Neurological Implications of Nonfatal Strangulation and Intimate Partner Violence
2019; Future Medicine; Volume: 14; Issue: 3 Linguagem: Inglês
10.2217/fnl-2018-0031
ISSN1748-6971
AutoresKathleen Monahan, Archana Purushotham, Anat Biegon,
Tópico(s)Child Abuse and Trauma
ResumoFuture NeurologyVol. 14, No. 3 CommentaryOpen AccessNeurological implications of nonfatal strangulation and intimate partner violenceKathleen Monahan, Archana Purushotham & Anat BiegonKathleen Monahan*Author for correspondence: E-mail Address: kathleen.monahan@stonybrook.edu School of Social Welfare, Stony Brook University, HSC, Level 2, Rm 093-G Nicolls Rd, Stony Brook, NY 11794-8231, USA, Archana PurushothamDepartment of Neurology, Baylor College of Medicine, Houston, TX 77030, USAMichael E DeBakey VA Medical Center, Houston, TX 77030, USA & Anat BiegonDepartment of Radiology, School of Medicine, Stony Brook University, HSC 4-106F, Nicolls Rd, Stony Brook, NY 11794, USAPublished Online:22 Aug 2019https://doi.org/10.2217/fnl-2018-0031AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit Keywords: abusefemicidestrangulationIntimate partner violence (IPV) remains a human rights and public health issue, and recent attention has focused on neurological deficits following IPV, particularly traumatic brain injury (TBI) [1,2]. Another common mode of assaultive behavior with IPV that can cause neurological damage is nonfatal strangulation (NFS) [3,4]. These types of injuries have been noted by domestic violence shelter staff, victims agencies and on a limited basis – medical professionals – for over 20 years [5–7]. Yet identification, assessment and standardized approaches for healthcare providers have yet to be employed universally, despite the development of several assessment measures [8,9]. The potential for mortality and long-term negative sequelae following this type of assault remains high [1–8]. However, responses to this issue by law enforcement and domestic violence programs have 'outpaced scholarly investigation of nonfatal strangulation' [4]. This brief review highlights the scope of the problem and the medical, psychological, physical and disabling conditions issues post IPV/NFS [10], and what healthcare providers can do.Scope of the problemThe National Intimate Partner and Sexual Violence Survey (NISVS) indicates that one in three women has experienced IPV during her lifetime and nearly one in ten, or 11.6 million women have been strangled by an intimate partner [11,12]. Previous research indicates that NFS is a highly gendered type of violence, generally utilized in a controlling context [13–16]. The financial costs of IPV are staggering with figures calculated for the USA at more than 8.3 billion annually [17].The American Academy of Neurology (ANN) has identified IPV as a public health issue underscoring the devastating consequences [18]. Many individuals do not seek law enforcement assistance, medical services and/or counseling/support services; therefore, data do not reflect the magnitude of this ongoing issue [1–8]. A landmark study conducted in Los Angeles in 2001 highlighted that 89% of victims experienced NFS during the course of IPV, yet 50% of the cases had no visible injuries [19]. Several different categories of strangulation exist: hanging; ligature strangulation; manual strangulation and positional strangulation [20]. All of these categories involve mechanically cutting off the airway and subsequent neurological insult unless interrupted.The Institute of Medicine (IOM) and Department of Health and Human Services, recommends screening regarding current and past IPV in both private and government-funded programs [21–26]. However, TBI and NFS, in particular, are not routinely identified and assessed [27,28]. A study conducted on women who disclosed IPV indicated that 75% disclosed only when asked; most women did not disclose but stated they would have, if asked [29]. A history of NFS is highly indicative of femicide [12,19]. Glass et al. indicate that prior NFS was associated with more than a sixfold odds ratio of becoming an attempted homicide and over a sevenfold odds of becoming a completed