Psychiatry · Interpersonal Violence
The facts most likely to be tested
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In a competent adult, the physician may NOT report IPV to authorities without the patient's consent, unlike mandatory child or elder abuse reporting.
Screen all patients universally, directly, and privately with the partner absent, since victims rarely disclose spontaneously.
Red flags include injuries inconsistent with the stated history, delayed presentation, and a controlling partner who answers for the patient.
Management centers on safety, validation, a safety plan, and referral to advocacy services, shelters, and hotlines.
Carefully document the history in the patient's own words and physical findings with body diagrams or photographs for potential legal use.
Victims frequently present with depression, anxiety, PTSD, substance use, and chronic pelvic, abdominal, or headache complaints.
Risk of harm escalates over time, especially around attempts to leave the relationship.
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A 27-year-old woman presents to the ED with a fractured wrist and facial bruising in various stages of healing. Her boyfriend stays at the bedside, answers questions directed to her, and appears reluctant to leave. The reported mechanism, a fall, is inconsistent with the injury pattern, and she presented two days after the injury. When interviewed privately, she discloses ongoing physical abuse but states she does not want anyone notified.
Which of the following is the most appropriate next step in management?
Provide safety planning and resources while respecting her decision not to report, as reporting requires her consent.
For a competent adult, intimate partner violence may not be reported to authorities without the patient's consent, in contrast to mandatory reporting of child or elder abuse. The physician should validate the patient, assess immediate safety, help develop a safety plan, document findings carefully, and refer to advocacy services.
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High yield triage
Etiology / Epidemiology
Pattern of coercive physical, sexual, or psychological abuse by a partner; all patients should be screened and most will not volunteer it.
Clinical Manifestations
Injuries inconsistent with the stated history, delayed presentation, a controlling partner who answers for the patient, and depression/anxiety/PTSD.
Diagnosis
Screen privately and directly; document findings carefully.
Treatment
Ensure safety, validate, provide resources/safety planning; in competent adults you may NOT report without the patient's consent.
Prognosis
Risk escalates over time, especially around attempts to leave; intervention reduces harm.
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Epidemiology & Etiology
Intimate partner violence (IPV), or domestic violence, is a pattern of coercive physical, sexual, emotional, or financial abuse by a current or former partner. It crosses all demographics but disproportionately affects women, and risk rises with pregnancy, substance use in the household, and social isolation. Because patients most often will not volunteer this information, all patients should be screened for IPV in a private setting.
Pertinent Anatomy
There is no specific anatomic lesion, but the clinician should recognize the pattern and distribution of injuries that suggest abuse: bruises in central/protected areas (face, neck, breasts, abdomen) and injuries at multiple stages of healing. Chronic stress exposure produces the neurobiology shared with PTSD and depression, HPA-axis dysregulation and altered amygdala-prefrontal fear circuitry, accounting for the high rate of associated psychiatric sequelae.
Pathophysiology
IPV operates through a cyclical pattern of escalating coercive control rather than a biological mechanism. Repeated trauma and chronic fear produce sustained HPA-axis activation and the same fear-circuit changes seen in PTSD, driving comorbid anxiety, depression, chronic pain, and somatic complaints. The dynamics of dependence, fear, and control explain why victims often remain with or return to the abuser and delay disclosure.
Clinical Manifestations
Red flags include injuries inconsistent with the offered explanation, delays between injury and presentation, repeated visits for vague somatic complaints, and a partner who is overly attentive, controlling, or insists on answering for the patient. Victims frequently present with depression, anxiety, PTSD, substance use, chronic pelvic or abdominal pain, and headaches. During pregnancy, IPV is associated with poor prenatal care and adverse outcomes.
Diagnosis
Detection relies on universal, direct, nonjudgmental screening conducted privately with the partner absent, since patients rarely disclose spontaneously. Use clear questions about feeling safe at home and being hurt or threatened. Carefully document the history in the patient's own words and the physical findings (with body diagrams or photographs where appropriate), as records may be needed later for legal protection.
Treatment
Management centers on safety, validation, and resources: affirm that the abuse is not the patient's fault, assess immediate danger, help develop a safety plan, and refer to advocacy services, shelters, and hotlines. Critically, for a competent adult, the physician may NOT report intimate partner violence to authorities without the patient's consent, intervention requires the patient's agreement, in contrast to mandatory reporting of child or elder abuse. Treat associated injuries and psychiatric comorbidity (depression, PTSD).
Prognosis
IPV tends to escalate in frequency and severity over time, and the period around attempting to leave the relationship is the most dangerous, carrying the highest risk of severe injury or homicide. Outcomes improve with safety planning, advocacy, and treatment of psychiatric sequelae, but recurrence is common. Sensitive, repeated screening and a supportive, nonjudgmental clinician relationship facilitate eventual disclosure and intervention.
Differential Diagnosis
Accidental injury: history is consistent with the injury pattern and timing, without controlling-partner behavior or delayed presentation.
Elder or Child Abuse: abuse of a dependent or minor, which (unlike competent-adult IPV) is subject to mandatory reporting regardless of consent.
Primary Major Depression / PTSD: mood or trauma symptoms without an identifiable abusive relationship; IPV must be screened for as an underlying cause.
Bleeding diathesis: easy bruising from coagulopathy or anticoagulation rather than trauma; clarified by labs and absence of suspicious injury pattern.
Somatic Symptom Disorder: recurrent unexplained somatic complaints without injuries or relationship coercion, though IPV can coexist and should be excluded.