Comorbidity Between Abuse of an Adult and DSM-III-R Mental Disorders: Evidence From an Epidemiological Study

Studies of partner violence reveal that 35%–50% of young adults are involved in some level of physical abuse (1). Accordingly, the mental health field has made partner violence a focus of clinical attention with its creation of the category physical abuse of adult in DSM-IV. Acknowledging that partner violence may represent a clinical condition raises the possibility that abusive relationships may co-occur with other clinical disorders. This study aimed to estimate the base rates of psychiatric disorders among women who are victims and men who are perpetrators of partner violence because these persons are most frequently treated in mental health facilities.

Previous studies found that women who are victims of partner violence have elevated rates of depression, anxiety, personality disorders, schizophrenia, and drug and alcohol abuse and that men who are perpetrators of partner violence have elevated rates of depression, personality disorders, and drug and alcohol abuse (2–7). However, these studies relied on samples from shelters (2, 4), medical settings (3), treatment programs (5–7), and correctional facilities (5). Such samples are biased by factors associated with treatment seeking or adjudication. Therefore, epidemiological studies such as this one are needed to identify rates and patterns of comorbidity in the age segment of the general population that is at greatest risk for partner violence (8). Such knowledge can inform theory about relations between these conditions and can inform clinicians who treat partner violence about what other disorders they should assess and treat.

METHOD

Participants were members of the Dunedin Multidisciplinary Health and Development Study, a representative birth cohort (N=1,037; 52% men, 48% women) studied since birth in 1972–1973. We report data gathered when the subjects were age 21, when 92% of the living study members provided data about their intimate relationships and mental health. The sample, design, and data are described extensively elsewhere (9–12). All subjects gave written informed consent.

Partner violence in the previous 12 months was measured through use of the Conflict Tactics Scales (13). We examined any physical violence, which referred to any of three minor or six severe violent behaviors in the Conflict Tactics Scales (minor: throw object at partner; push, grab, or shove partner; slap partner; severe: kick, bite, or hit with fist; hit with object; beat up; choke or strangle; threaten with a knife or gun; use a knife or gun), and severe physical violence, which referred to any of the six severe violent behaviors in the Conflict Tactics Scales.

The Diagnostic Interview Schedule (14) was used to obtain diagnoses of 15 DSM-III-R disorders in the previous 12 months: 1) six anxiety disorders: generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, agoraphobia, social phobia, and simple phobia; 2) three mood disorders: major depressive episode, manic episode, and dysthymia; 3) two eating disorders: anorexia nervosa and bulimia nervosa; 4) two substance use disorders: alcohol dependence and marijuana dependence; 5) antisocial personality disorder; and 6) “nonaffective psychosis,” which consisted of the positive symptoms of schizophrenia and schizophreniform disorder. Rates of partner violence (10) and mental disorders (11) in the Dunedin study are comparable to national rates for young adults in the United States.

RESULTS

Table 1 shows the prevalence and risk of psychiatric disorders among female victims and male perpetrators of any and severe partner violence. (Tables reporting findings for each of the 15 specific disorders are available from Dr. Moffitt on request.) Over half of the women victimized by violence suffered a DSM-III-R disorder; they had significantly elevated rates of mood and eating disorders. Nearly two-thirds of the women victimized by severe partner violence met criteria for one or more disorders and had significantly elevated rates of mood, eating, and substance use disorders, as well as antisocial personality disorder and symptoms of schizophrenia. Over half of the male perpetrators of partner violence met criteria for some type of disorder and had significantly elevated rates of anxiety disorder, substance use, and antisocial personality disorder. Virtually all male perpetrators of severe partner violence met criteria for one or more of a wide spectrum of psychiatric disorders.

DISCUSSION

This study provides evidence that abusive relationships co-occur with other clinical disorders. Women who were victims and men who were perpetrators of mild forms of partner violence had significantly higher rates of disorders that mirror gender differences in the general population: greater depression and eating disorder among women and greater substance dependence and antisocial personalities among men. In contrast, both women and men involved in severe partner violence showed elevated rates of a wider spectrum of psychopathology. The most severe forms of partner violence are likely to be experienced and perpetrated by individuals with poor mental health. This study probably underestimates the true extent of comorbidity because not all DSM disorders were assessed.

These epidemiological findings about comorbidity between partner abuse and psychiatric disorder underscore the need to screen for partner violence in mental health clinics. Recent discussions have focused on how general practitioners can screen for partner violence in medical facilities (15). The advantage of screening for partner violence in mental health facilities, in addition to medical facilities, is that medical practitioners see only the victims, generally after an injury, whereas mental health clinicians may see both victims and perpetrators, in time to prevent injury. Findings about comorbidity may also inform treatment programs for partner abuse. Some cases of partner violence could be resistant to treatment because comorbid psychiatric disorders complicate the clinical picture. For example, among male perpetrators of severe violence in our study, 48% met criteria for two or more psychiatric disorders. In attempting to change a batterer's behavior, health professionals may also have to treat disorders such as substance use and paranoid delusions for behavioral change to occur. The present findings suggest a need to reconsider institutional practices that separate services for victims and perpetrators of partner violence from services for persons suffering psychiatric disorders.

TABLE 1

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