Cognitive Functioning and Mental and Behavioral Health in Women Survivors with and without Traumatic Brain Injury Due to Intimate Partner Violence

Abstract

Women survivors of intimate partner violence (IPV) experience increased risk for traumatic brain injury (TBI) due to partner abuse, but few studies have examined cognition and mental and behavioral health outcomes among women with IPV-related TBIs. This pilot study examined differences in cognition, neurobehavioral symptoms, mental health symptoms, chronic pain, alcohol use, and social functioning between women survivors with and without repetitive IPV-related TBIs. Women with 2 or more IPV-related TBIs (n = 33; M = 36.5 years old, SD = 9.4; 63.6% White) were compared to women survivors without IPV-related TBI history (n = 22; M = 34.4 years old, SD = 10.3; 77.3% White) on the Rey Auditory Verbal Learning Test, NIH Toolbox Cognition Battery, and mental and behavioral health questionnaires. Women with repetitive IPV-related TBIs had greater cognitive concerns (one-tailed p = .006, d = 0.71), lower verbal learning (p = .045, d = 0.47) and delayed memory test scores (p = .034, d = 0.51), and reduced fluid cognition compared to estimated premorbid functioning (p = .035, d = −0.51), particularly executive functions (p < .001, d = −1.01). Women with IPV-related TBIs also had greater neurobehavioral (p = .003, d = −0.78), post-traumatic (p = .003, d = −0.75), depressive (p = .038, d = −0.50), and anxiety-related symptom severity (p = .047, d = −0.44). Women with IPV-related TBIs had worse pain intensity (p = .003, d = −0.79) and interference (p = .001, d = −0.87), greater social isolation (p = .002, d = −0.84), and less emotional support (p = .002, d = 0.80). Per adjusted analyses, group differences in delayed memory (p = .025, $η_{p}^{2}$ = 0.08) and reduced fluid cognition (p = .012, $η_{p}^{2}$ = 0.10) remained significant after controlling for comorbid mental and behavioral health conditions. Repetitive IPV-related TBIs were associated with worse objective cognitive performances and worse mental, behavioral, and social health. These pilot results require replication but indicate that women with IPV-related TBIs experience multidimensional health needs. In practice, women with IPV-related TBIs may benefit from psychological or neuropsychological assessments evaluating cognition, mental health, pain, substance use, and social support to characterize the health needs of survivors and inform treatment planning.

Introduction

Intimate partner violence (IPV) is a substantial public health issue^1,2 most often experienced by women^3,4 that impacts their physical and mental health.^5–8 Women survivors of IPV often experience polytrauma, including both orthopedic and traumatic brain injuries (TBIs)⁹ and potential hypoxic-ischemic brain injuries due to nonfatal strangulation.¹⁰ Many IPV-related injuries occur to the head or neck,^11,12 with up to 57.9% of IPV survivors experiencing a TBI involving loss of consciousness.¹³ Among women survivors of IPV, repetitive TBIs are common,^13–15 with 50%¹⁴ to 75%¹⁵ of women in prior samples reporting a history of multiple TBIs. IPV-related TBIs have been regarded as invisible injuries^15,16 and an overlooked public health issue,¹⁷ with calls for increased investigation in this area.^18–20

Most prior TBI outcome studies have involved predominantly male samples of veterans and athletes,^21,22 resulting in gaps in our understanding of IPV-related TBI sequelae among women. Women are underrepresented in TBI research in general,²³ and few studies have examined sex differences following TBI.^24,25 These studies have found greater symptom burden^26–30 and worse cognitive functioning^28,31,32 following injury. Limited understanding of how TBI impacts women could affect evaluation, treatment, and management following injury. IPV-related TBI, as a specific mechanism affecting primarily women,¹ has been notably understudied.^18–20 Based on limited published research, IPV-related TBIs are associated with worse cognitive functioning,^14,33,34 greater neurobehavioral symptoms,^35–37 and worse mental health (e.g., depression, post-traumatic stress).^14,38–41 These studies collectively demonstrate the impact of IPV-related TBI across multiple domains of health and functioning.

The current study involved a preliminary investigation into the biopsychosocial sequelae of IPV-related TBI among a sample of women survivors recruited from domestic violence shelters and the general community. The primary aim of this pilot study was to examine objective cognitive functioning differences between women survivors with and without repetitive IPV-related TBIs, providing effect size estimates to guide sample size determination for larger future studies. To date, few studies have assessed objective cognition among this population, but they have found lower attention, memory, and executive function performances associated with IPV-related TBI.^14,15,33 A secondary aim was to evaluate group differences in neurobehavioral symptoms, mental health symptoms, chronic pain, alcohol use, and social functioning among women survivors with and without repetitive IPV-related TBIs. Prior researchers have observed greater neurobehavioral⁴² and mental health symptoms⁴³ associated with IPV-related TBI, but have yet to examine pain, alcohol use, and social functioning in this population. The specific focus on repetitive IPV-related TBIs was based on prior research indicating a high frequency of repeated neurotrauma among survivors.⁴⁴

