Victimization is a serious and prevalent problem in individuals with serious mentally illnesses 1. Therefore, individuals with mental disorders, especially those with severe mental illness, living in the community are vulnerable to victimization and are considered as a high-risk group 2,3. Studies that have examined this correlation have reported victimization among psychiatric patients to be 2.3–140.4 times higher than that in the general population 4. Furthermore, Teplin et al.2 have estimated that 25% of mentally ill patients are victimized in comparison with only 3% of the general population. In addition, it is estimated that the yearly prevalence of victimization among psychiatric patients varies from 16 to 92% 5,6.
Many causes have been attributed to the increased risk of victimization of mentally ill patients, such as impaired reality testing, disorganized thought processes, impulsivity, and poor planning and problem solving, which can compromise an individual’s ability to perceive risks and protect himself/herself 7,8. Victimization is defined operationally as either covert/relational victimization or overt/physical victimization, in which an individual is either threatened with or subjected to corporeal damage 3.
Bipolar disorder is a chronic mental illness associated with significant functional and social impairments as well as poor overall health outcomes 9. Individuals with bipolar disorder show unique symptoms that make them vulnerable to victimization 10,11. Moreover, the recurrent manic episodes can lead to nonadherence to medication and risky behavior, besides leading to social consequences and consequent interactions with the legal system 9. These patients may experience high residential instability, as they leave their supported housing earlier than patients with schizophrenia, schizoaffective disorder, or depression, which leads to further exacerbation of nonadherence to medications and substance use problems, as well as vulnerability to victimization 12,13.
However, White et al.14, in their study on the relationship between bipolar disorder and victimization in the past 6 months, reported that one-third of the patients had been subjected to victimization, and women were almost twice as likely to have been victimized compared with men.
It is worth mentioning that violent victimization includes rape and sexual assault, robbery, and physical assault 15. In addition, a history of past victimization has a significant impact on two important aspects of clinical outcomes: increased homelessness and decreased quality of life. Moreover, it is predictive of future victimization 1.
Marly and Buila 16, in their study on 234 adults diagnosed with mental disorders who were victims of a traumatic crime, found that 51% reported the crime to the police and 70% to someone else, namely, a family member, relative, or service provider; however, perpetrators were significantly less likely to report the crime 3.
The aim of this study was to explore the clinical and psychodemographic profile, including the severity of symptoms and level of functioning, of patients with bipolar disorder who were victimized in comparison with their nonvictimized counterparts.
Participants and methods
Site of study
Patients were recruited from the inpatient and outpatient departments of the Institute of Psychiatry, Ain Shams University. The institute is located in Eastern Cairo and serves a catchment area for about a third of Greater Cairo. It serves both urban and rural areas, including areas around Greater Cairo as well.
The sample included 100 male and female patients, aged 18 years or older, with a primary diagnosis of bipolar disorder according to Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), not secondary to substance misuse or medical disorders. The patients should have had a history of mental illness for more than 1 year, in the absence of organic brain damage. The aims of the research were explained to the potential participants by our research team, who interviewed them and assured them that the data obtained would be confidential and that they could withdraw from the study any time. A total of 18 patients were excluded because of their refusal to participate or their withdrawal during the interview. The recruitment continued until 100 patients fulfilled the research criteria. The research including the pilot study was conducted during the period from August 2008 until the end of May 2010.
Preparation and pilot study
During the pilot study, the researchers were trained to use the Victimization Questionnaire 17 to collect data from patients about being victimized and they estimated the time required for the application of tools on patients recruited in the study. Data collection was carried out by both junior and senior psychiatrists in the research team, who were also trained on the use of the tools before the study.
The study proper
After the end of the pilot study, the study proper was initiated, and participants were interviewed in the assessment office on the inpatient department or the outpatient clinic. Each interview required about 90–120 min, sometimes divided into two sessions according to the cooperativeness of the patient. Interviews of individuals with severe mental illnesses with manic episodes were postponed until their condition stabilized.
- An extensive questionnaire was designed to obtain demographic data and other information, and to assess compliance with medications. In addition, we used the Fahmy and El Sherbini Scale 18 for determination of social class.
