Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence

"A whole ball of all-togetherness": The interwoven experiences of intimate partner violence, brain injury, and mental health

BACKGROUND

Intimate partner violence (IPV) is a global public health crisis, with physical violence leaving IPV survivors at high risk of brain injury (BI). Both BI and IPV have significant physical, psychological, cognitive, and social impacts, including a high risk of mental health concerns, yet there is limited exploration of IPV survivors' experiences with BI and mental health. This study aimed to explore the BI- and mental health-related needs and experiences of IPV survivors from the perspectives of survivors and service providers with the objective of developing knowledge translation materials to raise awareness and support survivors and service providers in addressing these concerns.

METHODS

This qualitative interpretive description study involved 19 semi-structured interviews and two focus group discussions (2-3 participants each) with 24 participants including IPV survivors experiencing BI and mental health concerns as well as IPV, mental health, and BI service providers between October 2020 and February 2021. Three screening questions were used to identify probable BI among survivors. Participants across groups were an average of 48.5±12.7 years old and were predominantly cisgender women (96%), of European origin (75%), with a university degree (71%). Interviews were recorded, transcribed, and thematically analyzed.

FINDINGS

Across interviews, participants spoke about IPV, BI, and mental health as being complex and interrelated experiences that have impacts across the survivor's life and extend well beyond the abusive relationship. Because of the underrecognized nature of BI in IPV, finding and accessing care requires persistence that survivors spoke of as being like "a full-time job." The benefit of making meaningful connections, particularly with other survivors, was highlighted.

CONCLUSIONS

Recognition of BI as a contributing factor shaping the lived experience of IPV survivors; acknowledgement that the impacts of IPV, BI, and mental health are far reaching and long lasting; and reducing barriers to finding and accessing appropriate care are critical to better supporting IPV survivors with BI and mental health concerns. Clinicians should consider BI and its lingering impacts among the IPV survivors with whom they work. Health and social policy that supports integration of care and the reduction of unnecessary barriers should be a priority.

Temporalities of emergency: the experiences of Indigenous women with traumatic brain injury from violence waiting for healthcare and service support in Australia

Globally, traumatic brain injury (TBI) has been recognised as a serious health issue not only because of the immediate impacts at the time the injury occurs but even more so due to the longstanding impacts. Even though TBI is a globally recognised condition, the research is disproportionately focused on its incidence in, and immediate and long-term effects on men. A growing body of research suggests that generally, women who experience family violence are at high risk of TBI and suffer its impacts in ways that reflect gendered differences in the patterns and frequency of violence. In Australia, the social and physical costs of TBI are multiplied for Indigenous women, whose experience of disability and access to healthcare lies at the intersection of gender and race in the historical context of settler colonialism. The present study addresses the need for research into the sociodemographic inequalities that affect access to culturally appropriate hospital care, timely response systems, and flexible, safe and engaged social services. This paper draws on data from interviews and focus groups with Indigenous women, hospital staff and community-based service providers and suggests potential pathways for further research in settler-colonial settings elsewhere in the world.

A Four-Country Study of Strangulation-Related Alterations in Consciousness in Women Who Have Experienced Intimate Partner Violence: Co-Occurrence with Traumatic Brain Injuries and Measures of Psychological Distress

At least one in three women experience intimate partner violence (IPV) in their lifetime. The most commonly sustained IPV-related brain injuries include strangulation-related alterations in consciousness (S-AICs) and traumatic brain injuries (TBIs). Moreover, survivors of IPV-related S-AICs and/or TBIs often demonstrate psychological distress such as depression, anxiety, and post-traumatic stress. However, the co-occurrence of S-AICs and TBIs, and whether such TBIs may be moderate to severe, has not been systematically examined, and most data have been collected from women in North America. The purpose of this study was to examine the co-occurrence of IPV-related S-AICs and TBIs across a range of geographical locations and to determine the extent to which these S-AICs are related to psychological distress. Women who had experienced physical IPV (n = 213) were included in this secondary analysis of retrospectively collected data across four countries (Canada, the United States, Spain, and Colombia). The Brain Injury Severity Assessment (BISA) was used to assess IPV-related BI across all sites. Because various questionnaires were employed to assess levels of depression, anxiety, and post-traumatic stress disorder at each site, we created a standardized composite score by converting raw scores into Z-scores for analysis. Mann-Whitney U tests and chi-square tests were conducted to examine differences between women with and without experience of S-AICs and to discover if there was a relationship between the occurrence of S-AICs and TBIs. Analysis of variance and analysis of covariance (to control for the potential confounding effects of age, education, and non IPV-related TBI) were used to compare levels of psychological distress in women who had or had not experienced S-AICs. Approximately, 67% of women sustained at least one IPV-related BI (i.e., TBI and/or S-AIC). In a subsample of women who sustained at least one IPV-related BI, approximately 37% sustained both S-AICs and TBIs, 2% sustained only S-AICs (with no TBIs), and 61% sustained TBIs exclusively (with no S-AICs). Furthermore, women who had sustained S-AICs (with or without a TBI) were more likely to have experienced a moderate-to-severe BI than those who had not sustained an S-AIC (BISA severity subscale: U = 3939, p = 0.006). In addition, women who experienced S-AICs (with or without a TBI) reported higher levels of psychological distress compared with women who never experienced S-AICs, irrespective of whether they occurred once or multiple times. These data underscore the importance of assessing for S-AIC in women who have experienced IPV and when present, to also assess for TBIs and the presence of psychological distress. Unfortunately, there were methodological differences across sites precluding cross-site comparisons. Nonetheless, data were collected across four culturally and geographically diverse countries and, therefore, highlight IPV-related BIs as a global issue that needs to be aggressively studied with policies established and then implemented to address findings.

Testing the Spillover Effect of Intimate Partner Violence Victimization on Emotionally Abusive and Harsh Parenting Practices: The Application of Propensity Score Matching

Prior research reported a significant association between intimate partner violence (IPV) victimization and negative parenting, but there was an overreliance on U.S. samples and families from low socioeconomic status backgrounds. Therefore, this quasi-experimental study examined the association between recent IPV victimization and abusive parenting practices in a sample of community-based women from Poland. Participants were mothers of children aged 2 to 5 years (N = 610) attending an outpatient clinic located in a city in south-eastern Poland. Mothers were asked about their IPV experiences in the past 12 months and were classed as either IPV positive or IPV negative. Outcome measures assessed emotionally abusive and harsh parenting practices. All data were collected online. To reduce bias in background characteristics (i.e., age, education, employment status, financial distress, self-esteem, childhood violence history, alcohol problems, current mental distress, social support, exposure to COVID-19-pandemic-related stressors, and child sex), we applied the propensity score matching (PSM) technique. Group differences before and after matching were examined using independent samples t-tests. Prematching analyses revealed that IPV-positive mothers used significantly more emotionally abusive and harsh parenting practices than IPV-negative mothers. However, the two samples differed substantially on six background characteristics which are known risk factors for IPV and child maltreatment (financial distress, self-esteem, childhood violence history, current mental distress, social support, and exposure to COVID-19-pandemic-related stressors). PSM was successful in reducing those imbalances. Postmatching group comparisons were statistically nonsignificant for emotionally abusive and harsh parenting, disproving the spillover hypothesis. We conclude that IPV victimization is not related to emotionally abusive and harsh parenting practices when controlling for confounding variables.

Investigating the Efficacy of a Community Support Network Rehabilitation Intervention for Improving Resiliency, Quality of Life, and Neurocognitive Function in Survivors of Intimate Partner Violence-Caused Brain Injury: Protocol for a Feasibility Study

BACKGROUND

Globally, approximately 1 in 3 women experience intimate partner violence (IPV) in their lifetime. Brain injury (BI) is a common, yet often unrecognized, consequence of IPV. BIs caused by IPV tend to be mild, occur repetitively over the course of months or years, are remote in time, and result in chronic symptoms. Similar to BI from other causes, therapeutic treatment for women with IPV-caused BI (IPV-BI) is crucial to help resolve any physical or cognitive impairments, enhance the quality of life (QoL), and minimize longer-term neurodegeneration.

OBJECTIVE

This study aims to investigate the feasibility and efficacy of a community support network (CSN) rehabilitation intervention regarding its impact on resiliency, QoL, and neurocognitive function.

METHODS

In this pre- and postexperimental design, women (aged 18 to 50 years) who are survivors of IPV and IPV-BI will be recruited from various community organizations serving survivors of IPV. Exclusion criteria will include current pregnancy and any diagnosed neurological disorder known to affect cerebrovascular, neurocognitive, or sensorimotor function. A CSN rehabilitation intervention that includes aerobic exercise, cognitive training, mindfulness meditation, and counseling will be administered. A trauma-informed approach will be integrated into the design and implementation of the program. Furthermore, the program will include a participant navigator who will provide trauma- and violence-informed advocacy and systems navigation support to participants, in addition to facilitating a monthly peer support group. The intervention will be provided for 2.5 hours a day and 2 days a week for 3 months. Participants will complete psychological assessments and provide clinic-demographic information in the first assessment. In the second (before intervention), third (after intervention), and fourth (at follow-up) sessions, they will complete tests of resiliency, QoL, and neurocognition. The estimated sample size is 100. The objective of this study will be accomplished by quantitatively measuring resiliency, QoL, and neurocognition before and immediately after the intervention. A follow-up assessment will occur 3 months after the completion of the intervention to evaluate the maintenance of any improvements in function. One-way ANOVAs will be used to evaluate the intervention outcome across the testing times. Relationships among various variables will be explored using regression analysis.

