Aggression and abuse

Aggression and abuse د.وليد العميدي
Aggression is behavior that is intended to injure another person (physically or verbally) or to destroy property , the key concept in this definition is intent .
Violence refers to acts of physical aggression against others ( against the law) .
Aggression as a drive :
? According to Freud psychoanalytic theory , many of our actions are determined by instincts , particularly sexual instinct , when expression of these instincts is frustrated , an aggression drive is induced .
? Later , psychoanalytic theorists broadened this frustration aggression hypothesis , proposing that whenever a person`s effort to reach a goal is blocked , an aggressive drive is induced that motivates behavior intended to injure the obstacle (person or object) causing frustration
This proposal has 2 critical aspects :One is that the cause of aggression is frustration , the other is that aggression has the properties of a basic drive.
? Being a form of energy that persist until its goal is satisfied , as well as being an inborn reaction like hunger or sex.
? If aggression is really a basic drive like hunger , we would expect other mammalian species to exhibit patterns of aggression that are similar to ours ( just as they exhibit pattern of hunger that are similar to us)
? Findings on biological bases of aggression in animals provide evidence for an aggressive drive in at least some species . Some studies shows that mild electrical stimulation of a specific region of the hypothalamus produce aggressive even deadly behavior in animals .
? The stimulation seems to trigger an innate killing response that was previously dormant.
? In these cases then , aggression has some properties of a drive , because it involves inborn reactions .
? Recent evidence suggests that the aspects of prefrontal cortex are dysfunctional in individuals who show impulsive violence.

Aggression as a learned response :
? Social learning theory concerned with human social interaction .
? It focus on the behavior pattern that people develop in response to events in their environment .
? Some social behavior may be rewarded and others may produce unfavorable results .
? Through the process of differential reinforcement , people eventually select the more successful behavioral pattern.

Aggressive expression and catharsis:
? Catharsis is purging an emotion by experiencing it intensely.
? If aggression is a drive , expression of aggression should be cathartic , resulting in a reduction in the intensity of aggressive feelings and actions ( analogue to the way eating leads to reduction of hunger based feelings and actions ).
? On the other hand if aggression is a learned response , expression of aggression could result in an increase in such action ( if aggression is reinforced ).
? The available evidence favors the learned response view.
? Several experimental studies have controlled children`s viewing of TV , in one study , one group of children watched violent cartoons for a specified amount of time each day and another group watched nonviolent cartoons for the same amount of time , the children who watched violent cartoons became more aggressive in their interactions with peers.
? Other studies indicating that girls tend to imitate aggressive much less than boys do unless they are specifically reinforced for doing so , in our society , girls are less likely to be reinforced for behaving aggressively .
? And because most of the aggressive roles on TV are male , females are less likely to find aggressive models to imitate .
? Despite this evidence , the visual media are become increasingly violent and diverse and now include interactive media , like video games.

Social and biological determinants of aggression:
1) Social determinants:
- Factors associated with increased aggression include poverty , frustration , physical pain , and exposure to aggression in media .
- Children at risk for showing aggressive behavior in adulthood frequently have moved and changed schools repeatedly , have been physically and/or sexually abused or their parents frequently display criminal behavior , and abuse drugs and alcohol.
- Homicide occurs more often in low socioeconomic populations.
2) Biological determinants:
1-Hormones:
-Androgens are closely associated with aggression .
- Androgens and anabolic steroids , often taken by body builders to increase muscle mass , can result in high levels of aggression and even psychosis .
- Esrtogen , progesteron and antiandrogens may be useful in treating male sexual offenders.
2- Substance abuse :
- Low dose of alcohol and barbiturates inhibit aggression , while high doses facilitate it .
- Increase aggression associated with cocaine , amphetamines and phencylidine.
3- Neural bases of aggression:
Serotonin and GABA inhibit aggression , and dopamine and norepinephrine facilitate it , low levels of serotonin metabolite (5-HIAA) are associated with impulsive aggression .
Drugs used to treat inappropriate aggressiveness include antidepressants , benzodiazepines , antipsychotics and mood stabilizers.
Abnormalities of the brain e.g. abnormal activity in the amygdala and TLE , and lesions of the temporal lobes , frontal lobes and the hypothalamus are associated with increased aggression.
Violent people often have a history of head injury or show abnormal EEG readings.