- The Structured Clinical Interview for DSM-IV Axis I diagnosis (Clinical Version) 19 is a semistructured diagnostic interview based on an efficient but thorough clinical evaluation administered by an experienced and trained bilingual researcher for Arabic-speaking patients.
- The Young Mania Rating Scale (YMRS) 20 consists of 11 items based on a patient’s subjective report over the last 48 h and on clinical observations. Given a severity rating, four of the items are graded on a 0–8 scale and seven on a 0–4 scale. Typical YMRS baseline scores are variable depending on the patients’ clinical characteristics such as mania (YMRS=12), depression (YMRS=3), or euthymia (YMRS=2). The scale is generally administered by a clinician or other trained rater and takes 15–30 min to complete.
- The Mood Disorder Questionnaire (MDQ) 21 was developed to address a critical need for a timely and accurate diagnosis of bipolar disorder. It takes about 5 min to complete and can provide important insights into diagnosis and treatment. Clinical trials indicated a high rate of accuracy, being able to screen nine of 10 individuals. It screens for Bipolar Spectrum Disorder (which includes Bipolar I, Bipolar II, and Bipolar NOS).
- Global Assessment of Functioning 22 is a numeric scale (0–100) to subjectively rate the social, occupational, and psychological functioning of adults – for example how well or adaptively is an individual dealing with various problems in life.
- Clinical Global Impression (CGI) 23 is a seven-point scale that requires the clinician to rate the severity of the patient’s illness at the time of assessment, relative to the clinician’s past experience with patients who have the same diagnosis. Considering the total clinical experience, a patient is assessed on the basis of the severity of mental illness at the time of rating.
- Victimization questionnaire developed by Missiry et al.24 includes questions about crimes such as personal theft, robbery, burglary, vandalism, assault with or without a weapon, attempted assault, biased physical and verbal assault, kidnapping, threatening, blackmailing, verbal or physical sexual harassment, emotional abuse, financial abuse, or different types of emotional victimization.
Ethical approval for the protocol of research was obtained from the Ain Shams University Ethical and Research Committee. The researchers obtained informed consent for participation from the patients after they were provided with a detailed description of the study and were assured of the confidentiality of information obtained. It patients were informed that participation in the study was voluntary and that they had the freedom to withdraw from the assessment at any point in time.
Data analysis was carried out using SPSS Version-15 (SPSS Inc., Chicago, Illinois, USA). Student’s t-test was used for comparison between the means of the different groups. The Pearson χ2-test was used for comparison between qualitative variables. The P-value was used to indicate the level of significance, where P up to 0.05 is considered significant, P up to 0.01 highly significant, and P up to 0.001 very highly significant.
The study included 100 patients who fulfilled the diagnostic criteria for bipolar mood disorder according to DSM-IV; they were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders to confirm the diagnosis. The entire sample of patients was assessed using the designed Victimization Questionnaire, and it was found that 48 patients had been previously victimized and 52 patients had never been subjected to victimization. Table 1 shows the sociodemographic characteristics of the sample studied.
It was found that more male than female patients were subjected to victimization. Of the victimized patients, 75% were living in an urban area; 50% had a regular job, and 41.7% were unemployed. It was also found that although two-thirds of the victimized group had secondary and university education, 8.3% of the patients were illiterate; however, none of the patients in the nonvictimized group were illiterate.
We explored and compared the family characteristics of patients in the victimized group versus those in the nonvictimized group (Table 2); it was found that both the groups differed significantly in terms of parental separation as victimized patients were more exposed to separation because of the early death of one of their parents. Parental domestic violence directed toward the mother and physical abuse during childhood were reported more by patients in the victimized group, with a highly significant difference between groups. A significant statistical difference was found between both the groups in terms of a family history of psychiatric illness and a highly significant statistical difference was found in terms of family history of substance abuse, being more prevalent in the families of victimized patients.
The clinical profile of the group studied is shown in Table 3. It shows that the severity of manic episodes as assessed by the YMRS is significantly higher and that as assessed by MDQ is higher in the victimized group, with a very high statistical difference between both the groups. A significant difference was also observed in terms of severity on CGI.
It was found that 41.7% (20 patients) of victimized patients had comorbid psychiatric disorder conditions (Fig. 1a); in contrast, 16.7% (eight patients) were involved in substance abuse and 8.3% (four patients) were dependent on psychoactive substances (Fig. 1b).
