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Article
TRAUMA, VIOLENCE, & ABUSE
2014, Vol 15(1) 22-33
Bridging Intimate Partner Violence and The Author(s) 2013
Reprints and permission:
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the Human Brain: A Literature Review DOI: 10.1177/1524838013496333
tva.sagepub.com

Janet Yuen-Ha Wong1, Daniel Yee-Tak Fong1, Vincent Lai2, and

Agnes Tiwari1

Abstract
Past studies mainly focused on the physical and structural brain injuries in women survivors with a history of intimate partner
violence (IPV), but little attention has been given to the biological impact and cognitive dysfunction resulting from such psy-
chological stress. In this article, we aim to establish the connection between IPV and the brain by reviewing current literature
examining (1) the biological mechanisms linking IPV, stress, and the brain; (2) the functional and anatomical considerations of the
brain in abused women; and (3) the abused womens behavioral responses to IPV, including fear, pain, and emotion regulation, by
utilizing functional neuroimaging. The major significance of this study is in highlighting the need to advance beyond self-reports and
to obtain scientific evidence of the neurological impact and cognitive dysfunction in abused women with a history of IPV, an area in
which current literature remains at a descriptive level.

Keywords
intimate partner violence, psychological stress, human brain, neurological impact, functional neuroimaging

Background to the U.S. CDC, mild TBI (MTBI) is defined as traumatically

Intimate Partner Violence and Related Physical Injuries
Intimate partner violence (IPV) has been recognized as an
important human rights issue for many decades. It is also a glo-
bal public health problem, significantly contributing to the hid-
den costs in health care utilization. According to the Centers for
Disease Control and Preventions (CDC) Web-based Injury
Statistics Query and Reporting System, the direct medical care
cost of IPV against women was around US$4.2 billion in 2005.
In the United States, the total health care cost burden of IPV
against women within the first 12 months after victimization
ranged between $2.3 and $7.0 billion in 2003 (Brown, Finkel-
stein, & Mercy, 2008).
Physical injuries are among the most costly health condi-
tions in abused women, with more than 90% of all injuries
being found on the head, face, or neck regions (Dolezal,
McCollum, & Callahan, 2009; Monahan & OLeary, 1999;
Wu, Huff, & Bhandari, 2010). In particular, traumatic brain
injuries (TBI) have been examined in a significant number of
studies (Banks, 2007; Jackson, Philp, Nuttall, & Diller, 2002;
Kwako et al., 2011; Valera & Berenbaum, 2003). TBI can be
caused by external forces, such as blunt trauma to the face,
or during rapid acceleration and deceleration or rotation (see
Figure 1), resulting in neurological deficits, loss of conscious-
ness, brain damage, and even death (Thurman, Sniezek, John-
son, Greenspan, & Smith, 1995). The severity of TBI can be
categorized to be mild, moderate, and severe according to the
duration of unconsciousness and loss of memory. According
induced physiological disruption of brain function, as mani-
fested by at least one of the symptoms of loss of consciousness,
loss of memory, alteration in mental state, and neurological
deficit; loss of consciousness does not exceed 30 min, posttrau-
matic amnesia does not exceed 24 hr, and the Glasgow coma
scale is at least 13 after 30 min (National Center for Injury Pre-
vention and Control, 2003). MTBI is commonly reported in
abused women with a history of anoxic or hypoxic brain injury
from choking or attempted strangulation (Kwako et al., 2011;
Smith, Mills, & Taliaferro, 2001; Wilbur et al., 2001). Pro-
longed TBI or MTBI may cause devastating long-term conse-
quences. One of the consequences is postconcussive syndrome,
defined as the presence of three or more of the following symp-
toms: (1) headache, (2) dizziness, (3) fatigue, (4) irritability, (5)
insomnia, (6) difficulty in concentration, (7) memory difficulty,
and (8) intolerance of stress, emotion, or alcohol for more than
3 months (World Health Organization, 1992). In addition, other
1
School of Nursing, LKS Faculty of Medicine, The University of Hong Kong,
Hong Kong
2
Department of Diagnostic Radiology, The University of Hong Kong, Hong
Kong
Corresponding Author:
Janet Yuen-Ha Wong, School of Nursing, LKS Faculty of Medicine, The Uni-
versity of Hong Kong, 4/F, William M.W. Mong Block, 21 Sassoon Road,
Pokfulam, Hong Kong S.A.R.
