Approximately 2 to 3 million women are battered by their intimate partners each year. Severe injuries requiring emergency medical treatment of battered women have been noted, yet the prevalence of head injuries and the negative consequences emanating from such injuries have been noticeably absent from the literature. The descriptive study discussed in this article examined the case records of residents in a domestic violence shelter over a three-month period and found a 35 percent prevalence rate of battered women who had experienced head injury during a battering incident with their intimate partner. This study calls attention to the long-range difficulties that head-injured battered women may experience as a result of cognitive, emotional, and behavioral difficulties resulting from domestic violence and how social workers can intervene with this population.
Researchers have suggested that from 1.8 million to 3 or 4 million women in the United States are assaulted by their partner every year (Stark et al., 1981; Straus, Gelles, & Steinmetz, 1980; Sugg & Inui, 1992). Straus et al. (1980) indicated that violence will occur at least once during the litetime of approximately halt of all married women.
Spouse abuse has been cited as the leading cause of severe physical damage to women (Browne, 1987; Rosenbaum, 1991; Stark & Flitcraft, 1988). Injuries such as burns, stab wounds, broken limbs, and bruises frequently are cited as requiring emergency surgery and hospitalization (Browne, 1987). McLeer and Anwar (1989) indicated a 30 percent prevalence rate of injuries for women in emergency departments when a thorough trauma history was obtained. Despite this fact, physicians historically have been reluctant to diagnose abuse (Mehta & Dandrea, 1988; Rounsaville & Weissman, 1977-78; Sugg & Inui, 1992). Battered women rarely report abuse without being asked and instead describe vague, psychosomatic complaints rather than the actual physical violence (Blair, 1986).
BATTERED WOMEN AND HEAD TRAUMA
Women who enter domestic violence shelters frequently report that they have received numerous blows to the head, have been unconscious for unknown periods of time, and have been in comas as a result of head trauma. Although several authors (Jezierski, 1994; Murphy, 1993; Tilden, 1989) mention head trauma as a serious outcome of physical abuse by a male partner, the scope and residual effects of this particular type of battering have yet to be studied. In addition, emergency departments may be attuned to the high-risk behaviors (fighting, motorcycle accidents) of men between the ages of 18 and 30, that result in head injury (Marshall et al., 1991) and therefore, not expect to see this kind of injury in women.
Women from a nonbattered population who experienced head trauma identified loss of employment and autonomy as areas of concern along with mood disorders, particularly depression (Willer, Allen, Liss, & Zicht, 1991). In a case study of four women with traumatic brain injury (TBI), researchers identified psychosocial difficulty and personality changes as problematic areas (Stratton & Gregory, 1995).
STATEMENT OF THE PROBLEM
Although issues relevant to battered women have been studied extensively by social workers, (Abel & Suh, 1987; Aguirre, 1985; Burg, 1994; Davis, 1984, 1987; Davis, Hagen, & Early, 1994; Harris, Mowbray, & Solarz, 1994; McNeely & Robinson-Simpson, 1987) difficulties with health, particularly that of head trauma, have received little attention. Women who have incurred head trauma may be severely impaired in terms of entering the workforce as well as caring for themselves and their children, yet the vast majority of head injury literature remains focused on the difficulties of men with head injuries and subsequent family disruption and adaptation (Acorn, 1995; Acorn & Roberts, 1992; Resnick, 1994). Furthermore, domestic violence shelters, which historically have provided safe havens to battered women (Newman, 1993), may not be well-versed in dealing with these consequences and subsequently, appropriate referral may be compromised.
Given that batterers will very often target the woman's head (Walker, 1979), it seems likely that thousands of women in this population have endured subtle to severe head injuries during their lifetimes. The present study emerged as an initial inquiry into the incidence, prevalence, and presenting symptomatology of head injury among battered women residing in a domestic violence shelter and the inherent issues that social workers need to address with this population.