Type of victimization among the victimized group of patients with bipolar mood disorder
On studying the type of victimization among patients with bipolar disorder included in the study (Fig. 2), it was found that all victimized patients were subjected to emotional victimization, which included being locked indoors, name calling, and false accusations, 66.6% (32 patients) were exposed to miscellaneous victimization, which included biased verbal assault, personal theft, sexual harassment, and unwanted sexual activity, and finally, 58.3% (28 patients) were exposed to physical victimization, which included hitting, slapping, and pushing.
Type of victimization and perpetrator
Victimized patients were asked whether the perpetrators of different victimization acts were one of their family members or strangers. The results presented in Table 4 show the percentage of patients victimized by different perpetrators. It was found that emotional victimization was mainly inflicted by family members, mainly a brother in 41.7% of cases, followed by the father in 33.3% of cases, followed by the mother, daughter, uncles, or aunts in 8.3% of cases each.
However, miscellaneous victimization was equally inflicted by acquaintances, spouses, and mothers, who were responsible for 8.3% of cases each.
Finally, physical victimization was inflicted by the brother in 16.7% of the patients and by strangers and acquaintances in 8.3% of cases each.
Victimized patients were also asked about reporting of victimization acts; it was found that none of the victimized patients had reported the occurrence of the victimization act. We further analyzed the reasons for nonreporting in each type of victimization; we asked the patient whether they dealt with the act in another way, considered it to be a personal matter, considered it not important enough to be reported, feared the offender or any publicity, or did not want the perpetrator to be arrested. Table 4 presents the different reasons for nonreporting.
Our analysis showed that of patients who were subjected to emotional victimization, 91.7% considered it to be a personal matter and 8.3% considered it to be not important enough to report.
Patients who were subjected to physical victimization did not report it because they considered the act to be a personal matter or not important enough to be reported, because they feared their offender, or because they did not want the perpetrator to be arrested.
In terms of miscellaneous victimization, 16.7% of the patients believed that the act was not important and 8.3% of patients considered it to be a personal matter.
As violence and crime represent the content in daily news, media reports tend to perpetuate misconceptions that individuals with mental health problems are an especially violent class of society, although current research suggests that the level of public fear of violence from individuals with mental illness in the community is largely unwarranted 25. In fact, psychiatric patients are at a higher risk of being victimized than the regular population 17,26; Maniglio 4 reported this risk to be 2.3–14.4 times higher than that in the general population, which makes victimization a greater public health concern than perpetration 26. Several risk factors for victimization have been proposed including demographic and psychosocial characteristics, as well as others related to the mental illness itself 1,17.
Bipolar disorder is associated with significant functional and social impairments because of recurrent manic episodes that can lead to nonadherence to medication, as well as high residential instability and risky behaviors 14. Accordingly, studies have shown that patients with bipolar disorder are at a high risk for victimization 14,16,27, especially female patients 17,27,28.
In this study, we assessed the prevalence of victimization among patients with bipolar mood disorders, as well as their sociodemographic variables and severity of illness in order to identify the risk factors for victimization. We also assessed the type of victimization, perpetrator, and the reason for not reporting the act of victimization.
The results of different studies that have examined the prevalence of victimization have been inconsistent and do not provide a definite answer. These differences may be attributed to differences in the sampling methods, tools of assessment, and definition of victimization. White et al. 14, Goodman et al.29, Farlane et al.29 and Dravez-Brounez 27 have reported prevalence rates of 33.3, 22, 17, and 15%, respectively, among patients with a diagnosis of bipolar disorder, who were subjected to victimization. Of the 100 patients enrolled in this study, 48 (48%) had been victimized (although the sample was not a representative one); hence the prevalence rate in our study was higher than those reported by other international reports; yet, in an earlier Egyptian study, the prevalence rate of victimization among female patients with bipolar disorder was reported to be 88.8% 29. However, this relatively higher prevalence rate in our study could be attributed to the different social and economical conditions, as well as historical and cultural attributes 30, taking into consideration eastern Egyptian traditions and attitude toward mental illness, which is attributed to the evil eye or possession by a jinni or an evil spirit.
