Correction

This article refers to:

The Psychology of Health and Illness: The Mental Health and Physiological Effects of Intimate Partner Violence on Women

In volume 152, issue 6 (2018), the article “The Psychology of Health and Illness: The Mental Health and Physiological Effects of Intimate Partner Violence on Women” published in error. The entire article is reprinted here in this special issue using the same page numbers as the originally printed article. The original article can be found in volume 152, issue 6 at Taylor and Francis Online. Any citations of the article should be as follows:

Lutwak, N. The Psychology of Health and Illness: The Mental Health and Physiological Effects of Intimate Partner Violence on Women. The Journal of Psychology: Interdisciplinary and Applied, 152(6), 373–387.

The Psychology of Health and Illness: The Mental Health and Physiological Effects of Intimate Partner Violence on WomenCONTACT Nancy Lutwak [email protected] VA New York Harbor Healthcare System, NYU School of Medicine, Departments of Psychiatry and Emergency Medicine, 423 East 23rd Street, New York, NY, 10010, USA

Abstract

Violence against women is a global public health problem with about one in three women experiencing either physical and or sexual intimate partner violence during their lifetime. Globally as many as 38% of homicides committed against women are by a male intimate partner. Violence against women may have negative effects on their mental, physical, and reproductive health (WHO fact sheet, 2016). Untreated individuals who have experienced violence or life-threatening situations may develop posttraumatic stress disorder (PTSD). This disorder has the potential to be life-changing and cause negative psychological and medical issues (Rokach, Ahmed, & Patel, 2017). This potentially life-changing nature and consequence of violence affecting women world-wide deserves greater attention to ensure elimination of risk factors, financial support of investigational studies to promote detection of victims, and research to increase therapeutic efficacy of remediation. These efforts should be bolstered by all physicians, mental health experts, social service specialists, and public health advocates.

Keywords:

• Depression
• homelessness
• intimate partner violence
• PTSD
• substance abuse
• trauma
• suicide

About one-third of adult females in the United States report experiences of intimate partner violence (IPV). This type of violence may result in posttraumatic stress disorder (PTSD) which is defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 (APA, 2013) as the posttrauma victim suffering from a constellation of symptoms. The four clusters of symptoms include intrusive and recurrent memories of the trauma, numbing, or negative changes in mood or cognitions related to the trauma, difficulties in reactivity and arousal, and avoidance of trauma-related stimuli. The physical and mental health effects of IPV, risk factors, intervention techniques, and therapeutic options recommended by the American Psychological Association (APA, 2017) will be outlined.

Struggles of Women Victimized by Violence

IPV affects about one-third of women in their lifetimes. This trauma, a type of interpersonal violence, represents a major threat to the physical, mental, or psychological safety and well-being of the victim. This violence results in physiological and psychological stress responses that are overwhelming and challenges the victim's capacity to cope (APA, 2017). A study which was published in 2002 whose authors analyzed data from the National Violence Against Women Survey (NVAWS) of women and men aged 18–65 documented physical IPV victimization was associated with increased risk of poor health, symptoms of depression, substance use, and developing either a chronic mental or physical illness (Coker et al., 2002).

IPV includes sexual coercion, physical aggression, psychological abuse, stalking, and/or controlling behaviors perpetrated by a current or previous intimate partner in a heterosexual or same-sex relationship. This trauma may cause physical injury, increased risk for sexually transmitted diseases, pregnancy complications, and death. Psychological sequelae may include depression, anxiety, PTSD, impulsivity, substance abuse, and suicidality. Victims of IPV may present to healthcare providers with physical signs of trauma, psychological problems as well as nonspecific complaints such as chronic back pain, headaches, generalized fatigue, or weight loss (Stewart, Vigod, & Riazantseva, 2016). Women battered by IPV affected by severe anxiety and depression may use alcohol and drugs excessively. Violence to pregnant women is linked to increased risk for low birth weight infants, preterm delivery, and neonatal death (Sarkar, 2008). In some regions of the world, women exposed to IPV are 1.5 times more likely to acquire HIV and have increased numbers of abortions compared to women who have not been battered (WHO, 2016).

