I was barely out of residency when I was asked to consult on a victim of abuse. I still recall the marks from the torch burns, the broken nose from repeated battering, and the scars on her face from countless cuts. By then it was too late to help six-year-old Lisa Steinberg who had already died, and her mother — my patient, Hedda Nussbaum — who had been hospitalized at a nearby psychiatric facility and was then living independently in a neighboring community. Nussbaum had seen numerous physicians before she came to me on routine visits and in the emergency room but no one had intervened. Since then, and perhaps partly because of her case, there has been a growing awareness of violence and abuse in homes and the role doctors can play in recognizing and stopping it.
Among women of childbearing age, domestic violence has been estimated to be the leading cause of serious injury and the second-leading cause of injury and death in the United States. The rate of injury to women from battering is greater than that resulting from motor vehicle crashes and muggings combined.
“Abuse is a common problem and as neurologists we may be overlooking a lot of people affected by it,” said Elliott A. Schulman, MD, who has recently completed the Palatucci Advocacy Leadership Forum and is working to increase awareness about it. As a headache expert practicing outside Philadelphia, he became sensitized to the issue three years ago when he added a question — “have you ever been abused?”— to his routine pre-visit questionnaire for new patients. Many patients with chronic refractory headaches said they had been abused, and he was almost always the first person who had asked them about it. Often, those who had never previously addressed the situation experienced a dramatic decrease in headaches once they started to see a psychologist or psychiatrist.
Most of us probably miss the opportunity to help these patients simply because we fail to inquire about abuse. In part, it's because we've never had training on the subject. Although the Accreditation Council for Graduate Medical Education (ACGME) has, since 2005 required that residents be taught to recognize and manage physical, sexual, and emotional abuse, only two neurology programs currently offer rotations on the subject, according to a Jan. 27 report in Neurology report by Lori A. Schuh, MD, neurology residency director at Henry Ford Hospital, in Detroit, and colleagues.
Among other findings, fewer than 18 percent of adult neurology residency programs have faculty within their department teaching about abuse, and 23 percent of programs had no faculty available to teach it. Although 59 percent had faculty available outside the department, only 35 percent said their programs provided didactic experience in the subject. Dr. Schuh, chair of the AAN Consortium of Neurology Program Directors, suspects that program directors rely on a less formal presentation of the topic, expecting that faculty will cover it during clinical experiences in ward and outpatient settings when the opportunity arises (e.g., recognition of abuse as a risk for non-epileptic seizures).
Anna D. Hohler, MD, a member of the Practice Safety Subcommittee, has created a residency program curriculum on abuse and violence training and recently developed an online CME course geared to all neurologists. She started working in the area of domestic violence while in medical school at Boston University. Dr. Hohler did her residency in the military and served as the medical representative to the family counsel committee, the group to whom all cases of suspected abuse were referred. It was there that she noticed that many individuals had neurological complaints — neck and back pain, headaches, seizures, and syncope.
“It's not only intimate partner abuse that needs greater exposure, but as neurologists, we also have to be conscious of elder abuse. We care for a vulnerable patient population — those with physical and cognitive difficulties — that place them at higher risk.” The burden of caring for them, she pointed out, may be too great for a single individual, leading to caregiver burnout that places those individuals in danger of becoming perpetrators of abuse themselves.
Dr. Hohler, who screens patients in a computerized online form or during face-to-face visits, said that the results are eye-opening. “You can't predict who has been abused,” she said. “Patients who suffer from abuse and neglect come from all age groups, racial, religious socioeconomic, educational, and occupational groups,” she said, and stressed the importance of routine screening.
Dr. Schulman was first inspired to use a screening program while listening to Gretchen Tietjen, MD, speak at an American Headache Society plenary session in 2005. Dr. Tietjen, professor and chair of neurology at the University of Toledo where she specializes in vascular neurology and headache medicine, had reported from surveys by US and Canadian investigators that maltreatment was common in women with migraine who had severe depression. The association was strongest among those abused in childhood and adulthood.
Dr. Tietjen and her colleagues at the University of Toledo routinely screen clinic patients for abuse. It is included in a new headache patient paper-pencil questionnaire, which details the type of abuse and ages it occurred. The questionnaire has since become a requirement from the Joint Commission, which mandates that hospitals ask all patients about abuse, and include it on intake forms. “I've noticed that patients often find it easier to complete a questionnaire than answer the question outright,” she said.
“Neurologists seeing patients (both men and women) with chronic headache, and other chronic ‘central sensitization’ syndromes (e.g. irritable bowel, chronic fatigue, fibromyalgia), especially with major depression and anxiety, should be alert to the higher prevalence of abuse,” Dr. Tietjen advised.
Data from numerous studies [see “References”] show that childhood abuse is associated with many changes in the brain in the body's response to stress that persist throughout adulthood, she explained, noting that childhood abuse has been associated with depression, anxiety, chronic pain conditions, and with substance abuse. It is also associated with revictimization in adulthood.
Once patients are identified as having been abused, various resources such as cognitive behavioral therapy and effective treatment of psychiatric comorbidities can help improve quality of life, often reducing or even resolving neurological complaints, several neurologists told Neurology Today.
As I write this column, the news has come in that the singer Rihanna has returned to her boyfriend, Chris Brown, after an alleged severe beating. Nussbaum, who had given me permission to write about her as a patient, said: “I understand why women return, whereas people who have not ‘been there’ can't understand. However, I think Rihanna and others like her regret their actions when they are beaten again, or worse, they never have a chance to be sorry because the next time they may end up dead.”
More About Getting Help for Abused Patients
- Federal land state laws mandate that all suspected cases of child abuse must be reported. State laws require that all suspected cases of elder abuse must be reported, and, in some states, spousal abuse must also be reported. The state law requirements vary.
- Recognizing Abuse in Your Neurology Patients, a CME program written by Dr. Hohler, will be available this summer. It is the first online CME program developed specifically for AAN.com.
- Domestic support groups for abuse are key. Hedda Nussbaum, who wrote about her ordeal of abuse in her memoir, Surviving Intimate Terrorism (PublishAmerica.com, 2005), and advocates for support groups, said: “In such a group, women learn that they are not alone, that other women are going through the same things, and they get support from peers. They also learn techniques for dealing with the abuser and how to make a safety plan. This is true for women who are being verbally and emotionally abused as well as for those who are being physically abused.”
- National Domestic Violence Hotline: www.ndvh.org, 1-800-799-SAFE (7233)
- National Sexual Assault Hotline: www.rainn.org, 1-800-656-4673
- Family Violence Prevention Fund/Health Resource Center: www.endabuse.org, 415-252-8900
- Child Welfare Information Gateway: www.childwelfare.gov/responding/reporting.cfm
- National Clearinghouse on Abuse in Later Life: www.ncall.us/, 608-255-0539
- National Center on Elder Abuse: www.ncea.aoa.gov/, 1-800-677-1116
- National Organization for Victim Assistance: www.trynova.org/, 1-800-879-6682
Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci
Carpenter LL, Carvalho JP, Mello MF, et al. Decreased adrenocorticotropic hormone and cortisol responses to stress in healthy adults reporting significant childhood maltreatment. Biol Psychiatry
Sachs-Ericsson N, Kendall-Tackett K, Hernandez A. Childhood abuse, chronic pain, and depression in the National Comorbidity Survey. Child Abuse Neglect
Widom CS, Czaja SJ, Dutton MA. Childhood victimization and lifetime revictimization. Child Abuse Neglect