ISSN electrónico 2011-7485 ISSN impreso 0123-417X vol. 29 n.° 2, mayo-agosto de 2012 Fecha de recepción: 29 de febrero de 2012 Fecha de aceptación: 11 de julio de 2012

ARTÍCULO DE INVESTIGACIÓN / RESEARCH ARTICLE

Post traumatic stress disorder and adaptive capacity in victims of intimate partner violence

Estrés postraumático y capacidad de adaptación en víctimas de violencia de pareja

José Juan Amar Amar *
Luz Elena Ocampo Otálvaro **

* Psicólogo, sociólogo e historiador. Ph.D con grado de mayor en psicología social de Columbia Pacific University. Doctor of Philosophy in Counseling Psychology de Newport University. Investigador del grupo de investigación en Desarrollo Humano (GIDHUM) . Decano de la División de Ciencias Sociales y Humanidades de la Universidad del Norte. jamar@uninorte.edu.co

** Universidad Pontificia Bolivariana - Medellín. luzeleoc@yahoo.es

Correspondencia: José Juan Amar Amar. Universidad del Norte, División de Humanidades y Ciencias Sociales. Barranquilla (Colombia). A.A. 1569. jamar@uninorte.edu.co

Keywords: pendiente

El objetivo de este artículo fue identificar la relación existente entre estrés postraumático y la capacidad de adaptación en un grupo de víctimas de violencia por parte de la pareja residentes en la ciudad de Medellín (Colombia). La muestra estuvo conformada por 26 personas de ambos sexos, seleccionadas en diferentes centros de atención clínica. Los instrumentos utilizados fueron la Escala de Gravedad de Síntomas de Estrés Postraumático y la Escala de Inadaptación. Para el análisis de los datos se utilizaron los estadísticos descriptivos y el Coeficiente de Correlación de Pearson. Los resultados refuerzan la iniciativa de considerar el TEPT como una categoría diagnóstica inequívocamente asociado a la violencia de pareja; 84.2% de la muestra reportó sintomatología de estrés postraumático, y sobresalieron las manifestaciones de evitación e hiperactivación y la presencia de manifestaciones somáticas. Los niveles de inadaptación fueron elevados promedios de 93.2%; las áreas con peor capacidad de adaptación fueron la vida de pareja y familiar, mientras que el nivel de inadaptación mostró asociaciones significativas con el estrés postraumático global y la hiperactivación (p< 0.01). En general, los participantes reflejaron aflicción emocional en sus respuestas, caracterizada por la presencia de ansiedad somática, un miedo intenso de volver a experimentar las situaciones de abuso y una respuesta notable de aumento de la excitación.

Palabras clave: Estrés postraumático, inadaptación, violencia de pareja, estudio ex post facto.

Intimate partner violence is a phenomenon that has always been present, regardless of how much effort public and private agencies have made to prevent and treat the problem. The elevated costs generated by domestic violence are highly visible, for the victims and their perpetrators, threatening social, family and personal stability, among others. The costs are not only physical, financial and social but also psychological; there are so many other consequences caused by the abuse. One of the most chronic effects caused by abuse from a psychological perspective is the development of Post Traumatic Stress Disorder ( PTSD), area covered by this study. The study will emphasize the relationship between this disorder and the individual's adaptive capacity in a group of victims of intimate partner violence residing in Medellin (Colombia), the measure of the PTSD symptomatology will allow to identify a significantly number of individuals who reported this type of behavioral manifestations.

The high prevalence and nocivity of this problem have led researchers to consider intimate partner violence as a public health issue (Ulla, Velázquez, Notario, Solera, Valero, & Olivares, 2009; Buvinic, Morrison, & Shifter, 2002) therefore, the World Health Organization (2003) through its official bulletin, has dedicated special attention to this problem, they have published several studies and data regarding this phenomenon (Vos, Astubury, Piers, Magnus, Hennan, Stanley, Walker, & Wesbster, 2006; García-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). Likewise, the American Psychological Association through their Psychology of Women Quarterly, often publish articles related to Intimate Partner Violence (Graves, Sechrist, White, & Paradise, 2005; McHugh, Livingston, & Ford, 2005; Sorenson & Taylor, 2005; American Psychological Association [APA ], 2002).