DEFINING HEAD INJURY
Subtle head injury, unlike TBI, which is easily detectable, may result in diffuse injury to the brain, and generally lesions or other abnormalities may not be observable through the use of CT scan or MRI (Mahon & Elger, 1989). Subtle head injury is harder to assess during emergency hospitalization and cognitive, emotional, or motor symptomatology, which may appear weeks or months later, may not be readily associated with the initial insult. O'Neal (1992) pointed out that subtle brain injury often causes residual cognitive deficits. He stated, "As has been well documented, these residual cognitive deficits are not specific to particular areas of cerebral function, such as language, perception, etc., but rather to general disruption of the speed, efficiency, execution and integration of mental processes. These are often associated with somatic complaints, such as headache and dizziness, that combined with the cognitive deficits, leads to additional and behavioral abnormalities" (p. 5).
This statement is noteworthy in relation to battered women in that continual physical battering, which may not be considered severe, may put them at risk of subtle but chronic head injury. In addition, although symptoms are usually subtle, they may be sufficiently debilitating to create disruptions in the person's daily life, employment status, and somatic and psychological adjustment (Mahon & Elger, 1989).
Participants were recruited from a shelter for battered women located in a suburban area of New York. Referral to the shelter was through Department of Social Services Emergency Housing, other domestic violence programs, hot-line services, the police, or self-referral. Most residents came from within the county, and five were referred to the shelter from out of county or state because of space or safety issues. Generally, these women were experiencing severe instances of ongoing physical violence with their partners.
The case records of 35 women who entered the shelter consecutively between November 1994 and January 1995 were reviewed for this study. Because the shelter census has continuous turnover and theoretically the house is never "empty," five women who were admitted previously and who were in residence during the month of November were also included, bringing the initial census to 40. It should be noted that 14 women who entered the shelter during this time were not included in the study because they were discharged from the program before the counseling intake could be conducted.
Discharge reasons included: inappropriate placement (the woman was not experiencing domestic violence), drug or alcohol use while in the shelter, curfew violations, severe psychiatric disturbance such as suicidal and homicidal ideation, and threatening behavior to staff or residents, including children. In total, there were 26 residents who were consecutive admissions and had received a counseling intake who were used for chart review.
Counseling by a social worker is mandatory in this domestic violence shelter, and residents are seen for the counseling intake one to five days after arrival. During the counseling intake several instruments were used to obtain a comprehensive view of the resident's presenting problem and her functional status, including any health difficulties. Residents completed a demographic data sheet that included the resident's premorbid status, particularly, educational and occupational functioning.
An initial assessment of depression was made for every resident through self-report, presenting affect and symptomatology. Specific inquiry regarding affect/depression was conducted as a freeform clinical interview throughout the resident's stay by the first author. We expected that during the first week, residents would experience depressed mood as a result of the crisis of violent incidents prior to shelter entry and as a consequence of being homeless. Therefore, initial depressed mood was seen as a normative response to a crisis situation and depending on presenting symptomatology, (depressed mood, anxiety, or anxiety and depressed mood) could be classified as an adjustment disorder (DSM-IV) (American Psychiatric Association, 1994). When symptomatology did not decrease (that is, lethargy, crying, sleeplessness, or fiat affect) by the second to third week, the clinical interview included questions consistent with ruling out several diagnoses identified in the DSM-IV, such as major depression, acute stress disorder, and posttraumatic stress disorder. Referral also was made for medication assessment.
All residents completed a medical history form, designed for this study. This form focused on reports of head injury. If reports of head injury were not spontaneously disclosed, residents were asked directly if they had experienced head injury by their partner during violent episodes as well as childhood head injury. Because many of the residents did not readily associate symptomatology with head trauma, all residents were asked about loss of consciousness, subsequent symptomatology (for example, headaches, dizziness, loss of concentration, and confusion), hospitalization and medical diagnosis (that is, concussion immediately resulting from battering incidents). The resident's perception of current symptomatology also was ascertained. When indicated, information was collected regarding the type of injury incurred (for example, location on head, what kind of object was used, in what kind of manner, and if the resident followed up with medical attention.
