Association between Emotional Abuses and Mental Disorder in Women: A Web-based Internet Survey in Southern China

Violence against women, which exists worldwide, is harmful to the quality of life and marital relationships of women. Domestic violence had been traditionally associated with physical violence. It is now more broadly defined, often including all acts of physical, sexual, psychological or economic violence [1] that may be committed by an intimate partner or spouse, irrespective of whether they lived together [2].


Background
Violence against women, which exists worldwide, is harmful to the quality of life and marital relationships of women. Domestic violence had been traditionally associated with physical violence. It is now more broadly defined, often including all acts of physical, sexual, psychological or economic violence [1] that may be committed by an intimate partner or spouse, irrespective of whether they lived together [2]. Domestic violence against women is a universal phenomenon across the world, with about 20 to 50% women experience domestic violence [2,3]. It is widely recognized as a serious human rights abuse, and is increasingly recognized as an important public health problem with serious consequences on women's physical, mental, sexual and reproductive health [4,5].
Intimate partner violence (IPV) affects the safety, health and quality of life of women. For the past decades, research has been more focused on the effects of physical or sexual violence on adverse mental health outcomes. A recent multi-country cross-sectional study on the relationship between men and violence in Asia and the Pacific found that the prevalence of physical or sexual IPV perpetration, or both, varied by sites, between 25.4% (190/746; rural Indonesia) and 80.0% (572/714; Bougainville, Papua New Guinea) [6], while the prevalence of emotional domestic violence was respectively 7.5% in Nepal and 44.4% in Iran [7,8].
Previous researches have shown that high prevalence of all violence types is associated with high prevalence of depression or even posttraumatic stress disorder [9,10]. Emotional abuse, which is also called psychological abuse or mental abuse, including verbal abuse, is defined as any behavior that threatens, intimidates, undermines the victim's self-worth or self-esteem, or controls the victim's freedom [11].
A systematic review has reported that there is a relationship between mental health and violence against women; the rate of depression, anxiety, drug misuse and suicidal thought are higher in such women [12].
It is necessary to better understand the underlying causes of emotional IPV and suggest appropriate actions to support them recovering their health and quality of life. Emotional abuse is also popularly called "Domestic Cold Violence" in China, particularly referring to coldness, indifference and keeping silence between spouses, which may cause mental distressed. It is often committed against women by their male partners and it is considered to be the silent killer in marriage.
China has the largest population in the world, and unequal gender relationship prevails in many provinces. A Chinese's study has reported that the overall prevalence of domestic violence in husbands was 40.0%. Experience of emotional violence in the past was associated with pain or discomfort feelings [13]. However, it is still under research in China. In this study, we aimed to explore the reasons of emotional abuse and the potential factors of adverse mental outcome.

Study design
The study was a cross-sectional, online-based survey of married women in the Guangdong Province, China. The target population was married women from different age groups that were collected through a convenience sampling technique. There were women from in different institutions, colleges and lay people who access to the internet. Our online survey was developed using Questionnaire survey software, and was conducted from 1 st Sept to 30 th Sept in 2015. The survey was anonymous and opened to all women residents aged 20 years and above who lived in Guangdong Province, China.
The survey was promoted on the web sites of a number of communities. The entry page to the survey provided detailed information about the survey, including the study aim, potential privacy and expected benefits. All participants must provide consent to the survey by acknowledging their understanding of the provided information before they were enrolled into the survey. At the end of the survey, participants were offered network currency, which can be spent on the internet. After the survey terminated, married women were included for meaningful analysis.
Demographic information including age, marital status, occupation, education background, monthly income and number of children were collected. Understanding and experience of emotional violence from intimate partners were investigated, followed by assessment of anxiety and depression status. A total of 810 females participated in the survey, 18 participants whom their information was incomplete were excluded.
The final sample consisted of 747 Chinese married females. Emotional abuse in marriage was defined as being indifferent or perfunctory to their partner, barely communicates or has stopped intimacy with their partners. Participants were asked about their past experience of emotional neglect from intimate partners, whether they ever had emotional abuse against their partners and the duration of the last cold violence, major causes of emotional abuse and their suggested solution to domestic cold violence.