Most of the intimate partner violence research has indicated women as the main victims. It has been reported that 75% of domestic violence cases are related to abuse against women, whereas only 2% of cases are related to abuse against men, and 23% of domestic violence cases are bilateral (Corsi, 1994). In addition, most of the reports indicate that men are the main aggressors (Arcos, Molina, Repossi, Uarac, Ritter, & Arias, 1999) and the episodes where men are the victims are characterized by a pattern of hostile actions that differ from those performed by men who tend to express more physical aggression, while women, on the other hand, exhibit stubbornness, demand very stereotyped masculine responses from men, present financial demands, complain about the work situation, may purposely get pregnant against their partner's will or refuse to sign the divorce papers (Trujano, 2001; Trujano, Martínez, & Benítez, 2002). Despite these reports, the studies on domestic violence against men are very limited and even more when referring to identifying the detrimental psychological manifestations such as PTSD.

Other studies (Calvete, Estévez, & Corral, 2007; Martin, Taft, & Resick, 2007; Coker, Weston, Creson, Justice, & Blakeney, 2005; Echeburúa, Fernández-Montalvo, & De Corral, 1998; Echeburúa, De Corral & Amor, 2002) have dedicated their efforts to evaluate how domestic violence accounts for the development of symptoms of chronic anxiety as described in the Diagnostic and Statistical Manual of Mental Disorders [DSM-IV- TR ] (American Psychiatric Association, 2000) under the PTSD category.

Apparently, violent situations experienced during a relationship with a partner, generate some difficulties in the individual, this can affect his/ her possibility to psychosocially adapt to the diverse areas where he/ she interacts with the milieu, in this way, victimization due to domestic violence detriments the overall performance and functionality of the individual, specifically employment, family, and academic performance as well as his/her performance with a partner, among others. The level of impairment is higher when the episodes of victimization are more intense. Labrador, Fernández-Velasco, and Rincón (2010), reported significant levels of PTSD among women abused by their partner (37.2%) co-occurring with depressive symptoms, which decrease the overall level of psychosocial performance in an individual.

According to Labrador, et al. (2010) victims exhibit a tendency to experience a loss of interest for meaningful activities, most likely the activities they used to share or enjoy are not longer enjoyable, consequently, they become isolated and irritable among other behaviors that prevent them from interacting and accessing social support. Moreover, studies indicate that victims of domestic violence lack a wide social support network (Matud, Aguilera, Marrero, Moraza, & Carballeira, 2003) which increases the adverse effects of violence.

Domínguez, García, and Cuberos (2008) identified some results that reinforce the previous statement. According to these authors, social support has a buffering effect against the different episodes and types of abuse experienced by the victim, while previous experiences of abuse on the other hand, seem to significantly increase PTSD levels in victims. Furthermore, the results indicated negative consequences on couples' relationships, social life and leisure time.

Similarly, Calvete, Estévez, and Corral (2007) in their study about PTSD and negative cognitive schemes in women, identified that 67.54% of the sample met PTSD diagnostic criteria, along with high scores on mental schemes related to abuse, vulnerability, guilt, dependency, imperfection, abandonment and detachment.

Arroyo (2002) suggests including this disorder as a criteria to recognize battered women. Although the DSM-IV-TR (2000) text revision does not specify domestic violence as one of the causing factors, it is possible to consider this clinical course as a unique manifestation of individuals who have been victimized by domestic violence if we take into consideration the high prevalence of reported symptoms by studies related to this phenomenon worldwide.

Amor, Echeburúa, De Corral, Zubizarreta, and Sarasua (2002) found that chronic psychopathology is related with certain abuse situations such as living with the perpetrator, repeated exposure to episodes of violence, duration and severity of the abuse, past child abuse and forced sexual intercourse.

Moreover, Amor et al. (2002) agreed with the empirical evidence supporting family and social support as protective factors with moderating effects against chronic psychopathology caused by abuse.