homicide [30,31].As several researchers point out, while law enforcement and legislative reforms have made advancement to address the issue of NFS, scholarly efforts at systematically researching the sequelae of this form of violence are sparse and the area is under-researched [4]. Thus far, 30 states consider NFS a felony [12].Medical/neurological issuesThe terms strangulation and choking are used interchangeably by the lay pubic, and healthcare professionals should be alert on how these terms are used by patients. Strangulation is defined as pressure placed externally on the person's neck constricting blood flow to the brain and/or airway, causing the inability to breathe. Campbell et al. [32] studied 901 women (n = 543 confirmed cases of IPV and n = 358 controls, never abused) in Baltimore, MD and the US Virgin Islands for TBI and CNS symptoms. They state, "The prevalence of reported probable TBI (from injury to the head or strangulation) in women who experienced IPV was 50% in this sample." The head, neck and face are the most commonly injured body parts in IPV, and NFS is acknowledged as creating serious negative health outcomes such as carotid artery dissection, stroke and seizures [33]. Orbital, mandibular and nasal fractures are common with most injuries occurring to the left side of the face as 90% of the population is right-handed [34].Strangulation generally occurs during chaotic and violent interactions [27,35]. Women have reported that the batterer strangled them with their hands, a rope or scarf, or they have been placed in choke hold [36]. As noted by Sorenson, Joshi and Sivitz [3], strangulation is an extremely painful way to die and creates terror in the victim.Outward signs of NFS such as petechia and red marks around the neck assist in diagnosis; however, physical signs may be absent. For darker-skinned women, alternate light sources may aid in detection of bruises or injury [8]. Consequently, inquiry regarding the details of the injury is imperative in making an accurate assessment.Strangulation can have immediate and late medical sequelae. The interruption of cerebral blood flow coupled with hypoxia from respiratory arrest, if severe enough, can lead to immediate loss of consciousness and later, a persistent disorder of consciousness [37]. Seizures, strokes, cardiac arrest, cortical edema and intracerebral hemorrhages may occur in the acute phase. In less severe cases, it is probable that cognitive deficits common in other forms of hypoxic–ischemic encephalopathy, in other words, impairments of memory and executive function – especially attention and processing speed – occur [38], although no studies of long-term sequelae in NFS have been carried out. In addition to direct hypoxic–ischemic damage from NFS, mechanical trauma to the cervical blood vessels and the airway can cause delayed neurological sequelae. Arterial dissections may occur, leading to stroke weeks later, making it difficult for the victim and healthcare providers to relate the stroke to the NFS event. Similarly, airway trauma can cause delayed airway obstruction from tissue swelling, compounding the initial hypoxic insult [39].Mechanisms underlying hypoxic–ischemic brain damageExperimental models of hypoxic/ischemic injuries in neuronal culture have demonstrated that oxygen and glucose deprivation cause neuronal death largely mediated by excessive glutamate release (excitotoxicity), calcium overload and free radical formation [40–42]. Interestingly, different brain regions and neuronal populations show varying levels of vulnerability, with the hippocampal formation (specifically the pyramidal neurons of the CA1 field) succumbing to short periods of ischemia (∼5 min), which do not affect other brain regions [43,44]. This regional sensitivity has been demonstrated in postmortem studies of human brains [45–47] as well as studies of glutamate toxicity in neuronal cultures derived from different brain regions [48]. As the duration of transient global ischemia increases, neuronal death can be observed in additional regions such as the thalamus and cortex. Since the hippocampus plays a crucial role in