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J Gen Intern Med. 2004 August; 19(8): 819–827.
PMCID: PMC1492498

Violence, Mental Health, and Physical Symptoms in an Academic Internal Medicine Practice

Christina Nicolaidis, MD, MPH,1,2 MaryAnn Curry, RN, DNSc,4 Bentson McFarland, MD, PhD,2,3 and Martha Gerrity, MD, PhD1,5

Abstract

OBJECTIVE

To assess how physical and/or sexual intimate partner violence (IPV), child abuse, and community violence relate to long-term mental and physical problems; to examine the overlap between different forms of violence and the impact of experiencing multiple forms of violence.

DESIGN

Cross-sectional survey.

SETTING

Three general internal medicine practices affiliated with an academic medical center.

PARTICIPANTS

English-speaking women aged 25 to 60.

MEASUREMENTS

Telephone or in-person interview and chart review.

RESULTS

One hundred seventy-four women completed interviews. A majority of participants experienced more than one form of violence. In separate multivariate analyses, each form of violence was associated with depressive symptoms or with at least 6 chronic physical symptoms, after adjustment for demographic factors and substance abuse. The degree of association with health outcomes was similar for each form of violence (odds ratio [OR], 2.4 to 3.9; P < .003). The association with chronic physical symptoms remained significant for IPV (OR, 3.3; P < .002) and community violence (OR, 3.4; P < .003), even after adjustment for depression and posttraumatic stress disorder. There were dose-response relationships between the number of forms of violence experienced and the odds of depressive symptoms and the odds of multiple chronic physical symptoms.

CONCLUSIONS

Multiple types of victimizations may contribute to patients’ current mental health and physical problems. Research or clinical protocols that only focus on one form of violence may underestimate the complexity of women's experiences and needs.

Keywords: intimate partner violence, sexual assault, child abuse, depression, physical symptoms

A growing literature documents the negative health consequences of violence against women, but studies often address only one form of violence. For example, survivors of intimate partner violence (IPV) have higher rates of depression, anxiety, and posttraumatic stress disorder (PTSD),17 higher rates of physical symptoms,811 and higher utilization of health services.4,1214 Several studies on health effects of IPV do differentiate between physical, sexual, and emotional abuse by an intimate partner,5,8,9,11 but most do not control for child abuse (CA) or community violence (CV).

Similarly, adult survivors of CA have higher rates of depression, anxiety, PTSD, and personality disorders,1517 higher rates of obesity and substance abuse,1820 higher rates of somatic complaints,21 irritable bowel syndrome,22,23 and higher overall numbers of symptoms and illnesses.15,16,24,25 Again, most studies of the long-term health consequences of childhood trauma do not adjust for other experiences of violence. One large study found that women abused both as adults and as children had higher rates of mental illness and greater numbers of physical symptoms than those abused only as children or as adults,15 but did not differentiate between family violence and assaults by strangers, nor between physical and sexual abuse.

Many studies have documented the relationship between sexual or physical assaults and long-term health problems2632 but did not consider the relationship between the perpetrator and victim, nor the role of repetitive trauma or of multiple forms of victimization. It is difficult to compare the findings from the IPV, CA, and sexual/physical violence literature due to differences in study participants and methods.

Our objectives were 1) to examine how physical and/or sexual IPV, CA, and CV relate to depression and physical complaints; 2) to examine the overlap between different forms of violence; and 3) to study how a history of multiple forms of violence may impact mental and physical health.

METHODS

Setting and Participants

We conducted a cross-sectional survey of female patients aged 25 to 60 presenting to the 3 general internal medicine clinics affiliated with an academic medical center. We excluded women who did not speak English, could not participate in an interview due to severe physical or mental impairment, or were known to the investigators.

Recruitment and Data Collection

Women aged 25 to 60 presenting for appointments on enrollment days were given a flier describing the project. A research assistant approached potentially eligible patients, explained the project, and obtained informed consent. Those who agreed to participate were scheduled for a telephone or in-person interview. Those who declined were given the option of completing a short anonymous questionnaire.

