-control behavior (Valavka, 1990). Interestingly, McWilliams (1994) stated that compared to other personality disorders, individuals diagnosed with BPD tend to be extremely sensitive to rejection from others. Walker (1984) reported that about one half of all batterers threaten suicide during violent episodes with their wives, although it is unclear as to the frequency of actual attempts or completion rates (Warnken & Rosenbaum, 1994).
The third typology of battering proposed by Holtzworth-Munroe and Stuart (1994) is the family-only typology. Many of the batterers that have this typology frequently have characteristics associated with a dependent personality profile. A study conducted by Hamberger et al., 1996) found that 85% of the participants in their study fell into a passive dependent personality pattern, and that this type actually had the highest frequency of spousal violence. Based the premise that batterers often are dependent upon their spouses and strive to gain power, Waltz et al., (2000) conducted an empirical study that tested the validity of Holtzworth-Munroe and Stuart’s family-only typology (1994). The results of the study were that generally violent men tended to be more dismissing and avoidant, whereas pathologically dependent men, diagnosed with a personality disorder, were more preoccupied, ambivalent and prone to feelings of jealousy. Family-only type batterers were different from nonviolent men in that they demonstrated a compulsive care-seeking attachment style, or an anxious and ambivalent way of relating to their spouses (Waltz et al., 2000).
Dependency Issues and Styles of Attachment
West and Sheldon (1988) have described compulsive care-seeking attachment as being comprised of the three factors which are: (a) perceiving life in terms of difficulties that require help from others to resolve, (b) organizing relationships based on receiving nurturing and support, and (c) assuming that others will be responsible for one’s own needs and
decisions. Men who become domestically violent may have experienced the threat of loss of a significant attachment figure. Bowlby’s (1980) research indicates that an anger response frequently occurs in individuals threatened with loss as an attempt to prevent further separation. Ganley and Harris (1978) proposed that anger may be a critical factor in domestically violent men as feelings of hurt, fear and jealousy often appear to be immediately transformed into feelings of anger. The anger may then manifest in acts of domestic violence as a reaction against the perceived loss of an attachment figure that they are dependent upon to fulfill their needs.
Self-Esteem, Depression and Aggression
As suggested by Holtzworth-Munroe and Stuart (1994), many marital aggressors suffer from depression, in addition to Axis II disorders (Warnken & Rosenbaum, 1994). Maiuro (1988) reported that domestically violent men were more likely to be significantly depressed than generally assaultive and nonviolent men, as measured by the Beck Depression Inventory.
A number of symptoms associated with depression have been noted in batterers in various studies. Gelles (1972) found that male aggressors tend to isolate themselves, and have difficulty establishing and maintaining support systems. Goldstein and Rosenbaum (1985) reported that males who engage in marital aggression have been found to have low self-esteem and poor self-images. In addition, domestically violent men showed significantly higher levels of hostility and anger than nonviolent men (Maiuro, 1988). Rosenbaum and Bennett (1986) have proposed that depression may be linked to a sense of personal injury and anger that may lead to outbursts of temper and violence.
Other Intrapersonal Factors Associated with Aggression
Impaired Perception
Violent men were observed to misinterpret responses from their spouses more frequently, and to believe that aggressive responses would be more effective as a means to accomplishing their goals. They were found to generate less competent responses in situations with conflicts involving rejection, challenges and betrayal in the areas of communication and finance (Anglin & Holtzworth 1997).
Holtzworth-Monroe (1992) has argued that unrealistic expectations, irrational beliefs, misperceptions and processing distortions in taking in and interpreting external stimuli may lead to faulty conclusions. Erroneous interpretations may result in hostile attributions that negatively effect decision-making, which may contribute to the initiation of an aggressive response (Holtzworth-Monroe, 1992). This is supported by the results of a study conducted by Giancola and Zeichner (1994). They found that aggression was significantly related to performance on the Conditional Association Task, which measures the ability to learn a series of conditional associations between unrelated stimuli.