Other studies have reported a significant relationship between domestic violence and PTSD along with other manifestations of decreased physical and mental health functioning in victims. Paz, Labrador, Arinero, and Crespo (2004) noted significant PTSD and depression comorbidity in their sample, as well as an important interaction with concomitant variables such as poor self esteem; these authors focused on overall maladjustment caused by domestic abuse conditions among victimized individuals. It seems that individuals with this type of difficulties exhibited high levels of negative factors associated with a low possibility of personal and social adjustment in relation to physical and mental health.

Plazaola-Castaño, and Ruiz-Pérez (2004) pointed out that available research on domestic violence addresses the presence of some other alterations associated with physical health such as fibromyalgia, gastrointestinal disorders and gynecological problems, which are more frequent among individuals who experienced abuse than those who never did and the most affected psychological aspects were characterized by a high prevalence of PTSD, depression and anxiety.

In reference to the statement mentioned above, Pico-Alfonso, García-Linares, Celda-Navarro, Blasco-Ros, Echeburúa, and Martínez (2006) found that women who had been exposed to intimate partner violence had a higher prevalence of chronic depressive symptoms and chronic anxiety, as well as PTSD and suicidal ideation compared to women who had never experienced domestic violence. In addition, it seems that the possibility of psychosocial adaptation is lower when the episodes of violence are extremely severe, since victims of domestic violence report constantly fearing for their own lives, experiencing a greater sense of vulnerability and personal and financial dependency (Echeburúa, Fernández-Montalvo, & De Corral, 2008).

Considering this outlook, it is pivotal to evaluate and work with intimate partner violence victims, since findings previously mentioned in the literature reinforce the hypothesis on how domestic violence severely affects victims, which also translates into a high prevalence of PTSD and adjustment disorders in the different surroundings where human beings interact. For this reason the purpose of this study is to describe the existing relationship between PTSD and Maladjustment in a group of victims of intimate partner violence in Medellín (Colombia).

The sample for the study was selected through a non-random sampling process and consisted of a group of victims of intimate partner violence. The participants were attending different community health clinics and family centers in Medellin (Colombia) and willingly decided to participate in this study and signed an informed consent.

The total sample consisted of 26 participants, 2 males (7.7%) and 24 females (92.3%), the average age for the sample ( Mage = 35.5 years, SD = 8.66), age range: 19-50 years. The participants reported average time of cohabitation with their partners in years was (M=10.92, SD = 5.88). It was found that 88.46% of the participants had children, compared to 11.54% with no children. In addition, the participants who were parents, they reported to have an average of 2.23 children. The average education level of the sample (M = 10.50, SD = 4.54), while the income level was quite low considering that 73.08% of the sample indicated no income, 3.84% of the sample received less than minimum wage, 15.38% of the sample received between one and two minimum wage salaries per month, and a lower percentage of the sample (7.69%) received between three and four minimum wage salaries per month.

In regards to participants' previous history of abuse, it was identified that 53.85% of the sample had a past history of abuse in their families of origin by a family member.

PTSD manifestations were assessed through the administration of the Post Traumatic Stress Disorder Symptom Severity Scale (Echeburúa, De Corral, Amor, Zubizarreta, & Sarasua, 1997). This assessment tool is a 17 item questionnaire, related to the DSM-IV-TR (2000) text revision criteria for this disorder. The answer sheet utilized a Likert-type scale with a possible scoring ranging from 0 to 3, depending on frequency and severity of symptoms. The assessment tool consists of three subscales, these subscales measure specific categories of PTSD, including, Reexperiencing of the traumatic event, with five items (ranging from 0 to 15); Avoidance, with seven items (ranging from 0 to 21) and finally, the Hyperarousal subscale with five items (ranging from 0 to 15).

This instrument also presents a complementary subscale which allows detection of Somatic Manifestations of Anxiety, this subscale also maintains the same answer sheet format, and is a 13 item subscale with a response scale ranging from 0 to 39. The reliability of scores was examined and a test-retest reliability of .89 was found, along with a .92 alpha coefficient. The content validity was considered satisfactory since the scale meets the diagnostic criteria for this disorder. The cut off score for the global subscale is 15 and 5, 6 and 4 for the other subscales previously mentioned.