Measures

Interviews consisted of multiple-choice questions. We used the Hopkins Symptom Check List 203335 to assess for depression and the PTSD Checklist 2036 to assess for PTSD. We asked about 16 chronic physical symptoms (fatigue, widespread pain, pelvic pain, headaches, back pain, jaw pain, chest pain, abdominal pain, rectal pain or sensation of incomplete evacuation, increased bloating or gas, diarrhea or constipation, dizziness, fainting spells, palpitations, severe sensitivity to chemicals, or other pain), each defined as occurring regularly for at least 3 months. We chose symptoms that were common in primary care, frequently unexplained medically, and/or key features of symptom syndromes such as fibromyalgia or irritable bowel syndrome.3739 We used a combination of the CAGE questionnaire40 and the substance abuse questions of the PRIME-MD41,42 to assess for substance abuse, dichotomizing results based on any “yes” response to the questions related to problem alcohol use or to use of illicit drugs other than marijuana. We used questions modified from the Negative Life Events Questionnaire43 and the Trauma History Questionnaire44 to assess for lifetime history of traumatic events, including CV, CA, and IPV. Those who answered yes to the questions about IPV were asked to participate in a second interview including the Conflict Tactic Scale (CTS)45 and Index of Spouse Abuse.46 A research assistant reviewed charts to determine how many times chronic physical symptoms and syndromes, depression, PTSD, IPV, CA, or CV were noted in the medical record.

Analysis

We defined a history of physical CV as answering yes to questions about being mugged, stabbed, shot, beaten up, held captive, or kidnapped by someone outside of the family. We defined sexual CV as answering yes to the question about being raped (defined as being forced to have vaginal, oral, or anal sex against one's will) by someone outside of the family.

When assessing CA, we limited answers to those where the perpetrator was a family member or other trusted individual, excluding current or past intimate partners. We defined sexual CA as being forced to have genital, anal, or oral sex at least once. We also included more minor forms of sexual violence if these occurred 10 or more times.

We defined physical and sexual IPV as scoring positive on the Ever Prevalence subscales of the Conflict Tactics Scale (CTS) for “Physical-Severe” or “Sexual-Severe,” respectively. We also included women who had 10 or more occurrences of more minor physical or sexual assaults. Though we asked questions about emotional abuse, threats, and controlling behavior, we did not use these as part of the definition of IPV. We chose the cutoff of 10 occurrences because the frequency distributions for questions on IPV and CA had bimodal distributions with a peak at 1 and another peak for greater than 10 occurrences.

Our main outcomes were depressive symptoms and chronic physical symptoms. Women with an HCL-20 score of 1.0 or above were considered to have depressive symptoms in the dichotomous analyses. This score corresponds to “mild depression.”35 We chose to use the median value of 6 physical symptoms as the cutoff for the dichotomous analyses. We assessed two-way associations using t tests and χ2 tests and used multiple logistic regression to adjust for potential confounders. We initially used all available data on demographic characteristics and substance abuse and eliminated potential confounders in a backward stepwise fashion, using P > .2 as our criterion for elimination. In order to be consistent, if a variable was to be included as a potential confounder in any model, we kept it in every model. Thus, all models are adjusted for age, race, personal income, tobacco use, and alcohol use. Further adjustment for household income, educational attainment, or drug use did not alter results. In our primary analyses of the relationship between violence and physical symptoms, we only adjusted for demographic characteristics and substance abuse variables. A second model also adjusted for depression and PTSD.