IPV may lead to PTSD causing recurrent dreams or flashbacks of the violent episodes. Individuals with PTSD avoid situations that remind them of the event and often suffer from irritability, hypervigilance, and difficulties with sleep (Stern, Fricchione, Cassem, Jelinek, & Rosenbaum, 2004). When the perpetrator of the assault is a trusted and depended upon individual, the trauma is considered betrayal trauma (Freyd, 1996, p. 76). PTSD has been found to create vulnerability for revictimization (Duckworth & Follette, 2012). It can be potentially life-changing as well as causing threatening psychological and medical issues (Rokach, Ahmed, & Patel, 2017).

The Enormity and Consequences of Violence Against Women

Homicide is one of the leading causes of death for women less than 44 years of age. In 2015, homicide caused the death of 3519 girls and women in the United States with nearly half of the victims killed by a current or former male intimate partner. During 2003–2014 in 18 states over half of all homicides of women 18 years old or greater were related to IPV. In the month prior to the homicides, over 10% of the victims had experienced some form of violence (Petrosky, Blair, Betz, & Fowler, 2017).

The Complex Needs of Women Victimized by Betrayal Trauma

About 30% of the general female adult population report being physically assaulted by a current or former spouse, partner, boyfriend, or date (CDC, 2017a). Most female victims of assault are victims of IPV which affects their psychological and physical health directly by injury and indirectly through a prolonged stress response that leads to chronic health problems. The influence of abuse can cause trauma long after the violence has stopped. The more severe the intimate partner abuse, the greater its impact on health. The longer the abuse continues, the more cumulative the damage to the victim (Dahlberg & Mercy, 2009; Heise & Garcia, 2002).

Those who have been victims of IPV are at great risk of poor health, depression, substance use and chronic mental illness (CDC, 2017a). Domestic violence survivors develop PTSD and depression resulting from feeling a sense of helplessness, ongoing threats to safety and anticipatory fear (Salcioglu et al., 2017). They may also suffer from general anxiety disorder (Cody, Jones, Woodward, Simmons, & Beck, 2015).

Women who are victims of IPV have a three to five times greater likelihood of depression, suicidality, PTSD, and substance abuse than nonvictims. The prevalence rates of PTSD among battered women vary from 31% to 84.4% (Jones, Hughes, & Unterstaller, 2001). In contrast, PTSD affects 3.5% of the adult US population (Bear, Connors, & Paradiso, 2016 p. 757). PTSD is associated with emotional dysregulation including flashbacks, startle responses, hypervigilance as well as emotional shutdown. It may lead to feelings of isolation, changes in cognition and moral questioning (APA, 2017). Victims of PTSD may exhibit risk taking, abuse themselves or others, become addicted to illicit substances and have difficulty with maintaining intimate and trusting relationships. Decreased ability to function at work may lead to job loss, anger, and criminal actions (APA, 2017).

Intimate partner emotional abuse as well as absence of partner caring and respectful behavior may lead to physical and mental health symptoms in addition to diminished quality of life (Queen, Brackley, & Williams, 2009). Women who are in abusive relationships may have feelings of loneliness, isolation, and social marginalization (Rokash, 2007).

Complex PTSD

Victims of chronic trauma that continued for months or years may exhibit additional symptoms alongside those more typical of PTSD. Complex PTSD may develop in women who have been traumatized for years by abusive partners and in persons who suffered years of child physical or sexual abuse. These victims often struggle with poor self-perception with feelings of stigma, seeing themselves as different from other persons, and a sense of helplessness. In addition to the “usual” symptoms of PTSD, victims of chronic trauma may have difficulties with explosive anger, a sense of dissociation, preoccupation with seeking revenge, distrust, and chronic sense of despair. They may engage in self-mutilation, use alcohol or other substances, and have overwhelming feelings associated with the traumatic experiences (Herman, 1997).