In the study presented by Calvete et al. (2007), the alpha coefficient for the Post Traumatic Stress Disorder Symptom Severity Scale was .92 and .90 for the Somatic Manifestations of Anxiety subscale.

The degree of adjustment or maladjustment was measured through the administration of the Maladjustment Scale (Echeburúa, De Corral, & Fernández-Montalvo, 2000). This scale allowed observing the degree to which individuals' personal problems may interfere with their capacity to adapt to different areas of interaction. The assessment tool is a six item self report screening instrument, utilizing a Likert type scale format with a scoring ranging from 0 to 5. Total ranges from 0 to 30, and a cutoff point of 12. This scale is constructed in a very direct manner which translates into the higher the scoring, the higher the maladjustment level is.

The study also utilized the Semi-Structured Interview for Domestic Violence Victims (Echeburúa & De Corral, 1998) with the sole purpose of identifying different variables related to domestic violence. This instrument allows assessing areas such as: demographic data, history of victimization, conditions of the abuse among others.

To begin with, the participants were informed about the purpose and potential of the present study.

Secondly, researchers proceeded to administer the instruments; this process was carried out individually and under the control and supervision of a licensed psychologist. The administration of the assessment tools lasted about 20 to 40 minutes.

The instruments were administered in two different sessions; during the rst interview, researchers collected specific information about domestic violence, obtained a signed informed consent from the participants and explained the procedure to the participants. Lastly, the specific assessment tools were administered.

The instruments administration process took about three months to complete. During this time, it was identified that only 57.69% of the sample openly exposed their abuse, while the rest decided to remain silent, and the percentage that decided to openly talk about the abuse, only 38.46% received appropriate medical care.

The results were processed with the Windows statistical package SPSS 17.0 version, this software was able to calculate the mean and standard deviations for the scores obtained from the different scales that were applied to participants, as well as the average calculation of such scores. Subsequently, the Pearson's Correlation Coefficient (r) was applied in order to determine the possible relation between the scores obtained from the PTSD instrument and its different subscales and the results reported by the maladjustment variable.

The measure of the PTSD symptomatology allowed identifying a significantly high number of individuals who reported this type of behavioral manifestations; in general, 84.2% of participants were found having elevated PTSD scores in each symptomatic subscale assessed by the instrument (see table 1 for PTSD symptom severity results). This score is significantly high if we take into consideration the small sample; the majority of these met the PTSD criteria.

The median obtained from the participants in the different subscales of PTSD exceeds the cut off scores previously stipulated for the assessment tool; the most noteworthy score was the tendency towards persistent avoidance of associated stimuli, in this case, stimuli associated with abuse conditions, followed by increased arousal, and finally, the tendency towards reexperiencing the stressful events. Consequently, the overall PTSD scores are significantly high, with scores surpassing the instrument's scoring criteria designed as a screening tool in order to determine the presence or absence of PTSD symptomatology.

On the other hand, the somatic manifestations of anxiety, resulted in scores very similar to the cut off scores, indicating the presence of expressions of anxiety within the parameter previously determined for the mean as it was established by the instrument.

As we can see in table 2, the table shows the scores from the Maladjustment construct, results indicated that 92.3% of the sample reported a wide variety of maladjustment manifestations (see table 2 for maladjustment scale results).

The areas of interaction more commonly affected by maladjustment conditions, in order of variance explained are: global scale (88.5%), marital life (80.8%) and family life (80.8%), while, social development (73.1%), employment or academic activities and leisure time (65.4%) seem to show a less significant effect, even though, the maladjustment average scores are also elevated when we compare them to the median. The Pearson Correlation Coefficient (r) allowed computing the variables and identifying the degree of relationship between them (fee table 3 for results obtained from the Pearson Correlation analysis).

Data analysis indicated important internal correlations between the different subscales of PTSD, an expected result since we are referring to the assessment of some variables that have been associated to the same category. Moreover, this category has been previously standardized when the instrument was designed.