Methods

Participants

Participants were recruited in central Kentucky from domestic violence shelters and IPV service organizations via posted flyers and in-person recruitment, along with the local community via flyers posted in public locations (e.g., grocery stores, libraries). Eligible participants were (a) cisgender women, (b) 18–59 years old, (c) experienced physical or sexual IPV, (d) and had either no lifetime IPV-related TBIs or 2 or more IPV-related TBIs, with the most recent TBI occurring >3 months ago. Notably, women with 2 or more IPV-related TBIs could also report prior TBIs due to mechanisms other than IPV, but to be eligible for the TBI group, women needed to attribute at least 2 prior TBIs to IPV exposure. The eligibility criterion of having 2 or more IPV-related TBIs was due to a specific focus on repetitive TBI among women survivors, meaning participants with singular IPV-related TBIs were not eligible to participate. Participants were recruited from August 2022 to August 2024. A total of 333 participants initiated an online screener to assess their eligibility. Among these participants, 254 completed the screener, with participants deemed ineligible if they identified as a gender other than woman (n = 3), did not report IPV (n = 28), responded in error to 2 self-directed validity questions (e.g., if you are paying attention, please select Very Often) (n = 15), reported a TBI <3 months ago (n = 19), reported single TBI or only TBIs unrelated to IPV (n = 32), or did not consent to being contacted for participation in the full study (n = 10). This resulted in 128 eligible participants. The study team reached out to these participants to schedule an in-person assessment; however, many did not respond to contact, were no longer interested in participating, could not find a common time to schedule, or did not attend their scheduled appointment (n = 73). A total of 55 women were successfully scheduled and completed the in-person assessment.

Upon completing the in-person assessment, some participants endorsed injuries or injury characteristics that would have initially made them ineligible, but were retained to ensure a larger sample size. There were 4 control participants who reported TBIs unrelated to IPV. These cases all involved remote mild injuries (e.g., pediatric concussions) and were retained as control cases. Some women with IPV-related TBIs reported recent injuries <3 months before participating (i.e., injuries occurring between scheduling and the in-person assessment), including 2 participants with recent TBIs and 3 participants with exposure to hypoxic-ischemic events (i.e., nonfatal strangulation). Sensitivity analyses indicated that the inclusion of these participants did not substantially change observed effect sizes for any analysis, and these participants were retained as TBI cases. The final sample included 33 women survivors reporting 2 or more IPV-related TBIs and 22 women survivors of IPV reporting no lifetime history of IPV-related TBIs. Among these participants, 52.7% (n = 29) were receiving residential shelter services, 9.1% (n = 5) were receiving nonresidential domestic violence services, and 38.2% (n = 21) were recruited from the community and not currently receiving shelter services.

Measures

Brain injury history

Participants completed a modified version of the Brain Injury Screening Questionnaire,⁴⁵ which queries possible brain injury mechanisms (e.g., vehicular crash, falling), including IPV-specific mechanisms (e.g., assault, strangulation, and violent shaking by an intimate partner).⁴⁶ Participants were asked whether each injury mechanism occurred and how many times, and whether they experienced loss or alteration of consciousness (i.e., being dazed and confused) and how many times. They also estimated the duration of loss or alteration of consciousness, if present. Any mechanism involving a physical force applied to the brain that resulted in loss or alteration of consciousness was considered a potential TBI. TBI severity was categorized based on Veterans Affairs/Department of Defense criteria.⁴⁷ Strangulation, partial drowning, and smothering involving loss or alteration of consciousness were considered potential hypoxic-ischemic brain injuries.

Cognitive functioning

Participants completed the Neurological Quality-of-Life Cognitive Function questionnaire,^48,49 a norm-referenced scale measuring subjective cognitive concerns with a T-score cutoff (≤40) indicating elevated concerns. Participants also completed a cognitive test battery, including the Rey Auditory Verbal Learning Test (RAVLT),⁵⁰ NIH Toolbox Cognition Battery (NIHTB-CB),^51,52 and the Word Choice Test⁵³ as a stand-alone measure of performance validity. Performances below expectation on both the Word Choice Test and RAVLT recognition⁵⁴ were considered invalid.

