Dowry-related domestic violence and complex -post-traumatic stress disorder: a case report

Abstract

Abstract
Objectives: This paper draws attention to the mental health impact of coercive practice of dowry demands, associated
with domestic violence (DV) in an immigrant woman.
Methods: This study was based on a case report and selective literature review.
Results: This case history illustrates the serious mental health impacts of repeated emotional and physical trauma
inflicted by a husband who was dissatisfied with his wife’s dowry. Bio-psycho-social / cultural aspects of mental
health treatments needed to be augmented with attention to safety, advocacy, and access to support networks.
Conclusions: Cultural factors are important determinants of mental illness. Psychiatrists need to be aware of DV
and dowry when treating immigrant women.
Keywords: domestic violence, immigrant woman, dowry, mental illness

Full text

https://doi.org/10.1177/1039856217700464
Australasian Psychiatry
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© The Royal Australian and
New Zealand College of Psychiatrists 2017
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DOI: 10.1177/1039856217700464
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1
AustrAlAsiAn
Psychiatry
Globally 1 in 3 women suffer domestic violence.1
Australia is no exception.2 Domestic violence
(DV) is increasingly being recognized for its seri-
ous mental health consequences1, 3 and is found to be
responsible for 8% of burden of health, predominantly
mental health, for women aged 15−44 years, greater
than smoking or hypertension.4 DV is a complex issue.
The ecological model of Heiss etal.5 illustrates the inter-
actions between societal, cultural, family and individual
factors that can give men the position of power, domi-
nance and control over women and children. The social
model of women’s mental health posits that women’s
social positions make them more prone and vulnerable
to poor mental health outcomes.6 South Asian cultures
predominantly practice patriarchy, a practice that dis-
advantages women at multiple levels: societal, familial
and individual.7 Dowry is a South Asian cultural prac-
tice where harassment by in-laws on issues related to
dowry is reported to be a major factor associated with
poor mental health and suicides in women8 and is also a
determinant of DV.8 Notably, the husband’s unsatisfac-
tory reaction to dowry is said to be strongly associated
with common mental disorders in Indian literature.9
Australia is a highly multicultural country.10 The inter-
mingling of many different cultures and ethnicities
results in hybrid identities and hybridization of cultural
practices.11 In this rapidly changing trans-migratory
world, studying the lives of individuals is crucial to the
study of cultural factors, which are increasingly recog-
nized as important determinants of mental health.11
This paper presents a case report of a South Asian migrant
woman, victimized by the social practice of dowry in
Australia, associated with DV and its serious impact on
her mental health
Case report
Ms A is a 25-year-old, recently separated woman referred
by her general practitioner for the treatment of mental
health impacts of DV. She was married in an arranged
marriage in India to an Australian-Indian resident. A day
after the marriage he stopped talking to her, he seemed
annoyed and his mother repeatedly complained about
dowry gifts being insufficient and of poor quality. Over
the next week Ms A increasingly became anxious and
sad. Over three ceremonies her parents had given extrav-
agant gifts comprising gold and cash, expenses totalling
over AUS$70,000. Indian culture is virilocal (i.e. the son
stays with the family and his bride moves in).4
Accordingly, Ms A moved in with her in-laws. Her per-
sonal gold jewellery was taken by her mother-in-law
ostensibly for ‘safe guarding’ (but never returned). Ms A
anxiously realized she was in a hostile environment
from which escape was difficult. Divorce was not an
Dowry-related domestic violence
and complex -post-traumatic
stress disorder: a case report
Manjula O’Connor Hon Sen Fellow, Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
Abstract
Objectives: This paper draws attention to the mental health impact of coercive practice of dowry demands, associ-
ated with domestic violence (DV) in an immigrant woman.
Methods: This study was based on a case report and selective literature review.
Results: This case history illustrates the serious mental health impacts of repeated emotional and physical trauma
inflicted by a husband who was dissatisfied with his wife’s dowry. Bio-psycho-social / cultural aspects of mental
health treatments needed to be augmented with attention to safety, advocacy, and access to support networks.
Conclusions: Cultural factors are important determinants of mental illness. Psychiatrists need to be aware of DV
and dowry when treating immigrant women.
Keywords: domestic violence, immigrant woman, dowry, mental illness
Corresponding author:
Manjula O’Connor, 3/20, Collins Street, Melbourne, VIC,
3000, Australia.
Email: manjud@bigpond.com
700464APY0010.1177/1039856217700464Australasian PsychiatryO’Connor
research-article2017
Regular Article