In addition, positive correlations are noteworthy, among the most significant ones; we can find the correlations between the subscales of PTSD and somatic manifestations of anxiety, which indicates that the high prevalence of PTSD symptomatology is associated with physiological responses of anxiety. Furthermore, the overall stress level displays a positive correlation that is statistically significant compared with the participants' maladjustment level (r=0.514; p < 0.01). A similar situation occurs with maladjustment and hyperarousal. These two variables also obtained a significant correlation (r=0.609; p < 0.01). The participants' maladjustment level has no correlation with avoidance of stimuli associated with abuse conditions and has no correlation with reexperiencing the abuse.

Finally, the different manifestations of PTSD were correlated with each particular area used to measure maladjustment (see table 4), in this process, it was noted that reexperiencing the abuse is a condition that is not significantly related to the participants' inability to adapt.

The analysis identifies social functioning and good use of leisure time as the variables that were mostly affected by the PTSD conditions, exhibiting a positive correlation that is statistically significant-except for reexperiencing- between all of the other conditions or variables, including the somatic manifestations of anxiety. Moreover, hyperarousal is the only PTSD symptom that is associated with occupational impairment and global level of maladjustment; as a paradox, there is no significant relationship between marital and family life and any of the PTSD symptoms previously evaluated, even though the variables marital and family life were reported as the variables with the highest maladjustment level (see table 2).

The present study evaluated the existing relationship between PTSD and Maladjustment in a group of victims of intimate partner violence.

The findings indicated significantly elevated PTSD average scores; these results are consistent with previous research on this phenomenon (Labrador et al., 2010; Calvete et al., 2007). The results reinforce the initiative of considering PTSD as a diagnostic category unmistakably associated to intimate partner violence (Arroyo, 2002); therefore, this consideration must be a relevant aspect when assessing the impact of this phenomenon on victims' mental health, consideration and initiative that was observed in the results

Among the PTSD manifestations present in the sample, it was observed the tendency to avoid (88.4%), as well as an elevated arousal response (76.9%). The data obtained from the study is consistent with the data obtained from Matud et al. (2003) who reported that victims of abuse exhibited a high tendency to complain of a variety of symptoms, especially anxiety symptoms. Following this, the results in our study demonstrated the presence of a considerable high average of somatic manifestations of anxiety (53.8%) just like the data in the studies conducted by Matud et al. (2003).

The detrimental effect on victims' psychological health, caused by suffering domestic violence is a fact that repeatedly appears in different studies on this subject; this condition generates an overall level of impairment in the abused individual who sees the possibility to overcome the abuse significantly reduced and suffers the damaging effects on overall achievement and psychosocial adjustment. In the particular case of the present study, this condition is evident on the considerably elevated maladjustment average scores identified in the sample. As a result, the areas of development evaluated in the participants seem to be affected as well, with a relationship between PTSD and maladjustment in the social scenario and leisure time, without overlooking the important implication related to employment and experiencing hyperarousal.

The findings allowed corroborating the reports offered by other research studies (Calvete et al., 2007; Pico-Alfonso et al., 2006; Plazaola-Castaño & Ruiz-Pérez, 2004; Paz et al., 2004; Amor et al., 2002; Arroyo, 2002; Domínguez et al., 2008) by identifying the significant relationship between the scores from both variables, which indicates that a high tendency to experience PTSD manifestations is associated with a high level of psychosocial maladjustment in individuals who have been victimized by their partners.

In conclusion, we found that in general, the participants exhibited emotional affliction in their responses, characterized by the presence of somatic anxiety, an intense fear of reexperiencing the abuse situations —therefore avoiding them— and a marked response of increased arousal; such psychopathological manifestations tie in with a considerable high level of dysfunction specifically in psychosocial adjustment. The areas of psychosocial adjustment that seemed significantly impaired were social life and feeling satisfied with leisure time activities.

Surprisingly, even though the results demonstrated high levels of family and marital maladjustment, which could be assumed as a logical and expected result, considering that the perpetrator is the victim's intimate partner, the present study did not establish a significant association between maladjustment in these particular areas and PTSD. These results may be explained by the way individuals interpret their partners' attitudes towards abuse. Agoff, Rajsbaum, and Herrera (2006) identified in a group of abused women the tendency to exhibit tolerance in response to these actions because they assume that the attacks are the result of external forces that cannot be controlled by their partners, from this approach, the research participants could be minimizing the hostility due to the idealized image of the intimate partner, therefore, the maladjustment experienced within the family and marital spheres is not attributable to the experience of violence, while the participants might simultaneously experience a higher level of maladjustment in other scenarios of psychosocial development where the relationship with the perpetrator is not perceived so straightforward.