Rey auditory verbal learning test

The RAVLT measured verbal learning and memory, asking participants to immediately recall a word list read to them over 5 trials and then recall the same list from memory following a 20-min delay. Performance on Trial 1 measures brief auditory attention, total learning (i.e., sum of words recalled across Trials 1–5) measures verbal learning, and the total words recalled on the delayed memory trial measures verbal memory. All RAVLT performances were compared to age-referenced normative data to compute z-scores (M = 0, SD = 1).⁵⁰

NIH toolbox cognition battery

The NIHTB-CB includes 7 tests measuring crystallized and fluid abilities.^51,52 The 2 crystallized tests include the Picture Vocabulary Test and the Oral Reading Recognition Test,⁵⁵ and the 5 fluid tests include List Sorting Working Memory,⁵⁶ Picture Sequence Memory,⁵⁷ Pattern Comparison Processing Speed,⁵⁸ Flanker Inhibitory Control and Attention,⁵⁹ and Dimensional Change Card Sort.⁵⁹ All scores are converted to demographic-adjusted T-scores (M = 50, SD = 10), considering age, sex, education, and race/ethnicity in their calculation.⁶⁰ Education was outside of the range for demographic-adjusted score calculation for a single participant, and her age-adjusted standard score was converted to a T-score to include her performances in analyses. The 2 crystallized and 5 fluid test scores combine to form crystallized and fluid composite scores, respectively.⁶¹ The crystallized composite measures language abilities typically unaffected by TBI, providing an estimate of premorbid functioning; whereas the fluid composite measures cognitive abilities reduced following TBI (i.e., memory, processing speed, executive functions).⁶² A crystallized-fluid T-score difference, calculated by subtracting the fluid from the crystallized composite, provides an estimate for decline in fluid abilities from estimated premorbid functioning.⁶³ For this score, a higher score (i.e., greater crystallized than fluid ability) indicates possible decline.

Self-report questionnaires

Participants completed a series of questionnaires related to neurobehavioral, mental, and behavioral health and social functioning. The Neurobehavioral Symptom Inventory (NSI)⁶⁴ measures neurobehavioral symptom severity in the past 2 weeks. The NSI has psychometric support among IPV survivors with and without brain injuries, providing a total score and 4 subscale scores capturing affective, somatosensory, cognitive, and vestibular symptom severity.⁴² The post-traumatic stress disorder (PTSD) checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) (PCL-5)⁶⁵ measures post-traumatic stress in the past 30 days, providing a total score and 4 subscale scores (i.e., re-experiencing, avoidance, negative alterations in cognition and mood, and arousal and reactivity). The 8-item Patient Health Questionnaire (PHQ-8)⁶⁶ and the 7-item Generalized Anxiety Disorder scale (GAD-7)⁶⁷ measure depressive and anxiety symptom severity in the past 2 weeks, respectively. The PCL-5, PHQ-8, and GAD-7 have shown evidence for reliability and validity among women survivors of IPV.⁶⁸ Published cutoff scores for the PCL-5 (≥32),⁶⁹ PHQ-8 (≥10),⁶⁶ and GAD-7 (≥10)⁶⁷ were used to determine rates of positive screens for PTSD, depression, and generalized anxiety disorder, respectively.

Participants completed the Alcohol Use Disorders Identification Test (AUDIT),⁷⁰ measuring past-year alcohol consumption and consequences. The AUDIT provides a continuous score of alcohol use severity, with a score ≥8 indicating hazardous or harmful alcohol use.⁷⁰ Participants also responded to questions on pain frequency and duration to determine the presence of chronic pain, with pain occurring most days and lasting ≥3 months categorized as chronic pain.^71–73 Participants also completed questionnaires from the Patient-Reported Outcomes Measurement Information System (PROMIS) measuring pain intensity and interference⁷⁴ and emotional support and social isolation.⁷⁵ The PROMIS questionnaires are norm-referenced with cutoffs of T ≤40 or T ≥60 depending on scale orientation.

IPV severity

Physical and sexual IPV severity was measured with questions from the 2015 National Intimate Partner and Sexual Violence Survey.⁷⁶ These questions asked about physical violence and nonconsensual sexual encounters resulting from physical force, threats, or inability to consent. All questions required yes/no responses, with item severity weighted in accordance with prior research^{42,68,77–84} and summed to calculate weighted physical and sexual IPV severity scores.

Procedure

The study protocol was approved by the University of Kentucky Institutional Review Board (Protocol: #75254/86269). Participants completed online screening via Research Electronic Data Capture.^85,86 In-person cognitive testing and questionnaires were completed in a private room at a domestic violence shelter or a testing room within a neuropsychology laboratory. Participants received a gift card for the online screener and a separate gift card for the in-person study. Written informed consent was obtained before participation.