Depression as an Independent Risk Factor for Cardiac Disease and a Systemic Illness

Depression is ubiquitous among victims of high betrayal trauma. Depression is additionally an independent risk factor for cardiac disease and is common among victims of childhood abuse and IPV. Women with depression, therefore, need careful evaluation for lipid management, diet, physical activity, and smoking. (Lutwak & Dill, 2012b, 2012c).

Depression is additionally a systemic disease that affects multiple medical illnesses via neurobiological mechanisms (Lutwak & Dill, 2012a, 2012b, 2012c; Sotelo & Nemeroff, 2017). It is a complicating factor of heart disease, stroke, diabetes, osteoporosis, and cancer. Diverse biological processes are influenced by depression and increased levels of proinflammatory cytokines are associated with anxiety. Inflammation, alterations in autonomic nervous system activity, and neuroendocrine dysregulation may, in turn, lead to the progression of depression in the setting of cooccurring medical disease. Experiences of childhood and adult trauma may magnify psychological as well as physiological illness (Sotelo & Nemeroff, 2017). Adulthood medical maladies may be affected by early childhood trauma through mechanisms of increased inflammation and hypothalamic-pituitary-adrenal axis activity (Sotelo & Nemeroff, 2017). Women with histories of childhood maltreatment have higher rates of physical health problems and greater medical utilization compared to women without abuse histories. Women with PTSD as well as depression have more medical conditions and worse physical problems, bodily pain, and lower energy levels than women with depression alone (Frayne et al., 2004; Lang et al., 2006).

Social Challenges of Women Who are Victims of High Betrayal Trauma

Domestic violence is one of the leading causes of homelessness for women and children. Among US city mayors surveyed in 2005, 50% identified IPV as a primary cause of homelessness in their city. Unemployment may also increase risk of homelessness and medical noncompliance (Hamilton, Poza, & Washington, 2011).

Being homeless introduces instability in daily life and may lead to problems for women adhering to scheduled preventive care and compliance with taking medications (Elsevier Health, 2014; Hunter et al., 2014). Smoking rates are high among homeless individuals making chronic obstructive pulmonary disease more likely (Baggett, Lebrun-Harris, & Rigotti, 2013; Baggett, Tobey, & Rigotti, 2013; Tsai & Rosenheck, 2012). People who are homeless are also at increased risk for premature death and contracting tuberculosis (Hwang, 2001). Being homeless is associated with pain and increased visits to emergency rooms (Doran et al., 2014). Thus, IPV resulting in homelessness has multiple psychological as well as medical consequences (Elsevier Health, 2014).

Data from the CDC indicate the pervasiveness of IPV against women in the general population with only about one-third of injured female rape and physical assault victims receiving medical treatment. Clearly violence prevention strategies are needed, there should be better detection of women at risk and public health authorities must encourage women who have been assaulted to seek proper medical care, psychological therapy, and social support (CDC, 2017a).

Risk Factors for IPV, Prevention, and Intervention Strategies

Risk factors may be better understood using the ecological model which organizes the likelihood of IPV into four levels of influence. They include the individual level, which encapsulates biological and personal history factors, the relationship level which includes association with one's closest social circle, community level which includes workplace, schools, and neighborhoods and finally the societal macro level. The latter larger societal level includes cultural belief systems, economic policies, religious beliefs, and issues of gender inequality. Interventions for prevention of IPV may be instituted at all four levels (CDC, 2017b)

Interventions in Schools

Dating violence is widespread, frequently unreported by fearful teens, and the cause of serious long-term and short-term consequences. A 2017 Center for Disease Control report found that approximately 7% of women who ever experienced rape, physical violence, or stalking by an intimate partner first experienced some form of violence by that partner before 18 years of age (CDC, 2017c). Data from high school students who participated in the Maryland Safe and Supportive Schools Initiative revealed 11% of students experienced physical teen dating violence (TDV) during the year prior to the study, with the same percentage experiencing psychological TDV over the same time period. The study showed alcohol use was associated with teen dating violence. Efforts to reduce teenage alcohol use might reduce TDV and future IPV (Parker, Johnson, Debnam, Milam, & Bradshaw, 2017).

