The Relationship Between Violence and Psychological Distress Among Men and Women: Do Sense of Mastery and Social Support Matter?

591978 research-article2015

JIVXXX10.1177/0886260515591978Journal of Interpersonal ViolenceBebanic et al.

Article

The Relationship Between Violence and Psychological Distress Among Men and Women: Do Sense of Mastery and Social Support Matter?

Journal of Interpersonal Violence 1–25 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260515591978 jiv.sagepub.com

Vedrana Bebanic, MSc,1 Jocelyne Clench-Aas, PhD,2 Ruth Kjærsti Raanaas, PhD,1 and Ragnhild Bang Nes, PhD2

Abstract The aims of this study were to examine associations between reported exposure to psychological and physical violence and psychological distress (PD) among men and women, and to explore the possible mediating or moderating roles of sense of mastery and social support. We used data from the nationally representative Norwegian Health and Level of Living Survey in 2005 and 2012 (Weighted N = 19,386). PD was measured with the Hopkins Symptom Checklist–25, using the subscales for anxiety and depression separately and in combination. Analyses were conducted using hierarchical logistic regression with complex sample adjustment. Altogether, 3.8% of men and 5.4% of women reported psychological violence during 1Norwegian 2Norwegian

University of Life Sciences, Akershus, Norway Institute of Public Health, Oslo, Norway

Corresponding Author: Jocelyne Clench-Aas, Division of Mental Health, Department of Health Surveillance and Suicide Prevention, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, NO-0403 Oslo 0403, Norway. Email: [email protected]

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Journal of Interpersonal Violence

the last 12 months, while 2.3% and 1.6% reported physical violence, respectively. Both forms of violence were associated with excess risk of comorbid anxiety and depressive symptoms above clinical cut-point (CAD) in men and women alike, and CAD occurred more frequently than anxiety or depressive problems separately. Sense of mastery, but not social support, partly mediated the association between both forms of violence and CAD in men, whereas both partly mediated the association between psychological violence and CAD in women. No moderator role was indicated. Overall, the results provide evidence for excess risk of PD, particularly CAD, in men and women reporting exposure to violence. Sense of mastery and to a lesser degree social support were shown to constitute significant mediators, underscoring the importance of systems for strengthening coping strategies and social support among violence victims, such as psychological and practical support by the health services. Keywords anxiety, depression, gender, violence, psychological distress

Introduction Exposure to violence commonly affects the victims’ short- and long-term health adversely and constitutes a considerable public health concern globally (Krug, Mercy, Dahlberg, & Zwi, 2002). Violence, one of the main causes of death in young people (World Health Organization [WHO], 2014), often results in serious physical injuries and hospital admissions, and is closely associated with anxiety and mood disorders including posttraumatic stress disorder (PTSD; Golding, 1999; Trevillion, Oram, Feder, & Howard, 2012). Although definitions vary, violence might be broadly understood as an aggregate of physically and/or psychologically abusive behaviors. Psychological violence, including verbal and emotional violence, comprises a range of behaviors, and is often more difficult to reliably and validly define than physical violence (Follingstad, 2009). It has been broadly defined by Murphy and Cascardi (1993) as a non-physical form of abuse that “. . . consists of coercive or aversive acts intended to produce emotional harm or threat of harm” (p. 105), for example, harassment, denigration, smearing, devaluation, and emotional control (Murphy & Cascardi, 1993). Physical violence commonly includes various physically abusive acts such as pushing, choking, biting, kicking, burning, and hitting the victim along with use of weapons that cause physical harm or death (Jordan, Campbell, & Follingstad, 2010).


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Internationally, the prevalence of self-reported victimization (defined as experiencing assault during the previous 12 months) has been shown to vary from below 2% in Canada to 13% in Mexico (Organization for Economic Co-operation and Development [OECD], 2013). The mean prevalence was reported to be approximately 4.0% in the countries represented in OECD, and in Norway, the prevalence was close to 3.0% (OECD, 2013). The British Crime Survey, conducted in 2001, showed that 4.5% of men and 6.0% of women reported exposure to psychological violence (e.g., domestic abuse, threats, or force) during the last 12 months, while 2.3% of men and 4.2% of women reported physical violence (Walby, Allen, & Britain, 2004). However, there are still limited data on the prevalence of different types of violence at both national and international levels (Krug et al., 2002). The relationship between violence and mental health problems among victims of violence is well documented and particularly so for women exposed to partner violence, which refers to violence committed by “. . . current or former husbands, unmarried domestic partners and other intimate partners” (Golding, 1999, p. 102). Mental disorders commonly include PTSD, major depression (MD), substance abuse (Kilpatrick et al., 2003), and psychological distress (PD; e.g., subdiagnostic levels of anxiety and depression). Numerous studies have shown a significant association between such forms of mental disorders and both psychological (Beeble, Bybee, Sullivan, & Adams, 2009; Coker, Davis, et al., 2002; Escriba-Aguir et al., 2010; Próspero, 2007) and physical partner violence in women (Beeble et al., 2009; Coker, Davis, et al., 2002; Escriba-Aguir et al., 2010; Fortin, Guay, Lavoie, Boisvert, & Beaudry, 2012; Próspero, 2007; Romito, Molzan Turan, & De Marchi, 2005). Many victims experience comorbidity (20%-50%) with PTSD and MD, commonly interacting to increase symptom distress and dysfunction and causing poorer prognosis (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kilpatrick et al., 2003) with mood disorder most often being secondary to trauma and PTSD (Kessler et al., 1995). However, the different conditions might also reflect independent sequelae (Shalev & Yehuda, 1998). Although most studies have focused on women victims and the higher prevalence of PTSD, MD, and related mood and anxiety conditions among women (Kilpatrick et al., 2003; Koch & Haring, 2008), several studies have shown excess risk of psychopathology also among men (Coker, Davis, et al., 2002; Fortin et al., 2012; Próspero, 2007). Although the association between partner violence and mental health is relatively well documented, less is known about the association between different forms of violence (e.g., physical and psychological) and mental health (Hjemmen, Dalgard, & GraffIversen, 2002), with the exception of PTSD (Golding, 1999; Helzer, Robins, & McEvoy, 1987; Iverson et al., 2013). Studying non-domestic violence,


