Violence against women has been documented over the centuries and is a pervasive health problem without racial or social boundaries.1,2 Violent acts against women may be a consequence of domestic partner abuse, sex trafficking injuries, or sexual assault.2,3 Regardless of cause, violence results in a complex triad of physical, emotional, and psychological injuries. There is clear evidence that female victims of violence or “battered women” experience brain injury. What is less certain is whether the constellations of events surrounding brain injury including postconcussion syndrome (PCS), depression, and posttraumatic stress disorder (PTSD) are acute symptoms after the brain injury, premorbid as a result of persistent abuse, or a synergistic triad of combined disorders as a result of the violent injuries.
The purpose of this article is to answer the question: What is the relationship between physical violence-associated mild traumatic brain injury (MTBI) and postinjury cognitive, emotional, and psychological disorders?
“Mild traumatic brain injury” was used as the key term with advanced searches using related terms “physical violence in women,” “battered women,” sex trafficking,” and “health outcomes after MTBI.” The search process was not restricted by year or publication type. Initially, the years 2000 to 2012 were entered searching for review and evidence-based articles. A yield of more than 200 articles was scanned for relevance. In addition, the citations in relevant articles were searched for important classic reviews and debates. The following electronic databases were included: Medline, PubMed, CINAHL, Cochrane database, UpTo Date, Centers for Disease Control, and National and State of Hawai'i Domestic Violence legislative reports and actions. The terms “abuse,” “abused,” “battered,” or “interpersonal violence” (IPV) are used interchangeably in the article to describe women who have sustained injury from violent acts.
Evidence was categorized using the system developed by the US Preventative Services Task Force (USPSTF) as Level I (evidence provided by at least one well-designed randomized controlled trial), Level II-1 (evidence provided by well-designed clinical studies without randomization), Level II-2 (evidence provided by well-designed cohort or case study analysis from more than once center or research group), Level II-3 (evidence provided by multiple time series with or without intervention or uncontrolled trials with dramatic results), or Level III (evidence provided by expert opinion, nonrandomized historical controls, or case reports).4
No Level I evidence was found using the search criteria. Results of the search revealed an injury-related triad that begins with MTBI and includes biological and psychological sequelae discussed below. Studies over 5 years old provided the most evidence-based support for answering the questions with more recent literature contributing a review of the problem to date.
REVIEW OF THE LITERATURE
According to the National Intimate Partner and Sexual Violence Survey, more than 1 in 3 women (35.6%) in the United States reported IPV that included rape, physical violence, and/or stalking.2 These violent experiences involve 43.7% to 46% women of non-Hispanic black or American Indian or Alaska Native race/ethnicity, and 53.8% occur in multiracial non-Hispanic women. One perpetrator, usually male, was found to have committed acts of violence against the woman. Overall state-level estimates of sexual violence against women were 23.3% to 49.1%. In Hawai'i, domestic violence has been reported in over 20% of women between the ages of 19 and 64 years. IPV was reported in 16% of Filipino women, 32.3% of Hawaiian women, and 16.1% in other Pacific Islanders despite total population group percentages of 14%, 20%, and 4.5%, respectively. These statistics suggest a cultural trend in violence.5 Those who experienced physical violence reported more frequent somatic, emotional, and psychological complaints leading to negative health consequences.1,2
Abuse and Health Outcomes in Women
There is growing support for negative health outcomes in women who have experienced abuse. A case-controlled study (n = 2535) conducted by Campbell et al6 compared abused and nonabused women aged 21 to 55 years for health outcomes. Abused women were reported to have 50% to 70% increase in gynecological, central nervous system, and stress-related problems. Sexually and physically abused women reported the most problems (Level II-3).6
In a similar study, Loxtom et al7 analyzed the relationship between domestic violence and physical health problems using a cross-sectional design that included more than 14 000 women aged 45 to 50 years. Single, widowed, and divorced women experienced more IPV than those women married or living with a partner. Smoking, drinking, lack of formal education, perimenopausal, and menopausal state were associated with higher risk for IPV. There was a high correlation with IPV and bowel problems, vaginal discharges, hearing difficulties, and vision difficulties along with increases in diabetes, cardiovascular disease, anemia, and cervical cancer (Level II-3).