memory formation [49,50], this mechanism supports the development of cognitive deficits in IPV victims that may contribute to the failure of many victims to sense the dangerousness of their situation and/or leave the abusive relationship.RecommendationsIPV literature contains voluminous data on the health/help seeking behaviors of women that experience IPV including the increase of women seeking medical assistance [23–25]. However, many do not, for a variety of reasons: the abuser would not let them; they are ashamed; they do not have transportation and they do not have health insurance [51–53]. Research on neurological difficulties for this population and addressing the serious gaps in service needs, delivery and rehabilitation is an important area of research inquiry.Consequently, the following steps are recommended to help address this problem:1.Universal screening in all healthcare settings, domestic violence shelters and community mental health/victim agencies inquiring about IPV and types of injuries particularly to the head and neck. These types of inquiries should be conducted in private and safely away from any second party. Failure to do so may put the patient at jeopardy for further abuse.2.Healthcare professionals need to educate the patient regarding the dangerousness of the situation. Unfortunately, many individuals believe that this event, as scary as it is, is a one-time event and do not understand the neurological, physical and psychological toll this type of trauma induces. Moreover, many women do not understand that chronicity of neurological insult will negatively impact their memory, attention, reasoning and ability to make informed decisions. Healthcare offices should have information on community resources for IPV and rehabilitation specialists familiar with IPV.3.Several NFS/lethality questionnaires exist and can be utilized such as the Abuse Assessment Screen which was originally developed in 1987 to assess for IPV and later revised by Coker [10] to include NFS. For further information refer to Laughon et al. [9], Mcquown et al. [54], Campbell et al. [32,55] and Messing et al. [56].4.More training is needed for specialty courts, for example, family courts, domestic violence courts and drug courts. Judges, lawyers, court officers, legislators and court advocates need to become familiar with the lethality aspects of NFS and the long-term neurological deficits that can emanate from this type of criminal behavior during IPV.5.A fuller examination regarding IPV and the health and mental health status of ethnic minority women is needed. For an excellent review see: Stockman et al. 2015 [57].6.For more information on NFS visit: www.strangulationtraininginstitute.comFinancial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript. The financial disclosure is correct.Open accessThis work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit: http://creativecommons.org/licenses/by-nc-nd/4.0/References1. Monahan K, Goldfine A, Biegon A. Traumatic brain injuries in victims of intimate partner violence: an under-appreciated source of neurological morbidity. Future Neurol. 12(4), 189–191 (2017).Link, CAS, Google Scholar2. Wong J, Fong D, Lai V, Tiwari A. Bridging intimate partner violence and the human brain: a literature review. Trauma, Violence, Abuse 15(1), 22–33 (2014).Crossref, Medline, Google Scholar3. Sorenson S, Joshi M, Sivitz E. A systematic review of the epidemiology of nonfatal strangulation, a human rights and health concern. Am. J. Pub. Health 104(11), e54–e61 (2014).Crossref, Medline, Google Scholar4. Pritchard A, Reckdenwald A, Nordham C. Nonfatal strangulation as part of domestic violence: a review of research. Trauma, Violence, Abuse 18(4), 407–424 (2017).Crossref, Medline, Google Scholar5. Diaz-Olavarrieta C, Campbell J, Garcia de la Cadena C, Paz F, Villa AR. Domestic violence against patients with chronic neurologic disorders. Arch. Neurol. 56, 681–685 (1999).Crossref, Medline, CAS, Google Scholar6. Massey JM. Domestic violence in neurologic practice. Arch. Neurol. 