All data were collected through open-ended questions. Guidelines for data selection were based on the most commonly associated symptomatology emanating from head trauma and self-report from the residents. Questions within these guidelines were based on extensive clinical observation and because of the previously unexplored nature of the study, questions were formulated on face validity.
The guidelines covered six areas:
1. Had the resident been hit directly in the head with an object (baseball bat, hand, fist, or hammer) or was her head pushed, shoved or slammed into an object (car, wall, or furniture) during battering incidents?
2. Did the resident follow-up with medical attention? Was a diagnosis given by medical personnel? If so, what was that diagnosis?
3. What were the symptoms following the battering incident? Did the resident feel that these symptoms were directly related to the head injury she received from the batterer?
4. What were the current symptoms that the resident was experiencing?
5. Did the resident have any head injuries during childhood? Were they accidental head injuries or did the resident consider them to be purposeful?
6. Did the resident consider any of these symptoms to interfere with her ability to function, and did she consider this debilitating state different from her functioning before the battering?
Assessment of resident functioning was made through social worker face-to-face observation during counseling sessions, observation of the resident's interactions during shelter activities (for example, chores, discussions with other residents), input from shelter staff, and finally, the resident's self-report of prebattering functioning and current functioning. All data were collected and reviewed by the first author, a doctoral level, certified social worker.
The case files of 26 battered women who received counseling and were residents in the shelter between November 1994 and January 1995 were reviewed. Forty-six percent of the women were white, 38 percent were African American, and 15 percent were from other racial groups such as Turkish, Haitian, Hispanic, and biracial.
The median age of residents was 27. Fifty-seven percent (n = 15) of the women did not complete high school, 31 percent (n = 8) had obtained a high school diploma, and 12 percent (n = 3) had some college. A majority, 73 percent (n = 19) of the women did not identify a specific occupation and were not working prior to shelter entry, whereas 27 percent (n = 7) had white-color or blue-collar employment such as clerical and service employment. Fifty-four percent (n = 14) of the women reported the abuser to be their husband, and 46 percent reported that the abuser was a live-in boyfriend. Eighty-five percent (n = 22) of the women reported increasing levels of psychological abuse as one of the primary factors for leaving the abusive relationship. Sixty-nine percent (n= 18) stated that the physical violence had increased to severe levels, so much so, that they feared that they would be murdered if they stayed. Abuse ranged from punching, slapping, pushing, kicking, and use of a weapon during physical assaults. Sever e physical damage ranged from broken jaw, arms, legs, and ribs to injuries of the sensory organs or injuries requiring stitches. Forty-two percent (n = 11) of the women sought medical treatment, but 58 percent (n = 15) did not.
Thirty-one percent (n = 8) of the women reported a history of substance abuse, and 42 percent (n = 11) had a history of psychiatric intervention (that is, evaluation for medication). Seventy-three percent (n = 19) of the women reported some form of childhood maltreatment. A breakdown of these data indicate that 46 percent (n = 12) had a combination of physical, emotional, and sexual abuse; 15 percent (n = 4) reported emotional abuse only; 8 percent (n = 2) reported physical abuse (only), and 4 percent (1) reported sexual abuse only during childhood. Childhood abusers were as follows: father (37 percent); mother (21 percent); grandmother (5 percent); stepfather (11 percent); brother (16 percent); and mother's boyfriend (5 percent). One woman indicated that she was sexually abused by a day care worker.
The length of stay in the shelter for each resident ranged from one day to 86 days with an average of 31 days (SD = 21.44). All 26 of the residents reported varying degrees of depressed mood, which could be categorized as an adjustment disorder, primarily as a result of abuse and secondarily because they were now homeless and in a shelter. In addition, all 26 women experienced some form of crisis as a result of the incidents that escalated to her shelter entry. Therefore, they were initially confused, tearful, anxious, and overwhelmed.