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Hjemmen et al. (2002) showed that the chances of having mental health problems as measured by Hopkins Symptom Checklist–25 (HSCL-25) increased with increasing frequency of exposure to violence and with exposure to different types of violence. Similarly, Mitchell and Hodson (1983) found that women who experienced more frequent and severe forms of violence were more likely to report symptoms of major depression and low self-esteem. Exposure to violence is also shown to be associated with exposure to nonviolence related to negative life events, which are independently related to excess PD (Hjemmen et al., 2002). In view of the increased risk of mental health problems in victims of violence, it is important to assess individual factors that might serve as protective factors. Such factors may act as either moderators that directly affect the relationship or mediators that provide alternative pathways. Sense of mastery refers to a perception of control in contrast to being fatalistically ruled, and thus, a belief that one has the ability to cause an outcome (Pearlin & Schooler, 1978, p. 5). Sense of mastery has previously been found to protect against the negative impact of other adverse life events (Dalgard, Mykletun, Rognerud, Johansen, & Zahl, 2007) and may also buffer the negative impact of violence. Thus, sense of mastery could conceivably function as a moderator in reducing or amplifying the effect of the association between violence and PD. Sense of mastery may also mediate the relationship (Calvete, Corral, & Estevez, 2008). Studies have previously shown that coping styles play an important role in the relationship between violence and PD among victims (Calvete et al., 2008; Iverson et al., 2013; Mitchell & Hodson, 1983). Canady and Babcock (2009) studied associations between domestic abuse (physical violence, psychological aggression, sexual abuse), mental health problems, and three coping strategies, namely, problem-focused engagement coping (i.e., solving both the problem and its cause), emotional-focused engagement coping (i.e., managing the emotions resulting from the violent situation), and disengagement coping (i.e., strategies such as avoidance, negotiation, distraction). Neither exposure to psychological or physical violence was associated with problem-focused engagement coping, but disengagement coping was shown to mediate the relationship between abuse and mental health (Canady & Babcock, 2009). Similar findings were also reported by Calvete et al. (2008). Furthermore, Mitchell and Hodson (1983) showed that increased exposure to violence was related to increased use of avoidance coping strategies in women, and the use of avoidance coping strategies was shown to be associated with more depressive symptoms, decreased self-esteem, and reduced sense of mastery (Mitchell & Hodson, 1983). Umberson, Anderson, Glick, and Shapiro (1998) examined the association between exposure to physical domestic violence and self-control (i.e.,


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self-perception of mastery and control). Domestic violence was shown to be associated with lower self-control (i.e., sense of mastery) among women, but not among men (Umberson et al., 1998). The authors argued that this gender difference might reflect the fact that women commonly are victims, and men perpetrators of domestic violence and abuse (Umberson et al., 1998). To our knowledge, the possible mediating role of sense of mastery on associations between different types of violence and mental health has not been examined in general population samples stratified by gender. Social support is well known to affect mental health, and several studies have examined the moderating effect of social support on mental health among victims of violence (Beeble et al., 2009). For example, Coker, Smith, et al. (2002) demonstrated that social support influences self-reported mental health among women victims. Research also shows that women victimized by partner violence, who report higher levels of social support, have lower levels of mental health problems compared with victims reporting low social support (Beeble et al., 2009; Escriba-Aguir et al., 2010; Kamimura, Parekh, & Olson, 2013; Suvak, Taft, Goodman, & Dutton, 2013). These effects may vary across gender and type of violence. For example, men and women might differ in their need for social support when facing stressors (e.g., psychological or physical abuse), or in their response to abuse (e.g., reduced feelings of selfworth, blame) affecting their social participation differently (e.g., withdrawal, avoidance). Exploring gender differences, Fortin et al. (2012) showed social support to have a moderating effect on PD in women exposed to psychological, but not to physical violence. Social support did not moderate any of the respective associations in men. The type of social support also seems to be important. In comparing four different dimensions of social support—including (a) perceived availability of material aid, (b) having someone to talk to about personal difficulties, (c) being a positive comparison when comparing oneself with others, and (d) having a sense of belonging in companionship— only the latter predicted changes in depressive symptoms (Suvak et al., 2013). Social support may also conceivably affect the association between exposure to violence and PD indirectly. Exposure to violence might lead to a decrease in social support (e.g., through greater isolation) that further leads to an increase in symptoms of anxiety and depression. This effect might reflect different scenarios, for instance, in which people disassociate themselves from victims due to fear of being themselves exposed to violence, or in which the perpetrator might isolate the victim (Beeble et al., 2009). People might also find it socially difficult to approach the victim and consider abuse to be a private matter (Beeble et al., 2009). Victims of violence also commonly experience personal shame, embarrassment, and guilt, and as a result might withdraw socially. Studies have, for example, shown that vulnerable individuals having experienced negative life events withdraw socially to protect Downloaded from jiv.sagepub.com at FLORIDA ATLANTIC UNIV on September 7, 2015