Our first set of analyses looked at each form of violence individually. The predictor in each of these analyses was a dichotomous variable describing whether or not the participant met criteria for that form of violence. Our second set of analyses explored the relationship between overlapping forms of violence and health. For these analyses, we created a variable with 8 mutually exclusive categories based on the overlap between IPV, CA, and CV. In order to limit the number of possible combinations, no distinction is made between physical and sexual violence. In the final set of analyses, we assessed the role of cumulative violence on health. We considered physical and sexual IPV, CA, and CV as 6 different forms of violence. We used a categorical variable with 7 categories (0 to 6) to represent types of violence experienced.

We performed statistical analyses using STATA software (version 6.0, STATA Corporation, College Station, Tex). The study was approved by the university's human subjects committee.

RESULTS

Participants

Of the 411 women given fliers about the study, 81 women were excluded (27 non-English speaking, 16 mentally impaired, 4 physically impaired, 4 known to investigators, and 30 previously approached to participate). Though 244 of 330 eligible women (74%) consented to the study, 70 women did not present for their scheduled interview. A total of 174 women (71%) completed the interview. Chart data were available on all 244 women. Sixty (70%) of the 86 women who declined to participate in the complete interview answered a short anonymous questionnaire.

Demographic characteristics of the 174 participants are shown in Table 1. Most participants were white and educated. However, participants had relatively low income levels and high rates of disability and unemployment. Health function was considerably lower than national samples.

Table 1
Demographic Characteristics of the 174 Women Who Completed the Interviews

Compared to responders, women who declined to participate but answered the short anonymous questionnaire were slightly younger (mean age, 40.8 vs 43.9; P = .0549) and less likely to be white (71% vs 87%; P = .008). Education characteristics and self-reported health status were similar. We performed a chart review on women who consented whether or not they completed the interview. There was no significant difference between women who did and did not complete the interviews in the rates of documentation of tobacco use, depression, PTSD, fibromyalgia, chronic fatigue, irritable bowel syndrome, or chronic pain. There was also no difference in the rates of screening for or disclosure of IPV, CA, or CV.

Table 2 summarizes answers to questions about violence. As shown in Figure 1, 79% of participants reported that they experienced at least one form of violence. Sixty-one percent met our criteria for a history of IPV, 55% for CA, and 42% for CV. The majority experienced more than one form of violence. Figure 2 shows the overlap between histories of IPV, CA, and CV. Twenty-five percent experienced all three major forms of violence.

FIGURE 1
Lifetime prevalence of physical and sexual assaults. IPV, intimate partner violence; CA, child abuse; CV, community violence; any violence, any of the above.
FIGURE 2
Overlap of different forms of violence. Numbers represent number of participants reporting each possible combination of violence, followed by the prevalence rate in parentheses. IPV, intimate partner violence; CA, child abuse; CV, community violence.
Table 2
Violence Characteristics

Violence and Health

Table 3 shows the associations between each form of violence, depression, and physical symptoms. For each form of violence, women who reported experiencing violence had significantly higher depression scores than those who did not (data not shown; P < .01). The association between each form of violence and the presence of at least mild depressive symptoms remained significant after adjusting for demographic factors and substance abuse. Odds ratios for the magnitude of the association were relatively similar, ranging from 2.4 to 3.7, for the individual forms of violence, and increasing to 4.4 for the analysis looking at any violence.

Table 3
Associations Between Various Types of Violence, Depression, and Chronic Physical Symptoms

For each analysis, women who reported experiencing a form of violence complained of a greater number of chronic physical symptoms than those who did not (data not shown; P < .02). All forms of violence, other than physical CA, raised women's odds of having 6 or more physical symptoms, even after adjustment for demographic factors and substance abuse (model 1). Odds ratios were similar, ranging from 2.4 to 3.9 for the individual forms of violence and increasing to 4.8 in the analysis looking at any violence. With the exception of CA (physical, sexual, or any), there were significant associations between each form of violence and the risk of having 6 or more chronic physical symptoms, above and beyond what could be attributed to depression or PTSD (model 2).