RESULTS

We anticipate that the CSN rehabilitation intervention will be effective in improving resiliency, QoL, and neurocognitive function in women who have experienced IPV-BI. Furthermore, we anticipate that this intervention will be feasible in terms of study recruitment, adherence, and retention.

CONCLUSIONS

The CSN rehabilitation intervention will have a positive impact on resiliency, QoL, and neurocognitive functions in survivors of IPV-BI. Subsequently, a comparative study will be conducted by recruiting a control group receiving usual care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54605.

Intimate Partner Violence, Mental Health, and Aging-Related Health Among Men and Women Veterans Across the Lifespan

BACKGROUND

A growing body of evidence suggests adverse health outcomes related to intimate partner violence (IPV), including traumatic brain injury (TBI). However, most research in this area has focused on reproductive-aged women.

OBJECTIVE

To examine relationships between IPV (with and without TBI), mental health, and aging-related health outcomes among men and women Veterans across the lifespan.

DESIGN

Cross-sectional analysis of Department of Veterans Affairs (VA) administrative data from fiscal years 2000-2019. Descriptive statistics and chi-square analyses were used to compare key comorbidities in matched samples of Veterans with and without IPV (gender-stratified and matched 1:3 based on demographics and index date). Comparisons between those with IPV and TBI relative to IPV alone were also examined.

SUBJECTS

Veterans aged 18 + with and without documented IPV in Department of Veterans Affairs (VA) electronic health records (n = 4108 men, 2824 women).

MAIN MEASURES

ICD codes were used to identify IPV, TBI, and aging-related medical (sleep disorder, hypertension, diabetes, dementia) and common psychiatric (depression, posttraumatic stress disorder, alcohol use disorder, and substance use disorder) diagnoses.

KEY RESULTS

Demographic characteristics were reflective of VA-enrolled Veterans (men: mean age 66, SD 16; 72% non-Hispanic White; women: mean age 47, SD 13; 64% non-Hispanic White). Relative to Veterans without IPV, both men and women with IPV had higher rates of all examined medical (e.g., sleep disorders, men: 33% vs. 52%; women: 45% vs. 63%) and psychiatric diagnoses (e.g., depression, men 32% vs. 74%; women 59% vs. 91%; all ps < .001), with evidence of an additive effect of TBI on some psychiatric outcomes.

CONCLUSIONS

IPV is broadly associated with aging-related and mental health, and TBI is a common correlate that may further contribute to psychiatric outcomes. Findings highlight the importance of trauma-informed care and recognizing the potential role of these exposures on men and women Veterans' health across the lifespan.

Exploring the Relationships Between Rehabilitation and Survivors of Intimate Partner Violence: A Scoping Review

Intimate partner violence (IPV) is a public health crisis affecting one in three women and one in ten men in their lifetimes. Rehabilitation professionals are highly likely to encounter survivors of IPV in their practice; yet, there exists no formal review assessing the relationship between IPV and rehabilitation. Our objective was to understand the types and contexts of rehabilitation care currently available for survivors of IPV, opportunities identified in the literature for rehabilitation care, and IPV awareness and education among rehabilitation providers. A search strategy related to IPV and four rehabilitation professionals of interest (occupational therapy, physiotherapy, speech-language pathology/therapy, and physiatry) was developed across 10 databases and complemented by a gray literature search. Two reviewers independently assessed articles for inclusion. In all, 44 articles met inclusion criteria, ranging from primary research articles (48%) to clinical newsletters. Included articles predominantly focused on opportunities for rehabilitation care (68%) and occupational therapists as a profession (68%). A minority of studies examined specific interventions for IPV survivors (18%) or assessed for knowledge and attitudes about IPV (16%) among rehabilitation professionals. To our knowledge, this is the first scoping review exploring the rehabilitation literature for IPV survivors. These findings show an awareness of IPV among rehabilitation professionals, the importance of identifying IPV in clients, and the ways in which rehabilitation professionals are uniquely situated to support survivors of IPV. There remains an opportunity to explore interventions designed specifically for IPV survivors.

IPV survivors' and service providers' perspectives on brain injury screening/evaluation process and impact

This study explores the perspectives of intimate partner violence (IPV) survivors and staff of brain injury (BI) screening, and the neuropsychological evaluation (NPE) process. We gathered qualitative data from 17 participants - 10 IPV survivors, at risk for a BI, who had received BI screening and a NPE and a total of 7 staff in IPV-serving organizations. Interviews were recorded, transcribed verbatim and analysed for key themes using thematic analysis. Survivors were over 18 years of age; the majority were between 19 and 45 years old, unemployed, unmarried, and had children. Survivors were angry, scared, and embarrassed to learn that they might have an IPV-related BI. They were thankful to have an explanation for some of their cognitive symptoms, which disrupted their daily activities, social relationships, and overall quality of life. Staff were pleased to be able to provide valuable information to their clients that could have a positive impact on their wellbeing. Overall, screening for a BI and participation in the NPE were well tolerated by IPV survivors with a possible BI. Inclusion of the perspectives of IPV survivors and support staff is an essential first step to better understanding their needs so interventions can be developed to aid their recovery.

Post-Concussion Symptoms in Women With Head Injury Due to Intimate Partner Violence

Limited research has examined the symptom sequelae of head injuries in women survivors of intimate partner violence (IPV), despite this community being at increased risk for neurotrauma due to partner abuse. The current study compared post-concussion symptom severity between women with and without IPV-related head injuries. Women were recruited from court jurisdictions in Kentucky, USA, after receiving a protective order for partner abuse. The sample included 268 women with no prior head injuries (age: M[standard deviation (SD)] = 31.8[9.8], 77.2% White) and 251 women with lifetime IPV-related head injuries (age: M[SD] = 31.8[9.8], 88.0% White). Women with IPV-related head injuries were slightly older (t = 2.46, p = 0.014) with lower education (χ2 = 5.81, p = 0.016), were more frequently unemployed (χ2 = 9.23, p = 0.002), and had a higher likelihood of residing in a rural setting (χ2 = 30.16, p < 0.001). Women with IPV-related head injuries were also more often White (χ2 = 10.47, p = 0.001), but this group difference was almost entirely related to rural versus urban residence. Women with IPV-related head injuries reported a higher severity of lifetime physical IPV (t = 7.27, p < 0.001, d = 0.64, 95% confidence interval [CI]: [.46, .82]) and sexual IPV (t = 4.65, p < 0.001, d = 0.41 [0.24, 0.59]). A three-factor model of post-concussion symptoms, inclusive of cognitive, physical, and emotional symptoms, fit well (χ2 = 368.99, p < 0.0001, comparative fit index [CFI] = 0.974, Tucker-Lewis index [TLI] = 0.968, root mean square error of approximation [RMSEA] = 0.079 [0.071, 0.087]), and showed evidence for strong measurement invariance across women with and without IPV-related head injuries. The subscale and total scores each had acceptable reliability: cognitive (ω = 0.88 [0.86, 0.90]), physical (ω = 0.74 [0.70, 0.77]), and emotional (ω = 0.88 [0.86, 0.89]), and total score (ω = 0.93 [0.92, 0.95]). Women with IPV-related head injuries reported all individual post-concussion symptoms at a significantly higher frequency, with medium group differences in cognitive (t = 7.57, p < 0.001, d = 0.67 [0.50, 0.85]) and physical symptoms (t = 7.73, p < 0.001, d = 0.68 [0.51, 0.86]) and large group differences in emotional (t = 8.51, p < 0.001, d = 0.75 [0.57, 0.93]) and total symptoms (t = 9.07, p < 0.001, d = 0.80 [0.62, 0.98]). All sociodemographic characteristics were independently associated with post-concussion symptoms, as were physical IPV (total score: r = 0.28 [0.19, 0.35], p < 0.001) and sexual IPV severity (total score: r = 0.22 [0.13, 0.30], p < 0.001). In hierarchical regression analyses, controlling for sociodemographic characteristics (i.e., age, race/ethnicity, education, unemployment, and rural/urban residence) and physical and sexual IPV severity, IPV-related head injury was independently significant and accounted for significant additional variance when predicting cognitive (ΔR2 = 0.05, p < 0.001), physical (ΔR2 = 0.03, p < 0.001), emotional (ΔR2 = 0.07, p < 0.001), and total symptoms (ΔR2 = 0.06, p < 0.001). Negative-binomial regression resulted in similar findings. This study demonstrates that multiple sociodemographic and IPV history variables are related to post-concussion symptom severity, but IPV-related head injury was independently associated with greater symptom severity. Women with IPV-related head injuries may be at increased risk for unaddressed health problems spanning cognitive, physical, and emotional domains. Future research is needed to psychometrically evaluate assessment instruments for this population and to assess efficacy of interventions to address their unique health care needs.