Coping and Anger Management Skill Deficits
In her research, Holtzworth-Monroe (1992) has identified deficits in sequential information processing in maritally violent men, linked to interpersonal interaction. Batterers often demonstrate a lack of ability in expressing themselves (LaViolette, Barnett, & Miller, 1984). In one study, maritally aggressive men, as defined by the Modified Conflict Tactics Scale (MTCS; Pan, Neidig, & O’Leary, 1994) and the Short Marital Adjustment Scale (SMAT; Locke & Wallace, 1959), were found to share the following characteristics: (a) fewer number of competent responses in spousal conflicts, (b) less likelihood of using coping skills involving reasoning, and (c) greater reliance on physical aggression. Anglin and Holtzworth (1997) found that physically aggressive spouses are less skilled in terms of problem-solving than nonviolent spouses, and appeared to have both marital and general skill deficits.
Impulsivity
Impulsivity may refer to an abrupt inclination towards an unpremeditated action, or action without conscious and deliberate judgment (Valavka, 1995). Impulsivity has been defined to include the three following aspects: (a) Motor impulsiveness, which refers to physical activity without forethought, or acting without thinking (a primary symptom of attention-deficit/hyperactivity disorder, (ADHD), (b) Cognitive impulsiveness, which refers to acts of rapid and careless decision-making, and (c) Non-planning impulsiveness, which is a lack of planning for the future. People who demonstrate non-planning impulsivity pay most attention to events in the here and now, and tend to “discount” time in the future (Valavka, 1995).
Impulsive behavior is often associated with people who are considered to be “sensation-seeking” (Valavka, 1995), often seen in conjunction with substance abuse. Male batterers have been found to demonstrate poor impulse control and an inability to control anger (Rosenbaum & O’Leary, 1981). Fedora and Fedora (1983) found that both psychopathic and nonpsychopathic criminals with violent behavior demonstrated greater performance deficits on tasks involving executive functioning and impulse control as measured by the Trail Making Test Part B (Reitan & Wolfson, 1985) as compared to a control group. Lueger and Gill (1990) conducted a comparison study between adolescent males with and without conduct disorder (CD), which is considered to be a precursor to adult antisocial behavior. Both groups were matched on age, education, substance abuse, and socioeconomic status. They found that the CD group scored lower on the Wisconsin Card Sorting Test, which is a measure of executive functioning in disinhibition and perseveration.
Substance Abuse and Aggression
Another frequent characteristic of male batterers, also often found in people who are both impulsive and/or depressed, is a history of substance abuse. A high rate of alcoholism was reported in abusive men by their wives (Goldstein & Rosenbaum, 1985), and heavy drinkers tend to become more abusive towards their wives than moderate drinkers (Kanter & Straus, 1986). Alcohol abuse has been reported for 20% to 80% of males who engage in marital aggression, and 18% to 35% of domestic violence offenders have reported problems with drug abuse. The disinhibitory effects of drugs and alcohol can exacerbate an emotionally charged situation and increase the potential for violence (Kantor & Straus, 1987).
Intelligence and Aggression
Adult violent offenders were found to have lower Full Scale Intelligence Quotients (FSIQ) than nonviolent offenders (Spellacy, 1978). A different study found that violent offenders tended to have lower Verbal IQs as compared to Performance IQs (Yeudall, 1977). Mutschler (1997) has proposed that lower Verbal IQ scores indicate a lack of resources and planning skills necessary to process emotional states, which results in an increase in tendencies towards aggressive behaviors.
Biological Factors Associated with Aggression
As mentioned earlier, aggressive behavior patterns have been found in families for several generations with the likelihood of affecting 50% of the offspring (Elliott, 1988). Although intergenerational aggression in families may be higher due to the effects of learning through environmental exposure, this cannot be the only reason. If aggression were solely due to environmental factors, then 100% of the children raised in aggressive families would be aggressive (Elliott, 1988). Aggression is also considered to be linked to a variety of biological factors. Some of the biological factors that have been associated with aggression include hormones, organic syndromes, epilepsy, perinatal insults, birth traumas, anoxia, post-natal brain infections and diseases, exposure to toxins and genetic disorders, and sustaining a brain injury (Elliott, 1988; Kandel & Mednick, 1991; Lezak, 1995; Miller, 1999; Pennington, 1991).
Hormone Theories
Higher levels of testosterone have been considered to be a cause of increased male aggression (Elliott, 1988a). Although a positive relationship exists between testosterone levels and aggression in males (Dabbs et al., 1987). Correlation does not necessarily mean causation (Carlson, 2002). A person’s environment has also been found to directly affect their level of testosterone (Carlson, 2002). Thus, a person’s environment may cause an increase in both testosterone and aggression levels simultaneously in a parallel fashion, without the testosterone directly causing the increased aggression levels.