Physical Injury and Consequences
The studies supporting poor health outcomes in women do not specifically address the patterns of physical injury or the residual effects of physical injuries. It is well recognized that women victims of violence sustain numerous physical injuries. Saddkiet al8 reported the maxillofacial region (50.4%) as being most frequently injured followed by limbs (47.9%) and head (24.4%). Assault methods included but were not limited to punching with a fist (56.2%), kicking (38.4%), slapping (37.2%), beaten with blunt instruments (14%), and strangling (7%). Often these acts of violence included multiple assault methods (57%).8 Soft-tissue rather than hard-tissue injuries were most commonly reported.9 However, blows from the fist generate enough force to cause fractures especially if delivered repeatedly at one site and falls as a result of punches and kicks also caused fractures.8–10 This pattern of injury, repeated blows to head and face, and falls related to punching and kicking provide a high index of suspicion for MTBI. Mild traumatic brain injuries related to abusive mechanisms are silent injuries often unrecognized and always underreported.11,12
Concussion and MTBI are used interchangeably to define brain injuries that are not accompanied by structural changes on the computerized axial tomography scan. At the time of injury and hours afterward, neurotransmitters (glutamate and aspartate among them) are released from the neurons increasing neuron firing and disrupting and altering neuronal pathways. The term “mild” is used in reference to the severity of the initial physical trauma that caused the injury. It does not indicate the severity of the consequences of the injury.13 After the blunt force occurs, a constellation of events including confusion, disorientation, memory loss of events before or after the event, and a brief loss of consciousness (LOC) are reported.13 Table 1 provides a description of the symptoms associated with each “grade” of concussion.
Over 75% of the 1.5 million brain injuries reported each year are MTBIs but the magnitude of the problem remains unknown because equal or greater numbers of MTBIs go undiagnosed likely as a result of underreporting, underawareness, misdiagnosis, or protected turfs.14 Banks15 posits that although greater than 80% of women involved in IPV are treated for injuries to the face, traumatic brain injury (TBI) is overlooked during the medical evaluation. It is not clear how many women who suffer repeated acts of violence to the face and head do not seek medical treatment. The incidence of TBI from IPV was examined in 51 women who were seen in an emergency department (ED). Using direct interviews, Corrigan et al16 found that LOC occurred in 80%, hospitalization was required for 15%, and 35% had residual deficits requiring outpatient therapy (Level II-3).
The impact of MTBI in abused women creates a multitude of sequelae that may or may not be recognized acutely but have long-term impact on health outcomes.
The effects of physical injury and MTBI extend beyond the soft and hard tissue damage. There is evidence that physical injury endured through IPV provides a platform for emotional and psychological problems as well.
Chronic battering and head injury were examined in a qualitative study of 52 battered women.17 Voices of the women revealed that severe and repeated battering was associated with flashbacks, insomnia, major depression, and nightmares. In addition, women experienced a variety of emotional and psychological problems including anger, irritability, hopelessness, and fear. Among the numerous mood changes reported, intolerance was most prevalent and led to antagonism against the environment, others, and self. Participants' lists of self-attributes reflected low self-esteem, dependence, unworthiness, anxiety, and poor self-image (victims viewed themselves as ugly). In addition, they identified themselves as lazy, angry, irresponsible, impatient, temperamental, moody, and cheap. More than 80% expressed depressive moods or were taking antidepressants, several related suicidal ideation or suicide attempts, and others felt being trapped or an enduring sense of hopelessness17 (Level II-3).