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themselves—the so-called helplessness-independence paradox (Dunbar, Ford, & Hunt, 1998; Fyrand, Moum, Finset, & Glennås, 2002). Coker, Watkins, Smith, and Brandt (2003) found that low emotional support had a mediating effect on the association between both physical and psychological violence and mental health (Coker et al., 2003). Another study found social support to have a mediating effect on the association between physical violence and well-being, but not on the association between psychological violence and well-being (Beeble et al., 2009). In addition, this latter study was longitudinal and showed that social support mediated both physical and psychological violence, meaning that victims with more social support were less exposed to both forms of violence over time (Beeble et al., 2009). Numerous studies have examined the relationship between violence and mental health problems in women, but few have examined psychological and physical violence simultaneously using a population-based sample and allowed for comparisons across gender. Therefore, based on the rationale presented above, the main objectives were (a) to explore the relationships between exposure to psychological and physical violence and PD (i.e., anxiety and depressive problems occurring separately or together) in the general population, (b) to study gender differences, (c) to examine whether sense of mastery or social support play a mediating role, and last, (d) to examine whether sense of mastery or social support moderate the relationship between violence and PD.

Method Participants and Procedure The present study is based on two waves of data from the Norwegian nationwide Health and Level of Living Survey collected in 2005 and 2012 and conducted by Statistics Norway (SN). A total of 10,000 participants above 16 years of age are invited to participate each survey year. The data collection was performed by a face to face or a telephone interview followed by a postal questionnaire. The data were linked with demographic information obtained from national population-wide registers. The postal questionnaire contained items on mental health, violence, and sense of mastery, whereas questions on social support were included in the interview. The sample used here was therefore restricted to interview respondents who returned the postal questionnaire. The sample was drawn from SN’s demography/population database (BEBAS in 2005/BEREG in 2012). In 2012, the response rate was particularly low among some subgroups leading to overrepresentation of women, individuals aged more than 45 years,


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and persons with higher education. Individuals with mental health problems tend to be underrepresented in health surveys (Knudsen, Hotopf, Skogen, Øverland, & Mykletun, 2010; Mykletun et al., 2007), and individuals exposed to severe violence might be underrepresented due to exclusion of institutionalized and hospitalized individuals in the Health and Level of Living Survey. SN has therefore developed a population weight based on national identification numbers (i.e., using information from public registers concerning the group that did not participate) that was applied in the study. The final weighted sample consisted of 19,386 participants. The participants, who were all volunteers, were informed about the intention of the study, and how the data could be used at a later stage. They all signed a consent form and could withdraw from the study at any time. Use of data for this study1 was approved by the Norwegian Social Science Data Services (NSD).

Measures Demographic Information The demographic variables gender, age, and educational level were obtained from SN’s national population registry. Educational level included three categories where low education refers to completed secondary school, medium education to completed high school, and high education to having a university degree. Age varied from 16 to 96 with the average age estimated at 46 years both for men and women (Table 1), which is slightly higher than the average age for those older than 16 in Norway (43.6 years).

Violence Two different measures of violence were included, namely, psychological and physical violence. These two variables were mainly analyzed separately. Psychological violence was measured by the question, “Have you been oppressed, debased or humiliated for a longer period of time in the past 12 months?” Exposure to physical violence was measured by the following question: “Have you been kicked, beaten or subjected to other forms of physical violence during the past 12 months?” All items were coded 0 = no, 1 = yes. The questionnaire additionally included a question concerning exposure to sexual violence, but the numbers were too low for meaningful analysis. However, as participants were asked about sexual violence separately, responses to the question concerning physical violence are not likely to reflect exposure to sexual violence. There was some missing information on


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Mental health None Anxiety alone Depression alone Comorbid anxiety and depression Psychological violence Yes No Physical violence Yes No Year 2005 2012 Age (M) Sense of mastery (Scale 0-20) M (SE) Social support (Scale 3-14) M (SE)

Variables 88.9 1.9 4.5 4.7 3.8 96.2 2.3 97.7 45.6 54.4 46 14.05 (0.04) 11.23 (0.02)

364 9,281 222 9,425 4,923 5,866 10,789 10,789 10,789

Prevalence

9,588 210 483 508

Weighted n

Men

Table 1. Prevalence of Weighted Data for Variables Included in Study.

4,751 5,490 10,242 10,242 10,242

147 9,100

495 8,733

8,626 258 643 714

Weighted n

46.4 53.6 46 14.03 (0.04) 11.37 (0.02)

1.6 98.4

5.4 94.6

84.2 2.5 6.3 7.0

Prevalence

Women

9,674 11,357 21,031 21,031 21,031

368 18,525

859 18,014

18,214 468 1,127 1,223

Weighted n

46.0 54.0 46 14.04 (0.03) 11.30 (0.02)

1.9 98.1

4.6 95.4

86.6 2.2 5.4 5.8

Prevalence

Total

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exposure to violence (528). Missing values on exposure to violence were associated with low education, being a woman, and higher age. There were also more missing responses in the second survey (2012). However, there was no association observed between missing responses and PD (see Table 2). Responses on the two violence questions were combined into a new variable with four response categories, reflecting 0 = no exposure to violence, 1 = exposure to psychological violence, 2 = exposure to physical violence, and finally 3 = exposure to both psychological and physical violence.