56, 659–660 (1999).Crossref, Medline, CAS, Google Scholar7. Monahan K, O'Leary KD. Head injury and battered women: an initial inquiry. Health Soc. Wk 24(4), 269–278 (1999).Crossref, Medline, CAS, Google Scholar8. Campbell JC, Glass N, Sharps PW, Laughon K, Bloom T. Intimate partner homicide: review and implications of research and policy. Trauma Violence Abuse 8, 246–269 (2007).Crossref, Medline, Google Scholar9. Laughon K, Renker P, Glass N, Parker B. Revision of the abuse assessment screen to address nonlethal strangulation. J. Obstet. Gyn. Neonat. Nurs. 37(4), 502–507 (2008).Crossref, Medline, Google Scholar10. Coker AL, Smith PH, Fadden ML. Partner violence and disabilities preventing work. J. Womens Health 14, 829–838 (2005).Crossref, Google Scholar11. Black MC, Basile KC, Breiding MJ et al. National Intimate Partner and Sexual Violence Survey: 2010 summary report. Centers for Disease Control and Prevention, GA, USA (2011).Google Scholar12. Thomas KA, Joshi M, Sorenson SB. "Do you know what it feels like to drown?": strangulation as coercive control in intimate relationships. Psychol. Women Q. 38, 124–137 (2014).Crossref, Google Scholar13. Anderson KL. Gendering coercive control. Violence Against Women 15, 1444–1457 (2009).Crossref, Medline, Google Scholar14. Johnson MP, Leone JM. The differential effects of intimate terrorism and situational couple violence. J. Fam. Issues 26, 322–349 (2005).Crossref, Google Scholar15. Stark E. Coercive Control: How Men Entrap Women in Personal Life. Oxford University Press, NY, USA (2007).Google Scholar16. Nemeth JM, Bonomi AE, Lee MA, Ludwin JM. Sexual infidelity as trigger for intimate partner violence. J. Womens Health 21, 942–949 (2012).Crossref, Google Scholar17. Valpied J, Hegaty K. Intimate partner abuse: Identifying, caring for and helping women in healthcare settings. J. Womens Health 11(1), 51–63 (2015).CAS, Google Scholar18. Schulman E, DePold X, Holder A. The American Academy of Neurology position statement on abuse and violence. Neurology 78, 433–435 (2012).Crossref, Medline, Google Scholar19. Strack G, Gwinn C. On the edge of a homicide: strangulation as a prelude. Crim. Jus. 26, 32–37 (2011).Google Scholar20. Shields LB, Corey TS, Weakley-Jones B, Stewart D. Living victims of strangulation, a 10 year review of cases in a metropolitan community. Am. J. Forensic Pathol. 31(4), 320–325 (2010).Crossref, Medline, Google Scholar21. Institute of Medicine. Clinical preventive services for women: closing the gaps. The National Academies Press, Washington, DC, USA (2011).Google Scholar22. United States Department of Health and Human Services. Affordable Care Act ensures women receive preventive services at no additional cost (2012). http://www.hhs.gov/news/press/2011pres/08/20110801b.htmlGoogle Scholar23. Ambue B, Hamberger LK, Guse C, Melzer-Lange M, Phelan M. Healthcare can change from within: sustained improvement in the healthcare response to intimate partner violence. J. Fam. Viol. 28, 833–847 (2013).Crossref, Google Scholar24. Miller E, McCaw B, Humphreys B, Mitchell C. Integrating intimate partner violence assessment and intervention into healthcare in the United States: a systems approach. J. Womens Health 24(1), 92–99 (2015).Crossref, Google Scholar25. Hamberger LK, Rhodes K, Brown J. Screening and intervention for intimate partner violence in healthcare settings: creating sustainable system-level programs. J. Womens Health 24(1), 86–91 (2015).Crossref, Google Scholar26. Decker MR, Frattaroli S, McCaw B. Transforming the healthcare response to intimate partner violence and taking best practices to scale. J. Womens Health 21, 1222–1229 (2012).Crossref, Google Scholar27. Reckdenwald A, Nordham C, Pritchard A, Francis B. Identification of nonfatal strangulation by 911 dispatchers: suggestions for Advances toward evidence-based prosecution. Violence Victims 32(3), 506–520 (2017).Crossref, Medline, Google Scholar28. Murray CE, Lundgren K, Olson LN, Hunnicutt G. Practice Update: what professionals who are not injury specialists need to know about intimate partner violence-related traumatic brain injury. Trauma Violence Abuse 17(3), 298–305 (2016).Crossref, Medline, Google Scholar29. Morse DS, Laffeur R, Fogarty C, Mittal