ABUSE AND NEGLECT OF CHILDREN AND THE ELDERLY
Types of child and elder (persons aged 65 and over) abuse include physical abuse , emotional or physical neglect, and sexual abuse . The elderly may also be exploited for monetary gain.
1.Abuse -related injuries must be differentiated from injuries obtained during normal activity. Examples of accidental (i.e., non-abuse) injuries in children include bruises and scrapes on bony prominences (e.g., chin, forehead, knees, elbows) or, in the elderly, bruising on extensor surfaces of the limbs.
2.Occurrence of abuse and characteristics and signs that indicate neglect and abuse are shown in following table :
Category Features of Child Abuse Features of Elder Abuse
Most likely abuser The closest family member
(e.g., the mother) The closest family member
(e.g., spouse, daughter, son, or other relative) with whom the person lives (and who is often supported financially by the elder)
Characteristics of the abused Hyperactivity or mild physical
handicap; child is perceived as slow or different
Premature, low-birth-weight infant
Colicky or "fussy" infant
In one third of cases, victims
Are younger than 5 yr of age;
in one fourth of cases, victims are
5–9 yr of age Some degree of worsening Cognitive impairment (e.g.,Alzheimer disease)
Physical dependence on others
Incontinence
Does not report the abuse,But instead says that he fell and injured himself
Characteristics of the abuser Substance abuse
Poverty
Social isolation
Delays seeking treatment for the victim
Personal history of abuse by
caretaker or spouse Substance abuse
Poverty
Social isolation
Delays seeking treatment
for the victim
Signs of Abuse
Neglect Poor personal care and Hygiene (e.g., diaper rash, dirty hair)
Lack of needed nutrition Poor personal care and Hygiene (e.g., urine odor in incontinent person),
lack of medication or health aids such as eyeglasses, or dentures
Lack of needed nutrition
Bruises Particularly in areas not likely to be
injured during normal play, such
as buttocks or lower back,
or not over bony prominences
Belt or belt-buckle marks Often on the inner (flexor) surfaces of arms from being grabbed
Fractures and burns Fractures at different stages
of healing
Spiral fractures caused by
twisting the limbs
Cigarette and other burns
Wrist or ankle rope burns
caused by tying to a bed or chair
Burns on the feet or buttocks
Caused by immersion in hot water Fractures at different
stages of healing
Spiral fractures caused by
twisting the limbs
Cigarette and other burns
Wrist or ankle rope burns
caused by tying to a bed or chair
Other signs Internal abdominal injuries
(e.g., ruptured spleen)
Shaken baby" syndrome
(i.e., retinal detachment or hemorrhage, and subdural hematoma caused by shaking the infant to stop it from crying)
Injuries of the mouth caused
by forced feeding Internal abdominal injuries
(e.g., ruptured spleen)
Evidence of depleted personal finances (the elder s money was spent by the abuser and other family members)
Injuries of the mouth caused by
forced feeding

Sequelae of child abuse
1- Children who are being abused often seem sad, show behavioral change s (e.g., are no longer outgoing and friendly), and do poorly in school.
2- Adults who were abused as children are more likely to :
a- Have dissociative disorders (e .g., dissociative identity disorder) and borderline personality disorder
b- Have posttraumatic stress disorder and other anxiety disorders
c. Have depression and substance abuse disorders.
d. Abuse their own children

Sexual abuse of children
Signs
1- Sexually transmitted disease s (STDs) in children are signs of sexual abuse; children do not contract STDs through casual contact with an infected person or with their bedclothes, towels, or toilet seats.
2- Genital or anal trauma also are signs of sexual abuse.
3- Young children have only a vague knowledge about sexual activities; specific knowledge about sexual acts (e.g., fellatio) in a young child often indicates that the child has been sexually abused.
3- Recurrent urinary tract infections and excessive initiation of sexual activity with friends or with younger children, also are signs of sexual abuse.

Occurrence
a- Most sexually abused children are 8 to 13 years of age , and 25% are younger than 8 years old.
b- Approximately 20% of women and 5% to 10% of men report sexual abuse at some time during their childhood and adolescence.

Characteristics of the sexual abuser
a- Seventy percent to ninety percent of sexual abusers are known to the child and 90% of these are men. About 50% of these men are relatives (e.g., uncle, father, stepfather), and 50% are family acquaintances (e.g., mother s boyfriend, neighbor).
b- Alcohol and drugs are commonly used by the abuser.
c- The abuser typically has marital problem s and no appropriate alternate sexual partner; occasionally, he is a pedophile (i.e., he prefers children to appropriate sexual partners)

PHYSICAL AND SEXUAL ABUSE OF DOMESTIC PARTNERS
A. Occurrence
1- Domestic abuse is a common reason women come to a hospital emergency room. The abuse may be physical or sexual and the abuser is almost always male.
2- The abused woman may not report to the police or leave the abuser because she has nowhere to go and because he has threatened to kill her if she reports or leaves him. (In fact, she does have a greatly increased risk of being killed by her abusive partner if she leaves.)