Anxiety and depression
Anxiety was assessed by Generalized Anxiety Disorder 7-item, which is based on the DSM-criteria for generalized anxiety disorder. Each item is reported on a four-point scale (0=not at all, 3=almost every day). The total score can range between 0-21. Scores less than 5 were categorized as 'normal'. Scores ranging from 5 to 9 were considered mild anxiety, scores of 10-14 were considered moderate anxiety, and scores of 15-21 were classified as severe [14,15].
Depression was assessed using the Patient Health Questionnaire (PHQ-9), a 9-items questionnaire that is used for screening in both clinical and research settings [16]. Each of the 9 items can be scored between 0 ("not at all") and 3 ("nearly every day"), and a summary score can range from 0 to 27 [17]. Scores less than 5 were categorized as 'normal', scores of 5-9 were considered mild, scores of 10-14 were considered moderate, and scores of 15-27 were classified as severe; participants who had severe depression should be recommended for anti-depressant treatment [18].
We grouped 'moderately severe' into the category of moderate depression in our analyses. Therefore, PHQ-9 scores were classified into 'mild', 'moderate' and 'severe' depression. In both questionnaires, the answers referred to the participants' experience in the past two weeks. We also collected information such as change in weight or physical discomfort in the last month of the survey.

Ethics
The study was submitted to the Ethics Committee in the first affiliated hospital of Shantou University Medical College for approval. Participants were informed about the content and aim of the questionnaire before survey. All participants were allowed to not answer any question that they perceived to be uncomfortable.

Statistical analysis
All collected data were entered into EpiData 3.0 and analyzed using SPSS 15.0. The percentage of personal characters and answered questions were calculated. Categorical variables between groups (abuse and non-abuse, etc.) were compared using Chi-squared test. A multivariable logistic regression analysis was used to examine associations between socio-demographic factors, predicting the anxiety or depression syndrome; and to explore the associations between emotional violence and anxiety or depression symptoms. Robust variance estimation was used to calculate the 95% Confidence Intervals (CI). All two-tailed p-values less than 0.05 were considered statistically significant.

Results
The socio-demographic characteristics of the study participants with and without emotional abuse are shown in Table 1. All participants were aged between 20-55 years. There were 214 women reported having emotional abuse by their husbands and 533 women did not have such experiences. The two groups were significantly different in age, education background, professional status, monthly income and number of children. Table 2 shows the self-reported prevalence of experiencing the emotional abuse from husband. In total, 214 (27.0%) women experienced emotional abuse or neglect in different frequency, 180 (22.72%) women experienced cold violence that last within six months and 34 (4.29%) women had such experience longer than a year.

Self-reported emotional abuse
The top three major causes of emotional violence were personality clashes (61.99%), great pressure (71.72%) and traditional perception of women being inferior to men (31.99%). The majority (90.15%) of them would choose communication as the first possible solution to stop emotional abuse, whereas 16.16% of them would call upon divorce.

Prevalence of anxiety and depression
The characteristics of women with and without anxiety (GAD-7 ≥ 5 and GAD-7<5) or depression (PHQ-9 ≥ 5 and PHQ-9<5) in abuse group and non-abuse group are respectively presented in Table 3. Among 214 emotional abuse victims, 65.9% and 75.8% had any degree of anxiety and/or depression.
Among 533 participants who did not experience emotional abuse, 41.5% and 55.5% had any degree of anxiety and/or depression. Most participants who developed anxiety or depression in violence group were aged within 26-35 (anxiety 55.3%, depression 50.6%), had college or bachelor degree (anxiety 76.6%, depression 78.4%), working in business, enterprise or government personnel (anxiety 38.4%, depression 38.9%) and with monthly income between 3001-6000 yuan (anxiety 40.0%, depression 44.7%).     [25]. It is easier to understand physical violence and sexual violence than domestic cold violence. A network forum survey reported that 54% of people believed that men deliberately left out his wife was not considered a domestic violence, there were up to 77% of people thought that such behavior does not require social intervention [26]. In our study, only half of the women had general idea of what emotional abuse is in family, and 22.75% of them had very clear conception.

Causes of emotional abuse
In China, women were traditionally perceived as being inferior to men. As a result of such patriarchal ideology, women are usually in the disadvantaged group. In this study, most emotional victims were females between 26-35 years old, mostly at the beginning of a marriage. Harmonious living is a major family subject for both men and women. As most Chinese regard, domestic disgrace should not be made known to public because that would violate privacy and negatively influence the reputation of family. Emotional abuse is not as easily identified as physical abuse because it is a hidden impairment that exhibits no physical scar or wound. Due to limited physically injurious forms of abuse detected and lack of evidence of injury, it is very difficult to prove an individual has been emotional abused. Therefore, it will not be subject to legal sanctions but to realize the purpose of torturing the partner. Pride was associated with fear of being judged and socially

