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ABSTRACT This article reviews studies pertaining to comorbidity of domestic violence, addictive disorders, and sexual abuse, and presents a model in which domestic violence parallels the chief features of chemical dependency.

Domestic violence and addictive disorders have a number of common characteristics, including loss of control, continuation of behavior despite adverse consequences, preoccupation or obsession, development of tolerance, and family involvement. Domestic violence predisposes the next generation to both domestic violence and addictive disorders. Clinicians encountering patients who are perpetrators or victims of domestic violence or sexual trauma, or have addictive disorders, must assess for the presence of either of the other problems.

My father came home from work late one night, staggering and intoxicated. He and my mother got into a terrible fight. They were hitting each other. My mother drew a kitchen knife out of a drawer and held it up to defend herself.

She was the only person who could control my father once he had begun drinking. Domestic violence and addictive disease will be seen to have a number of common features.

Domestic violence, spouse abuse, and battering all refer to the victimization of a person with whom the abuser has had an intimate relationship. Investigation and research on domestic violence and its impact on domestic partners, families, children, as well as its association with violence expressed in our society, has accelerated greatly over the past two decades.

Violence of all types is graphically presented to us as both news and entertainment by the media every day.

Statistics on the prevalence of domestic violence alone in North America are staggering and difficult to fully appreciate. Nearly one fourth of women in the United States will be abused by a current or former domestic partner within their lifetime AMA, ; Warshaw, More than a third of these women When women presenting to a Denver, CO, emergency department for any reason were asked three brief screening questions for detecting partner violence, Battery is the single most significant cause of injury to women in the United States.

Batterers come from all socioeconomic groups, cultural backgrounds, and sexual orientations; in one study, 63 percent of abusers reported having seen their mothers abused when they were children themselves AMA, The Canadian statistics are no better: One woman in six is physically or sexually abused by her husband, ex-husband, or live-in partner Lawson, For 70 percent of all pregnant wife assault victims, the violence begins or increases during pregnancy Bain, Family violence accounts for 60 percent of all murders of women in Canada MacLeod, Domestic violence is far more than a single episode of trauma.

On average, a woman will be assaulted 35 times before contacting the police Bain, Approximately 47 percent of husbands who beat their wives do so three or more times a year AMA, Rape is a significant or major form of abuse in 54 percent of violent marriages AMA, Among battered women who are first identified in a medical setting, 75 percent will go on to suffer repeated abuse Warshaw, Of women over the age of 30 who have been raped, 58 percent were raped within the context of an abusive relationship AMA, ; Warshaw, Domestic violence can, and in many cases does, lead to permanent physical and emotional injury and even mortality.

An FBI report for noted that 30 percent of women murdered that year alone were killed by their husbands or boyfriends AMA, This represents a mortality rate of 0. Increasing attention is now being focused on the problem of male victims of domestic violence. The authors pointed out that some experts in this field believe that attention directed at domestic violence against men will detract from the significance of domestic violence in women and the more limited choices this group has in responding to this problem.

They conclude by saying "Recognition of the global nature of violence may be more realistic than assuming that only women are victims" pg. Parallels between domestic violence and addictive disease A number of common features can be found between domestic violence and substance related disorders.

They often intersect with each other to compound the challenge of effective intervention, complicate treatment of each disorder, and predispose to relapse of either behavior. This paper will review the interrelationship of these two related social and family behavioral disorders. Addressing their many manifestations is crucial to the success of treatment of addictive disorders, and the prevention of domestic violence.

In the early days of alcohol treatment, it was believed that attaining and maintaining sobriety was fundamentally a matter of attending Alcoholics Anonymous meetings and "keeping the plug in the jug. Primary exacerbating factors include 1 the role of violence in the family and 2 the frequent presence of multiple addictions.

The interrelationship between these factors commonly serve to keep the patient and family stuck in active addictive disease. The DSM lists seven criteria, which can be summarized as: The loss of control seems to progress, with less provocation and increasing amounts and severity of violence over time. There are characteristically periods of contrition, when the abuser promises to reform and refrain from ever using violence again. The time between the thought or impulse to act upon anger and the behavior seems to diminish, much like the tendency of substance dependency to progress to impulsive as well as compulsive substance use.

In both these disorders, the behavior continues despite adverse consequences. Domestic violence continues despite knowledge that physical injuries have been sustained by the partner and symptoms of traumatic stress, intimidation and emotional pain are present.

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The source of problems is characteristically blamed on others, particularly the spouse or partner, or external causes, even the use of mood altering substances.

Over time both the abuser and battered partner become preoccupied with the behavior, even when violence is not presently occurring or being threatened.

A great deal of time is spent either anticipating or fearing violence, recovering from past consequences or associated physical or emotional sequelae, or engaging in efforts to avoid setting off any further episodes of violence.