Statistical analysis

Women with and without IPV-related TBIs were compared on all cognitive test and questionnaire scores. The primary analytic focus was on effect size estimation, determining which variables corresponded with the largest group differences. Effect sizes were calculated using Cohen’s d for continuous variables and odds ratio (OR) for categorical variables, interpreted as small (d = 0.20; OR = 1.50), medium (d = 0.50; OR = 2.50), and large (d = 0.80; OR = 4.25).^87,88 Inferential statistical tests were conducted using one-tailed t-tests with p-values <.05 indicating a significant group difference. The one-tailed tests were used because group differences in the unexpected direction were nonintuitive, uninterpretable, and considered spurious or null findings (i.e., TBI associated with better cognition or fewer symptoms).⁸⁹ The use of one-tailed t-tests also allowed for greater statistical power, with this pilot sample (n = 55) having sufficient power (1-β = .80) to detect a medium-to-large effect size (d = 0.69) at p < .05.⁹⁰ Additional analyses of covariance (ANCOVAs) were conducted for cognitive test scores that differed between groups, including 5 binary covariates reflecting positive screens for PTSD, depression, an anxiety disorder, problematic alcohol use, and chronic pain. These analyses were conducted to determine whether group differences in cognition attributed to TBI were not better explained by concurrent mental and behavioral health conditions. The ANCOVAs had sufficient power (1-β = .80) to detect a medium-to-large effect size (f = .39) at p < .05.⁹⁰ For all ANCOVAs, partial eta-squared ( $η_{p}^{2}$ ) was reported as an effect size. As a preliminary investigation, there was no adjustment to p-values for multiple comparisons.

Results

Participant demographics are presented in Table 1, showing no significant differences between groups based on age, race/ethnicity, education, or self-reported diagnoses of attention-deficit/hyperactivity disorder or learning disability. Women with IPV-related TBIs reported greater physical IPV severity (p < .001, d = −1.64) and sexual IPV severity (p = .005, d = −0.81). Among women with IPV-related TBIs, most women reported mild TBIs (n = 18, 54.5%), with fewer women reporting moderate TBIs (n = 12, 36.4%) and severe TBIs (n = 3, 9.1%). The average time-since-injury was 2.2 years (SD = 4.4; Mdn = 9 months, range: <3 months to 24 years). Lifetime number of TBIs and potential hypoxic-ischemic brain injuries due to obstruction of oxygen flow to the brain (e.g., nonfatal strangulation) are also reported in Table 1.

Table 1.

Participant Demographics, Intimate Partner Violence Severity, and Injury Exposure

Variable	Total (n = 55)	IPV-TBI (n = 33)	No IPV-TBI (n = 22)	p	d or OR	[95% CI]
Age, M (SD)	35.6 (9.7)	36.5 (9.4)	34.1 (10.3)	0.380	d = −0.24	[−0.78, 0.30]
Race/ethnicity, n (%)	—	—	—	0.284	OR = 0.52	[0.15, 1.75]
White	38 (69.1%)	21 (63.6%)	17 (77.3%)
Black	10 (18.2%)	7 (21.2%)	3 (13.6%)
Hispanic/Latina	2 (3.6%)	1 (3.0%)	1 (4.5%)
Asian	2 (3.6%)	1 (3.0%)	1 (4.5%)
Multiracial	3 (5.5%)	3 (9.1%)	0 (0%)
Education, n (%)	—	—	—	1.00	OR = 0.83	[0.21, 3.24]
<12 Years	11 (20.0%)	7 (21.2%)	4 (18.2%)
≥12 Years	44 (80.0%)	26 (78.8%)	18 (81.8%)
Self-reported diagnoses, n (%)	—	—	—
ADHD	18 (32.7%)	10 (30.3%)	8 (36.4%)	0.771	OR = 0.76	[0.24, 2.39]
Learning disability	7 (12.7%)	5 (15.2%)	2 (9.1%)	0.689	OR = 1.77	[0.31, 10.15]
Lifetime intimate partner violence, M (SD)	—	—	—
Physical intimate partner violence severity	29.5 (18.1)	38.8 (14.5)	15.6 (13.7)	<0.001	d = −1.64	[−2.26, −1.01]
Sexual intimate partner violence severity	19.6 (14.1)	23.9 (13.3)	13.2 (13.1)	0.005	d = −0.81	[−1.37, −0.25]
Injuries, Mdn (IQR)	—	—	—
Traumatic brain injury count	2 (0–6)	5 (3–10)	0 (0–0)	—	—	—
Repetitive head impact count	5 (0–12)	11 (7–15)	0 (0–1)	—	—	—
Potential hypoxic-ischemic brain injury count	0 (0–3)	2 (0–6)	0 (0–0)	—	—	—
Hypoxic-ischemic exposure count	2 (0–5)	3 (1–12)	0 (2–5)	—	—	—
Brain injury count	3 (0–10)	8 (3–15)	0 (0–0)	—	—	—
Head impact/hypoxic-ischemic exposure count	8 (1–18)	16 (10–25)	1 (0–2)	—	—	—

All participants were cisgender women. All p-values are two-tailed. Bold values indicate significant findings. Continuous variables were compared using t-tests and categorical variables were compared using either chi-squared or Fisher’s exact test.

