The complexities of TBI following domestic violence: effects on injury pathology, cognition and mood

Written by Sarah C Hellewell (University of Sydney, Australia)

The World Health Organization estimates that one in three women will experience violence at the hands of a domestic partner in their lifetime [1]. Despite this, domestic violence remains an under-reported and under-studied cause of traumatic brain injury (TBI), with complex barriers to diagnosis and post-injury management. Whether subconcussive, mild or severe, the pathology arising from this type of head injury has consequences for cellular function and inflammation, which are often heightened due to the frequently repeated nature of injury.

TBI arising from domestic violence is also likely to occur in a setting of fear for personal safety alongside new or longstanding anxiety and depression, the presence of which may exacerbate pathology and worsen cognitive and emotional outcomes. This article will discuss the difficulties in diagnosing TBI arising from domestic violence, the ensuing brain pathology and the long-term emotional and cognitive difficulties victims may face, with an aim to provide an overview of the current state of the literature. While people of any gender identity may be victims of domestic violence, the literature has overwhelmingly focused on experiences of women, and thus this article will largely report findings in women.


Difficulties in diagnosing domestic violence-related TBI

TBI of any cause can be hard to diagnose because it presents with a broad range of symptoms and individual experiences [2]. The ‘classic’ signs of head injury are dizziness, confusion, loss of consciousness, headache and vomiting, but absence of these symptoms does not necessarily indicate an absence of injury. TBI due to domestic violence may be additionally hard to diagnose because patients may be reticent to disclose the cause, may have memory loss or neurological issues, or may downplay the extent of their symptoms due to shame or fear of the perpetrator and the implications of reporting [3]. While a majority of domestic violence victims do not seek medical care at all, recent research suggests that over 80% of women who do seek medical help after domestic violence have experienced a TBI [4].

Pathological consequences of domestic violence-related TBI

“The initial (or primary) injury may cause contusion or hemorrhage in the brain tissue due to blows to the head [6], or may result in widespread damage to neurons without an obvious lesion [7]. This so-called ‘diffuse’ injury is especially common in domestic violence…”

TBI occurs on a spectrum of severity from subconcussive [5] (i.e., head injury with no discernable symptoms) to severe TBI, with severity largely based on physical indicators and symptoms. The initial (or primary) injury may cause contusion or hemorrhage in the brain tissue due to blows to the head [6], or may result in widespread damage to neurons without an obvious lesion [7]. This so-called ‘diffuse’ injury is especially common in domestic violence as a result of being shaken, thrown, or struck by (or into) objects [8]. Diffuse pathology cannot currently be detected by clinical imaging (e.g., MRI or CT scans), further complicating diagnosis.

Damage to the brain is partly caused at the time TBI is sustained, however the injury also sets off a cascade of secondary pathological mechanisms in the minutes to hours following TBI, which may extend pathology and worsen outcomes. These include changes to brain biochemistry and metabolism [9], swelling of brain tissue [10] and production of inflammatory mediators [11]. While inflammation is typically a positive response to promote wound healing, inflammation after TBI may be both reparative and damaging. Resident and infiltrating immune cells migrate to areas of damage in an attempt to clean up cellular debris but also produce chemical signals that perpetuate inflammation, to the detriment of the injured brain [12].

Secondary pathology also directly impacts neurons, with damage to cell bodies and axons (cell projections) initiated rapidly after TBI [13]. Degradation of the axon structural proteins allow fluid intake and impede transport of nutrients and waste, causing axons to swell [14, 15]. If the damage is recoverable, these swollen axons may gradually return to normal. However, more severe impairment may lead to breakage of the axon and eventual death to the neuron [16].

Repetitive head injuries arising from domestic violence

Although statistics are difficult to determine, repeated head injuries are thought to be frequently experienced in cases of domestic violence. A study examining repetitive TBI resulting from domestic violence found that 90% of female victims suffered head injuries two- to five-times per year [17], with some women reporting more than 20 individual events in that time [17]. While repetitive head injuries are more likely to be on the milder end of the TBI spectrum, such injuries have negative cumulative effects with regards to pathology, cognition and mood. Deficits with cognition such as memory impairment and difficulty concentrating have been found alongside altered brain structure in sportspeople experiencing repeated subconcussive injuries, particularly in the dorsolateral prefrontal cortex [18], a region crucial for cognition.

Cognitive and mood disorders, and post-traumatic stress

“A recent study also found that women who had domestic violence-related TBIs were 5.9-times more likely to experience PTSD compared to those with TBI experienced due to other causes, such as car accidents or sports-related TBI [24].”

TBI-related cognitive dysfunction is frequent after injury, with more than 60% of battered women reporting problems with concentration, memory and attention [17], while others have documented poorer performance in speed tasks, attention, working memory and response inhibition in victims of domestic violence [19, 20]. These deficits may make victims more reliant on their perpetrators, and decrease ability to make informed choices, access services, and respond in a safe and appropriate manner when domestic violence does occur [21].