Accordingly, families with such beliefs usually seek help from traditional healers, who beat the patient severely in order to exorcize the jinni or evil spirit from his/her body. Moreover, in the Egyptian culture, manic behavior and associated disinhibited behavior are considered to breach social norms of conduct, especially in women, and such behavior is believed to bring dishonor to the family. Patients who exhibit such behavior are usually isolated, restrained, subjected to various forms of violence, and sometimes also honor killing. Furthermore, sexually disinhibited behaviors are often misinterpreted as flirtation and seduction, which can result in an increase in sexual victimization of these individuals 29.
In terms of age, there was no significant difference between the patients in the victimized and the nonvictimized group. However, our results showed that more men (58/3%) compared with women (41.7%) were subjected to victimization, which is in agreement with the findings by Hiday et al.8, who reported a higher percentage of men, compared with women, as being victims of violent crimes, and vice versa for nonviolent crimes. In contrast, most other studies have reported that women are more likely to be victimized than men 1,17,27,29. Such a discrepancy between the results of this study and many others, is understandable in terms of the Egyptian legathy and culture which regards the women respect and honors her. Accordingly, assaults towards them are usually condemned. Another explanation of lower female reported victimization could be fear of victimized ones lest they should be subjected to more assaults if they reported.
In addition, El Missery et al.24, in their study on schizophrenia, reported that 53.3% of men and 46.7% of women had been subjected to victimization, which is very similar to our results in bipolar disorder patients; this can be considered in the context of the Unitarian theory of psychosis.
There was no significant relation between the marital status of patients, their social class, and the possibility of them being victimized. However, their occupational status was a significant factor as 41.7% of the victimized bipolar patients in our sample were unemployed versus 15.4% of the nonvictimized patients, and 8.3% had an irregular job versus 30.8% of the nonvictimized patients. This result is not surprising if we consider the episodic nature of the disorder, with the resulting episodic homelessness, residential instability, and consequent inability to engage in work and find a job, thus leading to poor financial support. These factors can be linked to the established role of the symptoms of mental illness, their severity, and their specific nature as high-risk factors for victimization 2,31.
In terms of level of education, more number of victimized patients had preparatory and secondary education, similar to earlier results as seen in the study by Hiday et al.32, who reported that individuals with higher levels of education have more feelings of vulnerability to victimization and higher perceptions of coercion.
Living in urban areas has been reported to be a major risk factor for victimization by several studies 8,33,34, which is in agreement with our results; only one quarter of victimized patients in the current study lived in rural areas, whereas the other three-fourth lived in urban areas. Clearly, this can be attributed to the differences in the life style and communities between rural and urban areas. In the rural areas of Egypt, families are well integrated (both nuclear and extended), social relations are strong, and friends, neighbors, and relatives are supportive. In contrast, there are redundant and weak familial relationships, and weaker social integration and support networks in urban areas because of fast-paced life styles.
In terms of the family characteristics of our patients, the following important risk factors for victimization were found in our sample: 25% of the victimized patients reported an early death of a parent; in addition, 8% reported being a victim of domestic violence versus none in the nonvictimized group, which may represent a risk factor for the development of bipolar disorder. It is noteworthy that the earlier the patient develops the disorder, the more severe the symptoms are, and the higher incidence of caregivers interference and housing instability. Both conditions reflect the dysfunctional familial backgrounds of such patients; being orphaned at an early age and being exposed to the disturbed interpersonal relationship between both parents result in an unsatisfactory nurturing environment, hindering the full and mature development of an individual, with well-established social skills and problem-solving abilities, thus increasing vulnerability to victimization later in life.
However, domestic violence may lead to impaired self-esteem, an important well-known risk factor for victimization.
Moreover, 16% of the victimized patients in the current study had a history of child abuse, as well as a family history of substance dependence, which is in agreement with previous studies 1,2,29,35,36 that have concluded that victimization in childhood will lead to victimization in adulthood. Coid et al.37 have reported that exposure to childhood abuse and illtreatment increases the risk of victimization in adulthood; in other words, domestic violence and victimization are interrelated and potentiate each other. Besides, abuse during childhood, self-abuse with the use of psychoactive substances, and negative emotions expressed by relatives or employers are interrelated factors that result in victimization 17.