Email: janetyh@hku.hk

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Wong et al.
Figure 1. A figure showing the mechanisms of accelerationdeceleration and rotational head injury.
studies have revealed the development of poor quality of life
(Marcel, 2004) and depression (Kreutzer, Seel, & Gourley,
2001) after TBI.
IPV and Related Psychological Stress
In addition to physical injuries, a significant portion of the
health care resource utilization is attributed to the chronic ill-
nesses of abused women, including chronic pain (Humphreys,
Cooper, & Miaskowski, 2011; Koopman et al., 2007; Wuest
et al., 2010), immune dysfunction (Inslicht et al., 2006),
inflammation, cardiovascular diseases, metabolic symptoms
(Kendall-Tackett, 2007), posttraumatic stress disorder (PTSD),
and depression (Golding, 1999; Mechanic, Weaver, & Resick,
2008). Indeed, some studies revealed that abused women may
have complaints of diminished cognitive abilities, difficulties
with memorization, and concentration problems. However, it
is unclear whether such cognitive dysfunction is directly
related to structural/physical brain injury or functional brain
damage as a consequence of psychological stress and trauma
exposure (Valera & Berenbaum, 2003).
The chronic nature of IPV has been recognized as a causa-
tive factor of psychological stress due to the fear of violent
attack or the actual experience of violence (Coker, Smith,
Bethea, King, & McKeown, 2000; Walker & Browne, 1985).
In fact, psychological stress may be further developed into
autonomic, hormonal, immunological, neurological, and neu-
ropsychological alterations relating to thoughts and feelings.
These alterations may lead to poor decision making about leav-
ing or staying in abusive relationships (Southwick, Rasmusson,
Barron, & Arnsten, 2005), as well as memorization and con-
centration problems (Roozendaal, McEwen, & Chattarji,
2009), behavioral responses to pain such as somatization , i.e.
bodily pain without a biological cause (Crofford, 2007; Fayed
et al., 2011), negative emotions or feelings, and even mental
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23
health disorders such as anxiety and depression (Drevets, Price,
& Furey, 2008).
Aim of the Review
This literature review aims to describe the connections among
IPV, neurophysiology, neurochemistry, and neuroanatomy by
reviewing the current literature on (1) the biological mechan-
isms linking IPV, stress, and the brain; (2) the functional and
anatomical considerations of the brain in abused women; and
(3) the abused womens behavioral responses to IPV, including
fear, pain, and emotion regulation, using functional neuroima-
ging studies.
The Physiological Mechanism Linking IPV,
Stress, and the Brain
The HypothalamicPituitaryAdrenal Axis
Figure 2 shows the hypothalamicpituitaryadrenal (HPA)
axis. This is a complex union consisting of the hypothalamus,
the pituitary gland, and the adrenal glands. In the physiological
regulation of our body, stressors trigger the sympathetic arousal
in the autonomic nervous system for the fight-or-flight
response to maintain homeostasis (Cannon, 1929). In response
to a threatening stimulation, the paraventricular nucleus (PVN)
of the hypothalamus excretes corticotropin-releasing hormone
(CRH), which stimulates the release of adrenocorticotropic
hormones (ACTH) from the anterior pituitary gland. This fur-
ther stimulates the adrenal cortex to release glucocorticoid hor-
mones, mainly cortisol, into the blood circulation. Cortisol is a
stress hormone that shuts down glucose metabolism, forcing
cells to operate on stored glycogen (i.e., gluconeogenesis).
Thus, cortisol mobilizes the energy from the storage site or
from nonessential organs to exercising muscles for the
24
Figure 2. The hypothalamicpituitaryadrenal (HPA) axis.
fight-or-flight response. However, prolonged stimulation
may cause either cell death or shutdown of the neurogenesis
processes in the amygdala and hippocampus because they are
recognized as nonessential brain regions during the fight-or-
flight response (Joels, Karst, Krugers, & Lucassen, 2007;
Warner-Schmidt & Duman, 2006).
