Differential Diagnosis

Perpetrators of violence are likely to present with a range of psychiatric diagnoses.Research in domestic violence has indicated that the vast majority of perpetrators suffer from one or more conditions including affective disorders, personality disorders, trauma related disorders and psychoactive substance disorders.There is also some recent evidence that suggests that some perpetrators may also suffer from neurological disorders stemming from prior brain trauma.Therefore, the clinician needs to approach each case individually rather than look for a single diagnosis that will be utilized in a repetitious manner.Sufficient research with regard to diagnosis does not exist in the domestic violence field, due in part to the persistence of interest in social variables rather than psychiatric factors.However, the violence field in general has accumulated quite a bit of data on the relationship between psychiatric disorders and violence or aggression.Part of the problem in drawing a link between violence and psychiatric illness is that there is unlikely to be a direct cause-and-effect relationship; intermediating variables are likely to play a significant role in the expression of violence and aggression.For example, persons suffering from schizophrenia are in general not likely to be any more violent than those without the illness.However, if the person suffering from schizophrenia is experiencing hallucinations or delusions of physical harm, hallucinations or delusions of feeling threatened, or beliefs of mind or body control, he/she is more likely to act aggressively or violently.If that same person has been prescribed medication but is noncompliant, another variable is added that increases the likelihood of violent acting out.This example illustrates how psychiatric illness may be related to violence and aggression through intermediating variables, such as symptomology or medication compliance.

Another example is anxiety or bipolar disorder.Once again, there is no conclusive evidence that these conditions in and of themselves cause an individual to become violent or aggressive.However, when a person has had a history of child abuse or is currently suffering from a psychoactive substance abuse disorder, and is noncompliant with medication treatment, he/she may be more prone to acting out aggressive impulses.

Depression is common in domestic violence perpetrators.Some clients have a long-standing personal and/or family history of depressive illness.Many untreated clients have self-medicated with the use of psychoactive substances.Typically, when an individual is in the throes of depression they are not likely to act out toward themselves or others simply because of his/her lack of energy in general.But acting-out may either precede a full depressive episode or the client may act violently upon gaining energy subsequent to a depressive episode.The client may have learned to use anger, aggression and violence as a means to mobilize his/her energy.Some younger individuals, as well as older adults, may develop an irritable depression, rather than the classic lack of energy, which could manifest in aggression or violence.

Many perpetrators experience depression as a result of criminal proceedings, but more commonly they become extremely depressed when their partner separates or files for divorce.This type of depression may be more related to their personality disorder than to the circumstances; however, experiencing the breakup of their relationship and family can be a serious blow to anyone.Therefore, therapists must be cautious about how they understand the depressive symptoms of their client -- whether they are situational and likely to resolve in time, or if they are long-standing and are likely to respond to medication or other medical intervention, or if they are symptomatic of a personality disorder that may quickly resolve once the client regains some emotional stability through therapeutic interventions.

Over two thirds of the perpetrators of domestic violence have suffered from some type of child maltreatment in their family of origin.In a significant percentage of these individuals, the abuse may have been severe enough to cause a post-traumatic stress disorder.These clients' violence may be understood as a deep and powerful reaction to feelings of powerlessness, not being in control of their lives or the lives of others, or fears that their self-esteem is being attacked.Many persons who experienced child abuse have learned early on in their lives how to avoid the dysphoric affect associated with feeling victimized -- by valuing self-control in their lives and/or by attempting to control their environment.Under the right circumstances, these traits may not only be helpful but may be a key to success; however, they may not work in all situations, particularly in intimate relationships.Nevertheless, individuals may continue to utilize these strategies interpersonally, in spite of their inappropriateness.When emotional stress and conflict rise above a certain tolerable level, an individual will re-experience the intense feelings of rage, helplessness, fear, and confusion.These intense emotions may overwhelm the person’s coping resources and as a result the individual resorts to those behaviors that caused the trauma in the first place.Although this scenario sounds very similar to the defenses employed by a person suffering from a personality disorder (certainly both diagnoses may exist within an individual), it is distinctly different in that persons suffering from post-traumatic stress disorder is more likely to find their symptoms or reactions to the situation as ego-dystonic or unlike themselves.The client suffering from a personality disorder is likely to see nothing wrong with his/her own behavior, and rather focuses on how the other person’s reactions are more problematic.The person suffering from trauma symptomology is likely to experience these defensive reactions only when experiencing an event that closely resembles the traumatic situation, whereas the person with the personality disorder is likely to react this way in all situations -- the disorder tends to be more pervasive in all areas of life.