M, Cerulli C. "They told me to leave": how health care providers address intimate partner violence. J. Amer. Board. Fam. Med. 25(3), 333–342 (2012).Crossref, Medline, Google Scholar30. Glass N, Laughon K, Campbell J et al. Non-fatal strangulation is an important risk factor for homicide of women. J. Emerg. Med. 35, 329–335 (2008).Crossref, Medline, Google Scholar31. Foley A, Gurney D. Strangulation: know the symptoms, save a life. J. Emerg. Nurs. 41, 89–90 (2015).Crossref, Medline, Google Scholar32. Campbell JC, Anderson J, McFadigion A et al. The effects of intimate partner violence and probable traumatic brain injury on central nervous system symptoms. J. Womens Health 27, 761–767 (2018).Crossref, Google Scholar33. Patch M, Anderson J, Campbell J. Injuries of women surviving intimate partner strangulation and subsequent emergency health care seeking: an integrative evidence review. J. Emerg. Nurs. 44, 384–393 (2018).Crossref, Medline, Google Scholar34. Bhole S, Bhole A, Harmath C. The black and white truth about domestic violence. Emer. Radiol. 21, 407–412 (2014).Crossref, Medline, Google Scholar35. Nemeth JM, Bonomi AE, Lee MA, Ludwin JM. Sexual infidelity as trigger for intimate partner violence. J. Womens Health 21(9), 942–949 (2012).Crossref, Google Scholar36. St. Ivany AS, Bullock L, Schminkey D, Wells K, Sharps P, Kools S. Living in fear and prioritizing safety: exploring women's lives after traumatic brain injury from intimate partner violence. Qual. Health Res. 28(11), 1708–1718 (2018).Crossref, Medline, Google Scholar37. Simpson RK Jr, Goodman JC, Rouah E, Caraway N, Baskin DS. Late neuropathological consequences of strangulation. Resuscitation 15(3), 171–185 (1987).Crossref, Medline, Google Scholar38. Anderson CA, Arciniegas DB. Cognitive sequelae of hypoxic-ischemic brain injury: a review. NeuroRehabilitation 26(1), 47–63 (2010).Crossref, Medline, Google Scholar39. Kuriloff DB1, Pincus RL. Delayed airway obstruction and neck abscess following manual strangulation injury. Ann. Otol. Rhinol. Laryngol. 98(10), 824–827 (1989).Crossref, Medline, CAS, Google Scholar40. Benveniste H, Drejer J, Schousboe A, Diemer NH. Elevation of the extracellular concentrations of glutamate and aspartate in rat hippocampus during transient cerebral ischemia monitored by intracerebral microdialysis. J. Neurochem. 43, 1369–1374 (1984).Crossref, Medline, CAS, Google Scholar41. Choi DW, Rothman SM. The role of glutamate neurotoxicity in hypoxic-ischemic neuronal death. Annu. Rev. Neurosci. 13, 171–182 (1990).Crossref, Medline, CAS, Google Scholar42. Schurr A, Rigor BM. The mechanism of cerebral hypoxic-ischemic damage. Hippocampus 2(3), 221–228 (1992).Crossref, Medline, CAS, Google Scholar43. Nitatori T, Sato N, Waguri S et al. Delayed neuronal death in the CA1 pyramidal cell layer of the gerbil hippocampus following transient ischemia is apoptosis. J. Neurosci. 15(2), 1001–1011 (1995).Crossref, Medline, CAS, Google Scholar44. Aitken PG, Schiff SJ. Selective neuronal vulnerability to hypoxia in vitro. Neurosci. Lett. 67(1), 92–96 (1986).Crossref, Medline, CAS, Google Scholar45. Petito CK, Feldmann E, Pulsinelli WA, Plum F. Delayed hippocampal damage in humans following cardiorespiratory arrest. Neurology 37(8), 1281–1286 (1987).Crossref, Medline, CAS, Google Scholar46. Zola-Morgan S, Squire LR, Amaral DG. Human amnesia and the medial temporal region: enduring memory impairment following a bilateral lesion limited to field CA1 of the hippocampus. J. Neurosci. 6(10), 2950–2967 (1986).Crossref, Medline, CAS, Google Scholar47. Zola-Morgan S, Squire LR, Rempel NL, Clower RP, Amaral DG. Enduring memory impairment in monkeys after ischemic damage to the hippocampus. J. Neurosci. 