Interviewee

Dr Christina Nicolaidis, Associate Professor of Medicine and Public Health & Preventive

Medicine, Division of General Internal Medicine, Oregon Health & Science University, Portland, OR, USA

Article

Nicolaiis, C., Gregg, J., Galian, H., McFarland, B., Curry, M., Gerrity, M. (2008) "You Always End up Feeling Like You're Some Hypochondriac": Intimate Partner Violence Survivors' Experiences Addressing Depression and Pain, JGIM: Journal of General Internal Medicine, 23(8):1157-63

Summary

Although statistics vary, over a life time, over twenty percent of women may suffer an Intimate partner violence (IPV) episode. IPV survivors can view their abuse as a breach of trust, isolating them from society and leaving them with an incredibly sense of loneliness. IPV survivors also have a higher rate of physical and mental health problems with an increase in depression, PTSD, drug abuse and poor health. Dr Christina Nicolaidis talked about her study, to Hamish Holewa, for IPP-SHR podcasts. Christina's study focused on how IPV survivors want their health providers to talk about the rest of their health, and on what IPV survivors thought about the connection between abuse and mental/physical health symptoms. It was found that women who are IPV survivors are very aware that the abuse is related to mental and physical symptoms, but they wanted the providers to holistically understand their symptoms and not dismiss symptoms purely because they are IPV survivors. Trusting health professionals to view their symptom holistically was a large concern, women felt unsure of disclosing information: the more the providers knew, the more chance they could use it against them, making the women feel their symptoms were all in their head. Respect from a health provider towards the women was seen as very important: women wanted respect towards their whole selves. Health providers need to be very sensitive about these issues: an appropriate preface is required before the discussion of violence can begin.

Transcript

Hamish Holewa: Hi and welcome to IPP-SHR podcasts, I’m Hamish Holewa, I’m speaking to Doctor Christina Nicolaidis, Associate Professor of Medicine and Public Health & Preventative Medicine, Oregon Health & Science University, Portland, Oregon, USA. We’re speaking to Christina, today, about her study and article titled: “You Always End up Feeling Like You’re Some Hypochondriac”: Intimate Partner Violence Survivors’ Experiences Addressing Depression and Pain; published in the Journal of General Internal Medicine, and co-authored with others listed on our website. Hi Christina, thanks for speaking with us today. Do you want to begin this podcast by providing our listeners with background information on the serious problem of intimate partner violence in the USA ,and outline the issues that your study explored?

Christina Nicolaidis: Well there’s no doubt that intimate partner violence or IPV is a serious problem, both in the United States and really in the rest of the world too. Of course, prevalence estimates can totally vary depending on how you define it, or measure it, but when it comes down to it, it’s extremely common, whether we’re talking about current year population based estimates of three to thirty percent, or lifetime estimates and clinical samples of twenty to fifty-five percent, it certainly affects a large proportion of women. Now the reason that IPV interests me as a health care provider is that it’s associated, at least statistically, with a host of, both, physical and mental health problems. There’s a tonne of studies showing increased rates of depression, PTSD, substance abuse, as well as poor overall health, and greater rates of a host of different physical conditions. Interestingly, even though IPV survivors have overall greater health care costs than other women; depressed IPV survivors seem to seek less mental health care than other depressed women. It’s unclear why they might be hesitant to seek mental health care, or how they understand the relationship between their physical and mental health problems. So, we built on a lot of other great studies that have looked at how IPV survivors want providers to talk to them about their IPV, but we’re more interested in how IPV survivors want providers to talk about the rest of their health; specifically our objectives were to explore what depressed IPV survivors believe about the relationship between abuse, mental health and physical symptoms, and then to use this information to develop patient informed recommendations for primary care providers about addressing depression, physical symptoms or other issues in women with a history of IPV.

Hamish Holewa: Sure, and your findings do indicate that physical and mental impact of abuse is interrelated, so health care providers should know about a woman’s past experiences in order to help them. Do you want to elaborate on that issue further?

Christina Nicolaidis: As a clinician I sometimes think I kind of arrogantly go in with the idea that I need to teach my patient that, in fact, these things are related. What we found that at least the women that were in our study were very well aware that these were interrelated.

Hamish Holewa: Sure.

Christina Nicolaidis: It wasn’t really that we needed to tell them that they’re related, it was kind of the other way around: they felt that providers really need to know about IPV and mental health to really understand who they are.

Hamish Holewa: Sure, but your participants also spoke about the fear of disclosure; do you want to talk about that issue?

Christina Nicolaidis: Yeah, and that was a very strong theme. As I said, they did recognise the interrelatedness of their abuse and their physical health and their mental health; but they were very concerned that if their providers knew about these things they would actually use that information against them, or that they’d think that their physical symptoms were, quote, “all in their head,” and this really counter played their desire to have their physicians understand them. One woman said here, “...and the last thing I learned is if they think you’ve got any kind of emotional problems they have this thing about giving you any kind of medication. They’ll say, ‘Is this for real, your pain? Oh, it’s probably in your mind. Let’s not give her the medicine that she needs...’ and stuff like that. I’m very suspicious and careful of what I tell my doctor because of that, because you always end up feeling that you’re a hypochondriac.”

Hamish Holewa: Right and that really does highlight the complex issue in relation to trust there for women who have experienced intimate partner violence. Do you want to explain that further?

Christina Nicolaidis: Women are actually very introspective about trust issues. Unfortunately, the abuse they’ve suffered in their relationship really was a breach of trust. This often was repeated by many people, it wasn’t just the partner or parents, it was other partners, it was friends; and the result was an extreme sense of loneliness and isolation. It’s actually very difficult to listen to some of these interviews because of that extreme sense of loneliness. At the same time, they recognised this and they were quite introspective about how this affects their trust in providers, as one woman said, “Am I willing to start learning how to trust again?”I mean the trust issues go huge and deep and long. That doesn’t mean that they couldn’t trust providers and many gave really great examples of where providers had earned their trust.

Hamish Holewa: Right and obviously one of the important practical implications that came out of your study there is the need to treat abused women with respect. Is there any other practical implications for your work?

Christina Nicolaidis: Respect is it’s sort of corny, we need to treat all of our patients with respect, and you don’t really need to study to tell you that. On the other hand, I think, these women were particularly interested in making sure that their providers respected them in many ways: they wanted them to respect their intelligence; they wanted to respect the complexity of their lives and of their health, and they wanted to respect them for understanding their own bodies. I think the practical implications are that even though these are important with all patients, we need to be particularly sensitive to these issues when dealing with intimate partner violence survivors. I am the first one to teach that if you’re seeing a patient who has mental health issues, chronic pain, unexplained physical symptoms, lots of physical symptoms, that it is absolutely imperative to ask about violence. On the other hand, if you hear about pain and the first thing you do is ask about violence without an appropriate preface, I’m afraid that what is going to happen is that people are going to assume that you’re asking because you’re trying to write them off or discount their symptoms. Make it really clear that I don’t think it’s all in their head, that I do believe that their experience is real, whether or not there’s a medical explanation for it, and I do respect how they understand their own bodies and their own health; and then the point is to really ask about violence, with a preface of, I’m asking about this because it actually makes symptoms, harder to treat, more severe. In a way, basically say that, I’m going to take you more seriously; I’m not going to use this information to discount you.

Hamish Holewa: Real sensitivity and understanding to the story there, pretty much.

Christina Nicolaidis: My guess is that it makes a bigger difference here because of the underlying trust issues.

Hamish Holewa: Well thank you today for a sharing your time with us to speak with us on IPP-SHR podcasts.

Christina Nicolaidis: Thank you.