Multiple Forms of Violence and Health

Figure 3 shows how the overlap of different forms of violence relates to physical symptoms. There was a significant association between a history of IPV alone and the risk of having 6 or more chronic physical symptoms, with an adjusted odds ratio of 3.3 (P < .05). The adjusted odds ratios increased to 5.9 to 6.5 (P < .05) for the three groups of women who had suffered any combination of two of the three major forms of violence, and further increased to 11.1 (P < .001) for the group of women who experienced all three forms of violence (IPV, CA, and CV). There was no clear pattern showing that a particular form of violence in combination with others led to a greater association with physical symptoms. An analysis using depressive symptoms as the outcome also found significant associations for all four groups of women with any particular combination of two or three forms of violence as compared to the group of women without a history of violence, but the gradation in odds ratios was less clear (data not shown).

FIGURE 3
Adjusted odds ratios of 6 or more physical symptoms by overlapping forms of violence. Number in each area represents odds ratio of having 6 or more physical symptoms after adjustment for age, race, income, tobacco use, and alcohol use. Further adjustment ...

As shown in Table 4, there was a strong dose-response relationship in the magnitude of the association between the number of forms of violence and either depressive symptoms or physical symptoms, after adjustment for demographic and substance abuse factors (model 1). The dose response in the association with physical symptoms remained similar even after adjusting for depression and PTSD (model 2).

Table 4
Dose-Response Relationship Between Number of Forms of Violence and Mental and Physical Symptoms

DISCUSSION

When studying or treating violence against women, patients are often considered survivors of a particular form of trauma. Our study, however, illustrates the importance of looking at the full picture of violence. The majority of participants (53%) reported experiencing multiple forms of violence. While the magnitude of association between violence and health outcomes was similar regardless of the type of violence, the strong dose-response relationship between depressive or physical symptoms and the number of forms of violence suggests the need to examine the cumulative impact of violence on health.

This study has several limitations including modest response rate. Women who recognized an association between their traumatic experiences and health may have been more likely to participate, biasing findings toward greater association. Moreover, we had few nonwhite participants. Thus, it may not be possible to generalize our results to women of color. As the sample size is rather small, no conclusions can be drawn about undetected associations. We did not have adequate power to assess for associations between different forms of violence and individual physical symptoms. Larger studies have found associations between IPV and a host of physical symptoms or illnesses.8,9 Given the great breadth of these symptoms and illnesses, we feel that the presence of multiple physical symptoms may be a better clue to victimizations than any particular clinical symptom. Similarly, our study was not powered to make distinctions based on severity and frequency of violence or time since abuse. Less than 5% of participants disclosed that they were experiencing current violence (i.e., within the past year). Limiting the analyses to women with past violence alone did not change the results. It is possible that some of the events described did not represent the full picture of what occurred, since we only used self-report data. We used very strict criteria in our definition of violence, excluding events where there was only emotional abuse or low-level assaults, to control for differences in what women may consider abusive. As a cross-sectional survey, this study can only examine associations, not causations. We cannot determine whether the violence described by participants led to their health problems, or whether it is simply a marker for other unmeasured circumstances that cause depression or chronic physical concerns.

Despite these limitations, there are important findings and implications. We found a higher than expected lifetime prevalence of violence. It is possible, given our modest response rate, that our sample was biased toward women with a history of violence. However, even if we assumed that all nonresponders had never experienced violence, the prevalence in our population would remain high. The rates of violence in our study are higher than those found in community samples4751 or studies of primary care populations drawn from health maintenance organizations4,52 or community-based clinics,9,15 but are similar to other studies drawn from inner-city, public hospitals or academic medical centers.5355 Those study populations have much greater racial diversity and lower educational levels than ours. The high rates of violence and disability and the low incomes and health function in our mostly white, well-educated patients highlight the challenges faced by academic medical centers and their patients, even in less racially diverse cities.

Our secondary analyses further the literature by showing that the association between IPV or CV and physical symptoms persists even after adjustment for depression and PTSD. This finding supports the notion that depression and PTSD should be seen as important comorbid illnesses that influence the health of violence survivors, but do not fully explain physical symptoms.

