Strangulation, Domestic Violence, and Brain Injury: An Introduction to a Complex Topic

By Jerrod Brown, Ph.D.

Affecting millions of individuals across the United States, intimate partner violence is the physical, sexual, or psychological harm of an individual by a romantic partner (Arroyo, Lundahl, Butters, Vanderloo, & Wood, 2017). Approximately one in four American women are the victims of severe physical violence perpetrated by their intimate partners at some point in their lifetime (Smith et al., 2017). Such intimate partner violence often takes the form of physical attacks including punching, shaking, hitting with an object, assaulting with a weapon, or near suffocation. The consequences of intimate partner violence can range from adverse physiological (e.g., broken bones and traumatic brain injuries) and mental health (e.g., post-traumatic stress disorder, depression, and anxiety) issues to homicide (Pritchard, Reckdenwald, & Nordham, 2017; Strack & Gwinn, 2011).

One particularly common yet destructive form of intimate partner violence is strangulation (Kwako, Glass, Campbell, Melvin, Barr, & Gill, 2011; Messing, Patch, Wilson, Kelen, & Campbell, 2018). Distinctly different than choking, strangulation is the application of pressure to the neck that restricts blood vessels and air passages. This in turn results in asphyxiation, or the restriction of oxygen, where oxygen fails to reach the brain and other parts of the body. It is thought that strangulation symbolizes the perpetrator’s control over the victim and demonstrates the perpetrator’s ability to kill the victim (Volochinsky, 2012).

There are two types of strangulation: manual and ligature. Manual strangulation is the process of using one’s hands or forearm to strangle the victim and may be the most common form of strangulation employed in the context of intimate partner violence. In contrast, ligature strangulation refers to the use of a rope, scarf, belt, or other similar object to strangle the victim (Volochinsky, 2012). Regardless of the type, strangulation may or may not be accompanied by visible symptoms of the injury.

Depending on length of time without oxygen, the victim may experience a loss of consciousness, potentially permanent medical consequences (e.g., strokes, brain injuries), and even death. In fact, victims of intimate partner violence who have experienced strangulation are much more likely to die as a result of intimate partner violence than those victims who do not experience strangulation. Even if the victims initially survive the strangulation, they may eventually die due to other complications. In these cases, victims die in the coming days or weeks after the strangulation as a result of blood clots, arterial complications, respiratory issues, or other reasons.

In the absence of death, brain injuries are often one of the most devastating and long-lasting consequences of strangulation. Victims of intimate partner violence may also experience traumatic brain injuries (TBIs) from blows to head and other assaults. (Prosser, Grigsby, & Pollock, 2018; Valera & Kucyi, 2017). Caused by open or closed injuries to the head, TBIs can be characterized as short- or long-term brain damage. This could include physical (e.g., loss of consciousness, headaches, and sleep disturbances), sensory (e.g., vision and auditory distortions and sensitivity to light and sound), cognitive (e.g., executive control and memory), and mental health (e.g., depression, anxiety, and mood fluctuations) symptoms. For a review of the injuries resulting from strangulation, please see Figure 1. As a result of these symptoms, individuals suffering from TBI could have difficulty functioning in daily life including performing regular tasks at home, school, or work.

The combination of psychological distress and brain injury can make it difficult to identify the presence of intimate partner violence. Specifically, the victims may have difficulty communicating the transpired events to authorities, physicians, and other professionals in a variety of contexts. For example, this could occur in conversations with police officers during criminal investigations or with mental health care providers during psychological assessments. The causes of communication difficulties may include short- and long-term memory impairments, post-traumatic stress disorder symptoms, or other intimate partner violence sequelae. The practical consequences of communication difficulties are the under-identification of intimate partner violence victimization. As a result, the individual may be (a) exposed to further intimate partner violence in community settings, (b) viewed as an unreliable source of information in criminal justice and legal settings, and (c) undiagnosed or misdiagnosed in psychiatric settings.

To improve the identification of survivors of intimate partner violence, professionals must adopt advanced methods of screening and assessment (Pritchard, Reckdenwald, Nordham, & Holton, 2018). One consideration should be the manner in which screening and assessments are conducted. Specifically, interactions with clients should be characterized by slow pace, repetition, checks for comprehension, and frequent breaks. Beyond this, professionals should specifically screen for both intimate partner violence victimization and brain injury. This could involve questions about concussions, blackouts, and loss of consciousness. Failure to adopt these suggestions and approaches may result in symptoms being misattributed to other ailments, misdiagnosis, and ultimately inappropriate and ineffective interventions.

A lack of recognition of the links between intimate partner violence, strangulation, and brain injury translates to under-treatment. This is troubling because timely intervention is essential in the minimization of negative short- and long-term outcomes. When untreated, brain injuries can worsen over time and have permanent consequences on the victim’s global functioning along with tremendous societal costs. As such, it is essential that the potential TBIs be evaluated by a physician with referrals to appropriate treatment services as soon as possible.

