Shedding Light on Intimate Partner Violence and Brain Injury

by Dr. Elizabeth McNally

One in four. One in seven.

Without any context, those numbers probably mean nothing to you.

What happens when you find out that they represent the individuals in the United States who suffer severe physical violence by an intimate partner in their lifetime?

Does one in four women and one in seven men take on a whole new meaning now?

The numbers are staggering. However, the public discussion of this epidemic in our society is nearly inaudible. This type of physical violence, and its associated long-term consequences, impact millions of US citizens, regardless of race, ethnicity, or socio-economic status.

Falling under the umbrella of Intimate Partner Violence (IPV), also known as domestic violence, is “severe physical abuse,” which is defined as: hitting, punching, slapping, kicking, strangulation, and/or the use of weapons/objects to inflict injury on another person. Severe physical abuse is also the most commonly recorded form of IPV, with the lifetime number of victims estimated to be near 40 million .

As a result of severe physical abuse, traumatic brain injuries often occur. They are typically the result of direct mechanical forces, including penetrating vs. non-penetrating injuries, and can occur with or without focal injury (such as a hematoma or hemorrhage), or via secondary injury at the cellular/molecular level, such as what occurs in ischemic (loss of blood flow) or hypoxic (loss of oxygen) events.

The most common type of traumatic brain injury is referred to as Mild TBI/mTBI, or Concussion.  Mild TBIs are most commonly identified as being induced by biomechanical forces, such as with a direct impact to the head/face or neck, or via indirect force, transmitted to the head by impact(s) elsewhere on the body.  Other forms of mTBI, related to IPV, are the result of asphyxia (deprivation of oxygen to body tissues), most commonly by strangulation. Strangulation is defined as external pressure applied to the neck, resulting in the closure of some or all of the blood vessels and/or air passages of the neck, which results in the loss of oxygen and compromises blood flow to/from brain tissues. The lack of oxygen immediately begins to induce cellular/metabolic changes. On average, within 6.8 seconds an individual can be rendered unconscious; brain death can occur as early as 62 seconds. Of the one in four women who are victims of IPV, evidence suggests that up to 68% will experience near-fatal strangulation by their intimate partner.

Through many years of research into sports-related concussions, blast-related concussions among military personnel, and concussions suffered as a result of falls or motor vehicle accidents, it has become evident that a large number of these injuries are likely under-reported. The lack of reporting is believed to be a result of a lack of understanding among the public and the medical world, that has gone on for years and years pertaining to both the immediate and long-term diffuse physiological, neurochemical, and functional effects associated with brain injury. As the science has progressed, and research has begun to hone-in on the short-and-long-term consequences, public awareness has begun to increase, but not to the level that one would hope.

Consequently, reporting of IPV injuries to medical personnel is minimal in relation to the number of incidents that occur each year. Statistics have shown that a mere 3% of strangulation victims seek medical care, and that in both non-fatal and fatal strangulation cases, only 50% of victims have visible injuries (such as bruising, abrasions, petechiae, swelling, etc.). Of those who do seek medical care, immediately following or in the days-to-weeks following the abuse, the screening and diagnosis of mTBI, historically speaking, has been overlooked by emergency medical personnel, even in instances where visible injuries to the head and face were, in fact, present. As a result, patient education related to mTBI/concussion signs/symptoms, and options for care, have been lacking, yet the frequency of mTBI/concussion injuries among victims of IPV is estimated to be significant. Among survivors, many factors are suspected to play a role in the under-reporting of intimate partner violence, most notably the psychological and emotional manipulation/abuse that the perpetrator also uses to victimize, which often results in downplaying the severity of the situation, or results in fear of the consequences that may be inflicted upon them by the abusive partner.

It is important for survivors to know that there have been significant changes over the years within the medical and legal systems, law enforcement, and among the countless advocacy organizations throughout the United States. These changes have been directed toward improving education of involved personnel, enhancing support and services for victims/survivors, and effectively establishing cases against perpetrators.

Statistics gathered by the National Intimate Partner and Sexual Violence Survey (2010-2012) indicated that the number of both women and men with a history of IPV was significantly higher in reporting adverse health conditions/symptoms than those without a history of such violence. The most common complaints included frequent headaches, chronic pain, difficulties with sleep, and limitations in activities. Consequently, some of the most commonly identified symptoms associated as sequelae of mTBI/concussion include:

• Physical symptoms (headaches, dizziness, fatigue, visual changes, noise sensitivity, light sensitivity, pain, etc.)
• Cognitive symptoms (attention problems, brain “fog,” memory impairments, difficulty forming thoughts, etc.)
• Emotional symptoms (aggression, depression, lability, etc.)
• Sleep disruption (difficulty falling/staying asleep, disruptions in normal sleep schedule, etc.).

Providers with advanced specialty training in concussions and traumatic brain injuries are capable of accurately diagnosing and developing a rehabilitation plan specific to the clinical presentation of each individual patient.

One in four women. One in seven men.

You don’t have to suffer in silence. You are not alone. You are a survivor.

Dr. Elizabeth McNally, DC, DACNB, FABCDD, FABBIR, FABVR is the founder and clinician of MidCoast Chiropractic Neurology, in Brunswick, ME.  As a medical trainer with the Cumberland County Violence Intervention Partnership, she is part of a multi-disciplinary team consisting of Victim’s Advocates, members of Law Enforcement and the local District Attorney’s office.  This Partnership Team provides trainings specific to Strangulation for other Advocates, Law Enforcement officials and Medical Personnel in the state of Maine.