One can speculate as to why or how violence increases the risk of depression or physical symptoms. Only 3% of women in our study had experienced CV alone. Perpetrators of family violence classically berate their victims, isolate them socially, control their activities, and alternate between extreme displays of love and abuse.56,57 Cognitive-behavioral theory attributes depression to maladaptive thoughts and behaviors.58,59 A victim may internalize negative beliefs about herself, which can then lead to depressive thoughts. The social isolation and control may cause her to adopt behaviors that also increase risk for depression. In our study, the number of different forms of violence was most associated with current risk of depression. It may be that experiencing violence from multiple different perpetrators and in multiple different situations may further reinforce negative beliefs that had been instilled in a victim by an abusive family member or partner.

Less is known as to why violence is associated with chronic physical symptoms, but one can imagine that the nature of abuse may contribute to the development of somatic complaints. Women are likely to have been told by their abuser that they are “crazy” or that the problem is “all in [their] head.” Moreover, survivors often feel that providers and others blame them for choosing to stay in an abusive relationship.56 An abuse survivor may be more hesitant to accept a mental health diagnosis, may interpret it as proof that her provider thinks “there is something wrong” with her for getting into an abusive relationship, or may be more likely to experience mental distress as physical symptoms.

Alternatively, it is possible that violence causes lasting changes in the neuroendocrine system that chemically mediate an increase in symptoms. Though evidence is emerging for neuroendocrine abnormalities in patients with chronic mental or physical distress,6067 little is known about the mechanisms linking violence to such changes.

Studies that only assess one form of violence may make inferences that are confounded by participants’ other violent experiences. Similarly, studies that lump all violence together in a dichotomous fashion may be missing the importance of multiple victimizations. Researchers interested in the relationship between violence and health need to consider the cumulative effect of many different forms of violence.

Clinicians need to be aware that a patient may not simply be a survivor of one form of violence. Most efforts to train clinicians focus on a specific form of violence.56,6870 However, clinicians need to take into account the complexity of women's experiences and needs. Conversely, when seeing a patient with depressive symptoms or multiple physical complaints, clinicians should consider the possibility that a lifetime of violence may be diminishing her health and should be aware of the repetitive nature of violence and the increased risk of future victimization.

Further research is needed to understand the relationship between violence and health, to test the effectiveness of interventions meant to decrease the impact of violence, and to explore ways to prevent future violence.

Acknowledgments

This work was funded by a grant from the Medical Research Foundation of Oregon (PI: Nicolaidis).

We greatly appreciate the work of Regan Duffy in recruiting participants and conducting interviews. We would like to thank Sarah Zwehl-Burke, MD, Lauren Shaw, Don Austin, MD, PhD, and Cari Gandrud for their contributions to grant writing and data collection, and Jacquelyn Campbell, RN, PhD, for her suggestions regarding data analysis.