Triad of Consequences Related to Brain Injury
A triad of disorders is hypothesized to result from MTBI including PCS, depression, and acute stress disorder leading to PTSD. Although MTBI alone can precipitate the triad, it is unclear in battered women whether depression and PTSD already exist and MTBI potentiates the effects of the already existing comorbidities. Regardless of the sequence, the triad of PCS, depression, and PTSD causes somatic, cognitive, emotional, and psychological dysfunction after MTBI. The diagnostic criteria and salient characteristics for each disorder are described below. Note the overlap of the clinical features, which increases difficulty for surveillance, diagnosis, and treatment (Table 2).
Postconcussion syndrome is a complex disorder with symptoms occurring 7 to 10 days after an MTBI, lasting for weeks to months and up to a year or more in some individuals. The constellation of symptoms includes headache, dizziness, fatigue, difficulty concentrating, irritability, anxiety, and noise and light sensitivity. The severity of the injury does not correlate with the duration or type of symptoms. Persons experiencing PCS report limitations in functional status, activities of daily living, school- or work-related activities, leisure and recreational activities, social interactions, and financial independence.19
Lishman20 was the first to propose the persistent symptoms after MTBIs were initiated by neurobiological factors and sustained by psychological factors. The debate over the origin and persistence of PCS continues today. After an extensive review of the literature, Silverberg and Iverson19 concluded that during the earliest stages of recovery after MTBI, psychological factors play a prominent etiological role. On the basis of the literature to date, they posit 4 predictions for the relationship between PCS and psychological stress: (1) psychological stress contributes to PCS as early as the first week after MTBI; (2) in persons with chronic psychological stress, acute psychological distress occurs early; (3) there is insufficient evidence to suggest psychological distress and PCS symptoms increase over time; and (4) early psychological distress is related to later PCS.
The sequelae, frequency, and severity of MTBI and the relationship with PCS were reported by Jackson et al.21 Fifty-three women, aged 18 to 48 years, who experienced either a blow to the head with LOC or alterations in consciousness after the blow to the head (amnesia, confusion, dizziness, or nausea), were included in the study. All women admitted to being hit on the head, with 91% reporting being hit in the head 2 to 5 times in the previous year. Headaches, forgetting appointments, distractibility, attention and concentration difficulties, and trouble with multitasking were among the problems reported by the women21 (Level II-3).
Major depressive disorder (MDD) is a disorder frequently encountered by primary care providers,22 and epidemiological studies have determined MDD to be a lifetime psychiatric disorder.23 Using the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition characteristics, MDD must include a total of 5 symptoms with a minimum of 1 depressed mood characteristic and 2 loss of interest characteristics occurring for at least 2 weeks.18 Other symptoms are changes in appetite or weight, insomnia or hypersomnia, psychomotor changes such as agitation, fatigue or loss of energy, feelings of worthlessness or guilt, memory or concentration difficulties, indecisiveness, and thoughts of death/suicide.18 Major depressive disorder involves neurobiological consequences, which alter brain structure, function, and molecular configuration. In women an association between pathogenic impact of stressful life events and previous number of depressive episodes was found. This kindling effect sustained through numerous depressive episodes is thought to be causal.24,25 Thus, although MDD may be characterized as an episodic illness, prospective studies have found that recurrence is the norm rather than the exception.26
Sutherland et al27 investigated the effects of injuries and stress from abuse in 397 community participants. Three relationships were addressed: injuries experienced, stress experienced, and the relationship between stress and depression. Of the 205 women who experienced physical assault, 32% reported sexual assault. Women who experienced violence reported sustained cuts, scraps, and bruises. Mild depression was reported in 60% of women, and severe depression was reported in 30% of women. Most frequent complaints were feelings of low energy, sleep problems, headaches, muscles ache, back pain, and fatigue. Abuse was a stronger predictor of stress than poverty, with no correlation found between low-income women and stress27 (Level II-3).