Several studies have previously reported that patients with more severe illness are more vulnerable to victimization 2,17,29,38. Clinical assessment of patients enrolled in the current study showed that victimized patients had significantly more severe forms of illness according to the results of the YMRS, as well as MDQ, which showed very highly significant differences between the two groups. In addition, in agreement with earlier results 5,39–41, we found that a greater severity of clinical symptoms as measured by the CGI was associated with a higher probability of being victimized.
In addition to severity, 41.7% of victimized patients with dipolar disorder had another comorbid psychiatric disorder. This finding is in agreement with those of western studies 1,42. However, 16.7 and 8% of our patients had a history of substance misuse or dependence, respectively, which is in agreement with the results of earlier studies 43–45.
Type of victimization among the victimized group
Study on the type of victimization among patients in the current study showed that all of them had been exposed to emotional victimization, including being locked indoors, name calling, and false accusation, whereas 66.6% had been subjected to miscellaneous victimization, such as biased verbal assaults, personal theft, sexual harassment, and unwanted sexual activity, and 58.3% had been subjected to physical victimization, which included hitting, slapping, and pushing. These percentages are higher than those obtained from studies conducted in western countries; however, in North Carolina, a study on 331patients with mental illness showed that 8.2% had been victimized physically 8, and also in addition, in their study of victimized psychiatric patients, Hiday et al.32 found that 9.9% had been subjected to violent victimization and 64 (28.7%) had been subjected to nonviolent victimization. In contrast, in a review of all US studies since 1990 on victimization of mentally ill patients (both inpatients and outpatients), Choe et al.26 reported that 35% had been subjected to violent victimization. However, in another study on 100 patients with bipolar disorder at the Bipolar Disorders Research Clinic of the New York Presbyterian Hospital, Garno et al.46 found that 37% reported emotional abuse, 24% reported physical abuse, 24% reported emotional neglect, 21% reported sexual abuse, and 12% reported physical neglect. In addition, in an Egyptian study on 583 women with different psychiatric illnesses carried out by Ragheb et al.30 to detect the prevalence and type of victimization among the studied group, it was found that 86.6% were subjected to physical abuse; 87.7% had been abused psychologically, and 4.8% had been abused sexually. About 9% of the patients in the group were diagnosed with bipolar mood disorder, among whom 6.6% had been subjected to physical abuse, 6% had been subjected to psychological abuse, and 13.8% had been subjected to sexual abuse.
This wide discrepancy between our results and those of others is because of the emotional overinvolvement of Egyptian families, besides the high emotional expression, including excessive blame, criticism, and sometimes over protection, as concluded previously by Okasha et al.47, wherein criticism is an accepted and acceptable part of interpersonal relations in the Egyptian culture, and that it may well reflect an element of care; thus, all of the victimized patients in the current study had been exposed at least once to overcriticism, and blaming, even if it was meant as an indication of caring.
Type of victimization and perpetrator
When victimized patients in the current study were asked about the perpetrator of different acts of victimization, whether inflicted by one of the family members or strangers, the results agreed with the above explanation as it was found that emotional victimization was mainly inflicted by family members, mainly the brother in 41.7% of cases, followed by the father in 33.3% of cases, followed by the mother, daughter, uncles, or aunt in 8.3% of cases each.
However, miscellaneous acts of victimization were equally inflicted by acquaintances, spouses, and the mother, who were responsible in 8.3% of cases each.
Finally, physical victimization was caused by the brother in 16.7% of patients and by strangers and acquaintances in 8.3% of cases each. This is because in some Egyptian families, according to specific cultural beliefs, beating and other forms of physical abuse are sometimes used as a form of behavioral reforming whenever acts deviating from the traditional norms are encountered.
In Philadelphia, among 69 patients with severe mental illness, two-third of whom had a diagnosis of bipolar disorder, Cascardi et al.48 reported that 35% had been severely victimized by a family member within the past year. In that study, severe victimization was defined as ‘hitting, punching, choking, beating up, and threatening with or using a knife or gun’. In contrast, Friedman et al.49 reported qualitative and quantitative findings on intimate partner violence perpetrated both against and by a sample of 53 Puerto Rican women diagnosed with major depression, bipolar disorder, or schizophrenia.