Australasian Psychiatry
2
option, a sign of shame and failure. The following week
her father visited Ms A. She was traumatized by her
mother-in-law exploding at him, she was dishonoured
by insufficient dowry gifts and threatened to send Ms A
home. Her father cried and pleaded, that would dishon-
our his family. He said he had spent all his life savings.
Ms A felt deeply sad, helpless and humiliated. The
mother-in-law relented.
Some months later, Ms A arrived in Melbourne. Her
husband started making escalating demands for
money. She told him he had to follow the tacit cultur-
ally accepted agreement (where the father gives a
dowry, and the husband takes care of the new wife).
Her ‘backchat’ angered him, he hit her, and slept in a
separate room. She asked why he was rejecting her, he
yelled abuse and hit her again saying she was costing
him too much. She was given little food to eat, no
access to money, and lost weight. She was often kicked
out of the house on cold nights and not allowed back
for hours. She would go and sit in the park nearby,
alone, fearful, tearful, sad, and becoming suicidal. His
sister and mother-in-law arrived from interstate, and
both made threats to her life on a number of occa-
sions. She recognized the ominous threats were dowry-
related. She reported that she knew that dowry
demands can lead to murders in her culture. She felt
acutely fearful and ran out of the house and went to
the police station obtaining an intervention order
against him and his family.
Mental health examination revealed a sad, anxious,
and fearful young woman who was suffering daily
panic attacks. Sleep was disturbed with nightmares.
She had poor concertation, low appetite and low
energy. She reported intrusive thoughts and flashbacks
of physical violence, threats to her life, and criticisms
of her on the basis of insufficient dowry with frequent
periods of disassociation and panic attacks. She felt
suicidal but did not attempt suicide. Her self-score on
the post-traumatic stress disorder (PTSD) checklist
PCL-512 was 80 out of a possible 80. The Clinical Global
Impression (CGI) score was assessed as 3/10. The core
symptoms of PTSD were hyperarousal, intrusion, and
depersonalisation. There was no previous history of
mental illness.
Her treatment comprised bio-psycho-social approaches.
She was commenced on escitalopram 20 mg daily and
diazepam 5 mg nocte. Culturally sensitive trauma-
based cognitive behavioural therapy (CBT) was com-
menced on a weekly basis. She was referred to specialist
domestic violence services for safety provision. Her
husband withdrew his support for her spousal visa, an
application for permanent residence on grounds of DV
was made. She was not eligible to receive unemploy-
ment benefits and unable to look for a job. She was
provided pro bono psychiatric reports to support the
intervention order against her husband, and for the
immigration department, supporting her application
for residency.
Progress
She received weekly trauma-focussed CBT, and crisis sup-
port. For example, she telephoned in a panicked state that
her Australian residency visa was in doubt. She was advised
to do slow rhythmic breathing and take clonazepam 0.5
mg. An urgent consultation with an immigration agent
was arranged. Another time she reported seeing her ex-
husband standing within 50 meters. She suffered an acute
attack of de-personalisation needing telephone support.
She suffered nightmares, panic attacks and fear. Sometimes
she felt he was standing right behind her looking over her
shoulders. She knew that to be not real. At other times she
had to confront him in court hearings, each contact with
him led to panic attacks and depersonalisation.
Escitalopram was changed over to des-venlafaxine 50
mg, due to severe insomnia and extreme anxiety, mir-
tazapine 30 mg nocte was added. Due to the ever-present
fear of being stalked, quetiapine 100 mg nocte was pre-
scribed. She took clonazepam on a prn basis. This com-
bination gave her partial relief from fear, anxiety and
insomnia. The PCL-5 score dropped to 55−60. Her men-
tal state fluctuated and concentration remained low. She
started applying for jobs. She was introduced to a non-
governmental organization with a social network of
young women with similar issues. She noted difficulty in
trusting people. Her CGI score hovered at around 5−6/10
Discussion
This case report shows a previously demonstrated com-
plex association between dowry demands, DV and men-
tal illness.8,13 The husband’s dissatisfaction with the
dowry appeared to be the major driver of rejection,
abuse, violence and threats. Demands for dowry are
shown to be an independent risk factor for common
mental disorders and suicidal ideation.9 In this longitu-
dinal study dowry demands turned out to be a stronger
predicator of mental illness in women than DV and hus-
band’s alcoholism. To our knowledge this is the first case
report that draws attention to the association between
dowry-related DV and complex PTSD. This case reveals
how bullying behaviour, abuse of power and control,
escalating coercive dowry demands leads to ‘intimate
terrorism’14 with increasing fear and threats to life and
PTSD.3 Despite its illegality, dowry-related murders in
India have steadily increased in the past decade.15,16
They are attributed to a toxic mix of patriarchy, greed
and materialism.15,16 The exact prevalence of dowry-
related DV is unknown in Australia but dowry-related
DV is documented in a previous qualitative Australian
research study,13 two dowry-related murders are reported
in Victoria17 and the problem is considered substantial.18
As the result of repetitive stress from which there is lim-
ited escape, associated with feelings of shame, worthless-
ness, and defeat, some have identified a variant of PTSD,
termed ‘complex PTSD’,19 a diagnostic category sug-
gested for ICD 11 but not present in DSM-5.20

O’Connor
3
Research is needed to determine prevalence of dowry-
related DV in Australia, its impact on mental health and
optimal treatments.
Disclosure
The author reports no conflict of interest. The author alone is responsible for the content and
writing of the paper.
Funding
The author received no financial support for the research, authorship, and/or publication of
this article.
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