Genetics and Heredity Factors
Over a decade ago an argument was made that attributed violent and criminal behavior to a XXY chromosomal abnormality; however, findings were inconsistent and inconclusive (Elliott, 1988a). Although chromosomal abnormality is not present in the majority of batterers, a structural abnormality with the X chromosome and the presence of the fragile X chromosome have been found to be tied to mental impairment, which has been correlated with aggression (Elliott, 1988a).
Both the hormone and the chromosome theories illustrate the problems that can occur when trying to determine the nature of the existing relationship between hereditary factors and aggression. Pennington (2002) describes some hypotheses to explain this kind of comorbidity which include: “ (1) The two conditions share a common risk factor that is consequently not specific to either disorder; (2) One disorder may cause the symptoms of the other disorder; (3) There is an etiological subtype in which a shared risk factor produces both disorders, but that other cases of each disorder do not share risk factors; and (4) there is a nonrandom mating such that individuals with transmissible risk factors (either genetic or environmental for one disorder are more likely to have children with individuals with transmissible risk factors for the other disorder (p. 22).” The fact that we are unable to study these factors within the framework of an experimental design using random selection and assignment limits our ability to determine the exact nature of the relationship between biological factors and aggressive behavior. Because of this, current research in this area is frequently a description of common themes and shared characteristics, rather than definite causal relationships.
Tuesday, June 24, 2008
Well-being in Women
For women in a state of well-being, a balance exists between the feminine and masculine aspects of our psyche that is not dictated by gender. Our feminine nature allows us to experience our creativity and intuition, and gives us our ability to nurture. Our masculine side enables us to manifest this inner creativity out in the world. In a place of psychological connectedness, we are able to accept all of who we are and function as wholly integrated beings.
Many of our mothers understood themselves solely within the context of their marriages and families. The birth of feminist movement gave us the opportunity to reclaim the masculine side of our nature. We learned to expand our awareness of ourselves beyond the context of marriage and family, and to rely more on our newly established professional identities. In struggling to break free of traditional gender roles in our effort for independence, many women become trapped. Our culture today has taught us to make different kinds of sacrifices in order to become successful. For many of us, this develops into a masculine one-sidedness causing us to view the gentle, nurturing qualities of our womanhood as weak and something to disown. Our “success” becomes determined by our professional achievements and may develop into the crux of our identity. When we allow either the masculine or feminine aspect of our nature to dominate us, our potential for inner growth and development becomes limited. Women learn to give up a part of their inner beings to prove themselves out in the world. Over time many women come to realize that something important in their life is missing. That which was once thought to bring meaning is no longer there.
If we allow ourselves to operate outside these established parameters, we may begin to explore our inner world at a deeper level. In the process of our own evolution and inner healing, the different components of our psyche become integrated. We learn to accept the masculine part of our nature as an aspect that complements and empowers our feminine essence. We come to know who we are in relationship to “being” as well as “doing.”
Many of our mothers understood themselves solely within the context of their marriages and families. The birth of feminist movement gave us the opportunity to reclaim the masculine side of our nature. We learned to expand our awareness of ourselves beyond the context of marriage and family, and to rely more on our newly established professional identities. In struggling to break free of traditional gender roles in our effort for independence, many women become trapped. Our culture today has taught us to make different kinds of sacrifices in order to become successful. For many of us, this develops into a masculine one-sidedness causing us to view the gentle, nurturing qualities of our womanhood as weak and something to disown. Our “success” becomes determined by our professional achievements and may develop into the crux of our identity. When we allow either the masculine or feminine aspect of our nature to dominate us, our potential for inner growth and development becomes limited. Women learn to give up a part of their inner beings to prove themselves out in the world. Over time many women come to realize that something important in their life is missing. That which was once thought to bring meaning is no longer there.
If we allow ourselves to operate outside these established parameters, we may begin to explore our inner world at a deeper level. In the process of our own evolution and inner healing, the different components of our psyche become integrated. We learn to accept the masculine part of our nature as an aspect that complements and empowers our feminine essence. We come to know who we are in relationship to “being” as well as “doing.”
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