The psychological consequences for young women of experiencing physical teen dating violence are an important factor contributing to future victimization a few years later. This has potential implications for advocating institution school-based programs to eliminate physical teen dating violence. Prevention of teen dating violence may lead to reduced future violence toward women (Jouriles, Choi, Rancher, & Temple, 2017).

Prevention and Detection in Healthcare Settings

Identifying victims of high betrayal trauma in all emergency departments nationally is paramount to enable provision of healing therapy and effective care management (Lutwak, 2014; Lutwak & Dill, 2012d; Lutwak & Dill 2013). The recognition of warning signs of abuse by providers at community health centers is also needed (Women's Health, 2017; HHS, 2017). In 2012, the United States Preventive Services Task Force recommended routine screening of all women of child-bearing age for abuse and IPV. The American College of Emergency Physicians subsequently issued a policy that such screening should be performed in emergency department settings. Screening for IPV is also recommended by the National Center of Injury Prevention and Control, as well as the American Medical Association. Screening for IPV has been instituted at Veteran Health Administration emergency departments nationally, given the scope and negative consequences of this problem (Lutwak, 2014).

Lack of privacy, lack of time, work pressure, inappropriate environment, poor knowledge of protocols, unwillingness of healthcare professionals, unclear referral pathways, lack of professional involvement in policies, and unclear prompts may decrease detection rates. Inattentiveness of professionals, lack of empathy, inappropriate training to develop confidence in asking sensitive questions and gender incongruence of screeners all play a part in poor detection of victimization. More effective screening must be in place since IPV detection is essential to help prevent further victimization (Ahmad, Ali, Rehman, Talpur, & Dhingra, 2017). Better provider patient communication about IPV is required (Rhodes et al., 2007). Verbal-based screening can be effective when the practitioner is skilled at developing rapport and trust. Use of computer-based detection is effective since the victim may answer questions without being interrupted, without embarrassment or feeling they are being judged. Culturally specific tools for different populations may be needed (Ahmad et al., 2017).

Women in chronic relationships who are battered may seek help in acute care settings more than once. Greatest risk factors for escalation of violence are linked to victim's age greater than 20, children present in the home and the perpetrator reported as dating partner or ex-partner (Brignone & Gomez, 2017). Contacting social service support services to alert them of women screening positive for IPV or those with frequent visits to emergency departments with possible symptoms related to being battered is requisite. Tools may include use of e-messaging in healthcare settings for immediate consultations and telehealth to contact patients in need of rapid support (Brignone & Gomez, 2017).

Interventions to Prevent and Treat Homelessness, Substance Abuse, Pain, and Suicidality

Suicide remains a major public health concern as the tenth leading cause of adult deaths in the United States (Hoffberg, Spitzer, Mackelprang, Farro, & Brenner, 2017). Prevalence of suicidal ideation and suicidal attempts among homeless adults is higher compared to a recent national sample of adults (Dietz, 2010). Homelessness and domestic violence for women and children overlap necessitating greater advocacy for the victims and funding from the U.S. Department of Housing and Urban Development for shelters and temporary domiciles (Department of Housing, 2018).

Women with substance use disorders have increased risk of suicide (Bohnert, Ilgen, Louzon, McCarthy, & Katz, 2017). Proinflammatory cytokines are now known to oppose opioid-induced acute and chronic analgesia suggesting that heightened depression or anxiety leads to increased production of interleukin-1 (Hutchinson et al., 2008). That might decrease the effectiveness of opioids resulting in need for increased doses and greater chance of addiction (Hutchinson et al., 2008; Olsen, Rollins, & Billhard, 2013).