The experience of IPV often induces chronic psychological
stress. While acute environmental stress would activate the
HPA axis, prolonged stress may result in HPA axis dysfunction
(Crofford, 2007; McEwen, 1998). Indeed, emerging evidence
has demonstrated that any history of abuse would be associated
with hyperreactivity of the HPA axis (Bremner et al., 2003;
Heim et al., 2000; Inslicht et al., 2006; Woods, 2005). The
effect has been found to be accumulative in women survivors
of IPV or childhood maltreatment (Heim et al., 2002; Shea,
Walsh, Macmillan, & Steiner, 2005).
The Relationship Between the HPA Axis and the
Functional and Anatomical Considerations of
Immune System
the Brain in Abused Women
Stress-induced cortisol, produced via the HPA axis, not only
protects the human body against the stressor but also protects
The Anatomical Structure of a Human Brain
against overreaction of the immune system by suppressing the
production of proinflammatory cytokines (Figure 2), such as
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TRAUMA, VIOLENCE, & ABUSE 15(1)
tumor necrosis factor-alpha, interleukin-1 (IL-1), and IL-6, as
well as Type I interferons-a/b; it also promotes the production
of IL-4, which is a kind of Th2 cytokine (Wong, 2002). Thus,
hyperactivity of the HPA axis in abused women, especially
those with chronic stress, should result in a high level of corti-
sol, leading to suppression of the immune system (Elzinga,
Schmahl, Vermetten, van Dyck, & Bremner, 2003). However,
the immunosuppressive effect of cortisol is still debatable.
Abused women with PTSD have been found to have higher
numbers of leukocytes and lymphocytes, which enhance their
immune responses (Woods, Wineman, et al., 2005). Moreover,
there is increasing evidence that cortisol should be more
accurately conceptualized as an immunomodulatory hormone,
rather than an immunosuppressive hormone (Silverman,
Pearce, Biron, & Miller, 2005).
Indeed, the relationship between HPA axis alterations and
the immune system is complex. For instance, cytokines have
also been found to have direct interactions at all HPA axis lev-
els, including the pituitary and adrenal glands, to stimulate the
production of glucocorticoids, ACTH, and CRH, which could
further explain the complexity of the HPA axis (Arzt et al.,
1999; Dallman et al., 2004).
Amygdala Involvement in the HPA Axis
The amygdala is a region in the brain located in the limbic sys-
tem, which is responsible for emotions. It is commonly activated
by fear and anxiety. The amygdala also plays a role in the HPA
axis. In response to a stressful or threatening condition, signals
are transmitted to the PVN of the hypothalamus. This results
in HPA axis activation, and hence enhances the release of CRH
and glucocorticoids, which activate the amygdala (Figure 2;
Aggleton, 1992; Weidenfeld, Newman, Itzik, Gur, & Feldman,
2002). Unlike other brain regions, the amygdala has glucocorti-
coid and mineralocorticoid receptors (de Kloet, 2000), indicating
that direct activation of the amygdala via elevated levels of glu-
cocorticoids results in chronic HPA axis alteration (Akana, Chu,
Soriano, & Dallman, 2001). In addition, many studies have
reported that the amygdala is substantially involved in regulating
stress effects on memory, so that individuals can remember the
stressful experience, which contributes to the long-term conse-
quences of anxiety if the individual is exposed to repeated stress
(McEwen, 2005; Roozendaal et al., 2009). The involvement of
the amygdala in the HPA axis helps explain why IPV-related
stress contributes to mental health problems, and it is also closely
linked to the thinking and emotional processes of abused women
(Heim, Ehlert, Hanker, & Hellhammer, 1998; Woods, Page,
et al., 2005).
Our brain is basically structured into four parts, namely the cer-
ebrum, cerebellum, limbic system, and brain stem (Figure 3).
Wong et al.
Anterior cingulate cortex (ACC)
Hypothalamus
Hippocampus
CEREBELLUM
BRAIN STEM
Figure 3. A figure showing the anatomical structure of a human brain.