PD: Anxiety and Depressive Symptoms PD (anxiety and depression) was measured by the HSCL-25 (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). This scale consists of altogether 25 items, including 10 questions on symptoms of anxiety and 15 questions on symptoms of depression during the last 14 days (Derogatis et al., 1974; Winokur, Winokur, Rickels, & Cox, 1984). The symptoms are scored on a Likert-type scale from 1 (not bothered) to 4 (extremely bothered), and a mean score of all questions is calculated. In the present sample, Cronbach’s alpha was estimated to be .85 for the anxiety subscale (HSCL-a) and .91 for the depression subscale (HSCL-d). According to convention, a mean score equal to or greater than 1.75 is defined as a case (indicates having high/clinical levels of symptoms; Sandanger et al., 1998). For both subscales (i.e., HSCL-a and HSCL-d), we used this standard cut-off value to select cases with high symptom levels (Winokur et al., 1984). As anxiety and depression tend to cooccur (Pollack, 2004), we combined the scores into four categories, reflecting 0 = no symptoms of anxiety or depression, 1 = only anxiety symptoms (>1.75), 2 = only depressive symptoms (>1.75), and finally 3 = comorbid anxiety and depressive symptoms (both subscales >1.75).

Sense of Mastery Sense of mastery was assessed by a five-item version of the seven-item scale developed by Pearlin, Menaghan, Lieberman, and Mullan (1981). Cronbach’s alpha was estimated to .84, and an exploratory factor analysis showed loadings ranging between .75 and .83 in this sample. A confirmatory one-factor analysis using AMOS (version 22.0) with data from 35,000 individuals participating in the Health and Level of Living Survey (1998-2012) fitted the data well (comparative fit index [CFI] = 0.98, root mean square error of approximation [RMSEA] = 0.06) with loadings ranging from 0.68 to 0.80. The scale consisted of the following statements: “I have little control over


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89.6 2.0 4.5 4.0 14.23 (0.04) 11.30 (0.02)

84.9 2.7 6.2 6.2 14.24 (0.04) 11.41 (0.02)

87.3 2.3 5.3 5.0 14.24 (0.03) 11.35 (0.02)

7,348 230 540 536 8,653 8,653

15,521 414 949 896 17,780 17,780

%

8,173 184 409 361 9,127 9,127

Weighted n

318 26 145 230 718 718

205 8 78 138 429 429

113 18 66 93 289 289

44.2 3.6 20.1 32.0 10.49 (0.15) 10.54 (0.10)

47.8 1.9 18.2 32.0 10.84 (0.20) 10.82 (0.12)

38.9 6.2 22.9 32.0 9.97 (0.24) 10.13 (0.17)

%

Psychological Weighted n

Note. Case defined as values >1.75. aSense of mastery and social support are presented as mean (SE).

Men No Anxiety Depression Comorbid problems Sense of masterya Low social support a Women No Anxiety Depression Comorbid problems Sense of masterya Social supporta Total No Anxiety Depression Comorbid problems Sense of masterya Social supporta

Psychological Distress/ Mediator Variables

None

184 12 9 13 218 218

56 9 6 1 72 72

128 3 3 11 146 146

Weighted n %

84.3 5.5 4.3 5.9 13.48 (0.27) 10.80 (0.19)

77.3 12.4 8.2 2.1 13.91 (0.53) 10.50 (0.43)

87.8 2.1 2.3 7.8 13.26 (0.31) 10.94 (0.20)

Physical

51 11 14 66 141 141

26 6 9 24 65 65

25 4 4 42 75 75

Weighted n %

36.1 7.5 9.6 46.8 10.36 (0.42) 10.77 (0.18)

39.1 9.4 14.5 37.0 10.71 (0.63) 10.49 (0.30)

33.5 5.9 5.4 55.2 10.07 (0.58) 11.01 (0.40)

Both

495 5 11 17 139 126

287 5 10 15 83 41

208 0 1 2 55 86

Weighted n

Missing

93.7 1.0 2.1 3.3 30.8 6.3

90.5 1.7 3.1 4.7 31.0 4.4

98.4 0.0 0.5 1.1 30.6 8.1

%

Table 2. Prevalence of Anxiety Symptoms, Depressive Symptoms, or Comorbid Symptoms for Individuals Exposed to No Violence, Psychological Violence, Physical Violence, or Both Psychological and Physical Violence.

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things that happen to me,” “There is really no way I can solve some of the problems I have,” “There is little I can do to change many of the important things in my life,” “I often feel helpless in dealing with the problems of life,” and “Sometimes I feel that I am being pushed around in life.” Responses are given on a 5-point Likert-type scale (1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, 5 = strongly disagree). The answers were initially summed (ranging from 5 to 25) and then recoded to 0 to 20. The variable was treated as a continuous variable.