Since depression affects severity of chronic pain the urgency of mental health treatment is magnified as is the importance of more effective strategies of pain management. Use of nonaddictive medication with concurrent holistic approaches including acupuncture, physical therapy, mind-body medicine, diet, and exercise/movement protocols should be considered (Hillinger, Wolever, McKernan, & Elam, 2017; Sehgal, Manchikanti, & Smith, 2012).

Healthcare providers should focus on the complex interplay between medical illness, psychological distress, trauma, suicidal ideation, and social problems. Routine screening for depression in all age groups and gender is requisite in all medical facilities since this disorder acts as a mediator leading to deterioration of medical diseases. The bidirectional interaction of depression and cardiovascular disease, cancer, renal disease, stroke, and diabetes should additionally be incorporated into healthcare decisions. This is important in rendering excellent care for women many of whom have experienced abuse in childhood and adulthood. Detection of IPV which leads to depression, chronic pain, suicidal ideation, PTSD, and medical illness (Sotelo & Nemeroff, 2017) is essential.

Strategies to Heal the Wounds of High Betrayal Trauma

Betrayal trauma is a type of trauma that involves violation by a person one trusts for survival or well-being (Freyd, 1996, p. 76). Child abuse and IPV are examples of betrayal trauma which may result in complex PTSD with feelings of negative self-perception, hopelessness, difficulty trusting others, shame, guilt, and impulsivity (McLean & Follette, 2016; Olsen et al., 2013). Depression as well as somatic problems result and victims may require comprehensive care for recovery including medical/psychiatric/social help in addition to legal advocacy services, support with child care, employment assistance as well as housing/economic help (Women's Health, 2017; HHS, 2017).

Childhood abuse and IPV leave painful deep scars, feelings of shame and guilt, anger, depression, fear, and lack of self-acceptance. Recovery may take years but multiple strategies are available to heal the wounds. Trauma exposure may lead to persistent symptomatology, however, the manner in which the victims think about and assess their experiences are important in determining the length and severity of distress. The quantity of traumas experienced and the relationship of the victim to the perpetrator are meaningful, but the appraisal of the trauma by the victim may be more significant in affecting the long-term impact (Martin, Cromer, DePrince, & Freyd, 2013).

Identification of victims and providing safe havens is an important step in recovery. Social support from trusted family members, friends, religious leaders, doctors, or nurses resulting in feelings of connection is another helpful strategy to start recovery (DVA, 2017a).

PTSD, depression, alcohol, and substance abuse are among the mental health effects of traumatization. PTSD may lead to personality-based vulnerability to responding negatively in the context of distress. Aggressive risk taking behavior resulting in negative consequences for individuals suffering from PTSD may be modified by psychological flexibility. Learning the skill of flexibility enables those with PTSD to make decisions consistent with positive goals even during stress, thereby avoiding negative urgency (Dutra & Sadeh, 2017).

PTSD and substance use disorder commonly occur together leading to impairment of functioning (Mason, Wolf, O'Rinn, & Ene, 2017). Individual-based trauma-focused cognitive behavioral therapy plus concurrent adjunctive substance use disorder intervention reduce levels of distress (Roberts, Roberts, Jones, & Bisson, 2016). Coordinated treatment between mental health providers, therapists to treat substance abuse and primary care doctors is essential (Mason et al., 2017). The team of providers must be cognizant that the stress of abuse may result in depression, anxiety, overeating, hypertension, and headaches. It may also increase risk of heart disease, stroke, and lead to poor medical compliance worsening chronic illness such as diabetes (Sotelo & Nemeroff, 2017). The importance of a team approach to improve care of battered women and those who experienced childhood assault is paramount (Machisa, Christofides, & Jewkes, 2017).