Head-Injured Battered Women
Thirty-five percent (n = 9) of the 26 residents in the current sample had a history of head trauma. Nine (44 percent) reported loss of consciousness at the time of the injury. Three (3 percent) of the women reported a childhood history of head injury prior to the battering relationship. Of these three, two (22 percent) identified the injury as physical abuse by a parent and one as accidental. Six (66 percent) of the nine residents described head injuries resulting from being hit in the head with a closed fist and one (11 percent) as a result of being hit with a broom handle. In one case (11 percent), the resident was stabbed across the front of her forehead with a knife, and another resident (11 percent) was head injured when her mate ran her down with their car. Still another (11 percent) resident reported that her mate frequently would attack her while they were in their van by repeatedly slamming her head into the van door.
All nine of the women reported symptomatology that is consistently associated with subtle to severe head injury. Somatic complaints consisted of headaches, blurred vision, hearing problems, and dizziness. One resident reported a history of strokes and another a history of seizures. Seven residents (77 percent) reported some form of current physical symptom (Table 1).
Cognitive deficits reported by nine women with head injuries were: confusion (n = 2), difficulty following directions (n = 2), difficulty retaining information (n = 3), difficulty concentrating (n = 5), inability to initiate self-directed behavior (n = 7), and difficulty with abstract thinking (n = 5). Three of the residents reported memory loss, and five reported mental fatigue (Table 1). Through social worker observation in counseling sessions, it became apparent that these women had more difficulty than non-head-injured battered women with decision making (n = 5), judgment (n = 6), abstract thinking (n= 5), particularly difficulty with projecting into the future and processing information. These processes appeared to be minimally to severely impaired for all nine women. Three of the nine women had a history of substance abuse difficulties. Emotional symptoms presented by these residents were depressed mood (n = 4), irritability (n = 9), apathy (n = 8), agitation (n = 7), low frustration tolerance (n = 6), and sleep difficulties (n = 4). Four of these residents had difficulty with management. Five were referred for psychiatric evaluation for medication assessment. Four of the residents went to the emergency room, and four obtained follow-up treatment. Three women received x-rays or CT scans. None of the women had gone to a rehabilitation center as a result of the head trauma. Several of the women reported that they understood the implications of the head injury and their present-day diminished functioning. Four of the women discussed how their memory, concentration, and ability to reason had been impaired and that in essence, they were not the people they used to be. Although all nine of the women reported coming from violent, chaotic family of origin environments, only two of the women reported head injury in childhood. Three women in this group returned to the batterer.
The following example, as reported by one resident, exemplifies the difficulty in ascribing etiology of head trauma and subsequent physical, cognitive, and emotional deficits.
At age six, Laurie witnessed her mother stab her father 14 times after he had brutally beaten her. Her mother died of AIDS when she was nine, and she went to live with a maternal aunt. Often and unpredictably, her aunt would take both Laurie and her cousin and "crack our heads together." Laurie's adult relationships were extremely violent and her abuser would hit her in the head with a closed fist or slam her head into anything available.
Non-Head-Injured Battered Women
Of the group of non-head-injured women (n = 17) one reported current somatic symptomatology (that is, headaches, and severe headaches) (Table 2). Cognitive difficulties among this group included confusion (n = 3), difficulty following directions (n = 2), inability to initiate self-directed behavior (n = 3), and mental fatigue (n = 2). Five of the non-head-injured women (29 percent) displayed poor or impaired judgment prior to shelter entry such as being in dangerous situations (drug deals), having numerous sexual partners with no form of protection, and making an inaccurate assessment of batterer lethality. All five of the women (29 percent) had histories of substance abuse (including several detoxification and rehabilitation stays) that may have contributed to impaired judgment.