B. Evidence of domestic abuse
1. The victim commonly has bruises (e.g., blackened eyes) and broken bones.
2- In pregnant women (who have a higher risk of being abused), the injuries are often in the "baby zone " (i.e., the breasts and abdomen).
3- An irrational explanation of how the injury occurred, delay in seeking treatment, and appearance of sadness in the victim are other indications of domestic abuse.

The cycle of abuse includes three phases
a. Buildup of tension in the abuser
b. Abusive behavior (battering)
c. Apologetic and loving behavior by the abuser toward the victim

Characteristics of abusers and abused partners
1- Abusers often use alcohol or drugs, are impulsive, have a low tolerance for frustration, and displace their angry feelings onto their partner.
2- The abused partner is often emotionally or financially dependent on the abuser, pregnant, and blames herself for the abuse.
3. Both the abuser and the abused commonly have low self-esteem.


THE ROLE OF THE PHYSICIAN IN SUSPECTED CHILD, ELDER, AND DOMESTIC
PARTNER ABUSE
A. Child and elder abuse
1- Physicians must report suspected physical or sexual abuse of a child or elderly person, or of an adult who appears to be physically or mentally impaired before or in conjunction with treatment of the patient.
2-The physician is not required to tell the suspected abuser of the child or impaired elder that he or she suspects abuse.
3-The physician does not need family consent to hospitalize the abused child or elderly person for protection or treatment.

B. Domestic partner abuse
Direct reporting by the physician of domestic partner abuse is not appropriate because the victim is usually a competent adult between the ages of 18 and 64.
1.A physician who suspects domestic partner abuse should
a. Document the abuse.
b. Ensure the safety of the abused person.
c. Develop an emergency escape plan for the abused person.
d. Provide emotional support to the abused person.
e. Refer the abused person to an appropriate shelter or program.
f. Encourage the abused person to report the case to law-enforcement officials.


SEXUAL AGGRESSION: RAPE AND RELATED CRIMES
A- Definitions. Rape is a crime of violence, not of passion, and is known legally as “sexual assault,” or “aggravated sexual assault.”
1. Rape involves sexual contact without consent.
2. Vaginal penetration by a penis, finger, or other object may occur.
3. Erection and ejaculation do not have to occur.
4. Sodomy is defined as the insertion of the penis into the oral or anal orifice. The victim may
be male or female.
B- Legal considerations
1. Because rapists may use condoms to avoid contracting HIV or to avoid DNA identification,
or because they may have difficulty with erection or ejaculation, semen may not be
present in the vagina of a rape victim.
2. A victim is not required to prove that she resisted the rapist for him to be convicted. A rapist can be convicted even though the victim asks him to use a condom or other form of sexual
protection.
3. Certain information about the victim (e.g., previous sexual activity, “seductive” clothing
worn at the time of the attack) is generally not admissible as evidence in rape trials.
4. Husbands can be prosecuted for forcing their wives to have intercourse. It is illegal to force
anyone to engage in sexual activity.
5. Even if a woman consents to go on a date with a man and consents to sexual activity not
involving intercourse, a man can be prosecuted for rape (“date rape”).
6. Consensual sex may be considered rape (“statutory rape”) if the victim is younger than 16 or
18 years old or is older than this but is physically or mentally impaired.
C- Characteristics of the rapist and victim
1. The rapist
a. Rapists are usually younger than 25 years of age.
b. They are usually the same race as the victim.
c. They are usually known to the victim.
d. They often use alcohol.
2. The victim
a. Rape victims are most typically between 16–24 years of age.
b. Rape most commonly occurs inside the victim’s home.
c. Vaginal injuries may be absent, particularly in parous women (those who have had
children).
D. The sequelae of rape
1. For a variety of reasons, including shame, fear of retaliation, and the difficulties involved
in substantiating rape charges, only 25% of all rapes are reported to the police.
2. Others may commonly blame the victim in rape cases.
3. The length of the emotional recovery period after rape varies, but is commonly at least
1 year. Posttraumatic stress disorder sometimes occurs after rape.
4. The most effective type of counseling is group therapy with other rape victims.
E. The role of the physician in rape cases
1. Immediately after the rape, the physician should
a. Take the patient’s history in a supportive manner, and not question the patient’s veracity
or judgment.
b. Perform a general physical examination and conduct laboratory tests (e.g., cultures for
sexually transmitted diseases from the vagina, anus, and pharynx; test for presence of
semen).
c. Prescribe prophylactic antibiotics and postcoital contraceptive measures if appropriate.
d. Encourage the patient to notify the police. The doctor is not required to notify the police
if the woman is a competent adult.
2. Up to 6 weeks after the rape
a. Discuss with the patient the emotional and physical sequelae of the rape (e.g., suicidal
thoughts, vaginal bleeding) and, if needed, refer her for long-term counseling or a support
group.
b. Do a pregnancy test and repeat other laboratory tests if appropriate