Robert Walker, M.S.W., L.C.S.W.
University of Kentucky Department of Behavioral Science and
Center on Drug and Alcohol Research
Injuries to the head from domestic violence are far more common than
thought.
Estimates of prevalence range from 18% -90% of DV victims having
brain injuries ((Jackson, 2002;Valera, 2003).
Clearly different kinds of DV populations account for much of the
variation in prevalence.
Among those with brain injuries, approximately half experienced
unconsciousness.
 Battery to the head
 Falls
 Suffocation, Submersion in water (hypoxic injury)
 Drug overdose (hypoxic injury)
 Auto accidents
 Sports injuries (soccer, football)
The typical cluster of problems related to TBI/ABI
ALCOHOL ABUSE
SLEEP DISORDER
CHRONIC PAIN
ABI
DEPRESSION
DRUG ABUSE
ANXIETY
DISORDER
PERSONALITY
DISORDER
Every brain injury is different.
Every person with a brain injury will present differently.
However, most experience frontal lobe injury with negative
effects on:
thinking
emotion regulation
and control of impulsivity
Brain injury can result in a wide range of physical and mental
problems and symptoms.
In addition, there is a wide range in the severity of injury.
This diversity of symptoms and problems makes it imperative that
advocates learn how a brain injury has affected the individual.
Safety plans must take into account these individual differences if
they are to succeed.
There are two major ways to define brain injury:
 “Traumatic brain injury” refers to blunt force
trauma to the head resulting in injury to the brain.
This used to be called “closed head injury”.
 “Acquired brain injury” is a broader term that
includes various insults to the brain including lack of
oxygen, bleeding in the brain, infection, or exposure
to toxins.
TRAUMATIC
Traumatic brain injury is an insult to the brain, not of
a degenerative or congenital nature but caused by an
external physical force, that may produce a
diminished or altered state of consciousness, which
results in an impairment of cognitive abilities or
physical functioning. It can also result in the
disturbance of behavioral or emotional functioning.
These impairments may be either temporary or
permanent and cause partial or total functional
disability or psychosocial maladjustment.
Adopted by the Brain Injury Association Board of Directors, February
22, 1986.
TRAUMATIC
 Symptoms of a traumatic brain injury can include a wide range of
physical and mental problems that are likely to be present immediately
after an injury:
- Spinal fluid (thin water-looking liquid) coming out of the ears or nose
- Loss of consciousness; however, loss of consciousness may not occur
in some concussion cases
- Dilated pupils or pupils appear of unequal size
- Loss of eye movement
- Respiratory failure
- Semi comatose state
Adapted from the Brain Injury Association of America
TRAUMATIC
- Coma
- Impaired muscle tone and impaired muscle movements
- Paralysis – particularly on one side of the body
- Slow heart rate
- Slow respiration rate, with an increase in blood pressure
- Vomiting
- Lethargy
- Headache
Adapted from the Brain Injury Association of America
TRAUMATIC
Confusion
Inefficient thinking/ impaired cognition
Inappropriate emotional responses
Adapted from the Brain Injury Association of America
TRAUMATIC
Depression
Anxiety
Possible hallucinations
Memory problems
Problems controlling impulses
Difficulty solving problems
Chronic pain, headaches
Inappropriate behavior
Learning difficulties
Problems with physical coordination
Fatigue
Adapted from the Brain Injury Association of America
TRAUMATIC
If these problems were present BEFORE the injury,
the injury may make them worse.
Adapted from the Brain Injury Association of America
TRAUMATIC
 Diffuse Axonal Injury
 Concussion
 Contusion
 Countre-coup
 Shaken-baby syndrome
A Diffuse Axonal Injury can be more wide-spread
throughout the brain than a specific or focal
injury to one part of the brain.
It can be caused by shaking or by strong rotation
of the head, as with Shaken Baby Syndrome, or by
rotational forces, such as can occur when a body
is thrown around in a car accident.
Injury occurs because the brain inside the skull
case lags behind the movement of the skull,
causing brain structures to tear.
It’s somewhat like having a jello-like substance
in a pail, then sloshing the pail back and forth.
The soft material is thrown around against the
hard containing surface. This can create shearing
effects and tearing of nerve cells.
There can be extensive tearing of nerve tissue throughout the brain.
This trauma triggers the release of brain chemicals (cortisol) that can
cause further damage. (Cortisol stops cell metabolism of glucose,
thus resulting in cell death).