Four women reported emotional difficulties, which consisted of irritability, and others reported apathy (n = 2), agitation (n = 2), low frustration tolerance (n = 2), and sleep difficulties (n = 2) in the form of nightmares and anxiety at sleep time. Two of these residents had difficulty in managing their anger. All 17 women reported initial depressed mood regarding their placement in the shelter, being homeless, not having money, being dependent on welfare, not having an occupation that would help them get off of welfare in the imminent future, and fear of being alone. By the end of data collection, all but six, or 35 percent of this group had reduced their depressive symptomatology considerably. The six women were referred for medication assessment.
Four of the 17 women had difficulties in all of the areas of judgment, cognition, emotion, and substance abuse. This group experienced severe beatings (for example, cracked ribs with a baseball bat, broken arm, broken ear drum), but none of the injuries were to the head. Three of the women in this group returned to the batterer.
Analysis was conducted to ascertain significant differences between non-head-injured battered women (n = 17) and head-injured battered women (n = 9) on current somatic complaints, cognitive, emotional, and behavioral functioning as well as judgment and behavior. We used the Fisher Exact Test (Siegel, 1956); probabilities are reported in Table 2. Examining this data, one can conclude that battered women with head injury in this study were much more likely to report somatic, cognitive, and emotional variables than non-head-injured battered women. Because the sample was relatively small, replication with a larger sample is quite important. Nonetheless, there were clear differences for battered women with head injury to have greater adverse consequences.
IMPLICATIONS FOR PRACTICE
Nine of the 26 women in this sample experienced head trauma as a result of severe domestic battering, indicating that head injury may be a heretofore unexplored problem when working with this population. Several salient issues emerged for professionals who intervene with battered women.
Battered Women and Medical Treatment
Battered women do not necessarily seek medical treatment immediately after an attack by an intimate partner, if at all (Brendtro & Bowker, 1989). It maybe because of shame, denial, lack of money and transportation, or attempts by the abuser to block intervention. The ramifications of waiting to seek medical care can complicate prognosis further. Furthermore, four women in this study reported that they were "left for dead" by the abuser and that it was usually their children who sought help for them. Despite injuries to the head, many women do not seek medical care. Therefore social workers will want to ask, "Did you ever receive medical treatment for head injuries?" and follow up with a second question, "Was there ever a time that you received injuries and felt you should go for medical treatment but did not?"
Head Trauma, Battered Women, and Employment
People who experience head trauma frequently report symptoms long after the initial insult (Rutherford, Merrett, & McDonald, 1977). Mahon and Elger (1989) found that 60 percent of patients who have sustained brain injury still exhibit symptoms three months after the initial insult. Delayed symptoms can create difficulties in daily functioning, interpersonal relationships, and work life. In addition, TBI can create significant impairment in the ability to learn and retain new material because of cognitive deficits (Leland, Lewis, Hinman, & Carrillo, 1988; Rosenthal, 1983). This has great significance for battered women in domestic violence shelters, who may be expected to enter job training programs or employment. Furthermore, these deficits can create difficulty in the shelter environment when the women attempt to abide by shelter rules (for example, accomplishing chores, making curfew, and attempting to discipline children).
Assessment and Diagnosis
The social worker must decipher if the woman's current emotional and behavioral status is the result of head injury or the anxiety and crisis inherent in domestic violence or both. Careful assessment and diagnosis should rule out comorbidity of several diagnoses. For example, battered women presenting at shelters may have a history of substance abuse (Coleman, Weinman, & Bartholomew, 1980; Kantor & Straus, 1989; Stark et al., 1981), mental retardation, personality or anxiety disorder (Carmen, Rieker, & Mills, 1984; West, Fernandez, Hillard, Schoof, & Parks, 1990), posttraumatic stress disorder (Kemp, Green, Hovanitz, & Rawlings, 1995), and depression (Newman,1993; Rosenbaum & O'Leary, 1981; Rounsaville & Weissman, 1977-78). These conditions may complicate assessment, diagnosis, treatment, remediation, case management, and referral following head trauma.