Posttraumatic Stress Disorder
Posttraumatic stress disorder, a type of debilitating anxiety disorder, is triggered by exposure to a traumatic experience. The experiences precipitating PTSD vary by individual with physical or sexual assaults, exposure to disaster or accidents, combat, or witnessing traumatic events reported most frequently. The symptoms, clustered in 3 distinct groups, consist of symptoms of reliving the event, avoidance or arousal, and the distress and impairment caused by the first 2 clusters. Commonly, people report flashbacks, nightmares, emotional numbing or detachment, irritability, anxiety, insomnia, agitation, headache, memory impairment, dizziness, and many others. Symptoms related to PTSD persist for over 30 days, whereas a companion disorder acute anxiety disorder presenting with similar symptoms is present for less time.28
Psychological effects of IPV were examined by Bogat et al29 using a cross-sectional study. The study included 205 women aged 18 to 40 years who had attained their third trimester of pregnancy. Participants were queried on their IPV history with current pregnancy with a current partner, previous year with a current partner, and with a previous partner. IPV history was found in 56% of the women, but in 44% IPV had not occurred in the last 6 months. The chronic group demonstrated the most negative psychological outcomes, which included symptoms of PTSD. Chronic violence across partners and time and severity of IPV were the most significant predictors of adverse psychological outcomes29 (Level II-3).
Screening for MTBI and the Triad of Associated Disorders
Recognizing the problem of MTBI and the triad of associated disorders is the first step albeit a difficult one. Conceptualizing the problem using a biopsychosocial approach provides the clinician with relevant domains for assessment and screening.19 There is no specific tool to screen for violence-related TBI in women nor is there a comprehensive assessment that includes the triad of sequelae (PCS, depression, and PTSD/acute stress disorder). A biopsychosocial approach has been advocated by the USPSTF for screening in IPV, citing the 4 elements of the socioecological model (individual, relationship, community, and society) used by the Centers for Disease Control in IPV screening literature.30,31 Although specific screening tools for violence-related MTBI and the triad of consequences is not available, there is evidence that screening is effective in IPV. According to the USPSTF, screening for IPV in women between the ages of 14 and 46 years has a moderate benefit.31 In the 2013 USPSTF report, a number of adverse effects of IPV including long-term health consequences, unintended pregnancy, chronic disorders, disabilities, and mental health conditions such as depression, PTSD, and substance abuse support the need for increased surveillance in women of child-bearing age. IPV-specific screening tools have been used in a number of studies with highest levels of sensitivity and specificity assigned to Hurt, Insult, Threaten, Scream (HITS),32 Ongoing Abuse Screen/Ongoing Violence Assessment Tool,33 Slapped, Threatened, and Throw (STaT),34 Humiliation, Afraid, Rape, Kick,35 Modified Childhood Trauma Questionnaire-Short Form,36 and Women Abuse Screen Tool.37 A more comprehensive review of these and other screening tools was reported in the systematic review updating the 2004 USPSTF Recommendations on Screening Women for Intimate Partner Violence and Elderly and Vulnerable Adults for Abuse.38
Assessment and screening may occur in a variety of venues such as primary care health clinics, community health centers, domestic shelters, or EDs. HITS has been used in primary care settings and STaT has been administered in ED settings.31 Recognizing that an interdisciplinary approach is necessary for accurate screening and management of MTBI and the triad of disorders, training of health care or community health workers (eg, nurse practitioner, social worker, and psychologist) should be designed to obtain information that is best suited for the place of the patient encounter or venue. For example, the intake questions may be different in an ED setting compared with a community health center. What is imperative across venues is the need to develop a high index of suspicion for MTBI and associated sequelae. The first step may be the use of a reliable and valid screening tool such as HITS or STaT, or a screening tool taking an algorithmic approach where referral or treatment decisions can be initiated on the basis of yes/no responses to questions. Further understanding of the nature and extent of injuries and injury consequences will be further elucidated through a comprehensive history followed by a physical examination. These steps will lead to valid diagnoses and an interdisciplinary treatment plan. Use of existing tools if sensitive and specific or new tools once developed should be widely distributed among venues along with generalized guidelines for use. No MTBI/triad disorder-screening tool currently exists but should be a project for future development and research. Table 3 provides a guide for the essential components of screening and diagnosing a woman suspected of being physically abused and who has likely sustained an MTBI. The guide consistent with a biopsychosocial approach includes physical, cognitive, emotional, psychological, and social domains.
