The Doctor Weighs In

By Pat Salber, MD

There is a haunting photo by Joao Silva on the front page of the NY Times (10/10/07). A young boy is looking inside a bullet-ridden white Oldsmobile. The front window is shattered and the driver’s side door is dripping bright red blood.

We are not told whether the boy knew or is related to the victims – two women -- one a 59 year old mother of three grown daughters; the other woman was her 30 year old passenger.  We can be fairly certain from expression on this youngster’s face, that this is a life-changing event for him. He will not be the same after this witnessing this horrific scene as he was before.

My speculation about this boy's future is supported by an article in the current issue of BMC Public Health. The authors, Asma Al-Jawadi and Shatha Abdul-Rhma, assessed 3079 children from families who attended primary health care institutions in Mosul, Iraq and found mental disorders in more than one third of the children. Let me repeat that, more than one third of children were found to have mental disorders.

Here are the details of the study. Mothers who came to the primary health centers in Mosul for vaccination of one of her children were included in a systematic sampling randomization. All children of these mothers (ages 1-15 years old) were considered in the interview and examinations. 3079 children were assessed. 1152 were diagnosied with a childhood mental disorder for a point prevalence of 37.4%. The ratio of males to females was 1.22:1.

The top ten diagnoses among the examined children were as follows:

• post-traumatic stress disorder (PTSD) ( 10.5%)
• enuresis (bed-wetting) (6%)
• separation anxiety disorder (4.3%)
• specific phobia (3.3%)
• stuttering &school refusal each had a point prevalence of 3.2%
• learning & conduct disorders have the same figure (2.5%)
• stereotypic movement (2.3%)
• feeding disorder of infancy or early childhood (2.0%).

Overall, the highest prevalence of mental disorders was found among children 10-15 year old (49.2%). While the lowest prevalence was in 1-5 year olds (29.1%). Boys were more afflicted than girls (40.2% & 33.2%) respectively.

Now that you have read this, please go back and look again at the face of the little boy in the photo. What is his future? PTSD?...probably. Acting out?...likely. Will he have problems concentrating at school?...yeah, that too. Without therapy – a scenario unlikely in war-torn Iraq- will this young boy be able learn a profession or trade and eventually make non-war-related contributions to his community and his country? Or will he be forever altered, unable to function “normally” in a “normal” society?

These are not just potential social or political problems, rather, they are important health care challenges that have had little, if any, discussion that I have seen in the national or international media. Yet, once this war is over and Iraq enters its post-war period, mental health disorders in the population - both adults and children -- will be a serious health care issue that will have to be addressed if Iraqi’s are able to build a healthy society.

Doubt the seriousness? If so, I suggest you go back and take one more look at that little boy’s eyes.

Ok, so I am tooting my own horn, but I want to share with you the latest review of the book I c0-authored together with Dr. Ellen Taliaferro, The Physician's Guide to Intimate Partner Violence and Abuse.  The book is published by Volcano Press, the leading publisher of books on family violence. 

The review appeared in the Permanente Journal's Spring 2007 issue.  It is written by Ruth Shaber, MD, an OB/Gyn at Kaiser Permanente's Daly City Medical Office in Northern California.  She is also the Director of Women's Health Services and Director of the Women's Health Research Institute for Kaiser Permanente Northern California. 

Here is her review:

"The facts are overwhelming. The Centers for Disease Control and Prevention (CDC) predicts that 5.3 million incidents of intimate partner violence (IPV) occur each year among US adult women and 3.2 million occur among men. Recent data from Group Health Cooperative demonstrates that about 46% of the female members have experienced physical, sexual, or emotional IPV in their lifetime, and data from the Kaiser Permanente Northern California Prevention Program estimates that in the previous year, at least 4% of women patients have experienced physical injury from an intimate partner--that is about 46,000 members in Northern California alone. The social and financial impact is enormous. The CDC estimates that the direct health care costs of IPV are over $4 billion a year. And, evidence has shown that IPV, along with its many comorbidities, is the number one cause of premature death, injury, and illness in women ages 15-­44 years.¹

It is difficult for even the most experienced clinician to recognize which of our
Ruth Shaber, MD patients are victims of IPV. The violence cuts across all socioeconomic and demographic categories. But we do know that routine screening of all patients is an effective way to identify victims and to offer them assistance. And we know that offering support and counseling to victims can improve the quality of their lives.

Now that we understand these facts, how can clinicians begin to care for patients who are victimized by this overwhelming social problem? The first step would be to open The Physician's Guide to Intimate Partner Violence and Abuse. This book is an essential tool for both experienced and new clinicians. It will help everyone better understand the impact of IPV and to start to comprehend the complicated issues that perpetuate the violence.

Patricia Salber, MD, and Ellen Taliaferro, MD, have compiled the definitive handbook for health care professionals. Their chapters, along with those of their expert contributors, help us navigate through the complicated web of social, psychological, and medical issues that lie underneath the surface of IPV. Many clinicians are intimidated by the thought of dealing with IPV: they are unfamiliar with the proper language to use to screen their patients and they dread the time when a patient will acknowledge the violence in their lives--for fear that they won't have the expertise or enough time to support them effectively. Fortunately, the authors help us realize the therapeutic value of simply asking the questions--even if our patients aren't able to make immediate changes in their lives. And they help clinicians better understand why immediate changes may be difficult and even dangerous. They provide simple tips for offering support and referral to identified victims. And they help explain the social dynamics and practical realities that limit the speed with which change will happen. The book also outlines effective strategies to set up IPV screening programs in our clinics.