Complex Care Management Programs

Trauma and chronic stress lead to poor psychological and physical health. Approximately 22%–30% of women experience physical, sexual, or psychological IPV during their lifetime (Women's Health, 2017; HHS, 2017). Poor healthcare outcomes occur as patients often experience fragmented, bureaucratic systems which are difficult to navigate. Complex care management programs utilizing interdisciplinary teams of providers to promote healing using trauma informed primary care are effective. These programs employ coordinated medical, behavioral health, and social service providers working together to improve chronic illness, access to food, housing, transportation, and engagement from family members. The team of physicians, nurses, social workers, and community outreach workers cooperate to increase medical adherence, reduce substance abuse, secure housing, and support self-management of chronic medical conditions (Thompson-Lastad et al., 2017).

Skillsets to Help Cope with Trauma and Alleviate Distress

Personal growth initiative (PGI), a skillset for promoting change in one's self through focus on developing realistic plans with use of available resources and accomplishing the envisioned action plan, may be useful to adapt after traumatic events. Persons with high intent of personal growth may have less distress following a traumatic event and greater ability to cope.

People with greater self-esteem may benefit from making decisions and thinking positively of future plans while engaging actively in making life changes. Avoiding unproductive rumination and developing high personal mastery may increase posttraumatic growth. Reflective coping strategies, acting on personal growth and productive thinking may protect against depression. People with commitment, control, and psychological hardiness may experience less stress posttrauma (Shigemoto, Low, Borowa, & Robitschek, 2017). Deliberate rumination and the cognitive component of PGI negatively predicts posttraumatic stress (Shigemoto, Ashton, & Robitschek, 2015).

Current Evidence-based Interventions and Some under Investigation

The American Psychological Association has published recommendation guidelines regarding PTSD treatment based on symptom reduction, improvement in quality of life, prevention or reduction of comorbid medical or psychiatric conditions, and functional impairment. Their strong recommendations include cognitive behavioral therapy, cognitive processing therapy, cognitive therapy, and prolonged exposure therapy. The guidelines do not recommend psychotherapy before or instead of medications (APA, 2017).

Cognitive processing therapy is effective for treating PTSD and depression, however, for increased success, therapists must have good treatment fidelity (Holder, Holliday, Williams, Mullen, & Suris, 2017). Two additional evidence-based interventions include cognitive trauma therapy for battered women and helping to overcome PTSD through empowerment. Cognitive trauma therapy for battered women emphasizes the role of irrational beliefs and evaluative language in chronic PTSD. It includes trauma history exploration, PTSD psychoeducation, and stress management. Helping to overcome PTSD through empowerment targets maladaptive cognitions about self, others, and the world with additional focus on increasing individual safety, sense of control/power/self-esteem, and ability to establish intimate relationships (Gerber et al., 2014).

Acceptance and commitment therapy fosters psychological flexibility aimed at improving adaptation to life's demands and focusing on personal goals. Depression is improved with acceptance of feelings and memories rather than through control of thoughts with avoidance of internal experiences. This technique does not focus on evaluation of symptoms but rather on creation of satisfying, fulfilling lives. This approach supports health with emphasis on living in the present moment. It guides trauma victims in moving forward with life while accepting previous traumatic events. The therapy reinforces the concept that despite negative experiences, it is possible to have a full and meaningful life. Survivors of trauma are helped by embracing the present and not being entrenched in old unpleasant memories. The aim is to find a positive sense of self and feel valuable despite having had painful experiences. The traumatic events are not denied but the aim is to avoid those experiences from defining one's current life (McLean & Follette, 2016; Schnurr & Lunney, 2016).

Present centered therapy, another useful innovative technique, is client-directed problem solving. It focuses on current life concerns and the connection between those concerns and the individual's symptoms (Schnurr & Lunney, 2016).