The tearing of the nerve tissue disrupts the brain’s
regular communication networks and normal chemical
processes.
This disturbance in the brain can produce temporary or
permanent widespread brain damage, coma, or death
OR, it can result in moderate global impairments that
can be misunderstood as other disorders (MS).
Adapted from the Brain Injury Association of America
A person with a diffuse axonal injury can present a variety of
functional impairments depending on where the shearing
(tears) occurred in the brain.
The impairments may be better described as “global”
because they include a wide range of physical and mental
functions.
Adapted from the Brain Injury Association of America
A concussion can be caused by direct blows to the head, gunshot
wounds, violent shaking of the head, or force from a whiplash
type injury.
Concussions can be mild, moderate or severe.
A concussion is caused when the brain receives trauma from an impact
or a sudden momentum or movement change like sudden crash or
acceleration during a car wreck.
The blood vessels in the brain may stretch and cranial nerves may be
damaged.
Adapted from the Brain Injury Association of America
A person may or may not experience a brief loss of consciousness
(not exceeding 20 minutes). A person may remain conscious, but
feel “dazed” or “punch drunk”.
A concussion may or may not show up on a diagnostic imaging
test, such as a CAT Scan. Skull fracture, brain bleeding, or
swelling may or may not be present.
Therefore, concussion is sometimes defined by exclusion and is
considered a complex neurobehavioral syndrome
Adapted from the Brain Injury Association of America
A concussion can cause diffuse axonal type injury (see above)
resulting in permanent or temporary damage.
A blood clot in the brain can also develop from a concussion and
can even be fatal.
Adapted from the Brain Injury Association of America
It may take a few months to a few years for a
concussion to heal and many individuals have life-long
consequences of these injuries.
Recently, a form of progressive dementia has been
identified among football players who sustained
multiple injuries years ago.
Adapted from the Brain Injury Association of America
A contusion is a bruise on the brain; It is where
blood vessels have been ruptured in brain tissue.
A contusion can be the result of a direct impact to
the head.
Large contusions may have to be surgically
removed
Adapted from the Brain Injury Association of America
Traumatic
 Contre-coup
 Where injury occurs on both sides of the brain
 Reverberation injury
 Shaken baby syndrome
 Brain tissue can be torn apart
 Blood vessels in the brain may be ruptured and
bleed
 This causes swelling and pressure damage to
neurons
Adapted from the Brain Injury Association of America
Acquired
An acquired brain injury is an injury to the brain, which is not hereditary,
congenital, degenerative, or induced by birth trauma. An acquired brain injury
is an injury to the brain that has occurred after birth.
An acquired brain injury commonly results in a change in neuronal activity,
which effects the physical integrity, the metabolic activity, or the functional
ability of the cell. An acquired brain injury may result in mild, moderate, or
severe impairments in one or more areas, including cognition, speech-language
communication; memory; attention and concentration; reasoning; abstract
thinking; physical functions; psychosocial behavior; and information
processing.
Adopted by the Brain Injury Association Board of Directors, March 14, 1997.
Acquired
 Acquired brain injury is generally related to
decreased oxygen to the brain and this is
defined in two ways:
 Anoxic events where the brain has lost its oxygen supply and nerve
cells die;
 Hypoxic events where the brain has experienced a reduced supply of
oxygen and nerve cells can be impaired.
Acquired B
 Tends to be more global and less specific in location
 Impairment in thinking and memory is likely
 Mental health problems are likely
 Movement disorders are likely
acquired
 Near drowning
 Drug or alcohol overdose
 Heart attack
 Stroke, aneurysm
 Meningitis
 Dementias
Having reviewed different types of brain injury, it is also
important to understand that there are different levels of
severity as well. Typically, injuries are classified into three
groups:
 Severe
 Moderate
 Mild
 Although the severity of the injury may predict the level of
impairment, there are many factors which influence the longterm outcome of the injury.
 Prior TBIs, history of substance abuse, age, quality of
rehabilitation and environmental supports are some major
factors that can affect long-term outcomes.
Headache
Fatigue
Sleep disturbance
Irritability
Sensitivity to noise or light
Balance problems
Decreased concentration and attention span
Decreased speed of thinking
Memory problems
Learning problems
Poor social skills
Nausea
Depression and anxiety
Emotional mood swings
Possible motor coordination problems (typically mild)
 Major depression is prevalent among persons with mild to
moderate brain injury, with between 14% and 29% experiencing
it (Jorge, Robinson, Arndt, et al., 1993; Rapoport, McCullagh,
Streiner, et al., 2003).