The cerebrum consists of cortexes responsible for cognitive
and higher thinking skills. The cerebellum is similar to the cer-
ebrum in structure, but is smaller and is mainly responsible for
balance, coordination, posture, and movements. The limbic
system is often referred to as the emotional brain and com-
prises the thalamus, hypothalamus, amygdala, hippocampus,
anterior cingulate cortex (ACC), insula, and several nearby
areas. The brain stem, which is located underneath the limbic
system, is responsible for vital function control, such as breath-
ing, blood pressure, heart rate, sensation, and consciousness.
In the past, neuroscientists studied the human brain through
structural brain lesions or operations on brain-damaged
patients. Nowadays, advanced technology has enabled func-
tional and structural analysis of the brain using noninvasive
imaging modalities, including magnetic resonance imaging
(MRI), functional magnetic resonance imaging (fMRI), posi-
tron emission tomography (PET), and single-photon emission
computed tomography. Also, structural alterations or volu-
metric changes can be studied using region of interest analysis.
The following sections will first provide basic information
about the structure and functions of the hippocampus, amyg-
dala, ACC, and prefrontal cortex (PFC). Then, we will outline
some of their key anatomical alterations, which are highly sus-
ceptible to be found in women survivors of IPV.
Hippocampus
The hippocampus, which is a small seahorse-shaped structure
in the limbic system, is responsible for learning and memory,
including the encoding of context during fear conditioning
(Figure 3). Also, it releases stress-evoked CRH to stimulate
ACTH production (Chen et al., 2004; Stern, 2011). The hippo-
campus is sensitive and malleable (McEwen, 2007). Reduced
hippocampal volume has been shown to have a positive corre-
lation with memory impairment (Bremner, 1999; Ystad et al.,
2009), executive dysfunction (Frodl et al., 2006), more severe
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25
CEREBRUM Prefrontal cortex (PFC)
Amygdala
depressive symptoms (Kiy et al., 2011), and poor treatment
response in depression (Frodl et al., 2008).
Many neuroimaging studies have found a reduced hippocam-
pal volume in trauma-exposed individuals, with or without
PTSD, when compared with healthy controls who have not been
exposed to trauma (Karl et al., 2006; Smith, 2005; Woon, Sood,
& Hedges, 2010). However, all these studies included both par-
ticipants who had experienced abuse-related trauma, and also
those who had been exposed to other trauma, such as wars, com-
bat, accidents, and disasters. Neuroimaging studies conducted
in abused women showed no significant difference in the
hippocampal volume between abused and nonabused women
(Fennema-Notestine, Stein, Kennedy, Archibald, & Jernigan,
2002; Flegar et al., 2011), rendering the findings on the effect
of IPV on womens hippocampal volume inconclusive. There
are two explanations for such inconsistent findings. First, comor-
bid conditions, such as depression and alcohol dependence, may
affect the results of hippocampal pathology (Davidson, Pizza-
galli, Nitschke, & Putnam, 2002; Hedges & Woon, 2010; Shin,
Rauch, & Pitman, 2006). From the demographical data of both
Fennema-Notestine, Stein, Kennedy, Archibald, and Jernigan
(2002) and Flegar et al.s (2011) studies, abused women had
more depressive symptoms than nonabused women. Also,
abused women in Flegar et al.s study were recruited from a pro-
gram to change drinking behavior and thus were highly alcohol-
dependent. Another potential explanation is related to the meth-
odological considerations. As the age at which traumatic stress is
encountered and aging might both contribute to hippocampal
atrophy, data analysis with adjustment for age and timing of the
traumatic stress is important (Bremner & Narayan, 1998;
Resnick, Pham, Kraut, Zonderman, & Davatzikos, 2003). How-
ever, neither Fennema-Notestine et al. nor Flegar et al.s study
conducted their data analysis with adjustment for age. Perhaps
replicating the studies with assessment and data adjustment for
age, as well as other potential confounding factors such as drink-
ing habits and depression, is necessary to verify the impact of
IPV on hippocampal volume.