REFERENCES

1. Golding JM. Intimate partner violence as a risk factor for mental disorders: a meta-analysis. J Fam Violence. 1999;14:99–132.
2. Roberts GL, Lawrence JM, Williams GM, Raphael B. The impact of domestic violence on women's mental health. Aust N Z J Public Health. 1998;22:796–801. [PubMed]
3. Marais A, de Villiers PJ, Moller AT, Stein DJ. Domestic violence in patients visiting general practitioners—prevalence, phenomenology, and association with psychopathology. S Afr Med J. 1999;89:635–40. [PubMed]
4. Petersen R, Gazmararian J, Andersen Clark K. Partner violence: implications for health and community settings. Womens Health Issues. 2001;11:116–25. [PubMed]
5. Lown EA, Vega WA. Intimate partner violence and health: self-assessed health, chronic health, and somatic symptoms among Mexican American women. Psychosom Med. 2001;63:352–60. [PubMed]
6. Woods SJ. Prevalence and patterns of posttraumatic stress disorder in abused and postabused women. Issues Ment Health Nurs. 2000;21:309–24. [PubMed]
7. Hathaway JE, Mucci LA, Silverman JG, Brooks DR, Mathews R, Pavlos CA. Health status and health care use of Massachusetts women reporting partner abuse. Am J Prev Med. 2000;19:302–7. [PubMed]
8. Campbell J, Jones AS, Dienemann J, et al. Intimate partner violence and physical health consequences. Arch Intern Med. 2002;162:1157–63. [PubMed]
9. McCauley J, Kern DE, Kolodner K, et al. The “battering syndrome”: prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med. 1995;123:737–46. [PubMed]
10. McCauley J, Kern DE, Kolodner K, Derogatis LR, Bass EB. Relation of low-severity violence to women's health. J Gen Intern Med. 1998;13:687–91. [PMC free article] [PubMed]
11. Coker AL, Smith PH, Bethea L, King MR, McKeown RE. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med. 2000;9:451–7. [PubMed]
12. Wisner CL, Gilmer TP, Saltzman LE, Zink TM. Intimate partner violence against women: do victims cost health plans more? J Fam Pract. 1999;48:439–43. [PubMed]
13. Ulrich YC, Cain KC, Sugg NK, Rivara FP, Rubanowice DM, Thompson RS. Medical care utilization patterns in women with diagnosed domestic violence. Am J Prev Med. 2003;24:9–15. [PubMed]
14. Kernic MA, Wolf ME, Holt VL. Rates and relative risk of hospital admission among women in violent intimate partner relationships. Am J Public Health. 2000;90:1416–20. [PubMed]
15. McCauley J, Kern DE, Kolodner K, et al. Clinical characteristics of women with a history of childhood abuse: unhealed wounds. JAMA. 1997;277:1362–8. [PubMed]
16. Bendixen M, Muus KM, Schei B. The impact of child sexual abuse—a study of a random sample of Norwegian students. Child Abuse Negl. 1994;18:837–47. [PubMed]
17. Rowan AB, Foy DW, Rodriguez N, Ryan S. Posttraumatic stress disorder in a clinical sample of adults sexually abused as children. Child Abuse Negl. 1994;18:51–61. [PubMed]
18. Simpson TL. Childhood sexual abuse, PTSD, and the functional roles of alcohol use among women drinkers. Subst Use Misuse. 2003;38:249–70. [PubMed]
19. Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 2003;111:564–72. [PubMed]
20. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245–58. [PubMed]
21. Barsky AJ, Wool C, Barnett MC, Cleary PD. Histories of childhood trauma in adult hypochondriacal patients. Am J Psychiatry. 1994;151:397–401. [PubMed]
22. Walker EA, Gelfand AN, Gelfand MD, Katon WJ. Psychiatric diagnoses, sexual and physical victimization, and disability in patients with irritable bowel syndrome or inflammatory bowel disease. Psychol Med. 1995;25:1259–67. [PubMed]
23. Goodwin RD, Hoven CW, Murison R, Hotopf M. Association between childhood physical abuse and gastrointestinal disorders and migraine in adulthood. Am J Public Health. 2003;93:1065–7. [PubMed]