Discussion
Domestic violence has become a global issue that exists across regions, races and nationalities. Its harmfulness and seriousness have aroused wide attention from all walks of life. However, there is little research on the quantitative study of psychological violence in China. Emotional abuse, which is popularly called "Cold violence" in China, has become a social issue nationwide. The National Bureau of Statistics website announced that the population of China has reached 1.37 billion people since the end of 2014, with females account for 667 million (Statistical Communiqué of the People's Republic of China on the 2014 National Economic and Social Development, 2014). China's Law Society (2003) has surveyed more than 3500 domestic families and discovered more than 60% of those families have been experiencing cold violence [19]. The incidence of cold violence is much higher than physical abuse. However, research on such violence against women is limited. Our study showed that 27.0% of Chinese women had experienced emotional abuse or neglect, which is lowered than the Iran study that reported 44% of emotional violence [20], but higher than a national survey in Mexico, the prevalence of emotional and physical violence were 18.5% and 16.8% respectively [21]. Emotional violence was found to be the most common form of violence [22]. In their studies, the relationship between mental health and violence against women was found in certain people with depression; anxiety, drug misuse and suicidal thoughts were higher in women of emotional victims [12]. Another Pakistan research [23] indicated that 51% of women confronted with violence suffered from physical problems such as nervous headache, stomachache, fatigue, beating and ill-speaking, anxiety and sleeping disorder.

Poor understanding of domestic cold violence
In China, domestic cold violence is known as the indifference to  stigmatized because that would result in emotional as well as material consequences [27]. The findings of the study showed that there was a statistically significant relationship between educational background and violence. It revealed a tendency that higher education degree was associated with greater likelihood of experiencing cold violence. That is because better educated individuals fully realize that the existing laws forbid physical violence but not emotional abuse. Victims would rather remain silence and tolerate, instead of having physical conflicts. A recent research on 3,893 married Malawian women has found that women's level of education is a significant predictor of their likelihood of experiencing intimate partner violence by her current husband [28], which was similar to other studies that have confirmed that women with higher educational attainment are less likely to be tormented by their husbands than women with lower educational attainment [29].

Impact of domestic cold violence on mental health in victims
When being treated with harmful emotional behavior, a spouse may feel unhappy, stressed and, even worse, a sense of depression. Previous studies have demonstrated that health problems are associated with experiencing harmful behavior from a partner. The most frequently reported consequence is feeling anxious or depressed. It has been reported that harmful behaviors are associated with a twofold to threefold increased odd of anxiety and depression symptoms in men experiencing or perpetrating harmful behaviors from their partners [30,31]. Women, who are exposed to physical or psychological spousal violence, are more likely to experience symptoms of depression, anxiety, psychogenic non-epileptic seizures and psychotic disorders [32]. In consistent with those results, our study revealed that among 214 emotional abuse victims, 65.9% have any degree of anxiety, 75.8% have depression and 10 of them had severe depression. This finding is also similar to another Chinese investigation in 2011, using Hamilton Depression Scale and questionnaire in 98 patients with depression, found that depressed patients with domestic cold violence had higher suicide rate than those without domestic cold violence [33]. Domestic cold violence is one of the risk factors for depression or psychological trauma [34]. Being exposed to emotional violence from intimate partner itself can be considered a risk factor of women's mental health. However, so far in China, there is little social support from the society to help female victim out of emotional abuse or recovering their mental health. Thus, our study requests the Government or Women's Rights Protection Agency to take appropriate actions on preventing and terminating the "domestic cold violence" in Chinese family.

Limitations
There are some limitations in this study. Although it is convenient to recruit applicable participants through the internet, it cannot be certain that all provided answers were credible. However, a face-toface interview on such private issues may not be available. Second, the sample size should be larger with participants recruited from various provinces to extend the generalizability of our findings. A nationwide population-based study would be more useful to more accurately reveal the prevalence of emotional abuse and assess its contributing factors. Third, some potential factors of emotional abuse, anxiety or depression, such as the lifestyle of participants' parents in their childhood from male partner. Last, suicidal attempt should be investigated and indepth interview should be carried out to further explore the possible reasons.

Conclusion
In summary, our finding has described that emotional violence from husband was associated with a significant increased anxiety and depressive symptoms in wife.
Emotional abuse in marriage is an important social problem that can be a great threat to the stability of a family and the physical and mental health of intimate partner or even their children. More awareness should be made on emotional abuses and neglects in women deserve more public awareness and support. This pilot study is to encourage further investigation large sample on the prevalence of intimate emotional abuse against women in China.