What comes to mind when you think of someone who has suffered a traumatic brain injury (TBI)? An athlete who plays a contact sport such as football or hockey? Someone who has served in the military? The victim of a car accident?

While these are likely candidates for TBIs, one MGH researcher has identified an often-overlooked segment of the population frequently suffering repeated TBIs – women who have experienced intimate partner violence (IPV).

Eve Valera, PhD, an investigator at the Martinos Center for Biomedical Imaging, along with Aaron Kucyi, PhD, now at Stanford University, recently completed the first study to use neuroimaging to examine the effect of TBIs on the brains of women who have been in abusive relationships.

What they found may be cause for a global public health concern.

In a study of 20 women from the Boston area who experienced IPV, Valera found the severity of TBIs the women sustained was associated with a reduction in the interaction between two areas of the brain that play a key role in everyday functioning. The less interaction there was between these two regions, the more poorly the women performed on tasks of memory and learning.

The results of Valera’s study suggest as the severity and number of TBIs increase, the brain may have more difficulty switching between the Default Mode Network – which manages the brain when we are not focused on the outside world (such as during deep thought, daydreaming and memoryrecall) – and the Salience Network – which supports more active task-specific functioning (i.e., paying attention, remembering a list).

While the patterns of diminished network interaction observed in Valera’s study are consistent with those of other TBI victims, there are significant differences in the way the women sustain their injuries.

The incidents of repeated violence detailed by Valera’s study participants are brutal and difficult to comprehend. Some of the women reported being punched, dragged, beaten or strangled as often as three to four times a week, being slammed into walls or floors, being thrown down stairs, hit with a bat or strangled into unconsciousness. In some cases, this pattern of abuse had lasted for years.

“Once people realize the type and frequency of abuse these women experience, it is easier to understand why they sustain frequent TBIs,” Valera says. Since the abusive incidents are frequently repeated, the women often don’t have time to recover from one TBI before sustaining another.  

“So the potential effects are compounded,” Valera explains. “To understand the potential consequences, some people might think we can just extrapolate from other patient populations – but we can’t. The injuries just aren’t comparable.”

Valera hopes the results of her study will increase awareness of the potential for TBIs in women who have suffered from partner violence, so police and paramedics will know to check for these injuries when responding to a violent incident. This awareness could also give counselors and advocates a better understanding of how TBIs can impair the efforts of women to seek help or leave an abusive relationship.

“Think of somebody who has just sustained a TBI as the result of domestic violence and you are telling them what to do: ‘Go to court, get an order of protection, and then do this and that,’” Valera explained. “You would never do that to a regular TBI patients, because you wouldn’t expect them to immediately take all that in.”

“Once people realize the type and frequency of abuse these women experience, it is easier to understand why they sustain frequent TBIs." --Valera

When the women don’t respond to guidance from police or counselors following IPV, it can result in misplaced assumptions and victim-blaming, Valera explains. “The reality is they are struggling to manage a complex and often dangerous situation with a possible brain injury that no one is acknowledging. These difficulties only get worse with multiple TBIs.”

Valera also notes her research was conducted in the United States, which is generally considered a “safe” country for women. There are other regions of the world where domestic violence is far more common and even culturally sanctioned. “So this is just the tip of the iceberg here. The number of women sustaining unrecognized and unacknowledged TBIs is likely staggering when considering the global population of victims of IPV.”

While the stories of IPV survivors can be grim, and funding for this research has been difficult to secure thus far, Valera is committed to continuing her work.

“It puts things in perspective,” Valera says. “If you’re having a bad day, well, it’s not that bad. And it makes me want to fight even harder for change.”

Read more articles from the 03/03/17 Hotline issue.