RECOMMENDATIONS FOR CLINICAL PRACTICE
The purpose of this article was to answer the question: What is the relationship between physical violence-associated MTBI and postinjury cognitive, emotional, and psychological disorders? There is strong support for the relationship between MTBI and concurrent triad of disorders, including PCS, depression, and PTSD in women who have experienced abuse from IPV.
Although discussed independently in many studies, the complexity of these disorders, as comorbidities and occurring simultaneously, has not been well addressed in the literature. Consequently, a comprehensive screening tool aimed at recognition of the problem is not available, and there is no well-developed systematic approach to treatment. As a result of MTBI and related sequelae, women have impaired cognitive, emotional, or psychological resources, making it difficult to make the best decisions on their own behalf. Thus, battered women who are seen in the ED for physical injuries related to abuse are discharged to environments that are perpetuated by the same factors that initiated the abuse.
Health care practitioners have the means to respond to violence by assisting women who are victims of violence and preventing the downward spiraling situations where they are further abused, become more hopeless, and are vulnerable to more acts of violence. Intervention and treatment can only be accomplished by increasing domestic violence surveillance, recognizing MTBI patterns of injury, and developing screening tools that delineate the triad of PCS, depression, and PTSD associated with MTBI.
This review of MTBI-associated violence in women was intended to heighten awareness of a possible connection between physical violence-associated MTBI and postinjury cognitive, emotional, and psychological disorders. A triad of disorders including PCS, depression, and PTSD after MTBI in women who experienced violent injury was hypothesized. The hypothesized triad was drawn from current research and classic review articles. No Level I evidence was found to support the triad, but there is Level II support for brain injury and violence, cognitive changes after brain injury, depression, and adult sexual abuse and PTSD. A critical analysis of the review of literature to date was not performed as the relationship of the concepts is underdeveloped in the research literature. This article contributes to the knowledge of MBTI and violent injury by heightening awareness of the problem and screening of women who are risk. The impact of this review sets a research agenda for future studies by identifying those women who are at risk for the postinjury sequelae.
1. Black M. Intimate partner violence and adverse health consequences: implications for clinicians. Am J Lifestyle Med. 2005;5:428–439.
3. Oram S, Stödkl H, Busza J, Howard LM, Zimmerman C. Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: systematic review. PLoS Med. 2012;9(5):e1001224. ISSN 1549-1277; doi:10.1371/journal.pmed.1001224.
4. U.S. Preventive Services Task Force Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. DIANE Publishing; 1989. ISBN 978-1-56806-297-6..
5. Magnussen L, Shoultz J, Oneha M, et al. Intimate-partner violence: a retrospective review of records in primary care settings. J Am Assoc Nurse Pract. 2004;16(11):502–512.
6. Campbell J, Snow Jones A, Dienemann J, et al. Intimate partner violence and physical health consequences. Arch Intern Med. 2002;162(10):1157–1163.
7. Loxtom D, Schofield M, Hussain R, Mishra G. History of domestic violence and physical health in midlife. Violence Against Women. 2006;12(8):715–731.
9. Tam S, Joyce D, Gerber M, Tan A. Head and neck injuries in adult victims of intimate partner violence. J Otolaryngol Head Neck Surg. 2010;39(6):737–743.
10. Shepherd J, Shapland M, Pearce N, Scully C. Pattern, severity, and aetiology of injuries in victims of assault. J R Soc Med. 1990;83:75–78.
11. Buck P. Mild traumatic brain injury: a silent epidemic in our practices. Health Soc Work. 2011;16:299–302.
12. Valera E., Berenbaum H. Brain injury and battered women. J Consult Clin Psychol. 2003;71:797–804.
14. Hux K, Schneider T, Bennett K. Screening for traumatic brain injury. Brain Inj. 2009;23(1):8–14.
15. Banks M. Overlooked but critical traumatic brain injury as a consequence of interpersonal violence. Trauma Violence Abuse. 2007;8(3):290–298.