An experience of TBI-related domestic violence could significantly increase comorbid depression and post-traumatic stress disorder (PTSD) and depression regardless of prior life experiences [22]. This may be particularly true for cases of repeated injury, where more than 80% of victims report that their experiences of severe, repeated battering resulted in depression and suicidal ideation [23]. A recent study also found that women who had domestic violence-related TBIs were 5.9-times more likely to experience PTSD compared to those with TBI experienced due to other causes, such as car accidents or sports-related TBI [24]. Women diagnosed with domestic violence-related PTSD may also have reductions in frontal and occipital gray matter, which might negatively contribute to cognitive dysfunction [25].

Conclusion

This article has presented an overview of the diagnostic challenges, pathology and outcomes that may be experienced when TBI arises from domestic violence. Although common, such injuries are under-recognized and receive far less research and community attention than TBI from other causes. Increased awareness of presentation and symptoms may aide the clinician in timely diagnosis and post-injury management, while further research is needed to determine the long-term consequences and comorbidities experienced by both female and male victims of TBI-related domestic violence.

References

[1] World Health Organization. Violence against women: intimate partner and sexual violence against women (2016).
www.who.int/violence_injury_prevention/violence/sexual/en/
[Accessed 18 February 2020]

[2] Lauterbach MD, Notarangelo PL, Nichols SJ, Lane KS, Koliatsos VE. Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: insights into psychiatric practice. Neuropsychiatr. Dis. Treat. 11, 1601–1607 (2015).

[3] Murray CE, Lundgren K, Olson LN, Hunnicutt G. Practice update: what professionals who are not brain injury specialists need to know about intimate partner violence-related traumatic brain injury. Trauma Violence Abuse 17(3), 298–305 (2016).

[4] Nemeth JM, Mengo C, Kulow E, Brown A, Ramirez R. Provider perceptions and domestic violence (DV) survivor experiences of traumatic and anoxic-hypoxic brain injury: implications for DV advocacy service provision. J. Aggress. Maltreat. Trauma 28(6), 744–763 (2019).

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[12] Woodcock T, Morganti-Kossmann MC. The role of markers of inflammation in traumatic brain injury. Front. Neurol. 4, 18 (2013).

[13] Povlishock JT. The pathogenesis and implications of axonal injury in traumatically injured animal and human brain. In: VIIth Lubek Workshop on Neurotraumatology – Biomechanic Aspects, Cytologic and Molecular Mechanisms. Lubek, Germany (1997).

[14] Maxwell WL, Graham DI. Loss of axonal microtubules and neurofilaments after stretch-injury to guinea pig optic nerve fibers. J. Neurotrauma 14(9), 603–614 (1997).

[15] Reeves TM, Phillips LL, Povlishock JT. Myelinated and unmyelinated axons of the corpus callosum differ in vulnerability and functional recovery following traumatic brain injury. Exp. Neurol. 196(1), 126–137 (2005).

[16] Büki A, Povlishock JT. All roads lead to disconnection? Traumatic axonal injury revisited. Acta Neurochir. 148(2), 181–193 (2006).

[17] Jackson H, Philp E, Nuttall RL, Diller L. Traumatic brain injury: a hidden consequence for battered women. Professional Psych. Res. Pract. 33(1), 39–45 (2002).

[18] Talavage TM, Nauman EA, Breedlove EL et al. Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion. J. Neurotrauma 31(4), 327–338 (2014).

[19] Stein MB, Kennedy CM, Twamley EW. Neuropsychological function in female victims of intimate partner violence with and without posttraumatic stress disorder. Biol. Psychiatry 52(11), 1079–1088 (2002).

[20] Twamley EW, Allard CB, Thorp SR et al. Cognitive impairment and functioning in PTSD related to intimate partner violence. J. Int. Neuropsychol. Soc. 15(6), 879–887 (2009).

[21] Monahan K, O’Leary KD. Head injury and battered women: an initial inquiry. Health Soc. Work 24(4), 269–278 (1999).

[22] Cimino AN, Yi G, Patch M et al. The effect of intimate partner violence and probable traumatic brain injury on mental health outcomes for Black women. J. Aggress. Maltreat. Trauma 28(6), 714–731 (2019).

[23] Roberts AR Kim JH. Exploring the effects of head injuries among battered women. J. Social Service Res. 32(1), 33–47 (2008).

[24] Iverson KM, Dardis CM, Pogoda TK. Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence. Compr. Psychiatry 74, 80–87 (2017).

[25] Fennema-Notestine C, Stein MB, Kennedy CM, Archibald SL, Jernigan TL. Brain morphometry in female victims of intimate partner violence with and without posttraumatic stress disorder. Biol. Psychiatry 52(11), 1089–1101 (2002).

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The opinions expressed in this interview are those of the interviewee and do not necessarily reflect the views of Neuro Central or Future Science Group.

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