A particularly interesting chapter entitled "What Do We Know About the Perpetrators of Intimate Partner Violence and Abuse" helps us understand the prevalence of alcoholism and personality disorders among perpetrators. There is also inspiring information about the effectiveness of batterer intervention programs--with some data suggesting a re-arrest rate as low as 8% among batterers who completed an intervention program. Some of the chapters will help you better understand information that you already knew or suspected about IPV. But some of the chapters--such as the one on Adverse Childhood Experiences and IPV--will turn everything you thought you knew about medicine upside down.

The book is an extremely well-organized resource. With its easy references, clear bullet points and excellent summary tables, it makes for fascinating reading all the way through--or an easy reference book to take off the shelf for a quick review. Wherever you are in your journey of understanding IPV, I highly recommend this book to take you further down the road.

Reference

1. Victoria Department of Human Services. The health costs of violence: measuring the burden of disease caused by intimate partner violence--A summary of findings (monograph on the Internet). Victorian Health Promotion Foundation 2004 Jun [cited 2006 Nov 13]. Available from: www.togetherwedobetter.vic.gov.au/resources/pdf/FinalReport_HealthCostsOfViolence.pdf.

Genes

In 1993 scientists reported on a Dutch family, 14 members of whom were sociopaths, involved in aggressive crimes such as bullying, physical violence, rape, and arson. They all had in common a mutation in a gene that makes an enzyme called MAOA. The function of this enzyme is break down neurotransmitters such as serotonin and noradrenaline (or norepinephrine, a chemical first cousin of adrenaline). The ready conclusion was: defective enzyme caused elevated level of serotonin and noradrenaline, resulting in overactive brain circuits that serve aggressive behavior.

Case closed? Not so fast…

In a wonderful summary of the topic in Newsweek magazine ( April 30, 2007 ) one of my favorite writers on the subject, Sharon Begley) describes a 2002 study in New Zealand of 442 men who were followed since their birth. Indeed, men with low MAOA were more likely to engage in persistent fighting, bullying, cruelty and violent crime. But not all of them; only men who had been neglected or abused as children fit the bill. Men who grew up in a normal environment exhibited none of the violent traits.

Neuroanatomy

In previous postings we waxed scientific about the amygdala, two almond-shaped structures deep inside the brain, that are the seat of primitive emotions such as rage and fear; these constitute the emotional basis of the fight or flight reaction, which is mediated by noradrenaline. These waves of seemingly overwhelming emotions are checked and inhibited by another, more modern structure in the brain: the prefrontal cortex. This structure is the seat of judgment, planning, abstract thinking. It inhibits inappropriate or impulsive behavior, and is engaged in constant self-monitoring (could it be the anatomical seat of the Freudian super ego?). So in typical Ying/Yang fashion, the outcome of our behavior must then be the product of the amygdala and prefrontal interaction. Remember the then famous case of Kip Kinkel, a 15 year old who in 1998 killed his parents and two dozen schoolmates in Springfield , Oregon ? His brain scan showed a completely silent prefrontal lobe; he had nothing to check and balance his raging anger emanating from his amygdala.

Is this it? Not quite…

Hormones

Women love to point out, without much evidence I might add, that men’s aggressive behavior can be traced to their testosterone-addled brain. Only partly true. The level of testosterone is within normal limits between 20% and 200% of the mean; that’s a huge range of normal. However, if the level of testosterone exceeds 400% of the mean, then indeed women are right—men with these levels are more prone to violence. In fact, testosterone is an equal opportunity hormone; in a species of hyenas (I forget which) the first newborn in a litter, be it male or female, will eat the rest of the brood within days of birth. It turns out that this vicious sibling has inordinately high levels of testosterone in its brain, much higher then the other hapless siblings.

But to assume that we are simple automatons, following helplessly the script written by our genes, brain circuits and hormones, would deny a self evident fact—we don’t behave automatically, we do have a certain degree of free will.

Psychology

The interaction of biology and the life one leads turns out to be of paramount importance in shaping the criminal mind. The most important characteristic of the behavior of mass killers is paranoia. They have the sense that the whole world is against them, that everybody but themselves is responsible for their troubles, that the world is unfair. They are usually depressed and socially isolated.

This kind of personality, you might say, could be the product of brain circuitry gone awry. But here is a fascinating finding from animal and human studies: behavior can change brain circuitry and function-- an outstanding example of nature/nurture interaction. So what are the non-biological roots of violent behavior? We finally arrive at the inevitable:

Society and culture

It is the social environment that allows, indeed encourages, psychopathic criminal behavior. Many societies have members with genes gone awry, with malfunctioning brain circuits, with males suffering from raging hormones, with children raised in violent homes. But, sad to say, we have the dubious distinction of being the champions of gun violence in the civilized world. In 2004 there were 29,645 deaths due to gun violence in the US , or 10.08 per 100,000. For comparison, France had 4.93, Belgium 3.67,and Spain 0.75 per 100,000.

In 5 years of war in Iraq about 3200 of our soldiers got killed. Yet, we tend to see the situation in Iraq as intolerable but we dismiss  the carnage in our own streets with a helpless shrug: "It’s the culture… "

We mentioned the case of Kip Kinkel. Yes, his prefrontal lobe did not do its job. But here is rest of the story: a psychotherapist actually suggested that his dad buy him a gun so they could have something to do together.

As Pogo said: we have met the enemy, and it is us.

Dov Michaeli MD, Ph.D