Use of telemedicine has shown promise for treatment of PTSD. Although there are multiple effective therapies for PTSD, geographic barriers impede rural patients from engaging in these evidence-based treatments. Telemedicine-based collaborative care is effective in treatment of PTSD and is useful to help patients in isolated areas. This technique utilizes off-site PTSD care teams consisting of telephone nurse care managers, telephone pharmacists, telepsychologists, and telepsychiatrists located at Veteran Health Administration medical centers supported by on-site community-based outpatient clinic providers. Nurses conduct care management activities, pharmacists review medication histories, and psychologists deliver cognitive processing therapy via interactive video. The teams are supervised by psychiatrists who also conduct interactive video psychiatric consultations. Previous evaluation of the effectiveness of such telemedicine techniques measured medication prescribing, regimen adherence and initiation of and adherence to cognitive processing therapy. Patients receiving the telemedicine outreach approach had significantly larger decreases in Posttraumatic Diagnostic Scale scores compared to their counterparts who had usual treatment. In that study, attendance at eight or more sessions of cognitive processing therapy significantly predicted improvement in Posttraumatic Diagnostic Scale scores. Telemedicine-based collaborative care can successfully render evidence-based psychotherapy to improve PTSD outcomes (Fortney et al., 2015).

Therapy for complex PTSD includes usual evidence-based treatment for PTSD, but it may involve addressing interpersonal difficulties as well as restoring feelings of control, safety, power while reconnecting with everyday life (Herman, 1997).

Medication for PTSD

Biological Disturbance in PTSD, Anxiety Disorders

PTSD may cause flashbacks, traumatic memories, self-blame, sleep problems, and anger. Cognitive behavioral therapy as well as psychopharmacology may be quite effective in the road to recovery. Experiences of IPV and child abuse result in enormous traumatic stress (Olsen et al., 2013) with severe mental health and physical debilities (Women's Health, 2017; HHS, 2017). Biological disequilibrium may result (Bear et al., 2016).

The biological disturbance causing PTSD involves dysregulation of the hypothalamic-pituitary-adrenal axis leading to hyperarousal. In PTSD, amygdala activation is adversely affected. Patients with PTSD have increased activation of the amygdala when they perceive stimuli as threatening (Bear et al., 2016). This activation influences the hippocampus, the orbital frontal cortex, the locus coeruleus, thalamus, hypothalamus as well as the dorsal/ventral striatum. The decreased restraints on amygdala activation, particularly on the anterior cingulate gyrus and orbitofrontal cortex, cause inaccurate appraisal of stimuli as threatening. This also results in sensitization of key limbic nuclei thereby lowering the threshold for fearful reactivity (DVA, 2017a).

Anxiety reactions additionally occur with hyperactivity of the amygdala, and diminished activity of the hippocampus after reception of information from the prefrontal cortex. The goal of psychotherapy is to increase exposure of the patient to stimuli that frequently produce anxiety to reinforce the idea that those stimuli are not dangerous. The goal is to alter connections of the brain so that the stimuli that produce fear no longer evoke the stress reaction. Medications which regulate the amygdala which increases the stress response and the hippocampus which suppresses it may be essential in addition to therapy in some cases (Bear et al., 2016).

GABA, gamma-aminobutyric acid, which is an inhibitory neurotransmitter of the brain also plays a part in anxiety disorders. The active ingredient in alcohol stimulates actions of GABA leading to decreased anxiety. Medications that stimulate GABA actions, such as the benzodiazepines, are also anxiolytic. This explains the frequent use of alcohol and misuse of benzodiazepines by individuals with anxiety disorder or PTSD (Bear et al., 2016).

Medications which improve the symptomatology of depression and anxiety modulate serotonin, norepinephrine, gamma-aminobutyric acid, N-methyl-D-aspartate, and dopamine levels. The FDA has approved the selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine for treatment of PTSD. Veteran Health Administration clinical practice guidelines additionally include use of the SSRIs fluoxetine, paroxetine and the serotonin and norepinephrine reuptake inhibitor venlafaxine. Mirtazapine added to sertraline may be helpful as well. Benzodiazepines worsen symptom outcomes in patients with PTSD, are addictive and are not recommended for long-term use (DVA, 2017a).

Second-line medications for PTSD include nefazodone, imipramine, and phenelzine. Topiramate is additionally an option for those who did not respond to first-line therapies (DVA, 2017a), but the American Psychological Association guidelines indicate insufficient evidence to recommend it (APA, 2017).