TBI count included injuries to the head involving loss or alteration of consciousness. Repetitive head impact count included any injuries to the head, including injuries that did not involve alteration or loss of consciousness. Potential hypoxic-ischemic brain injury count included injuries involving loss or alteration of consciousness due to obstruction of oxygen flow to the brain (e.g., nonfatal strangulation). Hypoxic-ischemic exposure count included any injuries involving potential obstruction of oxygen flow to the brain, including injuries that did not involve alteration or loss of consciousness. Brain injury count included traumatic brain injuries and potential hypoxic-ischemic injuries involving loss or alteration of consciousness due to obstruction of oxygen flow to the brain (e.g., nonfatal strangulation). Head impact/hypoxic-ischemic exposure count included any injuries to the head and any injuries involving potential obstruction of oxygen flow to the brain, including injuries that did not involve alteration or loss of consciousness.

ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; d, Cohen's d; IPV-TBI, intimate partner violence-related traumatic brain injury; IQR, interquartile range; OR, odds ratio.

Unadjusted group comparisons

Cognition

Group comparisons of subjective cognition and cognitive test scores are presented in Table 2. All cognitive test performances were considered valid based on performance validity testing. There was a medium-to-large group difference in subjective cognition (p = .006, d = 0.71). Elevated subjective cognitive concerns were significantly more common among women with IPV-related TBIs (81.8%) compared to women without IPV-related TBIs (50.0%), corresponding with a large effect (p = .006, OR = 4.50). Women with IPV-related TBIs had worse performances on the RAVLT. Verbal learning on RAVLT Trials 1–5 (p = .045, d = 0.47) and delayed memory (p = .034, d = 0.51) differed significantly between groups, corresponding with medium effect sizes. On the NIHTB-CB, the Fluid Cognition Composite showed a medium-sized group difference indicating worse cognitive performances by women with IPV-related TBIs, but this group difference did not reach significance (p = .053, d = 0.45). The largest, and only significant, group difference on individual NIHTB-CB tests was observed for the Dimensional Change Card Sort (p < .001, d = 1.01). The NIHTB-CB Crystallized-Fluid T-Score Difference was significantly higher among women with IPV-related TBIs, indicating a greater potential decline from estimated premorbid functioning among this group (p = .035, d = −0.51).

Table 2.

Group Comparisons on Cognitive Testing

Variable	IPV-TBI (n = 33)		No IPV-TBI (n = 22)		p	d or OR	[95% CI]
Subjective cognition	—	—	—	—	—	—	—
Elevated Cognitive Concerns, n (%)	27	81.8%	11	50.0%	0.006	OR = 4.50	[1.33, 15.20]
Neuro-QoL Cognitive Function (T-score), M (SD)	35.1	6.4	40.3	8.7	0.006	d = 0.71	[0.15, 1.27]
Rey Auditory Verbal Learning Test (z-scores)	—	—	—	—	—	—	—
Trial 1, M (SD)	−0.9	0.9	−0.7	1.2	0.242	d = 0.19	[−0.35, 0.73]
Total Learning: Trials 1–5 Total, M (SD)	−1.2	1.1	−0.7	1.2	0.045	d = 0.47	[−0.07, 1.02]
Delayed Memory: Trial 7, M (SD)	−0.8	1.2	−0.2	1.0	0.034	d = 0.51	[−0.04, 1.06]
NIH Toolbox Cognition Battery (T-scores)	—	—	—	—	—	—	—
Crystallized Composite, M (SD)	48.8	10.6	48.5	7.2	0.456	d = −0.03	[−0.57, 0.51]
Picture Vocabulary, M (SD)	46.3	9.4	46.9	8.1	0.410	d = 0.06	[−0.48, 0.60]
Oral Recognition, M (SD)	52.1	10.1	50.6	8.1	0.286	d = −0.16	[−0.70, 0.38]
Fluid Composite, M (SD)	39.5	12.5	44.9	10.7	0.053	d = 0.45	[−0.10, 1.00]
Flanker, M (SD)	36.3	11.2	40.3	8.8	0.085	d = 0.38	[−0.16, 0.93]
Dimensional Change Card Sort, M (SD)	38.8	11.7	51.6	14.0	<0.001	d = 1.01	[0.43, 1.58]
List Sorting, M (SD)	47.9	11.4	44.5	8.5	0.117	d = −0.33	[−0.87, 0.21]
Pattern Comparison, M (SD)	46.6	15.0	51.9	14.7	0.102	d = 0.36	[−0.19, 0.90]
Picture Sequence Memory, M (SD)	46.3	8.8	46.3	9.9	0.498	d = 0.00	[−0.54, 0.05]
Crystallized-Fluid T-score Difference, M (SD)	9.3	10.8	3.6	11.5	0.035	d = −0.51	[−1.05, 0.04]

All p-values are one-tailed. Bold values indicate significant findings.

CI, confidence Interval; d, Cohen's d; IPV-TBI, intimate partner violence-related traumatic brain injury; Neuro-QoL, Neurological Quality-of-Life.; NIH, National Institutes of Health; OR, odds ratio.