Psychoactive Substance Disorders

One of the most common psychiatric disorders in domestic violence perpetrators is psychoactive substance abuse and dependency.Early on, it was thought that violence and chemical dependence were two distinct disorders needing to be addressed separately.Today there is a proliferation of domestic violence and chemical dependency dual diagnosis treatment programs, where individuals can receive treatment for both disorders in the same treatment groups.It was also thought at one time that the substance abuse problems needed to be treated before the violence problem.Many providers with experience in drug and alcohol treatment held the view that the chemicals caused the undesirable behaviors.In fact, if a person was working in a good “12-step” program, it was thought that there might not even be a need for domestic violence treatment.Many domestic violence treatment programs require a period of abstinence ranging from days to several months prior to treating an individual with both violence and substance abuse problems. These assumptions, recommendations and treatment interventions have traditionally been based on the program’s treatment philosophy rather than on empirical research into these issues.In this workshop, I recommend assessment-based treatment, and therefore I do not recommend one approach over the other.Instead, I suggest that clinicians evaluate each case one at a time based on the available clinical, corroborative and historical information.

There are differing philosophies about how to treat the client who is experiencing domestic violence and who also presents with a psychoactive substance disorder.This client is commonly referred to as having a dual diagnosis.However, domestic violence is less of a diagnosis and more of a behavioral descriptor; therefore the second diagnosis should be either an Axis I or Axis II diagnosis such as an affective disorder or a personality disorder.In these cases, whether there is a single treating clinician or multiple clinicians, each diagnosis must be addressed in the treatment plan.

Personality Disorders

According to research, approximately 15% of the general population suffers from some type of personality disorder.According to the research in domestic violence perpetrators, that rate is approximately quadrupled. The most intensely studied personality disorder in the general psychiatric literature is the borderline personality disorder.This is also true for the domestic violence literature.

On the continuum between health and major mental illness, personality disorders fall between neurosis and psychosis.Unlike neurosis, where a person's problems generally fall into discrete areas of functioning, the personality disorder is pervasive in a person’s life.And unlike psychosis, where the person has lost touch with reality for the most part, the individual with a personality disorder still has a normal grasp of reality except for those moments when he/she is experiencing intense affect.

The DSM IV classifies personality disorders into three clusters:

1. People who appear odd or eccentric, and fear social relationships (paranoid, schizoid and schizotypal)
2. People who appear dramatic, emotional, or erratic and who tend to act out their conflicts directly on their environment (antisocial, borderline, histrionic, narcissistic)
3. People who are primarily anxious, fearful and careful and have few problems with reality testing (avoidant, dependent, obsessive compulsive and passive-aggressive)

There is a residual category for people with mixed or unspecified conditions.Although personality disorders are often thought of as distinct, they all have certain characteristics in common.Persons with character disorders exhibit ego functioning that is relatively impaired.Their responses to stress are usually inflexible and maladaptive.Another characteristic of individuals with a character disorder is that they usually feel their problems lie not within themselves but outside in the environment.Individuals with personality disorders are also not usually troubled by their behavior, and in fact, perceive themselves quite differently than others perceive them. Because of these psychological patterns, their ability to sustain loving, consistent and mutually satisfying relationships with others is impaired to varying degrees.Lastly, because the character-disordered individuals’ issues are so frequently acted out or enacted in the interpersonal realm, the countertransference reactions of the therapist in the treatment relationship are likely to become activated -- but these reactions can be invaluable tools in diagnosing, assessing and treating these clients.