Social Support Social support was measured using the Oslo 3 Support Scale (OSS-3 scale; Dalgard et al., 2006). This scale is comprised of three questions covering different aspects of social support related to number of close confidants, sense of concern or interest from other people, and relationships to neighbors: “How many people are so close to you that you can count on them if you have serious problems?” Corresponding scores were 1 = no one, 2 = 1 or 2, 3 = 3 to 5, or 4 = more than 5. “How much concern do people show in what you are doing?” Corresponding scores were 1 = great concern and interest, 2 = some concern and interest, 3 = slight concern and interest, 4 = no concern and interest, and 5 = uncertain. “How easily can you get practical help from neighbors if you should need it?” Corresponding scores were 1 = very easy, 2 = easy, 3 = possible, 4 = difficult, and 5 = very difficult. The corresponding scores on the two last questions were recoded in reverse order. Responses to these questions were summarized to an index with values from 3 to 14. The variable was used as a continuous variable in the analyses.

Data Analyses The analyses were performed by means of the Statistical Package for the Social Sciences (SPSS for Windows, version 22.0). Preliminary statistical analyses including descriptive analyses and Spearman’s correlations were performed for the variables anxiety, depression, psychological violence, physical violence, social support, and sense of mastery (results not shown). To test the inter-correlations among the predicting variables, multicollinearity tests were conducted. Tolerance and Value Inflated Factors (VIF) showed no violation of the multicollinearity assumptions (tolerance > 0.1; VIF < 10). Model fit was evaluated by R2s, which were significant for all outcome variables. Hierarchical multiple logistic regression models were then conducted to test associations between the two exposure variables (i.e., psychological and


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physical violence) and the three outcome variables (i.e., anxiety, depression, comorbid anxiety/depression). The data were weighted to account for nonrespondents by adjusting for gender, age, education, and family size. As weights were applied, the analyses were performed with the complex sample option in SPSS that adjusts the standard errors for the modified sample size (Osborne, 2011). Possible effects of gender and education on the association between the two types of violence and the three outcome indicators were checked by including interaction terms (i.e., Gender × Violence; Education × Violence) in the analyses. There were significant differences across gender for psychological violence, but not for physical violence. No differences were indicated for educational level. Consequently, we stratified the data by gender, but not by education in the subsequent analyses. The respondents’ age and the year of data collection (i.e., 2005 and 2012) were adjusted for in the first step (Block 1) in the hierarchical regression analyses. The two violence variables were then added independently in the second step (Block 2). In the third step, sense of mastery and social support were added independently as continuous variables. This resulted in four regressions for each gender for each of the three PD parameters. Effect sizes are given as odds ratios (ORs) with 95% confidence interval (CIs). Mediation was determined by examining significant changes in the relationship between the dependent and predicting variable before and after the inclusion of the proposed mediator (e.g., sense of mastery). The mediating role of sense of mastery and social support was examined by entering both mediators simultaneously using the PROCESS module in SPSS in Model 4. Mediation was tested for significance for the total pathway, and for the indirect pathway using the bootstrap method and finally the Sobel test—all provided in the PROCESS module. To investigate a possible moderating role of sense of mastery and social support on the relationship between violence and PD, the PROCESS module for SPSS provided by Hayes (Model 1) was applied (Hayes, 2013).

Results Descriptives Table 1 gives the descriptive statistics and prevalence estimates obtained from the weighted sample. Of the sample, 4.6% reported exposure to psychological violence (3.8% of men and 5.4% of women) during the last 12 months, whereas 1.9% reported physical violence (2.3% of men and 1.6% of women; Table 1). Closer examination revealed that 3.8% reported only psychological


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violence, 1.2% reported exposure only to physical violence, and 0.7% reported exposure to both types of violence. These values were different in men (3.0%, 1.5%, and 0.8% respectively) and women (4.7%, 0.8%, and 0.7%, respectively; data not shown). The prevalence of high levels of anxiety symptoms were 2.2% (men: 1.9%; women: 2.5%) whereas the respective estimates for depressive and comorbid symptoms were 5.4% (men: 4.5%; women: 6.3%) and 5.8% (men: 4.7%; women: 7.0%), respectively. All prevalence estimates were higher in women than men. Mean levels of sense of mastery and social support were similar between the genders. Of those reporting exposure to psychological violence, a greater proportion of men than women reported high levels of anxiety (6.2% vs. 1.9%) and depressive symptoms (22.9% vs. 18.2%), while the prevalence of comorbid problems were identical in both genders (32.0%; Table 2). Of those reporting exposure to physical violence, a greater proportion of women than men reported high levels of anxiety symptoms (12.4% vs. 2.1%) and depressive symptoms (8.2% vs. 2.3%), while the prevalence of comorbid problems were higher in men than in women (7.8% vs. 2.1%). Overall, comorbid anxiety and depressive problems were more common than anxiety or depressive problems occurring separately. Altogether, 32.0% of those reporting exposure to only psychological violence reported comorbid problems (i.e., scoring above the cut point on both subscales), whereas 46.8% of those reporting both physical and psychological violence reported comorbid problems (higher in men than in women) as opposed to 5.0% of those reporting no violence exposure. Among respondents reporting only physical violence, the respective estimate was 5.9%. Individuals exposed to psychological violence separately or in combination with physical violence were associated with 26% to 27% lower sense of mastery and 5% to 9% lower social support. Exposure to physical violence was associated with 5% lower sense of mastery and 8% lower social support (Table 2).