In instances where professionals lack expertise in brain injury, it may be fruitful to call on the assistance of specialists. Those with expertise can help ensure the client has not only been adequately assessed and diagnosed, but also provide guidance in the development of the course of treatment. This should include a discussion of how to address the client’s individualized needs throughout treatment with appropriate services and techniques. Further, professionals with expertise must also assist in the safety planning process. Such plans should clearly identify ways to minimize the risk of intimate partner violence and TBI along with safe places where the victim can receive treatment and recover from injuries (Murray, Lundgren, Olson, & Hunnicutt, 2016).

In light of the serious consequences reviewed in this article, there is an immediate and ongoing need for increased awareness of intimate partner violence and brain injury. This includes professionals working in law enforcement, forensic, criminal justice, mental health, medical, and social service settings. An essential path forward includes improving the accessibility of these professionals to education and training programs on the areas of intimate partner violence and brain injury, particularly programs that explore the intersectionality of these topics. In addition to broadening awareness, law enforcement agencies and organizations that serve survivors of intimate partner violence should adopt universal screening procedures for identifying brain injury. Any individual identified with potential brain injuries must be strongly encouraged to receive a thorough assessment and any necessary treatment. 

References

1. Kwako, L. E., Glass, N., Campbell, J., Melvin, K. C., Barr, T., & Gill, J. M. (2011).Traumatic brain injury in intimate partner violence: A critical review of outcomes and mechanisms. Trauma, Violence, & Abuse, 12(3), 115-126.
2. Messing, J. T., Patch, M., Wilson, J. S., Kelen, G. D., & Campbell, J. (2018). Differentiating among attempted, completed, and multiple nonfatal strangulation in women experiencing intimate partner violence. Women’s health issues, 28(1), 104-111.
3. Murray, C. E., Lundgren, K., Olson, L. N., & Hunnicutt, G. (2016). Practice update: what professionals who are not brain injury specialists need to know about intimate partner violence-related traumatic brain injury. Trauma, Violence, & Abuse, 17(3), 298-305.
4. Pritchard, A. J., Reckdenwald, A., & Nordham, C. (2017). Nonfatal strangulation as part of domestic violence: A review of research. Trauma, Violence, & Abuse, 18(4), 407-424.
5. Pritchard, A. J., Reckdenwald, A., Nordham, C., & Holton, J. (2018). Improving Identification of Strangulation Injuries in Domestic Violence: Pilot Data From a Researcher-Practitioner Collaboration. Feminist criminology, 13(2), 160-181.
6. Prosser, D. D., Grigsby, T., & Pollock, J. M. (2018). Unilateral anoxic brain injury secondary to strangulation identified on conventional and arterial spin-labeled perfusion imaging. Radiology Case Reports, 13(3), 563-567.
7. Smith, S. G., Chen, J., Basile, K. C., Gilbert, L. K., Merrick, M. T., Patel, N., Walling, M., &Jain, A. (2017). The National Intimate Partner and Sexual Violence Survey (NISVS):2010- 2012 State Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
8. Strack, G., & Gwinn, C. (2011). On the edge of homicide: Strangulation as a prelude.Criminal Justice, 26(3), 32.
9. Valera, E., & Kucyi, A. (2017). Brain injury in women experiencing intimate partner violence: Neural mechanistic evidence of an “invisible” trauma. Brain imaging andbehavior, 11(6), 1664-1677.
10. Volochinsky, B. (2012). Obtaining justice for victims of strangulation in domestic violence cases: Evidence based prosecution and strangulation-specific training. Student Pulse,4(10). 

 

About the Author:

Jerrod Brown, Ph.D., is Assistant Professor, Program Director, and lead developer for the Master of Arts degree in Human Services with an emphasis in Forensic Behavioral Health for Concordia University, St. Paul, Minnesota. Jerrod has also been employed with Pathways Counseling Center in St. Paul, Minnesota, for the past fifteen years. Pathways provides programs and services for individuals affected by mental illness and addictions. Jerrod is also the founder and CEO of the American Institute for the Advancement of Forensic Studies (AIAFS), the editor-in-chief of Forensic Scholars Today (FST), and a Youth Firesetting Prevention and Intervention (YFPI) Mental Health consultant for the Minnesota Department of Health (MDH). Jerrod is certified as a Youth Firesetter Prevention/Intervention Specialist, Thinking for a Change (T4C) Facilitator, Fetal Alcohol Spectrum Disorders (FASD) Trainer, and a Problem Gambling Treatment Provider. Jerrod has completed four separate master’s degree programs and holds graduate certificates in Autism Spectrum Disorder (ASD), Other Health Disabilities (OHD), and Traumatic Brain Injuries (TBI). Jerrod has published numerous articles and book chapters, and recently co-authored the book Forensic Mental Health: A Source Guide for Professionals (Brown & Weinkauf, 2018) with Erv Weinkauf.

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This article originally appeared in Volume 13, Issue 1 of THE Challenge! published in 2019.