Head Injury Due to Intimate Partner Violence: Injury Characteristics, Subacute Symptoms, and Receipt of Care

Women survivors of intimate partner violence (IPV) have increased risk of repetitive neurotrauma in their lifetime but have received less research focus compared with populations of athletes, veterans, and emergency department patients. The current study examined the importance of IPV as a contextual mechanism of injury, by comparing women survivors of IPV based on whether they experienced a head injury due to IPV or a head injury not due to IPV. The analyses involved archival data from in-person interviews conducted with women who received a protective order against an intimate partner in Kentucky from 2001 to 2004 (n = 641). Women were excluded if they reported no head injury history (n = 268), resulting in two groups compared based on a retrospective cohort design: 255 women with at least one self-reported IPV-related head injury (M = 33.8 ± 9.0 years old, range: 19-65; 87.5% White) and 118 women with self-reported head injuries due to reasons other than IPV (M = 32.2 ± 9.1 years old, range: 18-62; 89.0% White). Participants were compared on injury characteristics, lifetime physical and sexual IPV severity, subacute symptoms of head injury, and receipt of care for head injury. Compared with women with head injuries unrelated to IPV, women with IPV-related head injuries reported a higher number of lifetime head injuries (Mdn[range]: IPV-related = 3[1-515] vs. non-IPV-related = 1[1-13], p < 0.001, r = 0.51) and a higher number of head injuries involving loss of consciousness (Mdn[range]: IPV-related = 1[1-35] vs. non-IPV-related = 1[1-4], p < 0.001, r = 0.27), but lower rates of hospitalization (IPV-related = 56.1% vs. non-IPV-related = 73.7%, p = 0.001, odds ratio [OR] = 2.20 [95% confidence interval (CI): 1.36, 3.55]) and formal rehabilitation (IPV-related = 3.2% vs. non-IPV-related = 9.4%, p = 0.011, OR = 3.18 [1.24, 8.13]) following head injury. Women with IPV-related head injuries had greater lifetime severity of physical IPV (p < 0.001, d = 0.64 [0.41, 0.86]) and sexual IPV (p < 0.001, d = 0.38 [0.16, 0.60]). Women with IPV-related head injuries endorsed all symptoms at greater rates than women with non-IPV-related head injuries (ps < 0.001), including physical (e.g., headaches: OR = 3.15 [1.81, 5.47]; dizziness: OR = 2.65 [1.68, 4.16]), cognitive (e.g., trouble problem solving: OR = 2.66 [1.53, 4.64]; inattention: OR = 2.39 [1.52, 3.78]), and emotional symptoms (e.g., depression: OR = 7.39 [4.48, 12.20]; anxiety: OR = 4.60 [2.82, 7.51]). The total count of symptoms endorsed was higher for women with IPV-related head injury than women with head injuries unrelated to IPV (p < 0.001, d = 0.71 [0.49, 0.94]). When controlling for lifetime physical and sexual IPV, IPV-related head injury was independently associated with symptom count (β = 0.261, p < 0.001) and accounted for additional variance in symptom count (ΔR2 = 0.06, p < 0.001). Among women survivors of IPV, those reporting IPV-related head injuries reported greater subacute symptoms, but a lower likelihood of being hospitalized or receiving rehabilitative care. Women with self-reported IPV-related head injuries represent an underserved population that is often unevaluated following injury and may have many unmet care needs. Future studies should examine persistent symptoms following IPV-related head injuries and interventions that would be most beneficial for this population.

Traumatic brain injury screening and neuropsychological functioning in women who experience intimate partner violence

Objective: The potential for traumatic brain injury (TBI) to occur as the result of intimate partner violence (IPV) has received increased interest in recent years. This study sought to investigate the possible occurrence of TBI in a group of women who survived IPV and to measure the specific profile of cognitive deficits using standardized neuropsychological measures. Method: A comprehensive questionnaire about abuse history; neuropsychological measures of attention, memory and executive functioning; and measures of depression, anxiety and post-traumatic stress disorder were given to women who were IPV survivors, women who were sexual assault (SA) survivors, and a comparison group of women who did not experience IPV or SA. Results: Overall, rates of potential TBI, as measured by the HELPS brain injury screening tool, were high and consistent with previous studies. Consistent with potential TBI, lower scores were demonstrated on measures of memory and executive functioning compared to survivors of SA or those not exposed to violence. Importantly, significant differences on measures of memory and executive functioning remained, after controlling for measures of emotion. Of note, cognitive changes were highest among women who experienced non-fatal strangulation (NFS) compared to IPV survivors who did not. Conclusions: Rates of TBI may be high in women who survive IPV, especially those who survive strangulation. Better screening measures and appropriate interventions are needed as well as larger studies that look at social factors associated with IPV.

Profiles of Intimate Partner Violence Victimization: A Systematic Review

Person-centered approaches, such as latent class analysis (LCA) and latent profile analysis (LPA), aid the identification of subgroups within sample populations. These methods can identify the patterns of co-occurrence between different forms of intimate partner violence (IPV), providing valuable information for prevention and intervention efforts. The aim of this systematic review was to yield a summary and conduct a critical evaluation of the current research that utilizes LCA/LPA to investigate IPV victimization profiles. We provide an outline of 14 relevant studies, retrieved from searches conducted on PsycInfo, Scopus, and Eric databases. There was a large amount of variability in relation to the forms of IPV assessed, measures utilized, number of classes identified, and the sample populations recruited. However, broad similarities were revealed as there were some commonly identified classes, including the no/low violence class, the physical and psychological victimization class, and the multiple victimization class, yet the labels assigned to those classes differed across studies. A range of external criteria (risk factors and consequences) were also identified as being associated with class membership. We highlight the methodological features which may have impacted data collection and class enumeration, including the differences in sample population, the range of IPV indicators assessed, the time period from which IPV data were recorded, and whether data were collected regarding participants' current or previous relationships. Marginalized populations were underrepresented, and psychological abuse was most inconsistently operationalized. Recommendations for future research are provided, including recommendations with regard to labeling the classes for greater consistency across studies.

Differences in Symptom Report by Survivors With and Without Probable Intimate Partner Violence-Related Brain Injury

Survivors of intimate partner violence (IPV) are at heightened risk of sustaining a brain injury (BI). Problematically, a high overlap between BI and trauma symptoms leads to difficulties in identifying when an IPV-related BI has occurred. This paper investigated differences in symptom reports between survivors with (n = 95) and without (n = 42) probable IPV-related BI. Chi-squared analyses isolated a constellation of symptoms found to be specifically associated with BI status. These symptomatic markers may assist professionals in discerning BI from other comorbid conditions present in IPV, and thus help survivors access BI-specific treatments and resources.

Screening for Brain Injury Sustained in the Context of Intimate Partner Violence (IPV): Measure Development and Preliminary Utility of the Brain Injury Screening Questionnaire IPV Module

Abstract Intimate partner violence (IPV) is associated with risk for multi-etiology brain injury (BI), including repetitive head impacts, isolated traumatic brain injuries (TBI), and anoxic/hypoxic injury secondary to nonfatal strangulation (NFS). IPV-related injuries are often unreported, but evidence suggests that survivors are more likely to report when asked directly. There are currently no validated tools for screening of brain injury related to IPV that meet World Health Organization guidelines for this population. Here, we describe measure development methods and preliminary utility of the Brain Injury Screening Questionnaire IPV (BISQ-IPV) module. We culled items from existing IPV and TBI screening tools and sought two rounds of stakeholder feedback regarding content coverage, terminology, and safety of administration. The resulting stakeholder-informed BISQ-IPV module is a seven-item self-report measure that uses contextual cues (e.g., being shoved, shaken, strangled) to query lifetime history of IPV-related head/neck injury. We introduced the BISQ-IPV module into the Late Effects of TBI (LETBI) study to investigate rates of violent and IPV-specific head/neck injury reporting in a TBI sample. Among those who completed the BISQ-IPV module (n = 142), 8% of the sample (and 20% of women) reported IPV-related TBI, and 15% of the sample (34% of women) reported IPV-related head or neck injury events that did not result in loss or alteration of consciousness. No men reported NFS; one woman reported inferred BI secondary to NFS, and 6% of women reported NFS events. Those who endorsed IPV-BI were all women, many were highly educated, and many reported low incomes. We then compared reporting of violent TBIs and head/neck injury events among individuals who completed the core BISQ wherein IPV is not specifically queried (administered from 2015-2018; n = 156) to that of individuals who completed the core BISQ preceded by the BISQ-IPV module (BISQ+IPV, administered from 2019-2021; n = 142). We found that 9% of those who completed the core BISQ reported violent TBI (e.g., abuse, assault), whereas 19% of those who completed the BISQ+IPV immediately preceding the core BISQ reported non-IPV-related violent TBI on the core BISQ. These findings suggest that standard TBI screening tools are inadequate for identifying IPV-BI and structured cueing of IPV-related contexts yields greater reporting of both IPV- and non-IPV-related violent BI. When not queried directly, IPV-BI remains a hidden variable in TBI research studies.