The findings corroborated the worldwide reports supporting significant correlations between intimate partner violence and psychological variables; it seems undeniable the arguments about how individuals who experience intimate partner violence exhibit poor health, a permanent fear of aggression, sadness, emotional alterations and a gradual deterioration of psychological and physical defenses, which translates into an overall increase of health problems (Amor et al., 2002) with the presence of complex alterations such as body aches, headaches, fatigue, irritable colon, ulcers, anxiety and a high tendency to use medications such as anxiolytics or tranquilizers (Traverso, 2000; Morrison & Orlando, 1999; Larraín, 1994).

However, this study also recognizes the existence of some limitations. Initially, it is important to point out that the sample was small, which reduces the possibility of generalizing the results outside the group of abused individuals in the city context where the research was developed. Although, the sample consisted of both male and female participants, they were not equally or proportionally distributed in the sample because the number of male victims was significantly smaller.

On the other hand, the collection of data pertaining to PTSD and maladjustment was based on self reporting measurements, which could alter the participants' scores as a result of biased responses due to the implications of abuse reported by the sample (Naeem, Irfan, Zaidi, Kingdon, & Ayub, 2008). Nevertheless, the identified results demonstrate a relationship with the several research studies developed worldwide on this subject which are all supportive of the relationship between PTSD and psychosocial maladjustment in victims of intimate partner violence.

Undoubtedly, the scope of intimate partner violence research must move towards not only the recognition of the psychopathological effects of this phenomenon but also the establishment of proposals mainly focusing on rights restitution, personal and emotional rehabilitation and preventing the exacerbation of this problem, particularly because of the association with chronic psychological consequences, among others (Labrador, Fernández-Velasco, & Rincón, 2006).

Finally, the studies need to be more inclusive in choosing same sex couples in their sample, since same sex partnership is not a broadly explored area and warrants attention in order to characterize the problem. Overall, the research should focus not only on broadening the findings, but also on applying them to develop preventive strategies that positively affect public health and face the consequences of intimate partner violence.

Agoff, C., Rajsbaum, A., & Herrera, C. (2006). Perspectivas de las mujeres maltratadas sobre la violencia de pareja en México. Salud Pública de México, 48 (suppl. 2), S307-S314. Retrieved from: http://redalyc.uaemex.mx/src/inicio/ArtPdfRed.jsp?iCve=10604811.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC: American Psychiatric Press.

American Psychological Association. (2002). Violence and the Family: Report of the APA Presidential Task Force on Violence and the Family — Executive Summary. Retrieved from: http://www.apa.org/pi/pii/viol&fam.html.

Amor, P. J., Echeburúa, E., De Corral, P., Zubizarreta, I., & Sarasua, B. (2002). Repercusiones psicopatológicas de la violencia doméstica en la mujer en función de las circunstancias del maltrato. International Journal of Clinical and Health Psychology, 2 (2), 227-246. Retrieved from: http://redalyc.uaemex.mx/src/inicio/ArtPdfRed.jsp?iCve=33720202.

Arcos, E., Molina, I., Repossi, A., Uarac, M., Ritter, P., & Arias, L. (1999). Violencia doméstica y sexualidad. Revista Médica de Chile, 127 (11), 1-15. doi:10.4067/S0034-98871999001100006.

Arroyo, A. (2002). Mujer maltratada y trastorno por estrés postraumático. Revista de Psiquiatría de la Facultad de Medicina de la Universidad de Barcelona, 29 (2), 77- 82. Retrieved from: http://www.nexusediciones.com/pdf/psiqui2002_2/ps-29-2-003.pdf.

Buvinic, M., Morrison, A., & Shifter, M. (2002). La Violencia en América Latina y el Caribe: Un Marco de Referencia para la Acción. Washington, DC: Banco Interamericano de Desarrollo.

