Neurological implications of nonfatal strangulation and intimate partner violence

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.

The Darker the Skin, the Greater the Disparity? Why a Reliance on Visible Injuries Fosters Health, Legal, and Racial Disparities in Domestic Violence Complaints Involving Strangulation

The reliance on external injuries for justice is misguided given that assault injuries may be less visible among victims of color due to increased melanin in the skin. To date, however, less is known whether racial/ethnic disparities extend to officers' identification of signs of nonfatal strangulation (NFS). The current study estimates the extent of NFS indicators identified by officers who completed a standardized strangulation assessment in 133 family violence complaints. Breathing difficulties were the most common symptoms identified by officers (98%), followed by external signs (89%), and symptoms of impeded blood circulation (87%). Compared to cases involving White/Asian survivors, officers were less likely to identify external injuries on Black survivors' neck, chin, and chest/shoulders. While racial/ethnic differences did not emerge for symptoms of disrupted airflow, Hispanic survivors were twice as likely to report losing control of bodily functions. Implications for policy and practice are discussed.

Accounting for Multiple Nonfatal Strangulation in Intimate Partner Violence Risk Assessment

Nonfatal strangulation is a prevalent, underreported, and dangerous form of intimate partner violence (IPV). It is particularly important to assess for strangulation among abused women as this form of violence may not leave visible injury. The most severe negative physical and mental health consequences of strangulation appear to be dose-related, with those strangled multiple times or to the point of altered consciousness at higher risk of negative sequelae. This research examines the relationship between multiple strangulation, loss of consciousness due to strangulation, and risk of future near-fatal violence to modify the Danger Assessment (DA) and the Danger Assessment for Immigrant women (DA-I), IPV risk assessments intended to predict near-fatal and fatal violence in intimate relationships. Data from one study (n = 619) were used to modify the DA to include an item on multiple strangulation or loss of consciousness due to strangulation. Data from an independent validation sample (n = 389) were then used to examine the predictive validity of the updated DA and DA-I. The updated version of the DA predicts near-fatal violence at 7-8 months follow-up significantly better than the original DA. Adding multiple strangulation or loss of consciousness to the DA-I increased the predictive validity slightly, but not significantly. The DA and DA-I are intended to be used as a collaboration between IPV survivors and advocates as tools for education and intervention. Whether or not an IPV survivor has been strangled, she should be educated about the dangerous nature of strangulation and the need for medical intervention should her partner use strangulation against her. This evidence-based adaptation of the DA and DA-I may assist practitioners to assess for and intervene in dangerous IPV cases.

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.

How Victims of Strangulation Survived: Enhancing the Admissibility of Victim Statements to the Police When Survivors are Reluctant to Cooperate

Holding perpetrators accountable for family violence is challenged when survivors are reluctant to testify. In light of recent Supreme Court precedents limiting the admissibility of statements to law enforcement in victimless prosecutions, the current study examined 130 cases of nonfatal strangulation (NFS) to determine whether case characteristics and themes across survivors' on-scene statements can help prosecutors combat common legal defenses raised when victims are unavailable for trial. The history of prior violence and how only 6% of perpetrators stopped strangling victims on their own suggests that NFS complaints should be investigated as an attempted homicide until evidence suggests otherwise.

"If It Goes Horribly Wrong the Whole World Descends on You": The Influence of Fear, Vulnerability, and Powerlessness on Police Officers' Response to Victims of Head Injury in Domestic Violence

Domestic violence (DV) victims face significant barriers to accessing healthcare. This is particularly concerning in cases of brain injury (BI), which is difficult to diagnose and risks severe long-term consequences for DV victims. Police may be able to identify head injury (HI) and signpost victims to healthcare. This research investigated potential barriers to police supporting victim health needs by exploring police attitudes towards DV and considering how police interpret and respond to stories of HI in DV victims. Individual interviews were conducted with 12 police officers from forces in South and Central England. This included the use of a clinical vignette. Thematic analysis highlighted three global themes: ‘seesaw of emotions’, ‘police vulnerability’, and ‘head injury is fearful’. Police officers’ vulnerability to external blame was the predominant influence in their responses to HI.

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.

The neuropsychological outcomes of non-fatal strangulation in domestic and sexual violence: A systematic review

This systematic review draws together evidence from the literature for the pathological, neurological, cognitive, psychological, and behavioural outcomes of non-fatal strangulation in domestic and sexual violence. A systematic search of PubMed, PsycINFO, CINHAL, Proquest, ASSIA, Web of Science, WestLaw, Open Grey, and Ethos was conducted, with no date limits set, to identify eligible studies. Thirty empirical, peer-reviewed studies were found which met the inclusion criteria. Pathological changes included arterial dissection and stroke. Neurological consequences included loss of consciousness, indicating at least mild acquired brain injury, seizures, motor and speech disorders, and paralysis. Psychological outcomes included PTSD, depression, suicidality, and dissociation. Cognitive and behavioural sequelae were described less frequently, but included memory loss, increased aggression, compliance, and lack of help-seeking. However, no studies used formal neuropsychological assessment: the majority were medical case studies or based on self-report. Furthermore, few authors were able to control for possible confounds, including other physical violence and existing psychosocial difficulties. There is therefore a need for further neuropsychological research, focusing on cognitive and behavioural outcomes, using standardized tools, and control groups where possible. This is urgent, given societal normalization of strangulation, and legal systems which often do not reflect the act's severity and its consequences.