Brain Injuries often Overlooked in Intimate Partner Violence Eve M Valera PhD Assistant Professor Harvard Medical School Research Scientist Massachusetts General Hospital Psychiatric Neuroscience Program ID: 1043480
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1. Concussions and Strangulation: Brain Injuries often Overlooked in Intimate Partner ViolenceEve M. Valera, Ph.D.Assistant Professor, Harvard Medical SchoolResearch Scientist, Massachusetts General HospitalPsychiatric Neuroscience Program
2. Intimate Partner Violence (IPV) is a public health epidemicIntimate partner violence is violence perpetuated by a current or former spouse, partner, significant other, boyfriend or girlfriend. IPV is the leading cause of homicide for women globally. It is the most common form of violence against women. Traverses all socioeconomic boundaries.
3. 1 in 3 women experience physical or sexual IPV DaughtersMothersSistersColleaguesPartnersFriends
4. Women endure violent abuse to the head with an estimated 80-90% of injuries to the neck and higher
5. A mild TBI or concussion involves an external force to the head and disrupted brain function A hit, jolt or external force to the head that results in: any loss of consciousness (LOC); any loss of memory for events immediately before or after the incident;any alteration in mental state at the time of the incident (e.g., feeling dazed, disoriented or confused). any focal neurologic deficit(s) that may or may not be transient (e.g., visual disturbances)(Committee on Mild Traumatic Brain Injury, American Congress of Rehabilitation Medicine 1993)
6. Ask about disruptions of consciousness or awareness after a trauma to the headAfter anything your partner did to you, did you: Lose consciousness or black out?Not remember part of or have memory loss for the incident? Feel confused or disoriented?Feel stunned or dazed?See stars or spots?Feel dizzy?[if ‘Yes’] Can you tell me what happened?Listen for things that could result in impacts to the brain (e.g., head hit the wall, he shook me violently, punched me in the head)Number of times, first and last time, duration of LOC or amnesia
7. The majority of women experiencing IPV sustain IPV-related brain injury74% > 1 IPV-TBI51% repetitive IPV-TBI42,000,00031,080,00021,420,000(Valera and Berenbaum JCCP 2003; Valera et al J Neurotrauma In press)
8. IPV-related TBIs are associated with poor cognitive and psychological outcomesHaving more TBIs was associated with: Poorer performance on tests of memory, learning and ability to go back and forth quickly between tasksHigher ratings of general distress, depression, worry, anxiety, and traumatic stressWas NOT accounted for by: abuse severitypsychopathologysubstance abuse (Valera and Berenbaum, 2003)
9. We use magnetic resonance imaging to measure connectivity within the brainStructural connectivity which involves parts of brain cells that connect different brain regionsFunctional connectivity which involves regions of the brain that are working together but are not right next to each otherBoth are critical for optimal brain function and ultimately behavior
10. Concussions involve injury to brain cells that can affect structural and functional connectivity Traumatic shearing of this axon may occur when head rapidly undergoes acceleration, deceleration, or rotational forcesNeuron/brain cell can be injured so neurons can not communicate with one another efficiently or at all.
11. Number of mild TBIs is related to functioning of some of these long fibers/axons
12. Functional network communication is associated with number of IPV-related TBIs and cognition(Brain illustration by Eric Chudler)Anterior insulaPosterior cingulate/precuneusThe more recent and greater number of TBIs a woman had, the less positively these two brain regions communicated with one another.The less these two brain regions communicated with one another, the worse a women tended to be able to learn a list of words and remember them 20 minutes later.
13. Take Home Points for IPV-Related TBIIPV-related TBIs, especially repetitive mild TBIs occur at a high rate.Recognize the strong potential for a TBI in every IPV case. IPV-related TBIs have a negative effect on:cognitive functioning-psychological health-functional connectivity-structural connectivityIPV-related TBIs can interfere with a woman’s ability to escape a dangerous or lethal situation.
14. Strangulation can result in an acquired brain injuryJpmaweb.com
15. Strangulation is a serious form or abuse that can cause acquired brain injuries (ABIs)NOT “choking”External attack on neckAsphyxia – depriving the body of oxygen leading the body to unconsciousness or deathHypoxia: partial loss of oxygen to tissueAnoxia: complete absence of oxygen to tissue
16. Such that there is an obstruction of:1) Blood flow either from or to the brain (via the jugular vein/or carotid artery)2) AirwayStrangulation is a form of asphyxia from external pressure placed upon the neck
17. Strangulation often leaves no visible marks orexternal injuries50% of victims had no visible injuriesOnly 15% had photos of sufficient quality to be used in court.Victims sought medical attention within 48 hours in only 3% of cases.
18. Blood buildup or lack of enough oxygen from strangulation can cause damage quicklyUnconsciousness can result within 2 minutes from blood build-upUnconsciousness can result within 10 seconds from anoxiaStrangulation can cause brain death in less than 4 minutes while leaving no external markDamage may result in death weeks later (swelling, carotid dissection resulting in stroke, internal bleeding, respiratory problems and pneumonia)
19. Strangulation is one of the best predictors of later homicideThe odds of becoming a homicide victim increased by about seven-fold for women who had been previously strangled by their partnerStudy of 57 murdered Chicago women: 53% were strangled in the year prior to being murdered7X
20. Rates of strangulation vary depending on how it is measured but numbers are high“Did your partner ever choke you?”82% report at least 1 event22% reported more than 25 events“After anything your partner ever did to you did you ever lose consciousness, feel dizzy, feel dazed/confused, etc?”25% reported at least 1 alteration in consciousness12% reported repetitive strangulationsPreliminary results!! Related to ability to learn a list of words.