26 TRAUMA, VIOLENCE, & ABUSE 15(1)

Amygdala showing that the ACC has separate cognitive and affective
divisions to handle both cognitive and emotional processing
The amygdala interacts with the hippocampus and PFC in
(Bush, Luu, & Posner, 2000). Any structural alteration or dys-
responses to emotions and feelings (Aggleton, 1992). It is also
function of the ACC may potentially affect an individuals
involved in the process of memory encoding, consolidation,
emotional self-control and problem-solving capacity (Allman,
storage, and retrieval at various stages of information process-
Hakeem, Erwin, Nimchinsky, & Hof, 2001).
ing (Phelps, 2004). The memorized emotional reactions can
Many studies have reported a significant reduction in the
thus be retrieved for future use (LaBar & Cabeza, 2006; Phelps,
ACC volume of PTSD individuals who had been victims of the
2004; Richardson, Strange, & Dolan, 2004). When there is
subway sarin attack (Araki et al., 2005) or had been involved in
stress, the amygdala triggers the release of stress hormones
combat (Rauch et al., 2003; Woodward et al., 2006). Using
through the HPA axis, which enhances memory consolidation
volumetric analyses and the technology of voxel-based mor-
for stressful conditions (LaBar & Cabeza, 2006). In addition,
phometry, it was found that acute PTSD individuals had no sig-
in the situation of conditioned fear, the amygdala plays a vital
nificant volumetric differences but significant shape
role in mediating the states of increased arousal as well as phy-
differences in the ACC when compared with normal individu-
siologic and behavioral fear responses (LeDoux, 2000).
als (Corbo, Clement, Armony, Pruessner, & Brunet, 2005).
IPV is known to be strongly associated with prolonged and
Moreover, diminished volume of the dorsal ACC (dACC) has
repeated stress, PTSD, and depression (Golding, 1999). These
been consistently found to be associated with emotion dysregu-
emotions and feelings have a suspected link to functional or
lation (Giuliani, Drabant, & Gross, 2011), depression, anxiety,
anatomical changes in the amygdala. In the 1990s, volumetric
and panic disorders (Asami et al., 2008; van Tol et al., 2010).
change in the amygdala was found to be rare in humans, except
However, there remains insufficient evidence regarding the
in those who had operations due to epilepsy or behavioral dis-
effects of IPV, through both physical and psychological path-
turbances (Aggleton, 2000). Indeed, this fits with the recent
ways, on the ACC volume.
evidence that there is no significant difference of amygdala
volume in individuals with PTSD (Woon & Hedges, 2009) or
depression (Hamilton, Siemer, & Gotlib, 2008), or in those PFC
experiencing stressful conditions (Holzel et al., 2010). Never-
The PFC is the most anterior part of the brain (Figure 3) and is
theless, chronic and repeated stress was found to produce den-
responsible for executive and cognitive functions, such as per-
dritic growth in amygdala neurons, the basic cellular unit of the
ception, judgment, reasoning, problem solving, and choice
brain (Vyas, Mitra, Rao, & Chattarji, 2002). This indicates the
making (Roberts, Robbins, & Weiskrantz, 1998). Unlike the
silent anatomical alteration in the amygdala during stress. Also,
autonomic responses, the PFC performs complex top down
it explains the hypersensitivity of the amygdala demonstrated
processing by mapping between sensory stimuli and thoughts
by functional neuroimaging studies in individuals who have
to yield corresponding responses (Miller & Cohen, 2001).
experienced different types of trauma (Bryant et al., 2008;
Therefore, any damage to the PFC can result in impairment
Fonzo et al., 2010).
of various kinds of cognitive functioning and behavioral
Unfortunately, no study has compared the anatomical
responses. Indeed, there has been evidence showing that pre-
changes in the amygdala between abused women and nona-
frontal damage resulted in defective social and moral reasoning
bused women. Thus, there is still inadequate understanding
(Anderson, Bechara, Damasio, Tranel, & Damasio, 1999) as
of the anatomical changes of the amygdala in abused women.
well as moral judgments (Koenigs et al., 2007).