24. Lechner ME, Vogel ME, Garcia-Shelton LM, Leichter JL, Steibel KR. Self-reported medical problems of adult female survivors of childhood sexual abuse. J Fam Pract. 1993;36:633–8. [PubMed]
25. Moeller TP, Bachmann GA, Moeller JR. The combined effects of physical, sexual, and emotional abuse during childhood: long-term health consequences for women. Child Abuse Negl. 1993;17:623–40. [PubMed]
26. Walker EA, Katon WJ, Hansom J, et al. Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain. Psychosomatics. 1995;36:531–40. [PubMed]
27. Davila GW, Bernier F, Franco J, Kopka SL. Bladder dysfunction in sexual abuse survivors. J Urol. 2003;170(2 pt 1):476–9. [PubMed]
28. Walker EA, Gelfand AN, Gelfand MD, Koss MP, Katon WJ. Medical and psychiatric symptoms in female gastroenterology clinic patients with histories of sexual victimization. Gen Hosp Psychiatry. 1995;17:85–92. [PubMed]
29. Walker EA, Torkelson N, Katon WJ, Koss MP. The prevalence rate of sexual trauma in a primary care clinic. J Am Board Fam Pract. 1993;6:465–71. [PubMed]
30. Longstreth GF, Wolde-Tsadik G. Irritable bowel-type symptoms in HMO examinees. Prevalence, demographics, and clinical correlates. Dig Dis Sci. 1993;38:1581–9. [PubMed]
31. Talley NJ, Fett SL, Zinsmeister AR, Melton LJ., III Gastrointestinal tract symptoms and self-reported abuse: a population-based study. Gastroenterology. 1994;107:1040–9. [PubMed]
32. Sansone RA, Wiederman MW, Sansone LA. Health care utilization and history of trauma among women in a primary care setting. Violence Vict. 1997;12:165–72. [PubMed]
33. Derogatis L. SCL-90-R Symptom Checklist-90-R Administration, Scoring, and Procedures Manual. 3rd ed. Minneapolis, Minn: National Computer Systems; 1994.
34. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273:1026–31. [PubMed]
35. Lipman RS, Covi L, Shapiro AK. The Hopkins Symptom Checklist (HSCL)—factors derived from the HSCL-90. J Affect Disord. 1979;1:9–24. [PubMed]
36. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD checklist (PCL) Behav Res Ther. 1996;34:669–73. [PubMed]
37. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med. 1989;86:262–6. [PubMed]
38. Kroenke K, Spitzer RL, Williams JB, et al. Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994;3:774–9. [PubMed]
39. Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med. 2001;134(9 pt 2):868–81. [PubMed]
40. Buchsbaum DG, Buchanan RG, Centor RM, Schnoll SH, Lawton MJ. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Intern Med. 1991;115:774–7. [PubMed]
41. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. JAMA. 1999;282:1737–44. [PubMed]
42. Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am J Obstet Gynecol. 2000;183:759–69. [PubMed]
43. Pitzner JK, Drummond PD. The reliability and validity of empirically scaled measures of psychological/verbal control and physical/sexual abuse: relationship between current negative mood and a history of abuse independent of other negative life events. J Psychosom Res. 1997;43:125–42. [PubMed]
44. Green BL. In: Measurement of Stress, Trauma, and Adaptation. Stamm BH, Varra EM, editors. Lutherville, Md: Sidrand Press; 1996. pp. 366–8.
45. Straus MA. Measuring intrafamily conflict and violence: the Conflict Tactics Scales. J Marriage Fam. 1979;41:75–88.
46. Campbell DW, Campbell JC, King C, Parker B, Ryan J. The reliability and factor structure of the index of spouse abuse with African-American battered women. Violence Vict. 1994;9:259–74. [PubMed]
47. Anonymous. Lifetime and annual incidence of intimate partner violence and resulting injuries—Georgia, 1995. MMWR Morb Mortal Wkly Rep. 1998;47:849–53. [PubMed]
48. Anonymous. Intimate partner violence among men and women—South Carolina, 1998. MMWR Morb Mortal Wkly Rep. 2000;49:691–4. [PubMed]