Head Trauma and Its Effect on Judgment
To be sure, head injury can create far-reaching negative effects for victims of domestic violence. It is estimated that a woman will make several attempts to leave an abusive situation before she will leave permanently (Blair, 1986; Hilberman, 1980; Walker, 1979). Several variables have been cited to account for this, such as economic dependence (Frank & Golden, 1992; Strube & Barbour, 1983), fear of the unknown, learned helplessness (Walker, 1978, 1983), dependency and self-esteem issues as well as the intergenerational pattern of violence in which women learn to tolerate abusive situations and finally, denial.
However, when a woman has suffered head injury, her ability to make informed, consistent choices of whether to leave or return to the batterer may be compromised. In addition, the ability to plan, particularly with safety, health, child care and parenting issues may be deleteriously affected because of head injury. Sperling et al. (1990) stated that "one of the things that head injury often affects is the ability to plan, manage, and control impulses. Under those circumstances what you find is that a significant percentage of head injured clients, particularly severely head injured clients evidence problems of behavioral dyscontrol" (p. 3).
The head-injured women in this study displayed difficulty with retaining information, concentrating, initiating self-directed activity, abstract thinking, memory loss, mental fatigue, and difficulty with decision making, variables generally associated with head injury.
Patients with head injury may present as normal or near normal on neurological examination in the emergency department (Klauber et al., 1989; Stein & Ross, 1990). Hospital resources may be limited or strained to provide adequate observation of neurological deterioration and thus at-home observation may appear appropriate in the absence of presenting symptomatology. Although this intervention may be appropriate in some instances, the social worker must be aware that the battered woman may be returning home to the very same mate who has perpetrated the battering. Extended family members usually are overwhelmed with their own particular difficulties and therefore, are unable to offer ongoing assistance (West et al., 1990). Emergency department staff need to assess whether injuries are a result of battering and make appropriate referral (that is, extended family when safety is guaranteed, community support systems, legal systems, and shelter placement).
Shelter staff need to become well versed with such issues as assessment--including the importance of premorbid functioning--presenting symptomatology, neurological referral, comorbidity, as well as the long-term needs of head-injured battered women such as remediation and retraining. In addition, shelter staff need to recognize the emotional, cognitive, and behavioral deficits of battered women and how residents can negotiate these difficulties. For instance, once shelter staff understand that a resident may have difficulty with retention and carryover of material as the result of a head injury, they are less likely to view the resident's behavior as resistance or "forgetfulness." Staff training in regard to the problems of battered women with head injury increases awareness of the problem and assists in reducing the frustration of the shelter worker.
Social workers may find their role increasingly defined as advocate in assessing and obtaining medical care for this population. Following a brutal incident of battering by her partner (in which he hit her in the head with a hammer), a shelter resident was referred by the first author to her primary care physician (PCP) to obtain a referral for neurological consult. The resident exhibited numerous symptomatology consistent with head injury. The PCP denied the need for neurological consult, explaining to the resident that her headaches, depression, confusion, and disorientation were solely a result of the stress associated with the battering incident. A great deal of time and effort was spent to educate the PCP regarding the needs of head-injured battered women. In addition, the social worker must be cognizant of HMO policies regarding cost containment and their effect on PCP's referrals for expensive, specialized testing and how this negatively affects battered women.
Burg (1994) advised that domestic violence shelters have a unique opportunity to provide intervention and referral for diagnosis and remediation in terms of women's health care. This study is an initial inquiry into the prevalence of head trauma among a shelter population of battered women. Additional research is needed to determine the general prevalence of this phenomenon, the types of deficits that result, and how these deficits affect the woman, her children, and family life in general.
It should be noted that this initial study has several limitations. Neurological assessments and a standardized baseline (previous IQ testing or school records) were not used. This study was based solely on the resident's self-report of head injury, symptomatology, and function deficit along with social worker observation.
Future studies need to establish premorbid functioning and use formalized testing such as neurological assessment and standardized instruments that would determine cognitive deficits. In addition, comparison of a control group--that is, women who have experienced head trauma other than domestic violence--would enhance generalizability. Comparison of community samples of battered women who have experienced head trauma with domestic violence shelter samples also may yield significant data to enrich our understanding of this phenomenon.