Neurological Complications Secondary to Intimate Partner Violence: A Brief Review and Case of Posterior Cerebral Artery Cerebrovascular Accident Following Domestic Abuse

Intimate partner violence (IPV) is a growing public health concern, with millions of individuals experiencing IPV each year. Consequences of IPV include psychological disturbances, changes in physical health, and in extreme cases, severe disablement or death. Here, we describe a case of a patient who experienced IPV, leading to a variety of neurological symptoms, and was diagnosed with a posterior cerebral artery (PCA) cerebrovascular accident (CVA) 10 days later. While cases of traumatic brain injury leading to CVA, or stroke, have been documented, there is currently limited reported literature on the neurological complications, specifically stroke, secondary to IPV in adults. Due to this limited reporting, future studies on IPV will be needed to fully understand the long-term neurological complications that may occur.

Exploring the intersection of brain injury and mental health in survivors of intimate partner violence: A scoping review

Rationale

Intimate partner violence (IPV) is the most commonly occurring form of violence against women. The most common site of injury in IPV is the head, face, and neck, resulting in possible brain injury (BI). Independently, mental health (MH) concerns are highly prevalent among both IPV survivors and individuals with BI; however, no systematic review exists on the combined experience of BI and MH in IPV.

Objective

The aim of this review was to describe the identification of and relationships between BI, MH, and IPV in the literature and the implications for health policy and practice.

Methods

A search strategy including text words and subject headings related to BI, IPV, and MH was developed for MEDLINE and translated to EMBASE, PsycINFO, CINAHL, Cochrane, Scopus, and Web of Science. Two reviewers independently assessed articles for inclusion. Articles discussing MH, BI, and IPV in relation to one another were included in the review.

Results

Twenty-eight articles were identified for inclusion. Methods for identifying IPV, BI, and MH were highly variable across studies. Fourteen studies reported significantly higher MH scores in IPV survivors with BI than in those without BI. Articles predominantly focused on cis gender women in heterosexual relationships and the impact of race and ethnicity were largely overlooked. Healthcare access was explored by eight articles, though none discussed the implications of co-occurring BI and MH.

Conclusion

Brain injury and MH are highly prevalent among IPV survivors; however, little research discusses the implication for healthcare. Future research should explore healthcare-related needs and experiences to inform policy and practice and better represent the diversity of IPV survivors.

Battered and Brain Injured: Traumatic Brain Injury Among Women Survivors of Intimate Partner Violence-A Scoping Review

OBJECTIVES

The objective of this scoping review is to examine the extent, range, and nature of literature targeting health-care professionals on the prevalence and outcome of intimate partner violence (IPV)-related traumatic brain injury (TBI). The purpose is to gain an understanding of prevalence, investigate screening tool use, generate IPV/TBI-specific support recommendations, and identify suggestions for future research.

METHOD

The review was guided by Arksey and O'Malley's five stages for conducting a scoping review. A comprehensive search of nine databases revealed 1,739 articles. In total, 42 published research papers that focused specifically on TBI secondary to IPV were included in the study.

SYNTHESIS

The literature reports inconsistencies in prevalence rates from IPV-related TBI. There are no current standardized screening practices in use, though the literature calls for a specialized tool. Frontline professionals would benefit from education on signs and symptoms of IPV-related TBI. Empirical studies are needed to generate reliable data on prevalence, experience, and needs of brain-injured survivors of TBI.

CONCLUSIONS

Findings from this study demonstrate the need for the development of an IPV-sensitive screening tool, more accurate data on prevalence, an interprofessional approach to care, and raised awareness and education on the diffuse symptoms of IPV-related TBI.

The Effect of Intimate Partner Violence on the Physical Health and Health-Related Behaviors of Women: A Systematic Review of the Literature

AIM

The long-term effects of intimate partner violence (IPV) on physical health outcomes and health-related behaviors are underresearched in comparison to the effects on mental health and pregnancy. This systematic review examines the recent research in this area from 2012 through 2019.

METHODS

SCOPUS, PubMed, EBSCOhost, and gray literature were searched using the key words "intimate partner violence" and "health." To meet inclusion criteria, studies needed to be original research and focus on IPV during adulthood and its effects on the physical health or health-related behaviors of women. Fifty-two studies were qualitatively analyzed, with results grouped into broad categories of effects, including cardiovascular, endocrine, infectious diseases, and health screening.

RESULTS

IPV was shown to have negative effects on physical health outcomes for women, including worsening the symptoms of menopause and increasing the risk of developing diabetes, contracting sexually transmitted infections, engaging in risk-taking behaviors including the abuse of drugs and alcohol, and developing chronic diseases and pain. It also has significant effects on human immunodeficiency virus outcomes, worsening CD4+ cell depletion. Results varied regarding the effects of IPV on cardiovascular health outcomes.

CONCLUSION

The result of this review demonstrates that women who have experienced violence and abuse are at significantly increased risk of poor health outcomes in a variety of areas and so require specialized and tailored primary care. This review highlights significant gaps in this field of research, particularly in relation to cardiovascular disease, endocrine dysfunction, and neurological symptoms and conditions. It demonstrates a need for additional long-term studies in this field to better inform the health care of women who have experienced IPV and to establish the physiological mediators of these outcomes.

Sex and gender differences in mild traumatic brain injury/concussion

The high incidence of concussions/mild traumatic brain injury and the significant number of people with persisting concussion symptoms as well as the concern for delayed, neurodegenerative effects of concussions makes them a major public health concern. There is much to learn on concussions with respect to pathophysiology as well as vulnerability and resiliency factors. The heterogeneity in outcome after a concussion warrants a more personalized approach to better understand the biological and psychosocial factors that may affect outcome. In this chapter we address biological sex and gender as they impact different aspects of concussion including incidence, risk factors and outcome. As well, this chapter will provide a more fulsome overview of intimate partner violence, an often-overlooked cause of concussion in women. Applying the sex and gender lens to concussion/mild traumatic brain injury is imperative for discovery of its pathophysiology and moving closer to treatments.

School Discipline as a Consequence of Violent Victimization in Adolescence: Understanding the Mediating Roles of Head Injury and Behavior

Pathways from violence to head injury and poor long-term outcomes have been found among numerous populations, however, have not yet been widely examined with youth exposed to violence. Traumatic brain injuries (TBIs) are linked to a range of consequences salient to adolescent development and well-being, such as impulsivity, academic abilities, and emotional processing. This gap in research has led to a missed opportunity to understand the consequences of youth victimization, particularly within the academic setting. The current study examined whether head injury and problem behaviors mediate the relationships between victimization and suspension/expulsion using data from the Pathways to Desistance Study, a multi-site, longitudinal study of serious adolescent offenders age 14-18. A sample of male youth who had witnessed violence (n = 1,094) reported a total score of victimization, number of early behavior problems (i.e., cheating, fighting, etc.), ever having a head injury (32.9%), and number of times suspended (adjusted M = 13.13; SD = 19.31) or expelled (adjusted M = 0.65; SD = 0.99). Structural equation modeling was used to examine direct and indirect pathways from victimization to suspension and expulsion through head injury and behavior. Direct pathways from victimization to school discipline were significant; indirect pathways mediated by only head injury were not significant, but indirect pathways through only problem behavior and through TBI and problem behavior were significant for both expulsion and suspension. Results suggest that youth who have been victimized are at higher risk for both suspension and expulsion and that this risk may be, in part, explained through increased head injury and problem behaviors. TBI screenings/services for violence-exposed youth and trauma-informed school-based services may help to deter trajectories toward suspension and expulsion but should be developed with attention to the influence of racial bias on pathways to school discipline.

Sex and Gender Science: The World Writes on the Body

Sex and Gender Science seeks to better acknowledge that the body cannot be removed from the world it inhabits. We believe that to best answer any neuroscience question, the biological and the social need to be addressed through both objective means to learn, "how it is like" and subjective means to learn, "what it is like." We call bringing the biological and social together, "Situated Neuroscience" and the mixing of approaches to do so, Very Mixed Methods. Taken together, they constitute an approach to Sex and Gender Science. In this chapter, we describe neural phenomena for which considering sex and gender together produces a fuller knowledge base: sleep, pain, memory, and concussion. For these brain phenomena examples, studying only quantitative measures does not reveal the full impact of these lived experiences on the brain but studying only the qualitative would not reveal how the brain responds. We discuss how Sex and Gender Science allows us to begin to bring together biology and its social context and acknowledge where context can contribute to resolving ignorance to offer more expansive, complementary, and interrelating pictures of an intricate neuro-landscape.

The association of posttraumatic stress disorder, depression, and head injury with mid-life cognitive function in civilian women

BACKGROUND

Despite evidence linking posttraumatic stress disorder (PTSD), depression, and head injury, separately, with worse cognitive performance, investigations of their combined effects on cognition are limited in civilian women.

METHODS

The Cogstate Brief Battery assessment was administered in 10,681 women from the Nurses' Health Study II cohort, mean age 64.9 years (SD = 4.6). Psychological trauma, PTSD, depression, and head injury were assessed using online questionnaires. In this cross-sectional analysis, we used linear regression models to estimate mean differences in cognition by PTSD/depression status and stratified by history of head injury.

RESULTS

History of head injury was prevalent (36%), and significantly more prevalent among women with PTSD and depression (57% of women with PTSD and depression, 21% of women with no psychological trauma or depression). Compared to having no psychological trauma or depression, having combined PTSD and depression was associated with worse performance on psychomotor speed/attention ( β  = -.15, p = .001) and learning/working memory ( β  = -.15, p < .001). The joint association of PTSD and depression on worse cognitive function was strongest among women with past head injury, particularly among those with multiple head injuries.