Symptom reporting and social functioning

As displayed in Table 3, women with IPV-related TBIs had significantly worse ratings on nearly all symptom scores. The group comparison in total neurobehavioral symptom severity corresponded with a medium-to-large effect size (p = .003, d = −0.78), and all subscales differed significantly between groups with effect sizes ranging from medium to large (d range: −0.92 to −0.51). The largest group difference in mental health symptoms was on the PCL-5 (p = .003, d=−0.75), with all PCL-5 subscales differing significantly across groups with medium to large effect sizes (d range: −0.91 to −0.53). The PHQ-8 (p = .038, d = −0.50) and GAD-7 (p = .047, d = −0.44) both show medium-sized, significant differences across groups. Regarding alcohol use, the AUDIT corresponded with a small effect size that did not reach significance (p = .155, d = −0.28). A significantly greater proportion of women with IPV-related TBIs screened positive for PTSD (66.7%) compared to women without IPV-related TBIs (36.4%) (p = .014, OR = 3.50, medium effect size), but there were no significant differences between groups in incidence of depression, anxiety, or problematic alcohol use.

Table 3.

Group Comparisons in Mental and Behavioral Health and Social Functioning

Variable	IPV-TBI (n = 33)		No IPV-TBI (n = 22)		p	d or OR	[95% CI]
Neurobehavioral symptoms	—	—	—	—	—	—	—
NSI: Total score, M (SD)	36.4	14.6	25.1	13.9	0.003	d = −0.78	[−1.34, −0.22]
NSI: Affective, M (SD)	12.2	5.5	9.5	5.3	0.036	d = −0.51	[−1.05, 0.04]
NSI: Somatosensory, M (SD)	12.9	6.3	7.4	5.5	<0.001	d = −0.92	[−1.49, −0.35]
NSI: Cognitive, M (SD)	7.8	3.7	5.9	3.5	0.034	d = −0.51	[−1.06, 0.04]
NSI: Vestibular, M (SD)	3.5	2.3	2.4	1.9	0.035	d = −0.51	[−1.06, 0.04]
Psychiatric Symptoms and Substance Use	—	—	—	—	—	—	—
Positive PTSD Screen, n (%)	22	66.7%	8	36.4%	0.014	OR = 3.50	[1.13, 10.84]
PCL-5: Total score, M (SD)	43.8	19.4	30.5	14.9	0.003	d = −0.75	[−1.30, −0.19]
PCL-5: Re-experiencing, M (SD)	10.5	5.5	7.9	4.3	0.025	d = −0.53	[−1.07, 0.02]
PCL-5: Avoidance, M (SD)	5.5	2.2	3.5	2.1	<0.001	d = −0.91	[−1.47, −0.34]
PCL-5: Neg Alt Cog/Mood, M (SD)	15.4	7.4	10.8	6.4	0.011	d = −0.65	[−1.20, −0.09]
PCL-5: Arousal and Reactivity, M (SD)	12.4	6.1	8.3	4.5	0.003	d = −0.74	[−1.30, −0.18]
Positive Depression Screen, n (%)	21	63.6%	10	45.5%	0.092	OR = 2.10	[0.70, 6.30]
PHQ-8: Total score, M (SD)	12.9	6.9	9.6	6.1	0.038	d = −0.50	[−1.04, 0.05]
Positive Anxiety Screen, n (%)	20	60.6%	9	40.9%	0.076	OR = 2.22	[0.74, 6.68]
GAD-7: Total score, M (SD)	11.9	6.7	9.2	5.0	0.047	d = −0.44	[−0.99, 0.11]
Problematic Alcohol Use, n (%)	6	18.2%	3	13.6%	0.328	OR = 1.41	[0.31, 6.34]
AUDIT, M (SD)	4.8	6.2	3.3	3.1	0.155	d = −0.28	[−0.82, 0.26]
Pain	—	—	—	—	—	—	—
Chronic Pain, n (%)	21	63.6%	6	27.3%	0.004	OR = 4.67	[1.44, 15.13]
Elevated Pain Intensity, n (%)	17	51.5%	4	18.2%	0.007	OR = 4.78	[1.33, 17.21]
PROMIS Pain Intensity, M (SD)	59.0	12.0	49.6	11.6	0.003	d = −0.79	[−1.34, −0.23]
Elevated Pain Interference, n (%)	21	63.6%	5	22.7%	0.002	OR = 5.95	[1.75, 20.23]
PROMIS Pain Interference, M (SD)	59.8	10.4	50.8	10.4	0.001	d = −0.87	[−1.43, −0.30]
Social Functioning	—	—	—	—	—	—	—
Reduced Emotional Support, n (%)	13	39.4%	2	9.1%	0.007	OR = 6.50	[1.30, 32.60]
PROMIS Emotional Support, M (SD)	44.2	10.8	52.5	9.2	0.002	d = 0.81	[0.25, 1.37]
Elevated Social Isolation, n (%)	19	57.6%	6	27.3%	0.014	OR = 3.62	[1.13, 11.60]
PROMIS Social Isolation, M (SD)	61.0	9.1	53.0	10.2	0.002	d = −0.84	[−1.40, −0.28]

All p-values are one-tailed. Bold values indicate significant findings. All PROMIS scores are T-scores, and all other scores are raw values. Equal variances were not assumed for the GAD-7 score and PCL-5 Total, Re-experiencing, and Arousal and Reactivity scores.