Regression Analyses Both forms of violence (psychological and physical) were significantly associated with PD in terms of comorbid problems (Table 3). Men had higher odds of reporting comorbid problems than women when exposed to psychological (23.6 as opposed to 9.2) or physical violence (6.5 as opposed to 3.7). Exposure to psychological violence was significantly associated with anxiety and depressive problems (occurring independently) among men, but only with depressive problems among women. Women exposed to physical violence had significantly higher odds of reporting anxiety symptoms than men


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Men 1.92 [0.62, 5.96]ns 1.75 [0.55, 5.58]ns SM*** 2.22 [0.61, 8.12]ns SSns 1.00 [0.30, 3.40]ns 0.87 [0.26, 2.97]ns SM*** 0.12 [0.08, 4.65]ns SS*** 6.45 [3.37, 12.35]*** 4.08 [2.02, 8.26]*** SM*** 5.27 [2.32, 11.99]*** SS**

4.98 [3.34, 7.44]*** 2.58 [1.61, 4.14]*** SM*** 4.68 [2.83, 7.75]*** SS*** 9.19 [6.42, 13.15]*** 5.08 [3.21, 8.03]*** SM*** 9.03 [5.96, 14.54]*** SS***

Men

1.82 [0.80, 4.13]ns 1.22 [0.49, 3.03]ns SM*** 1.58 [0.50, 4.63]ns SSns

Women

Women

3.68 [1.78, 7.60]*** 2.18 [0.72, 6.62]ns SM*** 3.07 [0.89, 10.63]ns SS***

2.17 [0.96, 4.86]ns 1.22 [0.41, 3.61]ns SM*** 0.86 [0.16, 4.79]ns SS***

5.11 [2.26, 11.58]*** 4.03 [1.45, 11.18]** SM*** 3.54 [1.12, 11.24]* SSns

Physical Violence

Note. Age and year were controlled for in all blocks. SM and SS were added in Block 2 separately and independently. All data were weighted, and the analyses were performed using the module complex samples. SM = sense of mastery; SS = social support; OR = odds ratio; CI = confidence interval; ns = non-significant. *p < .05. **p < .01. ***p < .001.

Anxiety symptoms Block 1 7.73 [3.85, 15.50]*** Block 2 SM 5.96 [2.72, 13.03]*** SM*** Block 2 SS 8.66 [3.80, 19.75]*** SSns Depressive symptoms Block 1 11.68 [7.02, 19.42]*** Block 2 SM 6.85 [3.65, 12.85]*** SM*** Block 2 SS 6.93 [3.66, 13.13]*** SS** Comorbid anxiety and depressive symptoms Block 1 23.64 [15.05, 37.14]*** Block 2 SM 11.42 [6.53, 19.97]*** SM*** Block 2 SS 18.38 [10.40, 32.51]*** SS*

Psychological Violence

Table 3. Results of the Hierarchal Logistic Regression Analyses Showing the OR (95% CI)—Between Exposure to Violence (Psychological and Physical) and Anxiety and Depression Among Men and Women, Before and After Inclusion of SM and SS. N = 10,688.

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Figure 1. Role and effect size of sense of mastery and social support as mediators between exposure to psychological and physical violence and concurrent symptoms of anxiety and depression (CAD), in men and women. Note. CAD = comorbid anxiety and depressive symptoms; ns = non-significant. *p < .05. **p < .01. ***p < .001.

(5.1 as opposed to 1.9). However, for both men and women, the estimated ORs for all outcome variables were stronger for psychological than physical violence exposure with one exception (physical violence and anxiety symptoms in women). Both sense of mastery and social support significantly mediated the relationship between exposure to psychological violence and comorbid symptoms of PD for women (Figure 1) whereas only sense of mastery was a significant mediator in men. With respect to the association between physical violence and comorbid symptoms, sense of mastery partly mediated the association for men but not women. Social support did not serve as a mediator for either men or women exposed to physical violence. The results indicated a larger difference in observed ORs when sense of mastery was entered in the hierarchal regression of psychological violence than physical violence for both men and women (Table 3). Neither sense of mastery nor social support showed significant moderating effects on the measured relationships (data not shown). There were very


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modest changes in ORs between either form of violence and any form of psychological distress.

Discussion Exposure to psychological violence was reported more often among women than men, and our prevalence estimates (i.e., 5.4% for women and 3.8% for men) are consistent with results from the British Crime Survey (Walby et al., 2004). Altogether, 2.3% of men and 1.6% women reported exposure to physical violence. For men, this estimate is nearly identical to the prevalence reported in the above mentioned U.K. survey, whereas the respective estimate for women is lower than in the British sample (3.4%). Our prevalence estimates of physical violence are lower than those reported for Norway by the OECD, however, and the mean prevalence for OECD countries is twice as high as the prevalence estimated in the present study (OECD, 2013). We found that in women, exposure to psychological violence was significantly associated with PD in terms of high levels of depressive symptoms, occurring independently as well as in combination with anxiety symptoms. Exposure to physical violence, in contrast, was significantly associated with anxiety symptoms and comorbid symptoms. By contrast, for men, exposure to psychological violence was significantly associated with all three outcome measures, whereas exposure to physical violence was significantly associated with comorbid problems only. These findings are consistent with findings reported for women exposed to intimate partner violence exploring either psychological (Beeble et al., 2009; Coker, Davis, et al., 2002; EscribaAguir et al., 2010; Golding, 1999; Próspero, 2007; Romito et al., 2005) or physical violence (Beeble et al., 2009; Coker, Davis, et al., 2002; EscribaAguir et al., 2010; Fortin et al., 2012; Próspero, 2007; Romito et al., 2005). The results are also in line with previous research for men (Coker, Davis, et al., 2002; Fortin et al., 2012; Próspero, 2007), along with other types of violence such as criminal assault (Norris & Kaniasty, 1994). Of note, we find that for men and women alike, the associations between psychological violence and PD are considerably greater than those between physical violence and psychological distress, with these differences being more pronounced for men. The estimates for men are based on a very small number of individuals, however. Unlike our findings, neither Próspero (2007) nor Coker, Davis, et al. (2002) reported considerable gender differences in associations between exposure to psychological violence and psychological distress. The finding that PD is more closely associated with psychological violence than physical violence observed in our study may partly reflect that the item used to measure psychological violence queries about long-term exposure whereas the item measuring physical violence does not refer to any particular time frame. Downloaded from jiv.sagepub.com at FLORIDA ATLANTIC UNIV on September 7, 2015