Nevertheless, the work of Vyas, Mitra, Rao, and Chattarji
Many interventions and rehabilitations of abused women
(2002) has shown that there may not be volumetric changes
comprise an empowerment or educational component to help
in the amygdala in abused women, but there may be cellular
the women to manage the abusive relationship (Wathen &
level changes. It is crucial to set up a research hypothesis to
MacMillan, 2003). PFC damage may result in executive and
understand the impact of IPV on the structure of the amygdala
cognitive dysfunction and significantly diminish the effective-
at both the brain region level and the cellular level.
ness of interventions or rehabilitations for abused women. The
damage may be assessed by the volume of gray matter in the
PFC region, and neuroimaging studies have revealed a reduc-
ACC tion in gray matter volume in the PFC region in abused women
The ACC is located at the frontal part of the cingulate cortex, with PTSD (Fennema-Notestine et al., 2002). As the PFC is
which is anatomically connected to the PFC at the dorsal part, responsible for executive and cognitive functions, these abused
and also to the amygdala, hypothalamus, and anterior insula at women may have an impaired ability to make decisions when it
the ventral part (Figure 3). The ACC is particularly important comes to choosing between leaving and staying in the abusive
in conflict monitoring and error processing among the brain relationships. Fennema-Notestine et al.s (2002) study, how-
regions (van Veen, Cohen, Botvinick, Stenger, & Carter, ever, focused on a specific group of abused women with PTSD.
2001). It calls for further processing to the PFC to guide beha- Further studies are recommended to test for the association
vioral responses and decision making. The ACC is also between PFC volume and the planning and decision making
involved in emotions. There has been substantial evidence of abused women in general.

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Wong et al.
The frontal lobe of the brain was found to be one of the most
affected structural regions in abused women with TBI (Ken-
nedy et al., 2007), which often involves damage to the PFC due
to the shearing or tearing of brain tissue and neuronal damage
in the frontal regions against the inner skull (Bryant, 2008).
However, almost none of the current neuroimaging studies con-
ducted in abused women have measured the presence of head
injury or TBI.
Does IPV Alter the Neuroanatomy of Abused Women?
In summary, our review has identified three main themes in
regard to the functional and anatomical alteration of abused
women. The first theme is the scarcity of research on the altera-
tions in brain anatomy in abused women. Most work was con-
ducted on PTSD or depressed survivors. Hence, it is unclear
whether the identified anatomical alterations were due to the
IPV exposure or the sequelae of IPV exposure via PTSD or
depression. The second theme depicts the uncertainty about the
anatomical alterations in abused women as a result of psycho-
logical stress, physical brain injury, or both. In particular, the
reviewed studies did not report whether the abused women had
experienced head injury or TBI, making it difficult to assess the
impact of brain injury on anatomical alterations in abused
women. Further research should measure the types of abuse
and the presence of brain injury. The third theme relates to the
doseresponse relationship. None of the above studies reported
the duration of abuse, which is essential for understanding the
long-term effect of IPV on the human brain. Future studies
should measure the duration of abuse, so that the impact of IPV
on the anatomy of the brain can be analyzed in accordance with
different levels of IPV exposure in abused women.
Understanding Behavioral Responses of
Abused Women Using Functional
Neuroimaging
The development of noninvasive fMRI using the blood oxygen
level dependent (BOLD) technique has provided an effective
and safe means to study human brain activity. The BOLD tech-
nique indirectly measures brain activity by detecting the
change of oxygen concentration in the blood. Specifically, a
protein molecule in red blood cells, called hemoglobin, is
responsible for transferring oxygen from the lungs to other
organs, including the brain. Due to its iron-containing structure,
hemoglobin can be magnetized. The BOLD technique makes
use of the fact that the magnetic field of hemoglobin varies with
the degree of oxygen saturation. If the hemoglobin is highly
saturated with oxygen (oxyhemoglobin), it becomes a diamag-
netic substance (weakly repulses a magnetic field); whereas, if
oxygen has been used up (deoxyhemoglobin), it becomes para-
magnetic (attracts and distorts a magnetic field). Once a specific
part of eloquent cortex is activated, there will be an increase in
local cerebral blood flow which causes a reduction in deoxyhe-
moglobin concentration in the activated cortex. As deoxyhemo-
globin is paramagnetic, the decrease in deoxyhemoglobin
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27
concentration leads to changes in magnetic susceptibility. The
BOLD signals are then generated according to the degree of
reduced deoxyhemoglobin concentration in the activated area
of eloquent cortex, which provides an indirect measure of brain
activity (Harris, Reynell, & Attwell, 2011; Savoy, 2001). The
BOLD signal will be stronger with a higher degree of activation.