Tolerance develops to not only the threshold for defining uncontrolled anger and unacceptable behavior, but also the ability to endure physical, emotional, and sexual trauma and pain. In addition the abuser often believes that increasing threats, control and more severe violent behavior is necessary to adequately control the victim as the relationship progresses. Exchange of pain and antagonistic action is not uncommon as the battering relationship progresses.

Withdrawal is often experienced in these relationships as a period of anxiety or tension that follows episodes of violence. Over time the periods of contrition described in the classic cycle of violence seem to diminish, and the periods of tension in anticipation of further violence increase in duration and intensity.

The parallels between domestic violence and substance dependency are graphically outlined in Table 2. The abuser is contrite after the abuse, promises not to do it again, but inevitably does so.

The victim experiences emotional, sexual, and physical damage and loss of self-esteem; abuser experiences remorse and guilt at times, but the abuse continues. Abuser is preoccupied with controlling the victim and when sexual violence is involved maintaining access to sexual gratification.

There are many other parallels between chemical dependency and domestic violence. Some of the items outlined in Table 3 are self-evident, while others merit additional comment. The addictive cycle Carnes, , which is applicable to all addictive disorders, consists of preoccupation with the addictive behavior, rituals associated with the behavior, acting out, and remorse or guilt and shame. The remorse is relieved by preoccupation, and the cycle continues.

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For both addictive disorders and domestic violence, involvement of the workplace is a late manifestation. Intoxication at work, or sexual exploitation within the professional setting, is indicative of severe progression of an addiction; similarly, irritability and rage in the workplace is more typical of a late-stage batterer, who for a long time is able to restrict his outbursts to the home environment.

Both victims of domestic violence and partners of addicts often have difficulty leaving. In addition to realistic fears of escalation of violence and consideration of financial and parenting constraints, both types of domestic partners often get caught up in a cycle of codependency, where they blame themselves for the current situation and feel that if they are only able to do particular things better, the situation will improve.

Attendance at Al-Anon and similar step programs can help both types of partners to improve their self-esteem and place themselves in a situation where they are able to make appropriate choices for themselves DellaCorte, Other parallels between Domestic Violence and Addictions Domestic violence and addictive disorders have the following common features: They adversely affect intimacy and sexuality.

Constitute family disorders, and adversely affect all family members across generational lines. Involve ritualization of behavior: The cycle of violence and cycle of addiction both include periods of escalation of behavior often followed by a time of contrition and promises to change and give up the behavior, followed by a time of increasing tension and then a return to behavioral acting out.

Involve the use and abuse of power for personal gain and gratification: There is ego expansion and relief of tension when using substances and with the exertion of or threat of violence. Initially tend to be restricted to the home environment, but in late disease stages may involve behavior expressed in the workplace.

Result in shame, guilt, decreased self esteem and emotional numbness. Characterized by denial, minimization, and rationalization. Domestic partners and family members have great difficulty intervening upon, or abandoning the affected individual Violence and addictive disorders coexist. Domestic violence and family violence are associated with substance-related disorders. Alcohol sharply diminished impulse control; drugs of greatest concern are stimulants, as they can increase paranoia and lead to preemptive violence.

In a survey of 12, children from single-family households where at least one parent filled out an alcohol use questionnaire, children of women classified as problem drinkers had more than twice the risk of serious injury as matched controls. There was a statistically significant relationship between the number of alcohol-related problems the women had and the risk of injury to their children Bijur et al, However, not all batterers drink.

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To assume that alcohol causes battering is to relieve the batterer of responsibility and to deduce that violence will cease with abstinence. In actuality, while substance abuse and violent behavior frequently coexist, the violent behavior will not end unless interventions address the violence as well as the addiction AMA, Not only is domestic violence perpetrated by the alcoholic spouse on the sober spouse, it is also inflicted on the alcoholic spouse by the sober spouse.

This is particularly true when it is the woman who is drinking. Several studies have found an association between female drinking and increased victimization in marital violence Miller and Downs, ; Kaufman-Kantor and Straus, According to a U. Both men and women attributed more responsibility for the assault to an intoxicated rape victim than to a sober one; at the same time, the offender was blamed less when he was drunk than sober.

This attitude makes women who have been sexually assaulted while drinking, more reluctant to report it. Domestic violence in lesbian relationships occurs at about the same rate as in heterosexual relationships, and as in heterosexual relationships, alcohol may play a large role.

Several studies report that almost one-third of all women who identify themselves as lesbians drink excessively or experience alcohol-related problems Norris, Drinking was significantly correlated both with being the victim of abuse and with being the perpetrator Schilit et al.

Many of the same factors that predispose an individual to the development of an addictive or compulsive sexual disorder can also predispose one to being a participant in a violent relationship. Addictive sexual disorders When a person evidences a pervasive pattern of sexual behavior over which there is loss of control, continuation despite adverse consequences, and which includes preoccupation or obsession, that person has an addictive sexual disorder.

The range of fantasies, urges, and behaviors that can be considered addictive sexual disorders may be appreciated by reviewing the ten categories developed by Carnes