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Regarding differences between the outcome measures, we found that the observed ORs were greater for depressive and comorbid symptoms (e.g., sadness, worry), than for anxiety symptoms (e.g., fear) among respondents reporting psychological violence. By contrast, the ORs were greater for anxiety symptoms among respondents reporting physical violence. For women, these OR values were higher for anxiety symptoms occurring separately than for comorbid symptoms. Our results are supported by Próspero (2007) who showed increased symptoms of both anxiety and depression in women exposed to physical and psychological violence. The same was indicated for men, except that physical violence seemed to affect only depressive symptoms (Próspero, 2007). Interestingly, our results indicate that sense of mastery partly mediates the association between violence and psychological distress. Umberson et al. (1998) studied effects of domestic violence on perceived personal control, which is considerably related to our measure of mastery (Umberson et al., 1998) and finding that domestic violence led to reduced perception of personal control among women. The gender difference in perceived control was explained by a difference in the roles often found between men and women, where men more often are perpetrators and women victims (Odgers & Moretti, 2002). The present study did not measure domestic violence specifically, but shows that victimized men also report low sense of mastery. Of note, sense of mastery was not shown to moderate the measured associations. Previous studies suggest that the relationship between sense of mastery/control and PD might be bidirectional. Exposure to violence might lead to low sense of mastery (directly or indirectly) causing PD, and PD might reduce the level of perceived control (Calvete et al., 2008; Umberson et al., 1998). It is also conceivable that individuals with high levels of PD are more exposed to violence in part due to low sense of mastery. Our study is cross-sectional and does not provide information on causal mechanisms. Social support was not found to serve as a mediator or a moderator of the relationship between psychological violence and comorbid symptoms for men, but shown to constitute a partial mediator in women. When examining physical violence, social support neither mediated the association for men or women. Several previous studies have looked into the mediating effects of social support on the association between partner violence (both psychological and physical) and PD among women (Coker, Smith, et al., 2002; EscribaAguir et al., 2010; Kamimura et al., 2013; Suvak et al., 2013). Two previous studies also examined which specific characteristic of social support accounted for the effect. Escriba-Aguir et al. (2010) reported the size of the social network (i.e., more than four people) to be important, while Suvak et al. (2013) found that only perceived availability of people to do things


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with, mattered. Using a longitudinal design and following 160 women violence survivors, Beeble et al. (2009) found that social support played a complex role for women’s well-being, evidencing main, mediating, and moderating effects. Fortin et al. (2012) studied similar associations in both genders, and in line with our findings, social support seemed to mediate mental health problems in women, but not in men subjected to psychological violence. Also, in accordance with our findings, Fortin and colleagues did not evidence any moderating effect of social support. Differences between men and women may be related to a greater tendency among women to withdraw socially to protect themselves (Dunbar et al., 1998; Fyrand et al., 2002) or others (e.g., their children), and that women tend to blame themselves to a larger extent than men (Else-Quest, Higgins, Allison, & Morton, 2012). Embarrassment, stigma, and depression resulting from abuse might also lower their willingness or ability to seek or receive support.

Strengths and Limitations Our study sample is relatively large and representative of the various social strata as well as the different geographic areas within Norway. The use of standard, well-validated survey instruments such as HSCL-25 is also considered an advantage, and the availability of objective information from national registries on non-respondents enabled use of a non-response weight, which is considered unique. Several potential limitations need to be pointed out. The response rate is not optimal, and women, individuals aged 45 and older, and respondents with higher education were overrepresented in both survey years, whereas nonWestern immigrants were underrepresented. According to Dalgard et al. (2006) and Syed et al. (2006), non-Western immigrants commonly have higher prevalence of mental health problems compared with the non-immigrant population. Individuals with mental health problems likewise tend to be underrepresented in health surveys (Knudsen et al., 2010; Mykletun et al., 2007), and individuals exposed to severe violence might be underrepresented due to exclusion of institutionalized and hospitalized individuals in the Health and Level of Living Survey. Although the weighting of the data should at least partially control for these selection effects, the prevalence estimates reported in this article are quite likely to be conservative. PD and exposure to violence were based on self-report and thus not clinically diagnosed. Although the reliability may be limited due to the subjectivity of the responses, it is worth noting that a lower score might occur in face-to-face interviews due to a social desirability bias (King & Bruner, 2000). Of note, a significant hindrance to collecting self-report measures of