Type of victimization, reporting/nonreporting, and reasons for not reporting
When the victimized patients were asked about reporting of victimization acts, it was found that none of the victimized patients had reported the occurrence of the victimization act; on further analysis of the cause of nonreporting in each type of victimization, we found that 91.7% of all the patients who were emotionally victimized considered it to be a personal matter and 8.3% considered it not important enough to be reported, which is understandable as all of them were emotionally perpetrated by a family member. However, those who were exposed to physical victimization did not report it as they either considered the act to be a personal matter, believed that it was not important enough to be reported, were afraid of the perpetrator, or did not want him/her to be arrested. In terms of miscellaneous victimization, the act was not considered important by 16.7% of the patients and 8.3% considered it to be a personal matter.
Hence, the actual reason behind the nonreporting of the victimized patients is culture specific, that is, specific to the Egyptian culture. The nature of Egyptian families’ interrelations, with their overinvolvement, and high emotional expression attitudes, explains why none of them had reported about that matter. As much as they believe that being called bad names, severely blamed, or harshly criticized is very painful, yet they avoid talking openly about it and consider it as a familial and personal matter. Similarly, as 16.7% were physically victimized by the brother and only 8.3% by a stranger or an acquaintance, none of them reported, either for the above reasons or for sense of shame and not getting used to call for one’s right and stand for it until it is granted, which is maybe a defective pattern of raising children in many peaceful Egyptian families. Many of them did not wish to become involved in legal matters; meanwhile, there is no other outlet for their appeals, and no other agencies or parties available to them for help.
As is evident from the current study, victimization of mentally ill patients is a highly underestimated problem in our community. The most important finding of the current study is the role of the Egyptian culture as a dominant risk factor for victimization of mentally ill patients, as well as the rest of our objectives, such as the reasons for victimization (in terms of the nature of the symptoms in relation to culture) and type of victimization and perpetrator. Early death of a parent, disturbed familial interpersonal relationships, with domestic violence, and a history of childhood abuse were important risk factors for victimization, in addition to the presence of a family history of mental illness, substance dependence, and psychiatric comorbidity. This was mainly prevalent in urban areas, which lack the sympathizing, compassionate, and integrated social relationships that are present in Egyptian rural areas, and act as a buffer for people’s reactions and interactions with the mentally ill persons, thus protecting rather than harming them. Similarly, because of cultural reasons, none of the victimized patients in the study reported the assault. Other important reasons are feelings of ‘fear and shame’, on which many children are raised in our community, and lack of knowledge on basic human rights and how to defend and preserve them. Therefore, more attention should be paid to this critical issue, with routine questioning about victimization of psychiatric patients during clinical assessment. Finally, the current results represent important preliminary data that are informative for clinicians and policy makers to consider when designing strategies for the protection of mentally ill patients against victimization and providing efficient psychoeducational programs to patients’ families to help them accept and understand the abnormal behavior of the patients during episodes of illness.
Strengths and limitations
To our knowledge, this is the first Egyptian study to carry out an assessment of victimization in a sample of patients with bipolar disorder in terms of their demographics and the different variables involved in their victimization, as well as the type of victimization and the identity of the perpetrators. However, some limitations of the current study should also be considered. Our results cannot be generalized as our sample was a convenient one, and yet, they should be considered as preliminary results, with scope for future studies, with larger samples, the results of which would be more informative. In addition, examination of more correlations between different variables, such as sex, place of residence, level of education, and type of victimization, would have been useful. In the current study, we relied on the reliability and validity of the questionnaire as it has been used before in an earlier study assessing victimization of patients with another mental illness in an Egyptian sample. Reference to similar studies on various mental illnesses in Egypt and other Arab countries is recommended in order to gain a holistic view of the problem from all perspectives, in relation to our cultural values.
The authors thank Dr Ahmed El Missiry, Assistant Professor in Psychiatry, Ain Shams University, for his efforts in planning for this research and designing the victimization questionnaire. They are also grateful to Dr Marwa Sultan and Dr Marwa El Missiry, Lecturers in Psychiatry, Ain Shams University, whose participation who helped in the clinical assessment of patients in this study.
Conflicts of interest
There are no conflicts of interest.
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