CONCLUSIONS

Head injury, like PTSD and depression, was highly prevalent in this sample of civilian women. In combination, these factors were associated with poorer performance on cognitive tasks, a possible marker of future cognitive health. Head injury should be further explored in future studies of PTSD, depression and cognition in women.

Impact of mild traumatic brain injury on physical, mental and cognitive functioning of abused women admitted to emergency units

Limited studies exist on women's mild traumatic brain injury received from episode of intimate partner violence. This study aims to identify the occurrence of intimate partner violence-related mild traumatic brain injury in Chinese women admitted to emergency units; and examine the physical, mental, and cognitive functioning of abused women with mild traumatic brain injury related to violent episodes. Eighty-six Chinese abused women presenting at emergency units in four major local hospitals in Hong Kong between January 2014 and December 2016 were recruited. They were admitted for the treatment of intimate partner violence-related physical injuries and were screened for traumatic brain injury by the emergency unit nurses at triage. Participants were assessed for traumatic brain injury based on the definition from US Center for Disease Control and Prevention, post-concussion physical symptoms, anxiety and depression, health-related quality of life, and cognitive functioning. Structured multiphase regression was used to examine the impact of intimate partner violence-related mild traumatic brain injury on physical, mental, and cognitive functioning of participants. We found that 24.4% of participants had intimate partner violence-related mild traumatic brain injury. There were significantly more severe post-concussion physical symptoms in abused women with intimate partner violence-related mild traumatic brain injury than those without mild traumatic brain injury (estimate = 18.7, 95% CI = 10.9 to 26.6, p < 0.001). The Mental Component Summary was also significantly associated with intimate partner violence-related mild traumatic brain injury (estimate = -7.9, 95% CI = -13.8 to -2.1, p = 0.009). Regarding cognitive functioning, the mean total test scores indicated that both groups were cognitively abnormal and there was no significant impact from mild traumatic brain injury. This study provides evidence on the impact of mild traumatic brain injury and implications in screening for mild traumatic brain injury and early intervention for improving quality of life in abused women.

Public Attention and Sentiment toward Intimate Partner Violence Based on Weibo in China: A Text Mining Approach

The mobile internet has resulted in intimate partner violence (IPV) events not being viewed as interpersonal and private issues. Such events become public events in the social network environment. IPV has become a public health issue of widespread concern. It is a challenge to obtain systematic and detailed data using questionnaires and interviews in traditional Chinese culture, because of face-saving and the victim’s shame factors. However, online comments about specific IPV events on social media provide rich data in understanding the public’s attitudes and emotions towards IPV. By applying text mining and sentiment analysis to the field of IPV, this study involved construction of a Chinese IPV sentiment dictionary and a complete research framework. We analyzed the trends of the Chinese public’s emotional evolution concerning IPV events from the perspectives of a time series as well as geographic space and social media. The results show that the anonymity of social networks and the guiding role of opinion leaders result in traditional cultural factors such as face-saving and family shame for IPV events being no longer applicable, leading to the spiral of an anti-silence effect. Meanwhile, in the process of public emotional communication, anger often overwhelms reason, and the spiral of silence remains in effect in social media. In addition, there are offensive words used in the IPV event texts that indicate misogyny in emotional, sexual, economic and psychological abuse. Fortunately, mainstream media, as crucial opinion leaders in the social network, can have a positive role in guiding public opinion, improving people’s ability to judge the validity of network information, and formulating people’s rational behaviour.

Update on Domestic Violence and Traumatic Brain Injury: A Narrative Review

Research on traumatic brain injury (TBI) as a result of domestic violence has greatly increased in the past decade, with publications addressing the prevalence, diagnosis, evaluation, and treatment. Although TBI due to domestic violence has recently been found to occur quite frequently, it was not widely understood until the 1990s. Individuals who suffer from domestic violence TBI often experience sequelae such as decreased cognitive functioning, memory loss, and PTSD. The goal of this article is to increase awareness about TBI secondary to domestic violence, with the intent that it will highlight areas for future research on the diagnosis, evaluation, and treatment of TBI in this population. The articles in this study were first found using the search terms traumatic brain injury and domestic violence. Although, in recent years, there has been a significant increase in research on TBI due to domestic violence, the overall conclusion of this review article is that there is still a need for future research in many areas including the effects on minority populations, the effects of COVID-19, and improvements of screening tools.

Epidemiology and 6- and 12-Month Outcomes of Intimate Partner Violence and Other Violence-Related Traumatic Brain Injury in Major Trauma: A Population-Based Trauma Registry Study

OBJECTIVE

To compare the epidemiology, in-hospital outcomes, and 6-month and 12-month patient-reported, outcomes of major trauma patients with intimate partner violence (IPV)-related traumatic brain injury (TBI) with other interpersonal violence (OV)-related TBI.

SETTING

Victoria, Australia.

PARTICIPANTS

Adult (≥18 years) major trauma cases with TBI (concussion, skull fracture, or intracranial injury), injured through IPV or OV, between July 2010 and June 2020, and included on the population-based Victorian State Trauma Registry. There were 133 adult major trauma cases due to IPV and 1796 due to OV. The prevalence of TBI was 39% (n = 52) in the IPV group and 56% (n = 1010) in the OV group.

DESIGN

Registry-based cohort study.

MAIN MEASURES

Trauma care indicators and 6- and 12-month patient-reported outcomes (self-reported disability, Glasgow Outcome Scale-Extended, EQ-5D-3L, and return to work).

RESULTS

The annual incidence (95% CI) of major trauma involving TBI was 0.11 (0.08-0.14) per 100 000 population for IPV and 2.11 (1.98-2.24) per 100 000 for OV. A higher proportion of IPV-related cases were women (73% vs 5%), had sustained a severe TBI (Glasgow Coma Scale score 3-8; 27% vs 15%), were admitted to intensive care (56% vs 37%), and died in hospital (14% vs 5%). The median (interquartile range) time to definitive care (4.7 hours vs 3.3 hours) and head computed tomographic scan (5.0 hours vs 3.1 hours) was longer in the IPV group. Follow-up rates at 6 and 12 months were 71% and 69%, respectively. The 6- and 12-month outcomes were generally poorer in the IPV-related group.

CONCLUSION

The incidence of IPV-related major trauma with TBI was low. However, the prevalence of severe TBI, the time to key aspects of clinical care, in-hospital mortality, and longer-term work-related disability were higher. However, power to detect differences was low due to the small number of IPV-related cases compared with the OV group.

Prevalence and Risk Factors for Intimate Partner Physical Violence-Related Acquired Brain Injury Among Visitors to Justice Center in New York

OBJECTIVE

The recent United States Government Accountability Office report highlights the need for improved data on the prevalence of intimate partner violence (IPV)-related acquired brain injury (ABI) to help direct Health & Human Services public efforts. This article identifies the prevalence and risk factors for IPV-related ABI among survivors of IPV at a Justice Center in New York.

SETTING

Community Justice Center.

PARTICIPANTS

Forty survivors of IPV, aged 17 to 73 years (median 32, interquartile range: 25.25, 42) were assessed within 60 days of sustaining physical violence.

DESIGN

Retrospective chart review.

MAIN MEASURES

The HELPS and the Danger Assessment-Revised were used at the initial Center visit.

RESULTS

Of the 40 physical IPV survivors screened, all (100%) reported a prior history of partner-induced ABI within the past 60 days. Thirty-seven (92.5%) survivors also reported sustaining at least 1 potential hypoxic brain injury from strangulation. However, only 16 (40%) survivors screened positive on the HELPS for a history of IPV-related mild traumatic brain injury. Females (95%) and individuals with low income (67.5%) largely comprised our sample. Compared with the County's average, the proportion of African Americans/Blacks and refugees was 227% higher (42.5% vs 13%) and 650% higher (7.5% vs 1.09%), respectively. Refugee status (P = .017) also correlated with number of previous ABIs. On an exploratory binary logistic regression with stepwise selection, only balance difficulties (P = .023) and difficulty concentrating/remembering (P = .009) predicted a positive screen for mild traumatic brain injury.

CONCLUSIONS

Consistent with previous findings, our data indicate a high prevalence of IPV-related ABI among visitors to a New York Justice Center. An overrepresentation of African Americans/Blacks and refugees in our sample relative to the region signified a higher prevalence of IPV in these populations and warrants a provision of more trauma-informed ABI resources to these groups/communities. Intimate partner violence survivors visiting Justice Centers should be screened for motor/neurocognitive symptoms suggestive of mild traumatic brain injury. Further research to identify the prevalence and risk factors of IPV-related ABI statewide and nationwide is urgently needed to improve resource allocation and clinical management.

Longitudinal Analysis of Persistent Postconcussion Symptoms, Probable TBI, and Intimate Partner Violence Perpetration Among Veterans

OBJECTIVE

To determine veterans' intimate partner violence (IPV) perpetration following report of traumatic brain injury (TBI) and persistent postconcussion symptoms (PPCSs).

SETTING

Five Department of Veterans Affairs (VA) medical centers.

PARTICIPANTS

Veterans with nonmissing data on main measures, resulting in N = 1150 at baseline and N = 827 at follow-up.

