Are Domestic Violence Victims at Risk for Brain Injury?

In recent years, we've been seeing a sharp rise in news stories and research studies looking at Chronic Traumatic Encephalopathy (CTE) and the often-catastrophic effects it can have on people who have sustained repeated head injuries.

Originally known as dementia pugilistica because of its prevalence in boxers, CTE has been diagnosed in many retired professional or college football players, soccer players, and in many other athletic sports in which a player might have had repetitive head trauma. It's also been diagnosed in some soldiers with brain damage secondary to closed head injuries due to blast trauma.

Though repeated head traumas, even minor traumas, often go unrecognized, such trauma can result in hyperphosphorylated tau protein deposits and neurofibrillary tangles which are diffused through many parts of the brain and, over time, can result in mood disturbances and severe cognitive impairments in later years. Though often misdiagnosed as Alzheimer's disease or other dementias, severe CTE can leave many former athletes totally incapacitated.

But is CTE limited primarily to athletes or soldiers? What about victims of intimate partner violence (IPV), many of whom may sustain repeated head injuries over time? The latest issue of the journal Canadian Psychology presents a review paper highlighting the disturbing link between IPV and CTE and why it has been neglected up to now.

Written by Angela Colantonio of the University of Toronto, the paper was originally presented as a keynote address at the annual convention of the Canadian Psychological Association during which she outlined the relative disparity in research studies looking at brain damage in IPV victims compared to athletes. As she points out, IPV affects one out of four women in Canada alone (and the statistics are even higher in other countries). Of the physical injuries IPV victims sustain, 92 percent are to the head or face and, in many cases, involve repetitive injuries occurring over a number of months or years.

While men can be victims of IPV as well, there is no question that women make up the overwhelming majority of all IPV cases, whether or not they receive proper treatment afterward. Cases of traumatic brain injury (TBI) stemming from assault are also known to occur in many other often-marginalized groups, including homeless people, workers in high-risk professions, older adults experiencing elder abuse, and, at least in Canada, members of indigenous communities, including First Nations and Inuit peoples.

Among women admitted to family shelters following IPV, 30 to 74 percent show evidence of having sustained at least one, or in many cases, multiple head injuries inflicted by a partner. Research has also shown a direct link between the number of TBIs related to IPV and poorer performance on tests of memory, learning, and cognitive flexibility.

Evidence for IPV-related brain injuries has also been found in women recruited from primary care waiting rooms and family planning clinics. Given that many IPV victims deliberately hide their injuries to avoid official scrutiny, the problem of brain injuries in domestic abuse victims may be far more prevalent than previously suspected. Also contrary to popular belief, evidence of IPV-related brain injuries has been found a wide range of educational and income levels.

Interestingly enough, IPV perpetrators also show a much higher prevalence of TBI that in general populations, a finding that may reflect the increased impulsivity and reduced emotional control that can often occur in head-injured individuals. For that matter, women with a history of head injuries are also much more vulnerable to later IPV abuse though the reasons for this aren't clear.

But the long-term picture may be even bleaker for IPV victims. A recent data-mining study looking at over of over 235,000 cases of TBI showed that people with TBI were more likely to experience assault and child abuse than persons without TBI, even when age, sex, income, and geographic location were taken into account. For that matter, a longitudinal study of over 700,000 cases of TBI showed that women were more likely to develop dementia sooner after TBI than men and that comorbid spinal cord injury increased dementia risk significantly.

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Given these research findings, how likely are primary care physicians and other health care providers to investigate the possible effects of TBI in domestic abuse victims? In her review, Dr. Colantonio described survey research among members of Toronto's IPV support community that showed frontline workers, and even the victims themselves, generally showed little awareness about TBI. This includes not being able to recognize potential signs or symptoms of TBI and, as a result, failing to recognize that the clients they serve might have special treatment needs.

To address this knowledge gap, Dr. Colantonio and her colleagues recently conducted the first national network-building workshop in Canada. Bridging the worlds of brain injury and IPV, the workshop helped educate victims and frontline workers about TBI as well as generating recommendations for future research and treatment policies. With financial assistance from Canada's Federal Department of Justice, they have also developed an online toolkit for service providers as well as a workshop video that can also be accessed online.

Though Angela Colantonio and her colleagues are continuing their research efforts, it's clear that the risk of TBI in victims of domestic violence is still overlooked in many cases, especially in people from diverse social, ethnic, and racial backgrounds who may not seek help until too late. Not only is more education needed for health professionals dealing with IPV victims and people with TBI, but also for the victims themselves. Neurorehabilitation approaches specifically aimed at domestic violence survivors also need to be developed to reduce the risk of later medical problems such as dementia.