Recent research in domestic violence from an attachment theory perspective suggests a significant percentage of batterers present with borderline personality organization. They neither have a well-defined sense of self (and look to others for that definition) nor do they trust that others will have benign intentions towards them (which manifests in rageful attacks). Different conceptualizations of attachment theory suggest different attachment styles in this population.But the most recent studies by Donald Dutton suggest that batterers may suffer from an attachment disorder (specifically a fearful attachment style) that correlates with borderline personality characteristics.

Don Dutton, professor of psychology at the University of British Columbia, has conducted considerable research on the male batterer, and his findings have shed great light on this problem. Dutton suggests that many male batterers may be suffering from a disorder of attachment that results in high levels of anxiety, as well as in other dysphoric mood states, when they are involved in intimate relationships. These men regulate their mood state by adjusting closeness and distance (degrees of attachment) or by changing their environment (controlling their partner and children). Hence many male batterers withdraw from potential conflict, inappropriately intrude on personal boundaries of others, and/or attempt to control the perceived external cause of their discomfort. These men are so sensitive to rejection that they are likely to interpret any disagreement or uncomfortable emotional interaction as potentially threatening. Ironically, even though these men find intimacy so threatening, they are very dependent on their partner for a sense of self, that is, who they are; their value and worth are partly determined by their partner’s love and acceptance. So when their partner leaves or wants a separation, the men find this situation very threatening and therefore anxiety-producing. Getting the partner to return is one way of managing this anxiety and is the batterer's attempt to return to wholeness.

As indicated from the clinical literature, individuals with borderline personality disorders have tremendous problems with impulse control, affect regulation (particularly manifested as anger), reality testing (during times of intense affect) and anxiety.Therefore strengthening the ego functions is a first important step in helping these individuals manage their affective states more effectively.However, over the long run clinicians needs to work with their clients to help them develop a more complex view of self and others.Clients need to become aware of the defense mechanisms they use, particularly the splitting defense.This awareness can come only by the working through of psychological material the client brings to the sessions -- issues relating to interpersonal difficulties that bring about significant emotional reactions.Through this process, the clients learn how to hold the good and the bad in both self and others when under the influence of strong affect.

Neurological Impairment

There is some recent research that suggests that some violent individuals may have experienced head injury, which may be causing problems in neurological functioning.Along with injuries stemming from trauma, some individuals may present with other prominent neurological dysfunctions that may respond to appropriate medications, including attention deficit disorder, epilepsy and severe psychiatric and developmental disorders.

Rosenbaum and his colleagues have found clinically significant prior head injury in 53% of batterers, 25% of maritally discordant and 16% of maritally satisfied men.In a recent study, when comparing batterers with non-batterers, Cohen, Rosenbaum, Warnken and Benjamin found that 1) batterers had weaker performance on a test that measures cognitive flexibility which is related to frontal-lobe damage and 2) batterers had relative impairments on tests that demands focused attention, information processing efficiency, working and executive control ability Both of this results suggest impairments in executive control functioning.They conclude that executive discontrol is one of the most significant cognitive problems observed in batterers.Along with these patterns, batterers also exhibited deficits in: 1) learning, particularly for verbal information, 2) memory, particularly for verbal information, 3) verbal ability and 4) vocabulary knowledge.Batterers also exhibited high levels of emotional distress as compared with non-batterers.This data suggests that high levels of emotional distress in combination with cognitive deficits may be important variables in understanding the etiology of violence.Although there are many more questions than answers at this time, there is mounting evidence that some batterers may be suffering from neurological impairments and therefore traditional talk psychotherapy may need to be augmented with psycho-pharmacological interventions.

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