DESIGN

Prospective cohort study with secondary data analysis of self-reported TBI, PPCSs, and IPV perpetration, controlling for common predictors of IPV, including binge drinking, marijuana use, pain intensity, and probable posttraumatic stress disorder.

MAIN MEASURES

VA TBI Screening Tool to assess for probable TBI and PPCSs; Conflict Tactics Scale-Revised (CTS-2S) to assess for IPV perpetration.

RESULTS

Almost half (48%) of participants reported IPV perpetration at follow-up. Both probable TBI and higher PPCSs at baseline were associated with overall IPV perpetration and more frequent IPV perpetration at follow-up. Only PPCSs significantly predicted IPV perpetration after controlling for common predictors of IPV perpetration. Neither probably TBI nor PPCSs predicted frequency of IPV perpetration.

CONCLUSION

When considered alongside common risk factors for IPV perpetration, PPCS was uniquely associated with the likelihood of IPV perpetration in this veteran sample. Given post-9/11 veterans' elevated risk for head injury, findings emphasize the distinctive value of PPCSs in understanding risk for IPV perpetration. We recommend increased assessment for PPCSs in clinical practice among veterans enrolled in VA care and highlight several important areas for future research and intervention development.

The Intersection of Intimate Partner Violence and Traumatic Brain Injury: Findings From an Emergency Summit Addressing System-Level Changes to Better Support Women Survivors

BACKGROUND

Traumatic brain injury (TBI) occurring during intimate partner violence (IPV) is a largely unrecognized but significant public health crisis. One in 3 women will experience IPV in their lifetime, up to 75% of whom will sustain a TBI as a result. This article reports on the systems-level findings from a national summit to address barriers, needs, and priorities related to healthcare and support services for women survivors of IPV-TBI.

OBJECTIVES

(1) To identify key needs, facilitators, and barriers to care for women survivors of IPV presenting with TBI; and (2) to cocreate ideas for resources and principles for identification, clinical care, and support for healthcare practitioners who treat women exposed to IPV and TBI.

METHODS

Using a community-based participatory research approach, we engaged 30 stakeholders-drawn from a national IPV-TBI Knowledge-to-Practice (K2P) Network including diverse women survivors, service providers, researchers, and decision makers-in 2 half-day virtual meetings. Data were gathered through small group breakout sessions using semistructured discussion guides. Sessions were recorded, transcribed verbatim, and analyzed using thematic analysis techniques. Stakeholders contributed to the analysis and knowledge translation through member-checking activities. Ethics approval was obtained through the University of Toronto.

FINDINGS

Three main systems-level themes arose during these discussions: (1) the need for trauma-informed, anti-racist, and equitable health and social care systems; (2) the need for cross-pollination of knowledge between disciplines; and (3) the need for systems-level support for integrated and coordinated care. This article explores these needs and provides recommendations and suggestions for paths forward.

CONCLUSIONS

The findings of this project enhance understanding of system-level needs among women survivors and provide a template for a national agenda for IPV-TBI research and practice.

Brain Injury and Mental Health Among the Victims of Intimate Partner Violence: A Case-Series Exploratory Study

Intimate partner violence (IPV) survivors frequently report face, head, and neck as their injury site. Many mild traumatic brain injuries (TBIs) are undiagnosed or underreported among IPV survivors while these injuries may be linked to changes in brain function or pathology. TBI sustained due to IPV often occurs over time and ranges in severity. The aim of this case-series study was to explore risk factors, symptoms, and brain changes unique to survivors of intimate partner violence with suspicion of TBI. This case-series exploratory study examines the potential relationships among IPV, mental health issues, and TBI. Participants of this study included six women: 3 women with a history of IPV without any experience of concussive blunt force to the head, and 3 women with a history of IPV with concussive head trauma. Participants completed 7T MRI of the brain, self-report psychological questionnaires regarding their mental health, relationships, and IPV, and the Structured Clinical Interview. MRI scans were analyzed for cerebral hemorrhage, white matter disturbance, and cortical thinning. Results indicated significant differences in resting-state connectivity among survivors of partner violence as well as differences in relationship dynamics and mental health symptoms. White matter hyperintensities are also observed among the survivors. Developing guidelines and recommendations for TBI-risk screening, referrals, and appropriate service provision is crucial for the effective treatment of TBI-associated IPV. Early and accurate characterization of TBI in survivors of IPV may relieve certain neuropsychological consequences.

The Boston Assessment of Traumatic Brain Injury-Lifetime Semistructured Interview for Assessment of TBI and Subconcussive Injury Among Female Survivors of Intimate Partner Violence: Evidence of Research Utility and Validity

OBJECTIVE

To adapt the Boston Assessment of TBI-Lifetime (BAT-L) interview specifically for female survivors of intimate partner violence (IPV), validate the adapted BAT-L/IPV, and report the prevalence of head injury.

SETTING

The BAT-L is the first validated instrument to diagnose traumatic brain injuries (TBIs) throughout the life span for post-9/11 veterans. The BAT-L/IPV was adapted to target diagnostic issues belonging exclusively to IPV while maintaining its life span approach.

PARTICIPANTS

Community-dwelling convenience sample of 51 female survivors of IPV with subthreshold (n = 10) or full diagnostic criteria (n = 41) of posttraumatic stress disorder.

DESIGN

Standard TBI criteria were evaluated using a semistructured clinical interview.

MAIN MEASURES

The BAT-L/IPV is compared with the Ohio State University TBI Identification Method (OSU-TBI-ID) scoring approach as the criterion standard.

RESULTS

Correspondence between the BAT-L/IPV and the OSU-TBI-ID score was excellent (Cohen κ = 0.86; Kendall τ-b = 0.89). Sensitivity = 89.3% (95% CI, 81.2-97.4); specificity = 98.3% (95% CI, 95.0-100); positive predictive value = 98.0% (95% CI, 94.2-100); and negative predictive value = 90.6% (95% CI, 83.5-97.7). On the BAT-L/IPV, more than one-third (35.3%) of IPV survivors reported TBI secondary to an IPV-related assault, 76.5% reported IPV subconcussive head injury, 31.4% reported attempted strangulation, and 37.3% reported non-IPV TBI.

CONCLUSIONS

The BAT-L/IPV performed well in diagnosing TBI in female IPV survivors as compared with the criterion standard. The prevalence of TBI was frequent; subconcussive head injury was pervasive. Greater awareness for head injury risk and increased diagnostic specificity of TBI in IPV survivors is needed.

Strengthening the Connection Between Acquired Brain Injury (ABI) and Family Violence: The Importance of Ongoing Monitoring, Research and Inclusive Terminology

Family violence (FV) harms communities worldwide so FV prevention strategies and effective responses are urgently needed. This article reports on FV apparent in a study which explored the experiences of people with both ABI and justice system encounters in Victoria, Australia. One hundred interviews and one focus group consulted people with ABI, their families and carers, and various stakeholder groups in the Victorian justice system in Australia. Qualitative content analysis determined dominant themes and sub-themes and the less common themes. Inductive interpretive content analysis identified themes commonly found in previous published research and themes that appeared unique to, or unanticipated in, our data, such as the FV theme upon which this article focuses. Our findings reveal that FV has adversely affected many people with ABI who came into contact with Victoria's justice system. Further, as ABI and FV often co-occur with substance abuse, mental health problems, socio-economic and many other significant disadvantages, for some FV perpetrators with an ABI, their ABI symptoms and characteristic co-morbidities may be a mitigating factor in their offending. The connection between ABI and family violence emerged as a troubling research theme. Indeed, the impact of FV on too many of our participants with an ABI compels us to call for further related research and secondary prevention programs targeted at FV victims, and offenders, living with ABI. An intersectional understanding of family violence and TBI/ABI in social ecological contexts is required to better understand brain injury at both individual and population levels.

A global collaboration to study intimate partner violence-related head trauma: The ENIGMA consortium IPV working group

Intimate partner violence includes psychological aggression, physical violence, sexual violence, and stalking from a current or former intimate partner. Past research suggests that exposure to intimate partner violence can impact cognitive and psychological functioning, as well as neurological outcomes. These seem to be compounded in those who suffer a brain injury as a result of trauma to the head, neck or body due to physical and/or sexual violence. However, our understanding of the neurobehavioral and neurobiological effects of head trauma in this population is limited due to factors including difficulty in accessing/recruiting participants, heterogeneity of samples, and premorbid and comorbid factors that impact outcomes. Thus, the goal of the Enhancing NeuroImaging Genetics through Meta-Analysis (ENIGMA) Consortium Intimate Partner Violence Working Group is to develop a global collaboration that includes researchers, clinicians, and other key community stakeholders. Participation in the working group can include collecting harmonized data, providing data for meta- and mega-analysis across sites, or stakeholder insight on key clinical research questions, promoting safety, participant recruitment and referral to support services. Further, to facilitate the mega-analysis of data across sites within the working group, we provide suggestions for behavioral surveys, cognitive tests, neuroimaging parameters, and genetics that could be used by investigators in the early stages of study design. We anticipate that the harmonization of measures across sites within the working group prior to data collection could increase the statistical power in characterizing how intimate partner violence-related head trauma impacts long-term physical, cognitive, and psychological health.

