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 Table of Contents  
Year : 2022  |  Volume : 38  |  Issue : 1  |  Page : 93-98

Psychiatric manifestation and occurrence of violence toward caregivers

1 Department of Clinical Psychology, IMHH, Agra, Uttar Pradesh, India
2 Department of Psychiatric Social Work, Institute of Mental Health, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India
3 Mental Health Initiative, Health Portfolio, Tata Trusts, Mumbai, India
4 Department of Psychiatric Social Work, Central of Excellence in Mental Health, ABVIMS.Dr. RMLH, New Delhi, India

Date of Submission07-Jun-2020
Date of Decision08-Jul-2020
Date of Acceptance18-Aug-2020
Date of Web Publication25-Mar-2022

Correspondence Address:
Mr. Upendra Singh
Lecturer, Department of Psychiatric Social Work, ABVIMS.Dr. Ram Manohar Lohia Hospital, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_72_20

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Background: Individuals diagnosed with schizophrenia or bipolar affective disorder (BAD) are not always violent or make violent responses. However, psychiatric disorders such as schizophrenia and BAD are associated with violent acts of patients in various forms such as physical, verbal, and emotional violence. The victims to these violent acts by individuals suffering from schizophrenia or BAD are the caregivers most of the times. In addition, the treating team experiences violence by psychiatric patients during their stay in the hospital, especially in the initial days of hospitalization. Materials and Methods: This study was a cross-sectional, descriptive research. A total of 104 caregivers were selected for the study as per the inclusion and exclusion criteria. Sociodemographic and clinical details were collected through semi-structured interview schedule. Data were collected including sociodemographic details, Family Violence Scale, Family Burden Interview Schedule, and Depression Anxiety and Stress Scale. Results: The study states that caregivers of individuals diagnosed with schizophrenia or BAD experience overall burden. The experience is associated with being a victim of violence made by the relative suffering with psychiatric disorder. In addition, the events of violence create adverse impact on the psychological well-being of the caregivers, causing stress, anxiety, and depression. Conclusion: The study clearly indicates the need to attend the psychological needs of the caregivers of individuals suffering from schizophrenia or BAD.

Keywords: Burden, impact, manifestation, schizophrenia, violence

How to cite this article:
Sweta, Singh B, Kapse PP, Jha N, Singh U. Psychiatric manifestation and occurrence of violence toward caregivers. Indian J Soc Psychiatry 2022;38:93-8

How to cite this URL:
Sweta, Singh B, Kapse PP, Jha N, Singh U. Psychiatric manifestation and occurrence of violence toward caregivers. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Jun 30];38:93-8. Available from: https://www.indjsp.org/text.asp?2022/38/1/93/340954

  Introduction Top

Psychiatric illness causes deterioration in functioning such as information processing, decision-making, expressing emotions, being assertive, and responding to environmental stimulus.[1] These deficits of the individuals suffering from psychiatric illness create several other problems such as poor self-care, unemployment, issues in interpersonal relationships, and overall self-image.[2] Once diagnosed with a psychiatric illness, it is associated with unemployment, which, in turn, brings in social decline with many other problems also experienced by caregivers such as burden, stress, anxiety, and depression. Furthermore, individuals suffering from psychiatric illness show violence in various forms toward their caregivers.

Violence explained as a result of “loss of control” is contradicted by batterers' behavior as they target certain people at certain time and places.[3] The inter-generational cycle of violence explaining the perpetuation of violence by social learning fails to recognize that cognitions too play a role in the acquisition of behavior through vicarious learning.[4] The emotional trauma of caring for a loved one who responds by violence should not be underestimated.[5] Finally, violence increases the cost of treatment. It can be a cause of repeated hospitalization, and it may increase the stay length of hospitalization.[6] Violent patients require disproportionate amounts of staff time.[7] A systematic review and meta-analyses identified that 120 structured tools have been considered for assessing violence in psychiatric and correlated population.[8] Serper et al. in their study found that the level of patients' cognitive impairment significantly predicted the form of negative and positive symptoms, which contributed to the manifestation of inpatient aggressive behavior significantly.[9]

Caregivers who are taking care of individuals diagnosed with schizophrenia and bipolar affective disorders (BADs) have somewhat similar outcome as communicate; their day-to-day life is markedly overburdened, and their occupational, emotional, and physical life has problems due to the violent acts made by the patient. They have to fight stigma, isolation, and discrimination in their community. Thus, the present study aimed at identifying problems manifested on caregivers by the violent acts of individuals diagnosed with psychiatric disorders (schizophrenia and BADs).

  Materials and Methods Top

The aim of the study was to assess the psychiatric manifestation and occurrence of violence toward caregivers by persons with schizophrenia and BAD. It was a cross-sectional, hospital-based, descriptive study. Ethical permission was taken from the institute to conduct the research work. The study was conducted at RINPAS, Ranchi, Jharkhand.