12(7), 2582–2596 (1992).Crossref, Medline, CAS, Google Scholar48. Liraz-Zaltsman S, Alexandrovich AG, Trembovler V, Fishbein I, Yaka R, Shohami E, Biegon A. Regional sensitivity to neuroinflammation: in vivo and in vitro studies. Synapse 65, 634–642 (2011).Crossref, Medline, CAS, Google Scholar49. Izquierdo I, Medina JH. Memory formation: the sequence of biochemical events in the hippocampus and its connection to activity in other brain structures. Neurobiol. Learn. Mem. 68(3), 285–316 (1997).Crossref, Medline, CAS, Google Scholar50. Long NM, Kahana MJ. Hippocampal contributions to serial-order memory. Hippocampus 29(3), 252–259 (2018).Crossref, Medline, Google Scholar51. Iverson K, Litwack SD, Pineles SL, Suvak MK, Vaughn RA, Resick PA. Predictors of intimate partner violence revictimization: the relative impact of distance, PTSD symptoms, dissociation, and coping strategies. J. Trauma Stress 26, 102–110 (2013).Crossref, Medline, Google Scholar52. Mcleod AL, Hays DG, Chang CY. Female intimate partner violence survivors' experiences with accessing services. J. Couns. Dev. 88, 303–310 (2010).Crossref, Google Scholar53. Monahan K. Intimate partner violence, traumatic brain injury, and social work: moving forward. Social Work 63, 179–181 (2018).Crossref, Medline, Google Scholar54. Mcquown C, Frey J, Steer S, Fletcher GE, Kinkopf B, Fakler M, Prulhiere V. Prevalence of strangulation in survivors of sexual assault and domestic violence. Am. J. Emerg. Med. 34, 1281–1285 (2016).Crossref, Medline, Google Scholar55. Campbell JC, Webster DW, Glass N. The danger assessment: validation of a lethality risk assessment instrument for intimate partner femicide. J. Interpers. Violence 24, 653–674 (2009).Crossref, Medline, Google Scholar56. Messing JT, Campbell JC, Snider C. Validation and adaptation of the danger assessment-5: a brief intimate partner violence risk assessment. J. Adv. Nurs. 73, 3220–3230 (2017).Crossref, Medline, Google Scholar57. Stockman J, Hayashi H, Campbell J. Intimate partner violence and its health impact on disproportionately affected populations, including minorities and impoverished groups. J. Womens Health 24(1), 62–79 (2015).Crossref, Google ScholarFiguresReferencesRelatedDetailsCited ByThe Darker the Skin, the Greater the Disparity? Why a Reliance on Visible Injuries Fosters Health, Legal, and Racial Disparities in Domestic Violence Complaints Involving Strangulation25 January 2023 | Journal of Interpersonal Violence, Vol. 102A forensic approach to intimate partner homicide5 August 2022The neuropsychological outcomes of non-fatal strangulation in domestic and sexual violence: A systematic review12 January 2021 | Neuropsychological Rehabilitation, Vol. 32, No. 6Accounting for Multiple Nonfatal Strangulation in Intimate Partner Violence Risk Assessment5 December 2020 | Journal of Interpersonal Violence, Vol. 37, No. 11-12How Victims of Strangulation Survived: Enhancing the Admissibility of Victim Statements to the Police When Survivors are Reluctant to Cooperate5 July 2021 | Violence Against Women, Vol. 28, No. 5Prevalence and Risk Factors for Intimate Partner Physical Violence–Related Acquired Brain Injury Among Visitors to Justice Center in New YorkJournal of Head Trauma Rehabilitation, Vol. 37, No. 1Policing nonfatal strangulation within the context of intimate partner violence29 April 2021 | Policing: An International Journal, Vol. 44, No. 5Proving non-fatal strangulation in family violence cases: A case study on the criminalisation of family violence6 September 2021 | The International Journal of Evidence & Proof, Vol. 25, No. 4"If It Goes Horribly Wrong the Whole World Descends on You": The Influence of Fear, Vulnerability, and Powerlessness on Police Officers' Response to Victims of Head Injury in Domestic Violence2 July 2021 | International Journal of Environmental Research and Public Health, Vol. 18, No. 13A global collaboration to study intimate partner violence-related head trauma: The ENIGMA consortium IPV working group6 January 2021 | Brain Imaging and Behavior, Vol. 15, No. 2 Vol. 14, No. 3 Follow us on social media for the latest updates Metrics History Received 7 September 2018 Accepted 28 March 2019 Published online 22 August 2019 Published in print August 2019 Information© 2019 Kathleen MonahanKeywordsabusefemicidestrangulationFinancial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript. The financial disclosure is correct.Open accessThis work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit: http://creativecommons.org/licenses/by-nc-nd/4.0/PDF download
Referência(s)