A Multi-Method Approach to a Comprehensive Examination of the Psychiatric and Neurological Consequences of Intimate Partner Violence in Women: A Methodology Protocol

The number of women in the United States that experience blows to the head during assaults by intimate partners is substantial. The number of head blows that result in a traumatic brain injury (TBI) is virtually unknown, but estimates far exceed numbers of TBI in parallel populations (e.g., blast exposure, accidents, sports) combined. Research on the impact of TBI on post-traumatic stress disorder (PTSD) in survivors of intimate partner violence (IPV) is sparse. This methodology paper describes the comprehensive, multi-method approach used by a multi-disciplinary team of investigators from several different fields of expertise to assess the interaction of psychiatric, cognitive, psychological, and physical conditions that result from IPV. Using state-of-the-art instruments, a comprehensive assessment of lifetime trauma exposure, lifetime history of TBI, psychiatric history, and a full assessment of current cognitive, neuropsychological and biomedical function was conducted with 51 female survivors of IPV who screened positive for PTSD. This multi-method assessment included clinician-administered diagnostic interviews modified to specifically assess the sequelae of IPV, standardized self-report surveys, neuropsychological tests, structural, diffusion, and functional neuroimaging and blood-based biomarkers. The specific details and full report of the results of the full study are beyond the scope of this methodology paper. Descriptive characteristics of the complex clinical presentation observed in this unique sample are described. The sample reported high rates of trauma exposure across the lifespan and 80% met full criteria for current PTSD. Women also reported high rates of lifetime subconcussive head injury (88.2%) and TBI (52.9%) from various etiologies (35.3% secondary to IPV). Descriptive findings from the methodological protocol described here have begun to reveal information that will advance our understanding of the impact of subconcussive head injury and TBI on recovery from mental injury among IPV survivors.

Understanding Traumatic Brain Injury in Females: A State-of-the-Art Summary and Future Directions

In this report, we identify existing issues and challenges related to research on traumatic brain injury (TBI) in females and provide future directions for research. In 2017, the National Institutes of Health, in partnership with the Center for Neuroscience and Regenerative Medicine and the Defense and Veterans Brain Injury Center, hosted a workshop that focused on the unique challenges facing researchers, clinicians, patients, and other stakeholders regarding TBI in women. The goal of this "Understanding TBI in Women" workshop was to bring together researchers and clinicians to identify knowledge gaps, best practices, and target populations in research on females and/or sex differences within the field of TBI. The workshop, and the current literature, clearly highlighted that females have been underrepresented in TBI studies and clinical trials and have often been excluded (or ovariectomized) in preclinical studies. Such an absence in research on females has led to an incomplete, and perhaps inaccurate, understanding of TBI in females. The presentations and discussions centered on the existing knowledge regarding sex differences in TBI research and how these differences could be incorporated in preclinical and clinical efforts going forward. Now, a little over 2 years later, we summarize the issues and state of the science that emerged from the "Understanding TBI in Women" workshop while incorporating updates where they exist. Overall, despite some progress, there remains an abundance of research focused on males and relatively little explicitly on females.

Acquired Brain Injury in the Context of Family Violence: A Systematic Scoping Review of Incidence, Prevalence, and Contributing Factors

Brain injury is often a precursor to, or result of, family violence. Yet there is little research identifying the connection of these two phenomena. The health cost (personal or societal) of brain injury within the family violence context is difficult to ascertain. Family violence can lead to lifelong psychological or physical scars and even death. A systematic review was conducted over three databases using Medical Subject Heading terms to investigate incidence, prevalence, and contributing factors of brain injury within a family violence context. Inclusion criteria were primary studies, any person who experienced traumatic brain injury in a familial context. Seven hundred and seven studies of varied designs were initially identified with 43 meeting inclusion criteria. Data were extracted and a deductive narrative synthesis was performed. The accuracy and generalizability of incidence and prevalence statistics was hindered by underreporting of family violence and the specificity of some of the population groups (e.g., female inmates). The factors contributing to brain injury within the family violence context had multifactorial causation and varied greatly across the populations studied. Five social determinants of health were identified: biological, behavioral, structural, social, and environmental. These factors included age and gender of parent/baby, crying as an antecedent of family violence, previous exposure to abuse as a child, hostile living environments, previous trauma, financial pressures, employment status, housing availability, and exposure to natural disasters. Future investigation into the nexus between brain injury and family violence is required; however, this is complicated due to global inconsistency of definitions, assessment tools, and research methods used.

Self-reported Participation Restrictions Among Male and Female Veterans With Traumatic Brain Injury in Veterans Health Administration Outpatient Polytrauma Programs

OBJECTIVES

To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex.

DESIGN

Retrospective cross-sectional design.

SETTING

National VA Polytrauma System of Care outpatient settings.

PARTICIPANTS

Veterans with a confirmed TBI event (N=6065).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis.

RESULTS

The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item.

CONCLUSIONS

There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.

Intimate partner violence and subsequent depression and anxiety disorders

PURPOSE

The current longitudinal study examines the temporal association between different types of intimate partner violence (IPV) at early adulthood (21 years) and subsequent depression and anxiety disorders in young adulthood (30 years).

METHODS

Participants were from the Mater-University of Queensland Study of Pregnancy. A cohort of 1529 was available for analysis. IPV was measured using the Composite Abuse Scale at 21 years. At the 21 and 30-year follow-ups, major depression disorder and anxiety disorders were measured using the Composite International Diagnostic Interview.

RESULTS

We found a temporal relationship between almost all forms of IPV at 21 years and females' new cases of major depression disorder at 30 years. This association was not found for females who had previously been diagnosed with depression disorder. IPV did not predict the onset of new anxiety disorders, but it had a robust association with anxiety disorders in females with a previous anxiety diagnosis. We observed no significant link between IPV and males' subsequent major depression disorder. Interestingly, the experience of emotional abuse was a robust predictor of new cases of anxiety disorders but only for males.

CONCLUSION

Our results suggest the need for sex-specific and integrated interventions addressing both IPV and mental health problems simultaneously. IPV interventions should be informed by the extend to which pre-existing anxiety and depression may lead to different psychological responses to the IPV experience. Increased risk of anxiety disorders predicted by emotional abuse experienced by males challenges beliefs about invulnerability of men in the abusive relationships and demands further attention.

Angiogenic peptide hydrogels for treatment of traumatic brain injury

Traumatic brain injury (TBI) impacts over 3.17 million Americans. Management of hemorrhage and coagulation caused by vascular disruption after TBI is critical for the recovery of patients. Cerebrovascular pathologies play an important role in the underlying mechanisms of TBI. The objective of this study is to evaluate a novel regenerative medicine for the injured tissue after brain injury. We utilized a recently described synthetic growth factor with angiogenic potential to facilitate vascular growth in situ at the injury site. Previous work has shown how this injectable self-assembling peptide-based hydrogel (SAPH) creates a regenerative microenvironment for neovascularization at the injury site. Supramolecular assembly allows for thixotropy; the injectable drug delivery system provides sustained in vivo efficacy. In this study, a moderate blunt injury model was used to cause physical vascular damage and hemorrhage. The angiogenic SAPH was then applied directly on the injured rat brain. At day 7 post-TBI, significantly more blood vessels were observed than the sham and injury control group, as well as activation of VEGF-receptor 2, demonstrating the robust angiogenic response elicited by the angiogenic SAPH. Vascular markers von-Willebrand factor (vWF) and α-smooth muscle actin (α-SMA) showed a concomitant increase with blood vessel density in response to the angiogenic SAPH. Moreover, blood brain barrier integrity and blood coagulation were also examined as the parameters to indicate wound recovery post TBI. Neuronal rescue examination by NeuN and myelin basic protein staining showed that the angiogenic SAPH may provide and neuroprotective benefit in the long-term recovery.

Gender Differences in Outcomes after Traumatic Brain Injury among Service Members and Veterans

This scoping study describes the range of outcomes in traumatic brain injury (TBI) studies of military service members and veterans addressing gender differences. A secondary purpose is to identify differences in outcomes between male and female participants in such studies. We searched PubMed, CiNAHL, and PsycInfo databases for relevant articles. Two reviewers independently screened results. Of 822 unique titles and abstracts screened for eligibility, 55 full articles were reviewed, with 29 studies meeting full inclusion criteria. Twenty of the 29 included studies used retrospective designs and all but two used data collected from Veterans Affairs or Department of Defense health care settings. TBI was diagnosed by self-report, screening, and evaluation procedures, and medical record documentation. Ten different outcome categories were identified among the included studies. In general, female service members and veterans have not been well represented in TBI outcomes research. Evidence suggests that female veterans with mild TBI (mTBI) report more neurobehavioral symptoms and use more outpatient services than male veterans. Studies also indicate that female veterans with TBI are more frequently diagnosed with depression. Additional research is essential to support precision treatment recommendations for female veterans with TBI, as women represent a growing proportion of the patients served by the Veterans Health Administration. LEVEL OF EVIDENCE: IV.