 These rates are 3-5 times greater than for the general
population.
 It is now recognized that PTSD and TBI can be co-occurring
conditions with each complicating the other.
 Depression is associated with worse performance across a wide
array of cognitive domains.
 Yet depression among persons with ABI can be treated, thus
opening the possibility of improvement across cognitive areas
(Rapoport, McCullagh, Shammi, & Feinstein, 2005).
 A stronger case can be made for using SSRIs with these persons
as they cause increased brain-derived growth factor (BDNF)
which can reduce inflammation effects in the central nervouse
system.
 Memory deficits and associated attentional problems are not
always associated with severe and overt brain injury,
 but can result from mild to moderate injury even when there has
been no loss of consciousness with the injury (Kelly 1999; Malec
1999; National Institutes of Health 1999; Dixon, Taft & Hayes
1993).
Most individuals entering shelters or treatment form trauma-related
problems will have frontal lobe injury.
Individuals with frontal lobe injuries share problems with executive
functioning – planning for the future, inhibiting impulses, and
regulating emotion.
 Individuals with injury to the frontal lobes can have increased
difficulty reading social cues and emotional cues (Mah, Arnold, &
Grafman, 2004).
 Frontal lobe injury is associated with deficits in detecting lies and
forming a mental picture of how others think or feel about
situations (Stone, Baron-Cohen, & Knight, 1998; Stuss, Gallup, &
Alexander, 2001).
 Injury to specific regions of the frontal lobes may result in
different kinds of memory encoding and retrieval processes
(Stuss & Alexander, 2005).
 Storing of new information may be less accurate and less
complete.
 Ready retrieval of remembered information may be impaired and
slower.
 Apathy and indifference have also been associated with frontal lobe
injury (Stuss, Van Reekum & Murphy 2000; Edwards-Lee & Saul 1999;
Litvan 1999).
 The apathy may be associated with a reduced emotional responsivity –
even in startle situations and in novel situations (Van Reekum, Stuss, &
Ostrander, 2005).
 It may be important to differentiate apathy from depression.
 In some cases, persons with frontal lobe injury can have both
indifference characterized by minimization of symptoms,
 Or they may show emotional placidity and inappropriate joking or
social disinhibition (Edwards-Lee & Saul 1999).
 Their traits can easily be misunderstood in intervention settings as
resistance or transference issues.
 In fact, the reasons for the behavior may include cognitive impairment
secondary to brain injuries that may be mild, but significant.
 Generalized Anxiety Disorder, PTSD, and Obsessive-Compulsive
Disorder have also been found among individuals following a
traumatic brain injury (Van Reekum, Cohen, & Wong, 2000).
 In general, the prevalence of these disorders greatly exceeded
the rates for the population at large.
 Be sensitive to the likelihood of multiple mild injuries.
 Cumulative effects over time matter.
 Traumatic brain injury has been associated with alcohol and drug
use both as a contributing factor to the injury and as a complicating
factor for rehabilitation (Hested et al. 1995; Miller 1992; Boyle,
Vella & Moloney 1991).
 Up to two-thirds of brain injury cases have been found to have
histories of substance use before the injury (Corrigan 1995).
 Among those with injuries the probability of having a TBI tripled
when BAC was .15-.20, then increased 9-fold when BAC exceeded
.20 (Savola, Niemela & Hillbom, 2005 )
 The high prevalence of drug and alcohol problems
among traumatic brain injured individuals suggests
that drug abusers might be at high risk for brain injury
and vice versa.
 Being intoxicated at the time of injury predicts greater
severity and poorer outcomes.
 This relationship between ABI and substance use fits in
the picture of DV as well.
 Individuals may not “get it” about their risks and safety needs
because of denial.
 BUT - may not get it because they really just do not get it, due to
cognitive impairments secondary to brain injury, substance use,
PTSD or the combination of all three.
 It is easy to read brain injury victims as resistive to new
information and to safety planning.
 John Corrigan’s work at Ohio State is very helpful.
 Search for his work.
1. Have you ever been hospitalized or treated in an emergency room
following an injury to your head or neck? Think about any childhood injuries
you remember or were told about.