For women with major depressive disorder (MDD) who do not respond adequately to standard treatments, augmentation of conventional antidepressants with creatine monohydrate and 5-hydroxytryptophan (5-HTP) holds promise. Deficits in serotonin production and brain bioenergetics is associated with depression in women. There may be a synergistic benefit of addition of 5-HTP and creatine augmentation in women with MDD who previously failed selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) monotherapy. Women who have SSRI- or SNRI-resistant depression may improve with this augmentation approach (Kious, Sabic, Sung, Kondo, & Renshaw, 2017).

Medications Posttrauma Exposure

Acute interventions with corticotropin releasing factor antagonists or glucocorticoids following trauma exposure may reduce excessive stress-induced hypothalamus-pituitary-adrenal activation which may have neurotoxic effects. Pharmacological intervention for acute posttraumatic reactions includes targeting the adrenergic system to inhibit excessive alpha-1 and beta receptor activation and to increase inhibition of alpha-2 adrenergic receptors. This downregulates amygdala activity with decreased stimulation of secondary cortical and subcortical structures (DVA, 2017a).

Neurotoxicity may play a role in PTSD. Certain anticonvulsants, which block excitatory amino acid actions and prevent toxic calcium influx decrease neurotoxicity. The SSRI paroxetine also reverses neurotoxicity by promoting neurogenesis and increasing hippocampal volume which may be useful in treatment of PTSD (DVA, 2017a).

PTSD and Substance use Disorder (SUD)

Adherence to addiction-focused pharmacotherapy is recommended. Naltrexone and disulfiram should be offered as a treatment strategy for alcohol use disorder as they may have some direct benefit for PTSD symptoms. Buprenorphine/naloxone might be useful and benzodiazepines alleviate alcohol withdrawal but after detoxification are not recommended for chronic use (DVA, 2017b).

Sertraline and paroxetine have FDA approval as first-line recommended treatments in PTSD. They may be considered for PTSD with or without cooccurring SUD. Use of additional medications may be prescribed for those with concurrent SUD after consulting with pharmacotherapy specialists (DVA, 2017b).

Conclusion

The prevalence of violence against girls and women in our society is alarming. The immediate and future consequences are dire necessitating greater focus on prevention and effective treatment. Childhood abuse and IPV are forms of high betrayal trauma creating severe and long-lasting negative consequences. Survivors may require support from medical, mental health, and social service experts to improve quality of life, reduce depression, decrease stress, ameliorate physical symptoms, and prevent suicidal ideology. There may be need for economic and employment assistance as well as placement in safe housing. Institutional-based strategies to reduce teen dating violence and alcohol use may diminish trauma in future years. Identification of the victims in all medical and psychological treatment centers is paramount to prevent recurrence of abuse and to offer multiple complex therapies to help heal the deep scars. Chronic pain, substance abuse, and social isolation may worsen the initial posttraumatic ill effects.

Despite the severe trauma, recovery is possible through psychological interventions, pharmacotherapy, and supportive networks. The trauma informed team approach is effective for ameliorating the shame, guilt, anger, depression, and somatic manifestations of the victimization. Several innovative types of therapy are effective and should be offered after evaluating each victim's psychological stage and resilience. Presenting mental health treatment options with or without medication is imperative to ensure compliance and increased success. Learning skillsets of PGI may be useful to reduce stress. The significance of depression as an independent risk factor for cardiac disease, its influence on diverse biological processes and complicating factor of stroke, diabetes, osteoporosis, and cancer require attention by healthcare providers. An integrated team approach for improvement of psychological problems, physical illness, and social issues such as alcohol and drug dependency is needed to hasten recovery from betrayal trauma. Connection to friends, trusted family, other trauma survivors as well as clergy also diminish the sense of isolation to aid in the road to recovery. Finally, prevention and intervention strategies in school settings, the workplace, neighborhoods, and society as a whole should be instituted to promote gender equality and negate the acceptability of violence against women.