In fMRI studies, neuroscientists often use specific stimuli,
such as pictures, tone, colors, light, scripts, video, pain, or tem-
perature to test their research hypothesis. Many fMRI studies
are beginning to show consistent findings in functional activa-
tion and deactivation of certain areas of eloquent cortex, such
as the limbic structures, in abused women. The following sec-
tion summarizes the pattern and distribution of activated elo-
quent cortex in the brain, and how they may lead to certain
behavioral responses, in particular the fear response, pain
response, and emotion regulation, which are often found in
abused women suffering from IPV.
Fear Response
Fear has been consistently reported by women experiencing
IPV, and it has been found to be associated with the severity
and frequency of IPV (Kernsmith, 2006; Van Hightower, Gor-
ton, & DeMoss, 2000). In addition, for those abused women
who experienced forced sex, the fear level may be even higher
(DeMaris & Swinford, 1996). Ross (2012) summarized the
findings of 10 existing IPV research studies that evaluated fear.
The majority of them (7 of the 10) used a single item with a
Likert-type scale to quantify fear (Capaldi & Owen, 2001;
DeMaris & Swinford, 1996; Follingstad, Wright, Lloyd, &
Sebastian, 1991; Graham-Kevan & Archer, 2005; Kernsmith,
2006; Olson et al., 2008; Van Hightower et al., 2000), while the
remainder (3 of the 10; Fergusson, Horwood, & Ridder, 2005;
Hamberger & Guse, 2002, 2005) used multiple items to quan-
tify fear. However, none of them used a validated measurement
tool to evaluate fear, making the findings noncomparable
among the studies.
Our brain can learn to manage fear, a process known as fear
conditioning. Fear conditioning is a conditioned fear response
induced by linking certain objects/situations to unrelated
objects/situations. This is vital for the detection of danger,
self-protection, and survival. However, a hyperresponsive per-
son may be misguided by the fear conditioning and has unne-
cessary fear responses eventually leading to anxiety disorder,
panic disorder, or PTSD. For example, there is a notable asso-
ciation between fear conditioning and anxiety in children with
early childhood adversity (Anda et al., 2006; Grillon & Mor-
gan, 1999; LeDoux & Phelps, 2008; Pine, 1999).
There is an expanding body of evidence of hyperresponsive
limbic structures in women with a history of abuse or PTSD.
Using threat-related emotional face stimuli, two fMRI studies
found that abused women with PTSD had significantly ele-
vated activation in the left anterior insula, amygdala, and
dACC during matching of fearful versus happy faces, when
compared to women in the control group (Bryant et al., 2008;
Fonzo et al., 2010). A similar pattern resulted when matching
28 TRAUMA, VIOLENCE, & ABUSE 15(1)

of angry versus happy faces was performed (Fonzo et al., Emotion Regulation
2010). These results demonstrated that abused women with
Depression and anxiety are both common mental health disor-
PTSD had hyperresponsiveness in the anterior insula, amyg-
ders in abused women (Golding, 1999; Pico-Alfonso et al.,
dala, and dACC. Therefore, the fearful faces, which were orig-
2006), and they are widely considered to be the consequences
inally a nonspecific stimulus of threat, triggered strong
of emotion dysregulation (Berking & Wupperman, 2012). Emo-
activation of the limbic system. Another significant finding
tion dysregulation refers to the loss of control of emotions, which
of Fonzos study was that there was significantly greater acti-
includes decreasing, maintaining, or increasing positive/negative
vation of the dACC in the abused group with PTSD when com-
emotional reactions (Gross, 2002). Therefore, a good under-
paring male faces with female faces. The authors suggested that
standing of emotion regulation is highly relevant to the develop-
the hyperactivity of the dACC while matching male faces
ment of interventions for reducing depression and anxiety. A
might reflect hypervigilance, a core symptom of PTSD, due
recent meta-analysis investigated the relationships between six
to the dysregulated appraisal of the stimulus related to past
emotion regulation strategies (acceptance, avoidance, problem
trauma (Bryant et al., 2008). Both fMRI studies clearly showed
solving, reappraisal, rumination, and suppression) and mental
that abused women learned fear from their IPV experience. The
health problems (depression, anxiety, eating disorders, and sub-
fear response to fearful faces was unconscious, which helped in
stance abuse; Aldao, Nolen-Hoeksema, & Schweizer, 2010).