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violence is that the victims and perpetrators commonly are living together. Consequently, victims might be fearful of acknowledging victimization in writing. Our prevalence estimates of violence exposure might thus also be rather conservative. Another potential limitation concerns our measure of anxiety and depressive problems not reflecting formal Diagnostic and Statistical Manual of Mental Disorders (DSM) anxiety and mood disorders, including PTSD. A previous Finnish study has shown the specificity and sensitivity of the HSCL25 for any present DSM (3rd ed., text rev.; DSM-III-TR; American Psychiatric Association, 1987) psychiatric disorder to be 48% and 87%, respectively, and the positive and negative predictive power to be 34% and 92% (Veijola et al., 2003). There is considerable overlap between anxiety and depressive symptoms and PTSD, which is common among victims of violence and classified as an anxiety disorder in the DSM (4th ed.; DSM-IV; American Psychiatric Association, 1994) and as a stress disorder in the International Classification of Diseases - revision 10 (ICD-10) and DSM-IV. PTSD and other anxiety and mood disorders also share important risk factors (e.g., neuroticism; Kotov, Gamez, Schmidt, & Watson, 2010). Unfortunately, our data did not include PTSD, or more specific PTSD symptoms. Consequently, we were only able to examine elevated levels of anxiety and depressive symptoms more generally. However, despite our data not including any PTSD measure and the HSCL-25 not constituting an ideal indicator of formal psychiatric disorder, high levels of anxiety and depressive symptoms represent significant risk factors for subsequent major depression, and are considered important targets for prevention as well as intervention in their own right (Kessler, Davis, & Kendler, 1997). Of note, some individuals presenting with high scores on the HSCL-25 might fulfill criteria for a current PTSD disorder. Last, our study is cross-sectional, which impedes any conclusion on causal effects. More longitudinal research is needed to fully understand the causal effects, and the roles played by social support and sense of mastery over time.

Concluding Remarks Using a general population sample and linking self-report information to data from national registries, the present study shows that both psychological and physical violence are closely associated with anxiety and depressive problems in women and men alike. Altogether, 32% of women and men exposed to psychological violence reported comorbid problems above the clinical cut point. The risk estimates for developing PD in terms of comorbid anxiety and depressive problems were systematically substantial (Crude OR: 9-24) for victims of psychological violence and high also for those reporting physical


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violence (Crude OR: 4-6). The association between violence exposure and PD was partly mediated by sense of mastery (men and women) and social support (women only). Thus, exposure to violence causes heightened levels of PD in terms of anxiety and depressive problems. Psychological violence seems to erode women’s sense of mastery and social support system, while both physical and psychological violence appear to erode sense of mastery among men. The results thus corroborate the large scientific literature showing that exposure to violence often leads to severe negative health consequences with potentially long-term implications for the victims, their families, and the society at large and show that these associations partly reflect compromised social support systems and sense of mastery. The results underscore that interventions targeting and strengthening coping and mastery as well as the support systems of violence victims might constitute important preventive tools. Preventive measures probably need to be taken by multiple agents, including health workers, legal authorities, police, and other support systems. However, further knowledge is needed concerning who is likely to benefit the most from what particular interventions and at what stages. A recent qualitative study found that abused women were in need of practical support during the abusive situation, but primarily in need of psychological help and support afterward (Prosman, Lo Fo Wong, & Lagro-Janssen, 2014). Considering the complexity of abusive contexts, types of violence, and individual reactions, the care and support services for victims of violence should be multidisciplinary, coordinated, and able to provide varied types of support to the individual. Acknowledgments We would like to thank the institute and the department for providing us with access to data, workspace, and support. We are grateful to Rune Johansen and Leif Edvard Aarø at Norwegian Institute of Public Health for important guidance concerning the statistical analyses. In addition, we would like to thank Statistics Norway (SN) and Norwegian Social Science Data Services AS (NSD) for collection and distribution of data.

Authors’ Note This study was performed in collaboration with the Norwegian Institute of Public Health, Division of Mental Health.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


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Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note 1.

Data that is used in this study are part of SN’s Health and Level of Living Survey 2005—Cross Section Theme: Health and Level of Living Survey health, care and social contact 2012. Data are distributed and made available in anonymous form by Norwegian Social Science Data Services AS (NSD). Neither SN nor NSD are responsible for the analysis or the data interpretation presented in this study.

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Author Biographies Vedrana Bebanic is a physiotherapist and Health, Safety and Environment advisor with a BSc degree in physical therapy, Oslo University Collage, and an MSc degree in public health, Norwegian University of Life Science. Her main research interest is in mental health and violence. Jocelyne Clench-Aas, PhD, is a senior scientist at the Norwegian Institute of Public Health, specializing in epidemiology and mental health. Her principal research activities include investigation of factors that influence both life satisfaction and psychological distress in the general population. Ruth Kjærsti Raanaas, PhD, works as associate professor in public health science at the Norwegian University of Life Sciences. Her research focuses on health promotion and illness prevention, and particularly on factors that promote health and well-being and prevent development of mental health problems in the general population, such as social and environmental factors, social participation, and mastery. Ragnhild Bang Nes, PhD and psychologist, works at The Norwegian Institute of Public Health and as associate professor at the University of Oslo. Her main research agenda focuses on stability and change in mental health and well-being using longitudinal twin and family data and large prospective cohort data. Her teaching agenda includes behavior genetics, psychopathology, well-being, and personality.


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