Calvete, E., Estévez, A., & Corral, S. (2007). Trastornos por estrés postraumático y su relación con esquemas cognitivos disfuncionales en mujeres maltratadas. Psicothema, 19 (3), 446-451. Retrieved from: http://www.psicothema.com/pdf/3384.pdf.

Coker, A. L.,Weston, R., Creson, D. L., Justice, B., & Blakeney, P. (2005). PTSD symptoms among men and women survivors of intimate partner violence: The role of risk and protective factors. Violence and Victims, 20(6), 625- 643. Retrieved from: http://www.ingentaconnect.com/content/springer/vav/2005/00000020/00000006/art00002.

Corsi, J. (1994). Violencia intrafamiliar. Una mirada interdisciplinaria sobre un grave problema social. Buenos Aires: Paidós.

Domínguez, J. M., García, P., & Cuberos, I. (2008). Violencia contra las mujeres en el ámbito doméstico: consecuencias sobre la salud psicosocial. Anales de Psicología, 24 (1), 115-120.

Echeburúa, E., De Corral, P. Amor, P. Zubizarreta, I., & Sarasua, B. (1997). Escala de gravedad de síntomas de estrés postraumático: propiedades psicométricas. Análisis y Modificación de Conducta, 23 (90), 503-526. Retrieved from: http://www.ehu.es/echeburua/pdfs/7-egs.pdf.

Echeburúa, E. & De Corral, P. (1998). Manual de violencia familiar. Madrid: Siglo XXI Editores.

Echeburúa, E., De Corral., P., & Fernández-Montalvo, J. (2000). Escala de Inadaptación: propiedades psicométricas en contextos clínicos. Análisis y Modificación de Conducta, 26 (107), 325-340.

Echeburúa, E., De Corral, P., & Amor, P. (2002). Mujeres maltratadas en convivencia prolongada con el agresor: variables relevantes. Acción Psicológica, 1 (2), 135-150. Retrieved from: http://e-spacio.uned.es/fez/eserv.php?pid=bibliuned:AccionPsicologica2002-numero2-0003&dsID=pdf.

Echeburúa, E., Fernández-Montalvo, J., & De Corral, P. (2008) . ¿Hay diferencias entre la violencia grave y la violencia menos grave contra la pareja?: un análisis comparativo. International Journal of Clinical and Health Psychology, 8 (2), 355-382. Retrieved from: http://redalyc.uaemex.mx/src/inicio/ArtPdfRed.jsp?iCve=33712001001.

Garcia-Moreno, C., Jansen, H., Ellsberg, M., Heise, L., & Watts, C. (2006). Prevalence of intimate partner violence: findings from the WHO multicountry study on women's health and domestic violence. The Lancet, 368 (9543), 1260-1269. doi:10.1016/S0140-6736(06)69523-8.

Graves., K., Sechrist., S., White., J., & Paradise, M. (2005). Intimate partner violence perpetrated by college women within the context of a history of victimization. Psychology of Women Quarterly, 29 (3), 278-289. doi: 10.1111/j.1471-6402.2005.00222.

Labrador, F., Fernández-Velasco, M. R., & Rincón, P. (2006). Eficacia de un programa de intervención individual y breve para el trastorno por estrés postraumático en mujeres víctimas de violencia doméstica. International Journal of Clinical and Health Psychology, 6 (3), 527-547. Retrieved from: http://www.aepc.es/ijchp/articulos_pdf/ijchp-190.pdf.

Labrador, F., Fernández-Velasco, M. R., & Rincón, P. (2010). Características psicopatológicas de mujeres víctimas de violencia de pareja. Psicothema, 22 (1), 99-105. Retrieved from: http://www.psicothema.com/pdf/3702.pdf.

Larraín, S. (1994). Violencia puertas adentro. La mujer golpeada. Santiago de Chile: Editorial universitaria.

Martin, E. K., Taft, C. T., & Resick, P. A. (2007). A review of marital rape. Aggression And Violent Behavior, 12 (3), 329-347. doi: 10.1016/j.avb.2006.10.003.