Purposive sampling technique was used for the selection of respondents from the Psychosocial Clinic, in the Outpatient Department, RINPAS. A total of 104 patients along with their caregivers were recruited. They were explained the purpose and procedure of the study before obtaining written consent. The study was conducted only on the primary caregivers of persons diagnosed with schizophrenia and BAD according to ICD-10, DCR.[10] Primary caregivers are those who are closely involved in the care of person for her/his daily living activities, medicine, and work. However, only those primary caregivers who were staying for at least 6 months continuously with the patient were included in the study. Caregivers were excluded from the study if they are taking care of persons with comorbid psychiatric disorders or physical illness, taking care of patients with substance use or abuse, and having care for more then one person with psychiatric illness.

Study tools

Sociodemographic datasheet: The study started with collecting sociodemographic information of the caregivers and clinical details of the patients, on a semi-structured questionnaire designed for the study.

The Family Violence Scale[11] consists of five broad areas of family violence namely physical violence, verbal violence, social violence, emotional violence, and intellectual violence. The scale reports a good test–retest validity for the scale in Indian culture.

The Family Burden Interview Schedule[12] comprises of 25 questions on a 3-point scale from severe burden (2) to no burden (0). The scale's reliability score has been reported between 87% and 90% for its item which is highly acceptable. The Depression Anxiety and Stress Scale (DASS)[13] has been translated and adopted from English. It has 42 Likert-type questions (14 each for depression, anxiety, and stress), with responses from strongly agree (0) to strongly disagree. Higher score indicates higher difficulty, and it can be ranged from normal to extremely severe. Cronbach's alpha score for the scale was 0.83 with good test–retest reliability.

Statistical analysis was done by using (IBM-SPSS) Statistical Package for Social Sciences software 20 version. Descriptive analysis was done on sociodemographic and clinical profile of the participants. Pearson's product moment correlation was used for assessing the relationship between dependent factors. Chi-square test and t-test were used to know the difference between schizophrenia and BAD groups.

  Results Top

[Table 1] reveals that 35.6% of caregivers are graduates or holding a professional degree; 19.3 of them are professionals and 15.45% are business person. Patients' relationship with caregivers was reported significantly different between both the groups. With regard to bipolar disorder, most (36.5%) of the participants are fathers followed by mother (26.9%) and siblings; moreover, in schizophrenia, siblings and spouses constituted 30.8% in each. Nearly 60% of the participants don't have hospitalization, but 7.75% of them reported hospitalization history three or more times. Only caregivers' relationship was found significantly different in both the groups.
Table 1: Sociodemographic characteristics

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The mean and standard deviation (SD) of incidents of violence with caregivers were 23.37 ± 14.52 among individuals with schizophrenia and 33.83 ± 11.54 among individuals with BAD manic type, which was statistically significantly indicating that caregivers of BAD have more incidence of experiencing violence from their family member having BAD.

The results in [Table 2] also showed that the mean and SD of subjective burden of caregivers was 19.38 ± 9.25 with schizophrenic individuals and 18.54 ± 6.63 with BAD manic type; no significant difference was found between the groups. Perceived features of depression, anxiety, and stress were 8.65 ± 4.58, 4.05 ± 3.48, and 6.98 ± 3.90, respectively, by caregivers of schizophrenia patients and 6.92 ± 3.66, 3.78 ± 3.11, and 5.71 ± 3.15, respectively, by caregivers of BAD mania patients, however depression was found to be significantly high in the caregivers of schizophrenia [Table 2].
Table 2: Comparison of dependent variables in schizophrenia and bipolar disorder

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[Table 3] shows the correlation between various domains of violence, with family burden and depression, anxiety, and stress. There was a significant positive correlation between financial burden and all the domains of violence (physical violence –0.435, verbal violence –0.485, emotional violence –0.264, social violence –0.426, and intellectual violence –0.350). There was no significant correlation between social violence and daily routine burden (r = 0.177), but there was a significant positive correlation between daily routine burden and physical (r = 0.260), verbal (r = 409), emotional (r = 0.290), and intellectual (r = 0.310) violence. Family leisure burden has a positive correlation with verbal (r = 0.222), social (r = 238), and intellectual violence (r = 196) with significance at 0.05 level. Family interaction burden has a positive correlation at 0.05 level with verbal (r = 0.324), emotional (r = 0.294), and intellectual violence (r = 0.331) and 0.01 level of significance with social violence (r = 0.213). Physical health burden had a positive correlation with verbal violence, social violence, and intellectual violence at 0.01 level with r = 0.258, 0.281, and 0.370, respectively. However, physical burden had r = 0.248, which was significant at 0.05 level with emotional violence and no significance with physical violence. Similarly, mental health burden had a positive correlation at 0.01 level with intellectual (r = 0.345) burden and a significant positive correlation with social (r = 0.212) violence at 0.05 level but no significant relation with physical, verbal, and emotional violence. The result showed a significant positive correlation between stress and intellectual violence with r = 0.240 and anxiety and intellectual violence with r = 0.207 at 0.05 level. Depression had a significant positive correlation at 0.05 level with verbal, social, and intellectual violence at r = 0.340, 0.268, and 0.327, respectively. When of overall burden, there lays a significant positive correlation between physical (r = 0.299), verbal (r = 0.467), emotional (r = 0.357), social (r = 0.305), and intellectual (r = 0.438) violence at 0.01 level of significance, which is very high. However, the composite scores of DASS have a positive correlation with verbal (r = 0.224) and emotional (r = 0.209) violence at 0.05 level and with intellectual (r = 0.312) violence at 0.01 level.
Table 3: Correlation between burden, depression, anxiety, stress, and violence