Practitioner perspectives on the nexus between acquired brain injury and family violence

Family violence has been highlighted by the World Health Organization as a major public health concern. Although family violence occurs to all genders, a higher prevalence of victims are female. Estimates report around 30% of all women experience intimate partner violence worldwide. Experiencing assault in the family violence context can lead to an acquired brain injury (ABI); however, the connection between these two phenomena has not been well established. The aim of this qualitative study was to explore the extent of, and factors contributing to, ABI and family violence. We conducted 22 semi-structured interviews and one focus group (n = 4) with practitioners working with family violence victims and/or perpetrators. Thematic data analysis utilised inductive and deductive coding approaches. The Social Determinants of Health Framework was used to guide analysis. Practitioners estimated 30%-40% of the clients on their caseloads had a suspected or diagnosed ABI. They identified that contributing factors were extremely complex. These included acquiring an ABI through assault (past family violence or other criminal act), and transport crashes. Complicating factors of ABI were identified as mental health conditions, alcohol and drug use, and post-traumatic stress disorder. Additional factors contributing to family violence were recognised as biological (age of parent, twin births, pregnancy, premature births, and children with congenital abnormalities), relationships (intimate partner, father, boyfriend, mother and siblings), previous trauma (family violence), and life stressors (unemployment, financial, and lack of housing). Social determinants of health included cultural (ethnicity, societal attitudes, values, and beliefs) and organisational (legislation and policy) factors which influenced behaviours and outcomes across all sectors. A model of Brain injury Family violence Nexus (BFN) was created to understand the interaction between these phenomena. Utilising the BFN model to understand the interaction can enhance the methods used within health and social services for a more efficacious approach.

Intimate partner violence in emerging adulthood and subsequent substance use disorders: findings from a longitudinal study

AIMS

To examine the temporal association between the experience of different types of intimate partner violence (IPV) in early adulthood (21 years) and substance use disorders in young adulthood (30 years).

DESIGN

Prospective birth cohort study using data from the Mater-University of Queensland Study of Pregnancy (MUSP).

SETTING

Brisbane, Australia.

PARTICIPANTS

A total of 1353 people (822 females and 531 males).

MEASUREMENTS

IPV was measured using the Composite Abuse Scale (CAS) and alcohol, substance and nicotine use disorders were assessed using the Composite International Diagnostic Interview (CIDI).

FINDINGS

In females, the experience of different forms of IPV at 21 years remained a robust risk factor for subsequent alcohol use disorder [adjusted odds ratios (aORs) ranged from 1.6 to 2.6 (all P < 0.05)], substance use disorder [aORs ranged from 2.1 to 4.0 (all P < 0.001)] and nicotine use disorder [aORs ranged from 2.0 to 2.4 (all P < 0.05)] at 30 years, even after controlling for antecedent substance disorders. However, in males only physical and emotional abuse (but not harassment) were significant in predicting alcohol use disorder [aORs ranged from 1.4 to 1.8 (all P < 0.05)] and drug use disorder [aORs ranged from 1.6 to 2.0 (all P < 0.05)] in the fully adjusted model.

CONCLUSION

Intimate partner violence (IPV) in early adulthood is robustly associated with alcohol, substance and nicotine use disorders in women, whereas in men the association is clear for only some forms of IPV and types of disorder.

Associations between traumatic brain injury from intimate partner violence and future psychosocial health risks in women

OBJECTIVE

The effects of traumatic brain injury (TBI) incurred during military service are widely studied; however, less is known about TBI resulting from intimate partner violence ("IPV-related TBI"). Women Veterans are at high risk for IPV, yet no research has examined future psychosocial health risks associated with IPV-related TBI history in this population.

METHODS

We examined psychiatric and physical health outcomes, as well as IPV, in a sample of women Veterans who, at Time 1, reported IPV-related TBI with (n = 13) or without (n = 20) persistent symptoms; that is, symptoms such as memory problems, balance problems or dizziness, sensitivity to bright light, irritability, headaches, and sleep problems that began or got worse immediately following the IPV-related TBI and occurred within the past week. These women completed web-based surveys 18 months later (Time 2), which included validated measures of psychiatric and physical health symptoms as well as past-year IPV. We conducted linear regressions to model whether T1 IPV-related TBI with persistent symptoms predicted worse health outcomes at T2, in comparison to T1 IPV-related without persistent symptoms.

RESULTS

Controlling for significant covariates (i.e., military sexual trauma; MST), IPV-related TBI with persistent symptoms at Time 1 was associated with significantly worse outcomes at Time 2 across all health outcome domains (sr² range: 0.12-0.37). After controlling for MST and probable posttraumatic stress disorder (PTSD) at Time 1, IPV-related TBI with persistent symptoms at Time 1 remained significantly associated with worse Time 2 symptoms of insomnia, depression, and physical health (sr² range: 0.12-0.25).

CONCLUSION

Women who experience IPV-related TBI with persistent symptoms are at higher risk for worse psychosocial health outcomes 18 months later. Findings necessitate screening IPV survivors for TBI with persistent symptoms and tailoring TBI and psychosocial interventions to reduce risk for ongoing health sequelae.

Randomized Controlled Trials and Quasi-Experimental Studies Published in Nursing Journals: Findings From a Scoping Review With Implications for Further Research

BACKGROUND

Experimental studies are considered capable of generating substantial evidence; therefore, their production and diffusion are continuously encouraged. However, their trends as publication outputs in nursing journals have rarely been evaluated to date.

AIMS

To describe experimental study design features among the highest indexed nursing journals.

METHODS

A scoping review was performed by retrieving and analyzing experimental studies published between 2009 and 2016 in nursing journals with a 5-year impact factor >1.5 according to Thomson's Journal Citation Reports.

RESULTS

A total of 602 studies were reviewed and 340 (56%) were included; in all, 298/340 (87.6%) were randomized controlled trials (RCTs) and 37/340 (10.9%) pilot studies. The publication trend exhibited a fluctuating pattern with a slight decrease over time (from 54 studies in 2009 to 32 in 2016). Researchers working in Asia and Europe have published more frequently in the selected journals. Published studies most often involved oncological (n = 69, 20%), surgical (n = 41, 12%), and elderly patients (n = 38, 11%). Educational and supportive (n = 119, 35%) interventions were mainly tested for effectiveness. Approximately half of studies enrolled <100 patients, and only two-thirds had included an a priori sample size calculation. Less than one quarter (n = 76) of the research teams were multiprofessional, and 70% of studies were funded, generally, by public institutions.

LINKING EVIDENCE TO ACTION

A broad range of research questions has been investigated to date by using experimental study designs. However, study methods and multidisciplinary collaborations must be enhanced with the intent of producing large-scale and methodologically sound studies. Furthermore, reasons for limited funding and, particularly, the lack of support from private funding should be further investigated.

Uncharted Waters: Developing Mental Health Services for Survivors of Domestic Human Sex Trafficking

In recent years, heightened attention has been paid to commercial sexual exploitation, including domestic human sex trafficking (HST), with mental health concerns named the most dominant health concern among survivors. Human sex trafficking is associated with significant and long-term mental health consequences. Research to date has emphasized ways to identify survivors in health care settings. Once identified, however, few specialized services are available to help survivors exit and recover. The current services infrastructure for HST has been compared to the disjointed social response to intimate partner violence before the women's movement helped develop a system of battered women's shelters. Although research has highlighted the need for a multidisciplinary and interagency response to HST, including mental health care, best practices have not yet been formulated. Furthermore, available services are fragmented across sectors. With psychology and psychiatry taking tentative steps to develop services for HST survivors, this article identifies six principles to help avoid a fragmented and potentially retraumatizing clinical and systemic response. The overarching goal is to design services that are flexible, accessible, trauma informed, survivor driven, responsive to stages of change, multidisciplinary, and enduring, especially given the centrality of healthy attachments and community in trauma recovery. Principles are derived from the limited available research on HST services and from examples of efficacious interventions for patient groups with similar characteristics. The discussion is also informed by composite clinical vignettes from a specialized clinic for adult survivors of HST, housed in a major teaching hospital. Finally, practice recommendations and strategies for building interdisciplinary collaborations are discussed.

Battered and Brain Injured: Assessing Knowledge of Traumatic Brain Injury Among Intimate Partner Violence Service Providers

Background: Traumatic brain injury (TBI) as a result of intimate partner violence (IPV) is a significant health concern; yet, little is known about the intersection between the two. Existing research is scarce, limiting the ability of health care providers to develop effective supports. This pilot project surveyed the IPV support community in Toronto, Canada to understand the degree of existing TBI-specific knowledge and relevant services available among these service providers and to seek to bridge the divide between research and practice by developing a national knowledge-to-practice network to support brain-injured women survivors of IPV. Materials and Methods: In phase 1, 68 agencies providing IPV support services were invited to complete an anonymous online survey. In phase 2, 22 stakeholders attended a workshop held to disseminate existing knowledge, develop a national knowledge-to-practice network, and determine next steps in research and practice. Results: The results highlighted a general lack of TBI awareness and understanding among IPV service providers. In addition, participants stated that frontline workers and women survivors of IPV alike do not recognize signs or symptoms of TBI. Recommendations addressing research gaps, professional and public education, and service development were identified and are discussed herein. Conclusions: The identified lack of TBI knowledge among IPV service providers highlights the immediate need to increase education among management and frontline workers. Further investigation identifying best practices for knowledge transfer are suggested. The development of a national strategy addressing education, research, and funding is critical for successful uptake and integration of TBI-sensitive services within the IPV sector.