Yes
No
2. Have you ever injured your head or neck in a car accident or from some
other moving vehicle accident?
Yes
No
3. Have you ever injured your head or neck in a fall or from being hit by something?
Yes
No
Bogner, J.A., Corrigan, J.D. (2009). Reliability and validity of the OSU TBI Identification
Method with Prisoners. Journal of Head Trauma Rehabilitation, 24(6), 279-291. Corrigan, J.D.,
Bogner, J.A. (2007). Initial reliability and validity of the OSU TBI
4. Have you ever injured your head or neck in a fight, from being hit
by someone or being shaken violently?
Yes
No
5. Have you ever been nearby when an explosion or a blast
occurred? If you served in the military, think about any combatrelated incidents.
Yes
No
If all above are “no” then stop. If answered “yes” to any of the
questions above, ask:
6. Were you knocked out or unconscious following the injury(ies) you
mentioned above? DO NOT INCLUDE LOSING CONSCIOUSNESS DUE TO
DRUG OVERDOSE OR FROM BEING CHOKED (see #8, below).
Yes
No
If answer to #6 is “No”, ask:
7A. Were you dazed or have a gap in your memory from the injury(ies) you mentioned above?
[RULE OUT ALCOHOL BLACKOUTS]
Yes
No
If answer to #6 is “Yes”, ask:
7B. How long were you knocked out? (If identified multiple injuries with loss of consciousness,
ask for each. If not sure of the time frame, encourage them to make their best guess.)
For How
For How
For How
For How
For How
long ________ How old
long ________ How old
long ________ How old
long ________ How old
long ________ How old
were you? _____
were you? _____
were you? _____
were you? _____
were you? _____
If more than 5, how many times more?______
Longest time knocked out?_____
How many ≥ 30 mins.?_____
Youngest age?____
8. Have you ever lost consciousness from a drug overdose or being choked?
Number of times from a drug overdose
Number of times from being choked
Bogner, J.A., Corrigan, J.D. (2009). Reliability and validity of the OSU TBI Identification Method
with Prisoners. Journal of Head Trauma Rehabilitation, 24(6), 279-291. Corrigan, J.D., Bogner, J.A.
(2007). Initial reliability and validity of the OSU TBI
_________# TBI-LOC (number of TBI’s with loss of consciousness from #7B)
_________# TBI-LOC ≥ 30 (number of TBI’s with loss of consciousness ≥ 30 minutes from #7B)
_________age at first TBI-LOC (youngest age from #7B)
_________TBI-LOC before age 15 (if youngest age from #7B < 15 then =1, if ≥ 15 then = 0)
_________Worst Injury (1-5):
If responses to #1-5 are “no” classify as 1 “improbable TBI”.
If in response to #6 reports never being dazed or having memory lapses classify as 1 “improbable
TBI”.
If in response to #7A reports being dazed or having a memory lapse classify as 2 “possible TBI”.
If in response to #7B loss of consciousness (LOC) does not exceed 30 minutes for any injury classify as
3 “mild TBI”.
If in response to #7B LOC for any one injury is between 30 minutes and 24 hours classify as 4
“moderate TBI”.
If in response to #7B LOC for any one injury exceeds 24 hours classify as 5 “severe TBI”.
________# anoxic injuries (sum of incidents reported in #8)
https://osuwmcdigital.osu.edu/sitetool/sites/psychiatry2public/documents/Psychiatry_Documents/corrigan.pdf
 Then, plan for shorter sessions.
 Use visual, auditory, and written materials and media – multi-
sensory.
 Have the person write down safety planning steps and actions.
 Have the person report back what key assignments are (if there
are assignments).
 Watch for signs of “forgetting to remember.”
 Brain injuries can take many forms depending on the type and
severity of injury.
 Also, pre-existing conditions can affect the clinical manifestations of
brain injury in both the long and short term after an injury.
 Examine whether persons get it versus being resistant to new
information.
 At the end of safety planning sessions, have the person report back
what the plan consists of;
 Put situations to the person and ask her to describe the safety
actions;
 If these steps are carried out well, then comprehension is
relatively intact.
 If not, repeat everything using smaller chunks of info.
 Many mental health problems emerge following a brain injury and
these conditions may actually mask a brain injury.
 Substance abuse is a likely contributor to the risk for brain injury
and increased substance use may be a consequence of the injury.
 Safety planning should always consider the possibility of
neurocognitive problems secondary to ABI.