Matud, M. P., Aguilera, L., Marrero, R., Moraza, O., & Carballeira, M. (2003). El apoyo social en la mujer maltratada por su Pareja. International Journal of Clinical and Health Psychology, 3 (3), 439-459. Retrieved from: http://www.aepc.es/ijchp/articulos_pdf/ijchp-81.pdf.

McHugh., M., Livingston., N., & Ford, A. (2005). A postmodern approach to women's use of violence: Developing multiple and complex conceptualizations. Psychology of Women Quarterly, 29 (3), 323-336. doi: 10.1111/j.1471-6402.2005.00226.

Morrison, A. & Orlando, B. (1999). Social and Economic Cost of Domestic Violence: Chile and Nicaragua. In A. Morrison & M. Loreto (Eds.), Too Close to Home. Domestic Violence in the Americas. (pp. 51-80). Washington, DC: Inter-American Development Bank.

Naeem, F., Irfan, M., Zaidi, Q., Kingdon, D., & Ayub, M. (2008). Angry Wives, Abusive Husbands: Relationship between domestic violence and psychosocial variables. Women's Health Issues, 18 (6), 453-462. doi: 10.1016/j.whi.2008.08.002.

Paz, P., Labrador, F., Arinero, M., & Crespo, M. (2004). Efectos psicopatológicos del maltrato doméstico. Avances en Psicología Latinoamericana, 22, 105-116. Retrieved from: http://redalyc.uaemex.mx/src/inicio/ArtPdfRed.jsp?iCve=79902210.

Pico-Alfonso, M., García-Linares, M., Celda-Navarro, N., Blasco-Ros, C., Echeburúa, E., & Martínez, M. (2006). The impact of physical, psychological, and sexual intimate male partner violence on women's mental health: depressive symptoms, post traumatic stress disorder, state anxiety, and suicide. Journal of Women's Health, 15 (5), 599-611. doi: 10.1089/jwh.2006.15.599.

Plazaola-Castaño, J. & Ruiz-Pérez. I. (2004). Violencia contra la mujer en la pareja y consecuencias en la salud física y psíquica. Medicina Clínica, 122 (12), 461-467. Retrieved from: http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=13060003&pident_usuario=0&pcontactid=&pident_revista=2&ty=49&accion=L&origen=elsevier&web=www.elsevier.es&lan=es&fichero=2v122n12a13060003pdf001.pdf.

Sorenson, S. & Taylor, C. (2005). Female aggression toward male intimate partners: An examination of social norms in a community-based sample. Psychology of Women Quarterly, 29 (1), 78-96. Retrieved from: http://www.sp2.upenn.edu/ortner/docs/sorenson_doc3.pdf.

Traverso, M. T. (2000). Violencia en la pareja: la cara oculta de la relación. Washington, DC: Banco Interamericano de Desarrollo.

Trujano, P. (2001). Violencia conyugal cuando la víctima es el varón. Psicoterapia y Familia, 14 (2), 29-39.

Trujano, P., Martínez, K., & Benítez, J. C. (2002). Violencia hacia el varón. Psiquis, 23, (4), 5-19.

Ulla, S., Velásquez, C., Notario, B., Solera, M. Valero, N., & Olivares, A. (2009). Prevalence of intimate partner violence and its relationship to physical and psychological health indicator. International Journal of Clinical and Health Psychology, 9 (3), 411-427. Retrieved from: http://www.aepc.es/ijchp/articulos_pdf/ijchp-330.pdf.

Vos, T., Astbury, J., Piers, L., Magnus, A., Heenan, M., Stanley, L., Walker, L., & Webster, K. (2006). Measuring the impact of intimate partner violence on the health of women in Victoria, Australia. Bulletin of the World Health Organization, 84 (9), 739-744. Retrieved from: http://web.ebscohost.com.bibliobd.upb.edu.co:2048/ehost/pdfviewer/pdfviewer?sid=aeb963d6-7817-456a-b8d9-d3258620827a%40sessionmgr115&vid=2&hid=104.

World Health Organization. Oficina Regional para las Américas de la Organización Mundial de la Salud. (2003). Informe mundial sobre la violencia y la salud. Washington, DC.