Nonetheless, this study identified a 35 percent prevalence rate of battered women residing in a domestic violence shelter who had experienced head injury during a battering incident. It appears reasonable to conclude that head injury may be a pervasive dynamic in the continuing cycle of domestic violence, which has serious outcomes for women.
ABOUT THE AUTHORS
Kathleen Monahan, DSW, CSW, is assistant professor and director, Family Violence Education and Research, School of Social Welfare, Health Science Center, Level 2, and K. Dan O'Leary, PhD, is distinguished professor of psychology, Department of Psychology, State University of New York at Stony Brook, Stony Brook, NY 11794-8231. Preparation of this article was supported in part by NIMH grant no. PHS MH 19107-06 awarded to K. Dan O'Leary.
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Characteristics of Head Injury for Residents of a Domestic Violence Shelter (N = 9) Loss of Previous Resident Age Cause of Injury Consciousness Head Injury 1 44 Hit with broom No No handle 2 21 Run over by car No Yes 3 28 Closed fist; stabbed Yes No in head 4 33 Closed fist No No 5 20 Closed fist No Yes 6 23 Closed fist Yes No 7 28 Head slammed into Yes No car door 8 34 Closed fist No No 9 20 Closed fist Yes No Current Resident Symptoms 1 Headaches, severe Headaches Dizziness 2 Headaches, severe Headaches Dizziness 3 Headaches Dizziness Inability to fucus 4 None reported 5 None reported 6 Headaches, severe Headaches Dizziness Memory loss Seizures 7 Headaches Dizziness Memory loss 8 Headaches Dizziness Memory loss 9 Headaches Dizziness
NOTE: Three women reported that they were diagnosed with a concussion as a result of head injury received during battering incidents. One woman reported a stroke after head injury.
Comparison of Non-Head-Injured Battered Women and Head-Injured Battered Women Residents in a Domestic Violence Shelter (N = 26) Non-Head- Head-Injured Injured Women Women (n = 17) (n = 9) Variable n % n Current somatic complaint Headaches 1 6 7 Severe headaches 1 6 3 Dizziness 0 0 7 Seizures 0 0 1 Cognitive difficulty Confusion 3 18 2 Difficulty following directions 2 12 2 Difficulty retaining information 0 0 3 Difficulty concentrating 0 0 5 Inability to initiate self-directed behavior 3 18 7 Difficulty with abstract thinking 0 0 5 Memory loss 0 0 3 Mental fatigue 2 12 4 Judgment difficulty Difficulty with decision making 3 18 5 Inaccurate assessment of batterer lethality 5 29 4 Emotional difficulty Depressed mood 6 35 4 Irritability 4 24 9 Apathy 2 12 8 Agitation 2 12 7 Low frustration tolerance 2 12 6 Sleep difficulties 2 12 4 Behavior difficulty Difficulty with anger management 2 12 4 Fisher Exact Test, Variable % One Tailed Current somatic complaint Headaches 77 .0004 Severe headaches 33 .1039 Dizziness 77 .0001 Seizures 11 .3462 Cognitive difficulty Confusion 22 .5784 Difficulty following directions 22 .4314 Difficulty retaining information 33 .0323 Difficulty concentrating 55 .0019 Inability to initiate self-directed behavior 77 .0048 Difficulty with abstract thinking 55 .0019 Memory loss 33 .0323 Mental fatigue 44 .3654 Judgment difficulty Difficulty with decision making 55 .0626 Inaccurate assessment of batterer lethality 44 .3654 Emotional difficulty Depressed mood 44 .4828 Irritability 100 .0002 Apathy 88 .0002 Agitation 77 .0016 Low frustration tolerance 66 .0077 Sleep difficulties 44 .0841 Behavior difficulty Difficulty with anger management 44 .0841…