AUDIT, Alcohol Use Disorders Identification Test; CI, confidence interval; d, Cohen's d; GAD-7, 7-item Generalized Anxiety Disorder scale; IPV-TBI, intimate partner violence-related traumatic brain injury; Neg Alt Cog/Mood, negative alterations in cognition and mood; NSI, Neurobehavioral Symptom Inventory; OR, odds ratio; PCL-5, post-traumatic stress disorder checklist for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition; PHQ-8, 8-item Patient Health Questionnaire; PROMIS, Patient-Reported Outcomes Measurement Information System; PTSD, post-traumatic stress disorder.

Participants were also compared on pain experiences, showing a large group difference in rates of chronic pain (p = .004, OR = 4.67): 63.6% of women with IPV-related TBIs reported chronic pain compared to 27.3% of women without IPV-related TBI. Pain intensity (p = .003, d = −0.79) and pain interference (p = .001, d = −0.87) showed large, significant differences between groups. Lastly, social functioning was compared between groups. Women with IPV-related TBIs reported significantly lower emotional support (p = .002, d = 0.81) and significantly higher social isolation (p = .002, d = −0.84), with both differences associated with large effect sizes. Large significant group differences were observed between groups in rates of elevated pain intensity (p = .007, OR = 4.78), elevated pain interference (p = .002, OR = 5.95), reduced emotional support (p = .007, OR = 6.50), and elevated social isolation (p = .014, OR = 3.62).

Adjusted group comparisons

ANCOVAs were conducted for cognitive test scores that significantly differed across groups, adjusting for positive PTSD screen and chronic pain as covariates. These analyses examined whether differences in cognitive performances were potentially attributable to comorbid clinical conditions. After including covariates in the model, the RAVLT Total Learning (Trials 1–5) no longer significantly differed between groups (F = 2.25, p = .070, $η_{p}^{2}$ =0.05), whereas the RAVLT Delayed Memory trial (F = 4.08, p = .025, $η_{p}^{2}$ =0.08), NIHTB-CB Crystallized-Fluid Composite T-Score Difference (F = 5.44, p = .012, $η_{p}^{2}$ =0.10), and the Dimensional Change Card Sort test score (F = 15.20, p < .001, $η_{p}^{2}$ =0.24) remained significantly different between groups.

Discussion

This pilot study provided preliminary evidence of substantially greater subjective cognitive concerns among women with repetitive IPV-related TBIs compared to women survivors without IPV-related TBIs, corresponding with lower performances on tests of verbal learning and memory and reduced fluid cognitive abilities, specifically executive functions. Women with IPV-related TBIs also had greater severity of neurobehavioral symptoms, worse mental health, higher pain intensity and interference, and reduced social connection and emotional support. Differences in cognitive functioning related to IPV-related TBI were not attributable to concurrent mental and behavioral health conditions. These findings indicate multiple domains of potentially unaddressed health needs among women with IPV-related TBIs.

The current findings align with results from prior investigations on biopsychosocial effects of IPV-related TBIs. Consistent with published findings, IPV-related TBIs were associated with lower scores on tests of executive functions and verbal learning and memory,^14,33,34 greater PTSD symptoms,^14,40,41,91 and pain interfering with daily functioning.⁹² The current results also provide new insights. One novel finding was that some of the largest group differences were related to physical symptoms, specifically somatosensory symptoms on the NSI (e.g., headaches, sensory changes) and chronic pain. Women with IPV-related TBI experience greater exposure to physical violence to the body, which likely contributes to ongoing pain; however, TBI commonly co-occurs with chronic pain,⁹³ and the observed association between IPV-related TBI and pain herein emphasizes the need to further examine this relationship and potential interventions in future studies.

Another novel finding relates to the examination of alcohol use in relation to IPV-related TBI, which has been underexamined in prior research.⁹⁴ There were no differences in problematic alcohol use across groups. Whereas researchers have found associations between IPV and drug and alcohol use,^95–99 research on TBI and substance use has been more variable. Some findings indicate that TBI is associated with either no change or reductions in substance use,¹⁰⁰ whereas other researchers have found that worse neurobehavioral symptoms following TBI corresponded with greater substance misuse.¹⁰¹ Prior researchers have posited that substance use may reflect a coping strategy for physical pain and mental illness resulting from IPV^102–105; however, there were overall low rates of problematic alcohol use among the current sample, and use of other substances (e.g., opioids, marijuana) was not examined.

