“Brain injury in women experiencing intimate partner-violence: Neural mechanistic evidence of an “invisible” trauma”

Authors: Eve Valera, PhD1,2, Aaron Kucyi, PhD1,2

Affiliations: 1Department of Psychiatry, Harvard Medical School, Boston MA; 2Department of Psychiatry, Massachusetts General Hospital, Charlestown, MA

Online Resource Methods

Subject characteristics

Upon in-person interviews, three enrolled women were found to have heavy current alcohol use, and one woman reported no current dependence but reported a history of heroin dependence just over six months prior. Therefore, results are presented both with and without these four women included in the analyses. Subjects currently taking psychotropic or anticonvulsant medication (N = 3) were also noted and analyses were run both with and without inclusion of these women. One subject was taking abilify for anxiety; one was taking topamax for depression and migraines as well as lorazepam for anxiety; one was taking dilantin as a seizure prophylactic since she experienced 2 brief seizures one day approximately 7 months prior. These seizures were subsequent to this woman sustaining a high number of partner-related TBIs.

Brain injury severity score, abuse, cognitive and psychopathology measures

Abuse, cognitive and psychopathology assessments were conducted withvalid and reliable commonly used measures.

Brain injury severity score

Data show that TBI sequelae tend to resolve over time (McLean et al., 1983)and that there are cumulative effects in terms of both symptom severity and time to recover after sustaining multiple TBIs (Gronwall et al., 1975; Dretsch et al., 2015). Additionally, moderate to severe TBIs are more likely to have greater negative effects than are mild TBIs (Dikmen et al., 1986). Therefore, we computed a brain injury score based upon the number and recency of reported TBIs as well as whether a moderate or severe TBI was ever sustained. Only partner-related TBIs were included in a woman’s brain injury score. Women who reported non-partner-related TBIs within the past three months or moderate to severe non-partner-related TBIs ever were excluded.

The brain injury score was computed identically to that previously reported (Valera and Berenbaum, 2003): “The frequency score was the number of brain injuries based on the woman’s report of alterations in consciousness. The recency score was defined as the number of weeks since the most recent brain injury. Whether a brain injury was mild versus moderate to severe was defined as noted in the main text. Each woman was assigned a score for each of these criteria as follow: frequency, 1–5 brain injuries = 1, 6–10 brain injuries = 2, 11–15 brain injuries = 3, 16 or more brain injuries = 4; recency, more than 52 weeks ago = 0, 27–52 weeks ago = 1, 14–26 weeks ago = 2, 0–13 weeks ago = 3; severity, never sustained a moderate to severe brain injury = 0, sustained a moderate to severe brain injury = 1. The three scores were added to create the brain injury score.”

Abuse Measures

Partner abuse severitywas assessed using a 28-item scale composed of the 18-item Conflict Tactics Scale (Straus, 1979) and 10 severe violence and sexual abuse items from The Severity of Violence Against Women Scale (Marshall, 1992).Women were asked how frequently these incidents occurred within the past year. Following established guidelines (Straus et al., 1990), responses were weighted according to potential to cause injury and summed to produce an abuse severity score.

The Childhood Trauma Questionnaire – Short Form (34-item version) was used to assesschildhood abuse and neglect (Bernstein et al., 1994). The Childhood Trauma Questionnaire asks participants to indicate the degree to which they experienced a wide variety of undesirable incidents while growing up (e.g., “someone in my family yelled and screamed at me”) using a five-point scale (1=never true; 5=very often true). The Childhood Trauma Questionnaire measures physical abuse, sexual abuse, emotional abuse, physical neglect and emotional neglect. It has been found to be associated with interview-based ratings of childhood maltreatment (Bernstein et al., 1994) and with independent corroborations of childhood maltreatment (Bernstein et al., 1997).

Cognitive Measures

The California Verbal Learning Test (CVLT; Delis et al., 1987)is a test of memory and learning. In this test, participants were required to try to learn a list of orally presented words with five learning trials. Participants were asked to recall the words immediately and then again after a 20-min delay. The sum of CVLT trials 1-5 represents the total number of words recalled in the first five trials. The CVLT long-delay free-recall represents the number of words recalled spontaneously after the 20-min delay.

Trails-B (War Department, 1944)was used to test cognitive flexibility. Participants were required to draw a line to connect a series of numbered and lettered circles in alternating sequence as quickly as possible.

Psychopathology Measures

The Mood and Anxiety Symptom Questionnaire (short form; Clark and Watson, 1991)is a 62-item questionnaire based upon Clark and Watson's tripartite model of anxiety and depression. Itincludes 4 subscales designed to assess both specific and non-specific symptoms of depressionand anxiety. Items were summed to create a total score.

The Clinician Administered PTSD Scale for DSM-IV- One Week Symptom Status Version (CAPS-2; Blake et al., 1995) is a semi-structured interview used to assess post-traumatic stress disorder symptoms. For each participant, a single-dimensional post-traumatic stress disorder severity score was calculated based on frequency and intensity of symptoms.

Psychoactive substance dependence was assessed using a modified version of the psychoactive substance use module from the Structured Clinical Interview for DSM-IV Disorders (First et al., 2012).This module was modified to be briefer but still allow assessment of current dependence on drugs or alcohol based on the DSM-IV criteria.

Online Resource Analyses and Results

For exploratory purposes, we examined the relationship between rAI-PCC/PCu connectivity and the frequency and recency of partner-related TBI separately. Results hint at the possibility of a stronger relationship with cumulative effects of TBI (ρ = -.61; p = .004) over recency (ρ = .29; p = .212); however, given the complexity of these variables and likely interactions, future work would be needed to determine whether there are meaningful differences between these observed relationships.

Online ResourceFig 1Areas in posterior cingulate cortex/precuneus, retrosplenial cortex, and lateral parietal cortex showing functional connectivity with the anterior insula that significantly correlates with brain injury score, including only subjects without potential substance abuse issues (n=16) (FWE-corrected Z>2.3, cluster-based p<0.05). PCC/PCu = cingulate cortex/precuneus; RspC = retrosplenial cortex; LPC = lateral parietal cortex.

Online Resource Fig2 A cluster in posterior cingulate cortex/precuneusshowing functional connectivity with the anterior insula that significantly correlates with brain injury score, including only subjects without potential medication use issues (n=17) (FWE-corrected Z>2.3, cluster-based p<0.05). PCC/PCu = posterior cingulate cortex/precuneus.

Online Resource Fig 3 A cluster in posterior cingulate cortex/precuneus showing functional connectivity with the anterior insula that significantly correlates with brain injury score, with subjects with potential anoxic brain injury entered as anadditional covariate of no interest (FWE-corrected Z>2.3, cluster-based p<0.05). PCC/PCu = posterior cingulate cortex/precuneus.

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