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  Discussion Top

Mental illness-related violent behavior is a social stigma especially with schizophrenia[14] although it has been reported that violence rate in individuals with schizophrenia is high in comparison to that of the general population.[15] Several researches conducted on schizophrenia and BAD as variables reported that family members including parents, spouse, sibling, and children get affected by persons diagnosed with schizophrenia and BAD in their family[16],[17],[18],[19] and family members suffer domestic violence by the patient.[20]

This study investigated the perception of caregivers' experience of violence, committed toward them by their patients diagnosed with schizophrenia or BAD as per ICD-10, DCR.[10] Individuals in both the groups were very similar in every sociodemographic aspect except caregiver's relationship.

The current findings state that caregivers of person with BAD face more violent acts and events by their patients when compared to caregivers of person with schizophrenia; similar findings have been reported previously.[21] Our findings suggest that caregivers of persons diagnosed with schizophrenia as well as BAD experience high burden; the findings are similar to those of previous research.[22] Violence committed by their relatives with psychiatric illness is very common as reported by the caregivers.[18],[23],[24] Caregivers have to maintain day-to-day activities such as hygiene, meals, monitoring mental state, identifying early signs of relapse, remembering dates of follow-up, maintaining relation in extended family on behalf of the patient, and offering financial support, expectations that multiply the level of burden for them. In a previous study, the level of burden was found high among the caregivers of schizophrenia in comparison to bipolar disorder,[16] but, in the current study, we found very slight high score in caregivers of schizophrenia. Our findings specify that caregivers from both groups undergo similar levels of burden, previous studies[17],[25] also reported similar findings.

Taking care of an individual suffering with mental illness becomes a chronic process in most of the cases, leaving caregivers with stress, anxiety, and low mood. Caregivers of patients with schizophrenia reported higher stress and anxiety when compared to caregivers of BAD patients; moreover, depression is significantly high in caregivers of patients with schizophrenia. In the long run, facing community's discriminations and stigma may cause mental illness in the caregivers itself. A similar study found that the important challenges faced by the caregivers were burnout and high burden of care, high social stigma, low social support, and low quality of life.[26]

The findings also indicate a positive relationship between financial burden and violence among the caregivers of schizophrenia and BAD. Caregivers develop many self-designed management strategies for providing care to their loved ones.[27] Caregivers face loss of income source or extra expense per month on treatment. The burden increases by poor financial availability.[28] This financial problem is perceived as burden when the caregivers have to experience violent acts of their patients. In Asian countries like India, caregivers play multiple roles involving day-to-day care of hygiene, supervising medicine, accompanying patient with follow-ups, etc.[29],[30] Patients all day staying ideal at the home not going for their job, not helping at household chores, and at times caregivers have to neglect other family responsibilities to look after the patient.[17],[18],[27],[29],[30],[31] Thus, caregivers facing more physical, verbal, emotional and intellectual violence by their increases daily routine burden. Due to this burden caregivers experiences difficulty in maintaining direct communication between the patient and other family members. We found a significant positive correlation between physical health burden and verbal, emotional, social, and intellectual acts of violence by persons with schizophrenia and BAD toward their caregivers.

Caregivers facing intellectual violence by their patients experience high stress, anxiety, and depression. In addition, it was reported by the caregivers that facing verbal, social, and intellectual violence by the individual for whom they care caused significant symptoms of depression in them. Caregiving causes anxiety, stress, and depression;[32] being a caregiver can be physically and emotionally stressful and this condition worsens if the violence for caregiver is present. When taking care of a loved one, caregivers often put others' needs before their own. Caregivers regularly forfeit energy and their own emotional and physical needs, which could lead to stress, anxiety, and/or depression; this condition could be multiplied due to violence.

The findings may help clinicians in developing therapeutic intervention strategies for patients and skill trainings for caregivers. The study has its limitations such as the sample size was very small and has been made with nonprobability technique. It also missed the associated neurotic symptoms and functionality of the patients that directly influence the caregivers' perception and well-being.

  Conclusion Top

Psychosocial needs of family members of persons suffering from schizophrenia and BAD (mostly chronic psychiatric disorders) are an essential component that needs to be addressed timely. Family burden and violence of patients were interrelated and make significant influence on each other. Caregivers face poor physical health when they are troubled by violent acts of their patients in the form of verbal abuse, emotional detachment, humiliation in public, and intellectual violence.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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