49. Schafer J, Caetano R, Clark CL. Rates of intimate partner violence in the United States. Am J Public Health. 1998;88:1702–4. [PubMed]
50. Glick B, Johnson S, Pham C. 1998 Oregon Domestic Violence Needs Assessment: A Report to the Oregon Governor's Council on Domestic Violence. Portland, Ore: Oregon Health Division and Multnomah County Health Department; 1999.
51. Plichta SB, Falik M. Prevalence of violence and its implications for women's health. Womens Health Issues. 2001;11:244–58. [PubMed]
52. Tollestrup K, Sklar D, Frost FJ, et al. Health indicators and intimate partner violence among women who are members of a managed care organization. Prev Med. 1999;29:431–40. [PubMed]
53. Bauer HM, Rodriguez MA, Perez-Stable EJ. Prevalence and determinants of intimate partner abuse among public hospital primary care patients. J Gen Intern Med. 2000;15:811–7. [PMC free article] [PubMed]
54. Coker AL, Smith PH, McKeown RE, King MJ. Frequency and correlates of intimate partner violence by type: physical, sexual, and psychological battering. Am J Public Health. 2000;90:553–9. [PubMed]
55. Paranjape A, Liebschutz J. STaT: a three-question screen for intimate partner violence. J Womens Health. 2003;12:233–9. [PubMed]
56. Nicolaidis C. The Voices of Survivors Documentary: using patient narrative to educate physicians about domestic violence. J Gen Intern Med. 2002;17:117–24. [PMC free article] [PubMed]
57. Campbell JC, Radford J, Russel DEH. “If I can't have you, no one can”: power and control in homicide of female partners. Femicide The Politics of Woman Killing. Boston, Mass: Twayne; 1992.
58. Beck AT, Rush AJ, Sahw BF, Emery G. Cognitive Therapy and Depression: A Treatment Manual. New York, NY: Guilford Press;
59. Craighead WE, Hart AB, Craighead LW, Hardi SS. Psychosocial treatments for major depressive disorder. In: Natham P, Gorman J, editors. A Guide to Treatments that Work. 2nd ed. New York, NY: Oxford University Press; 2002. pp. 245–61.
60. Neeck G, Riedel W. Neuromediator and hormonal perturbations in fibromyalgia syndrome: results of chronic stress? Baillieres Clin Rheumatol. 1994;8:763–75. [PubMed]
61. Crofford LJ, Engleberg NC, Demitrack MA. Neurohormonal perturbations in fibromyalgia. Baillieres Clin Rheumatol. 1996;10:365–78. [PubMed]
62. Bennett RM. Emerging concepts in the neurobiology of chronic pain: evidence of abnormal sensory processing in fibromyalgia. Mayo Clin Proc. 1999;74:385–98. [PubMed]
63. Cannon JG, Angel JB, Abad LW, et al. Hormonal influences on stress-induced neutrophil mobilization in health and chronic fatigue syndrome. J Clin Immunol. 1998;18:291–8. [PubMed]
64. Clauw DJ, Chrousos GP. Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation. 1997;4:134–53. [PubMed]
65. Demitrack MA, Crofford LJ. Evidence for and pathophysiologic implications of hypothalamic-pituitary-adrenal axis dysregulation in fibromyalgia and chronic fatigue syndrome. Ann N Y Acad Sci. 1998;840:684–97. [PubMed]
66. Pillemer SR, Bradley LA, Crofford LJ, Moldofsky H, Chrousos GP. The neuroscience and endocrinology of fibromyalgia. Arthritis Rheum. 1997;40:1928–39. [PubMed]
67. Weigent DA, Bradley LA, Blalock JE, Alarcon GS. Current concepts in the pathophysiology of abnormal pain perception in fibromyalgia. Am J Med Sci. 1998;315:405–12. [PubMed]
68. Thompson RS, Meyer BA, Smith-DiJulio K, et al. A training program to improve domestic violence identification and management in primary care: preliminary results. Violence Vict. 1998;13:395–410. [PubMed]
69. Alpert EJ, Tonkin AE, Seeherman AM, Holtz HA. Family violence curricula in U.S. medical schools. Am J Prev Med. 1998;14:273–82. [PubMed]
70. Alpert EJ, Cohen S. Educating the nation's physicians about family violence and abuse. Acad Med. 1997;72(1 suppl):Sv–viii. S3–115. [PubMed]

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