21. Things to remember….
22. TBIs can make it harder for a woman to survive, escape, or keep childrenHaving a TBI might make it harder to:Assess danger and defend herself against further abuseMake and remember safety plansGo to school or hold a job (financial dependence)Leave abusive partner and live on her ownAccess necessary servicesAdapt to living in a shelterRetain custody of her childrenHaving a TBI does NOT = “unfit”!
23. Women rarely report that they sustained a TBI or were strangled“I sustained a brain injury/I was strangled.” Very unlikely!“We were arguing and then I was getting up from the floor.” Yes“He put his hands on my throat.” Yes“I fell backwards and hit the wall.” Yes“I am not sure how I got to the other room.” Yes “He choked me.” MaybeThere are often no visible signs of external injury (imaging may show signs of internal injury for strangulation). Victims rarely seek medical attention. “Well, it’s not a broken arm.”
24. TBIs unobserved behind closed doors are likely to be misinterpreted or missedSomeone who may appear to be: disorientedconfuseddistractibleinconsistentheadachesuncooperativedizzyoff-balance
25. Danger signs / Red Flags for TBIOhio DV Network
26. Women subjected to IPV report a range of post-concussive symptomsCognitivePhysicalEmotionalMemory problemsHeadaches/migrainesAnxiety/irritabilityTaking longer to thinkFatigue and sleep problemsDepression/mood swingsDecreased concentrationBalance problemsImpulsive behaviorImpaired word findingDizzinessRestlessnessImpaired judgmentNauseaInappropriate behaviorDifficulty with initiation and follow through Visual disturbancesAggressive behavior
27. Post-Concussive Syndrome is common in women subjected to IPV (of 20 women) 63% met criteria for at least mild PCSMost common symptomsFeeling depressed or tearful (58%)Headaches (53%)Being “irritable or easily angered”, “frustrated or impatient”, restlessness (47%)Poor concentration (42%)“Sleep disturbances”, “forgetfulness, poor memory”, “taking longer to think” (37%)
28. Signs of strangulation, when visible often appear as red or bruisedRed eyes (blood shot, bleeding in eyes)Redness on neck (short-lived)Tiny red spots (petechiae)Swelling of neck (perhaps internal bleeding)Bruising behind earsSmall, round finger marks on neck (if manual)
29. Coughing, vomitingVoice changes, loss of voiceLoss of consciousnessDifficulty swallowing, breathingRaspy breathingPain or tendernessMental status changes (combativeness, amnesia)Involuntary urination/defecationVision changesSymptoms of strangulation may also be observed later
30. Danger Signs / Red Flags for StrangulationOhio DV Network
31. Keep in mind the high likelihood that a TBI or strangulation may have occurredHave the right questions been asked? A woman will not necessarily know that she has sustained a TBI.A woman may not recognize the relevance of reporting that she sustained a TBI.A negative scan does not mean that there is no TBI.
32. Interact with women in a way that is sensitive to the possibility of a brain injuryMinimize distractions, meet in quiet locations, short meetings, breaksAvoid loud noises and bright lightsRepeat information Prioritize goals, make them smaller steps, and write them outTalk slowly and to the pointDouble check with her to be sure that she understood information
33. Interact with women in a way that is sensitive to the possibility of a brain injuryWork on one task at a time and stick to the task at handBe factual and concreteAllow extra time or help her to to complete tasks (e.g., fill out forms, make calls)Point out possible consequences of decisions she may need to make Provide respectful feedback on problem areas that affect her safety if she thinks she is functioning better than she isEncourage self-determination and identify strengths
34. Consider potential effects of TBIs when safety planningBreak plans down into small steps and sequenceReview plans frequently and in detail to help compensate for problems with memory, motivation, initiative and follow-throughIncorporate needs and abilities into plans for her to live, work or drive on her ownBe realistic in how much she can accomplish in a given day Provide extra support and coaching when she needs to deal with the justice system or family court (e.g., role play)Reach out to a domestic violence shelter with information on TBI and potential accommodations
35. Raising awareness everywhere is critical!First responders including police and paramedicsJudges – custody, criminal, restitutionIPV support staffWomen themselves – understanding the potential impact of TBI and its sequelae on their livesMay be interfering with their ability to functionHindering their ability to escape the abusive situationUnaware of the possible long term effects and that they may be related to TBI; Chronic Traumatic Encephalopathy (CTE)
36. Remember! Every little bit of support helps!
37. All the women who entrusted me with their information and gave of their time to participate in this important research.Domestic violence shelter staff in the Boston and Champaign-IL areas University of IL, NIH and Harvard Center of Excellence for grant funding. Athinoula A. Martinos Center for Biomedical Imaging at MGH for scanning-related resources and additional scan time.AcknowledgementsCollaboratorsHoward BerenbaumAaron KucyiGreg SorensenMargaret O’ConnorOfer PasternakMartha ShentonAihua CaoNikos MakrisMarek KubickiFrom Noun Project:Louis PradoVasily GedsunHeadsofBirdsPhamDuy Phuong HungDTDesignMade
38. IPV-related TBIs are very common and dangerous!It is our job to recognize and intervene!eve_valera@hms.harvard.edu