It was refreshing to read a paper1 and editorial2 that sought to identify causes of patients' anxiety in their life events, as patients complain that doctors often fail to ask why they are anxious or depressed.3 The reported research identified domestic violence and abuse (DVA) as a cause of anxiety using the HARK questions (four short questions relating to Humiliation, being Afraid, Raped, and Kicked).4
The paper also notes that the Generalised Anxiety Disorder Scale (GAD-7) can be used as a ‘case-finder’ for panic-disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD), as well as generalised anxiety disorder (GAD). The questions of the GAD-7 overlap with the questions required to make the diagnoses above, that is why GAD-7 can act as a ‘case-finder’.1 However, I think it is a mistake to conclude from the paper that domestic violence causes GAD, as the editorial seems to. Sherina et al do not claim this. They did not pursue further analysis of the type of anxiety disorder patients were suffering from in their research. Diagnostic rigour helps the doctor and patient understand the consequences of DVA and thus find appropriate solutions. Sherina et al discuss the association of PTSD and DVA.
A meta-analysis5 on the prevalence of mental health problems among those who had experienced DVA found mean prevalences of 63.8% in 11 studies of PTSD, 47.6% in 18 studies of depression, 17.9% in 13 studies of suicidality, 18.5% in 10 studies of alcohol abuse, and 8.9% in four studies of drug abuse. Dose-response relationships of violence to depression and PTSD were observed.
The best explanatory model linking domestic violence and anxiety disorders is PTSD. It makes sense that terrifying and humiliating experiences of DVA result in nightmares, flashbacks (intrusive thoughts), avoidance behaviours, and hyper-arousal. However, a positive GAD-7 score may usefully act as a tool of communication, and a prompt to the GP for further questioning about PTSD symptoms and DVA using HARK questions.
The linked editorial2 correctly identifies the lack of evidence for the use of ‘routine enquiry’ for DVA in general practice, as opposed to its evidence-based use in antenatal clinics.6 This is reiterated by the Department of Health.3 I am writing the RCGP e-learning course on DVA. I encourage GPs to work from patients' symptoms, using ‘diagnostic enquiry’ rather than ‘routine enquiry’.7 The course will, I hope, provide safe, pragmatic guidance that is congruent with how we GPs work.
- © British Journal of General Practice 2011