An additional contribution pertains to the differences observed in social isolation and emotional support, which were among the largest group differences. Social isolation and limited social support reflect risk factors for IPV,^106,107 but also consequences of TBI.^108,109 This group difference in social variables could reflect a predisposition to greater violence exposure or a reduction in social engagement following TBI, but both interpretations reflect a need to address social health among IPV survivors.

This study involved limitations. As a pilot study, the small sample size had sufficient power to detect just medium-to-large effects based on one-tailed tests; and the sample, recruited from a single region of Kentucky, may not be representative of the broader population of IPV survivors. These results require replication with larger samples from other regions to verify group differences. The study was also cross-sectional, meaning group differences may not be causally related to TBI. The study also relied on a self-report questionnaire for TBI determination, without available medical records. Notably, self-report may be the standard for retrospective IPV-related TBI assessment among women survivors, because most women do not seek medical care following injury.⁸³ Performance validity was evaluated, but not symptom validity, which stands as another limitation. The NSI has embedded validity indicators, but these indicators were validated with primarily male military and veteran samples,¹¹⁰ and include many somatosensory and vestibular items that women report in greater severity than men,²⁷ especially women with concurrent PTSD and bodily injury.¹¹¹

The current preliminary findings indicate that women survivors of IPV, and particularly women with repetitive IPV-related TBIs, have many cognitive, mental, behavioral, and social health needs that may benefit from intervention. That said, the results of this pilot investigation require replication, but indicate multiple variables that merit further study among this population. The results also provide effect size estimates to guide sample size determination, which could support the design of future observational studies focused on IPV-related TBI. The findings may also inform assessment and treatment practice following IPV-related TBIs. A comprehensive psychological or neuropsychological assessment evaluating cognition, mental health, pain, substance use, and social support could help characterize the health needs of an individual survivor and inform treatment planning.

Although multiple guidelines exist for TBI diagnosis and management,¹¹² none has specifically instructed practice with women survivors of IPV. As per a prior study, PTSD treatment outcomes among IPV survivors did not differ based on history of IPV-related head injury,¹¹³ but apart from this study, no prior research has examined interventions specific to women with IPV-related TBIs. Considering the multiple health needs of survivors, future research may prioritize evaluating multicomponent interventions that target multiple outcomes through a single treatment protocol. A multicomponent intervention designed for veterans with TBI combined cognitive rehabilitation for TBI with cognitive processing therapy for PTSD, which led to improvement in PTSD symptoms, neurobehavioral symptoms, and objective cognitive test performances.¹¹⁴ Similar interventions may merit evaluation among women with IPV-related TBIs to address the complex health needs of this population.

Transparency, Rigor, and Reproducibility

This study was not preregistered. As a pilot study, the target recruitment was 30 women survivors with repetitive IPV-related TBIs and 30 women survivors without lifetime history of IPV-related TBI. In total, 333 participants initiated screening, 128 participants were eligible based on screening, and 55 were successfully scheduled and completed the in-person assessment. At the conclusion of the study, 33 women survivors with IPV-related TBIs and 22 women survivors without IPV-related TBIs were successfully recruited and completed the protocol. As per sensitivity analyses, the sample size (n = 55) had sufficient power (1-β = .80) to detect a medium-to-large effect size (d = 0.69; f = .39) using one-tailed t-tests or ANCOVAs at p < .05.⁹⁰ Data were collected from 2022 to 2024 via online screening and in-person assessment. The in-person assessment involved symptom questionnaires and cognitive testing. All instruments are described in text above. Each instrument has established evidence for reliability and validity. Data analyses, conducted using SPSS, were performed by investigators who were aware of relevant characteristics of the participants. The sample sizes and degrees of freedom reflect the number of independent measurements (i.e., number of individual participants). There were no missing data in the analyses. Effect sizes and confidence intervals have been reported in the main text for all outcomes. As a pilot study, corrections were not made for multiple comparisons. No replication or external validation studies have been performed or are planned/ongoing at this time. The data from this study will not be shared due to the sensitivity of the participant population.

Footnotes

Authors’ Contributions

J.E.K. was involved in conceptualization, study design, funding acquisition, data curation, formal analysis, project administration, supervision, and writing (original draft preparation). A.E.W. was involved in study design, data curation, project administration, and writing (review & editing). S.E.L. was involved in study design, data curation, and writing (review & editing). TK.L. was involved in study design and writing (review & editing).

Author Disclosure Statement

The authors have no competing interests or conflicts of interest to report.

Funding Information

This work was supported, in part, by a Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) grant (#K12-DA035150) from the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH). This publication was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH, through Grant UL1TR001998. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Abbreviations Used

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