16. Corrigan J, Wolfe M, Mysiw W, Jackson R, Bogner J. Early identification of mild traumatic brain injury in female victims of domestic violence. Am J Obstet Gynecol. 2001;188(5):71–76.
17. Roberts A, Kim J. Exploring the effects of head injuries among battered women: a qualitative study of chronic and severe woman battering. J Soc Ser Res. 2007;32(1):33–47.
18. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. 5th ed. Washington, DC: American Psychiatric Press; 2013.
19. Silverberg N, Iverson G. Etiology of the post-concussion syndrome: physiogenesis and psychogensis revisited. Neurorehabilitation. 2011;29:317–329.
20. Lishman W. Physiogenesis and psychogenesis in the “post-concussion syndrome.” Br J Psychiatry. 1988;153:460–469.
21. Jackson H, Nuttall R, Philip E, Diller L. Traumatic brain injury: a hidden consequence for battered women. Prof Psychology Res Pr. 2002;33(1):39–45.
22. Remick R. Diagnosis and management of depression in primary care: a clinical update and review. CMAJ. 2002;167:1253–1260.
23. Kessler R, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095–3105.
24. Kendler K, Thornton L, Gardner C. Stressful life events and previous episodes in the etiology of major depression in women: an evaluation of the “kindling” hypothesis. Am J Psychiatry. 2000;157:1243–1251.
25. Monroe S., Harkness K. Life stress, the “kindling” hypothesis, and the recurrence of depression: considerations from a life stress perspective. Psychol Rev. 2005;112:417–445.
26. Maletic V, Robinson M, Oakes T, Iyengar S, Ball S, Russell J. Neurobiology of depression: an integrated view of key findings. Int J Clin Pract. 2007;61(12):2030–2040.
27. Sutherland C, Bybee D, Sullivan C. Beyond bruises and broken bones: the joint effects of stress and injuries on battered women's health. Am J Community Psychol. 2002;30:609–636.
28. Ciechanowski P, Katon W. Posttraumatic stress disorder: epidemiology, pathophysiology, clinical manifestations, and diagnosis. In: Stein M, ed. UpToDate. Waltham, MA: UpToDate; 2012.
29. Bogat G, Levendosky A, Voneye A, Davidson W. Predicting the psychosocial effects of interpersonal partner violence. J Interpers Violence. 2003;18(11):1271–1291.
32. Sherin KM, Sinacore JM, Li XQ, Zitter RE, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med. 1998;30(7):508–512.
33. Weiss SJ, Ernst AA, Cham E, Nick TG. Development of a screen for ongoing intimate partner violence. Violence Vict. 2003;18(2):131–141.
34. Paranjape A, Rask K, Liebschultz J. Utility of STaT for the identification of recent intimate partner violence. J Natl Med Assoc. 2006;98(10):1663–1669.
35. Sohal H, Eldridge S, Feder G. The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in general practice. BMC Fam Pract. 2007;8:49.
36. Bernstein DP, Stein JA, Newcomb MD, et al. Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse Negl. 2003;27(2):169–190.
37. MacMillan HL, Wathen CN, Jamieson E, et al. McMaster Violence Against Women Research Group. Screening for intimate partner violence in health care settings: a randomized trial. JAMA. 2009;302(5):493–501.
38. Nelson HE, Bougatsos C, Blazina I. Screening women for intimate partner violence: A systematic review to update the 2004 U.S. Preventive Services Task Force recommendation. Ann Intern Med. 2012;156(11):796–808.
39. Picard M, Scarisbrick D, Paluck R. HELPS TBI Screening Tool. International Center for the Disabled, TBI_NET, US Department of Education, Rehabilitation Services Administration; 1991.
40. Marshall S, Bayley M, McCullagh S, Velikonja D, Berrigan L. Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Can Fam Med. 2012;58:257–267.
Depression; Interpersonal violence; Mild traumatic brain injury and violence in women; Postconcussion syndrome and posttraumatic stress disorder; Violence and women