explaining why women can develop hyperactivation of danger
Rumination was found to be highly associated with poor mental
perception in the emotion-related circuitry of the brain after
health, while avoidance and suppression had a moderate associ-
being abused.
ation with poor mental health. Problem solving was found to
have a moderate to high association with good mental health,
Pain Response while reappraisal was noted to have a moderate to low associa-
tion with good mental health. Unexpectedly, acceptance, which
Pain is associated with more health care utilization (Plichta,
has been long perceived as one of the methods for healing
2004; Wong, Wester, Mol, Romkens, & Lagro-Janssen,
depression, was not observed to be significantly associated with
2007). Chronic pain is often reported in abused women (Hum-
mental health. These relationship patterns provided relevant
phreys et al., 2011; Kendall-Tackett, Marshall, & Ness, 2003;
information about emotion regulation strategies in the preven-
Wuest et al., 2010). This can be chronic low back pain, chronic
tion or treatment of mental health problems. However, the
headache (Humphreys et al., 2011), chronic pelvic pain (Tho-
cross-sectional nature of this study and the subjective self-
mas, Moss-Morris, & Faquhar, 2006), or fibromyalgia (Rubin,
assessment of emotion regulation were the major limitations.
2005).
Neuroimaging studies, on the contrary, examined emotion
Pain response in abused women has not yet been clearly
regulation in a more objective domain. For instance, deficits
explained using neuroimaging studies. Only two fMRI studies
of ACC function were determined by both an fMRI study (New
investigated the pain response of women with a history of
et al., 2009) and a PET study (Bremner et al., 2004) in women
abuse. Noll-Hussong et al. (2010) performed a pilot study on
with a history of sexual abuse. The ACC is responsible for
women suffering from chronic pain with or without a history
emotion regulation. Both studies found that there was less acti-
of childhood sexual abuse. By viewing 120 pictures with four
vation in the ACC during downregulation of emotions to a neg-
levels of pain (no, low, medium, and high pain), the partici-
ative stimulus in abused women compared with healthy
pants were instructed to rate the pain intensity during fMRI
controls. Therefore, it is suggested that IPV may impede
scanning. Women who were sexually abused during their child-
womens ability to decrease emotional responses to negative
hood were found to have higher activation in the left medial
stimuli.
and lateral PFC than women without a history of childhood
A cognitive emotional regulation strategy was found to be
sexual abuse. Given the involvement in memory retrieval of the
helpful for women to regulate their emotions in an fMRI study
left frontal areas, the study concluded that sexually abused
when women were shown threat-related and neutral pictures
women were much more sensitive in their response to pain.
(Eippert et al., 2007). The findings showed that the activation
In contrast, another fMRI study did not show higher activation
of the amygdala, which is known to be involved in the response
of the brain regions related to pain in response to experimental
to a threat-related picture, diminished when the participants
pain perception (i.e., nonpainful temperatures, slightly painful
were asked to downregulate emotions. In contrast, the frontal
temperatures, and moderately painful temperatures) in abused
regions, including the ACC, dorsal PFC, and orbitofrontal cor-
women (Strigo et al., 2010). Instead, with repeated exposure
tex, were much more reactive, when compared with the base-
to painful temperatures, abused women experienced a reduced
line. In other words, the emotional responses in the amygdala
subjective pain intensity compared with nonabused women.
were susceptible to top-down control from the frontal region.
The authors explained the findings in terms of avoidance,
These results indicated the potential effective use of cognitive
which is a PTSD symptom. However, this argument cannot
strategies in emotion regulation as a treatment for mental health
explain the experience of chronic pain in abused women. It
problems. However, the study did not measure the abuse his-
may be that the pain experienced by abused women is psycho-
tory of the participants, making the results inconclusive in
somatic or social, which is different from the physical pain
abused women.
tested in Strigo et al.s (2010) experimental fMRI study.

Downloaded from tva.sagepub.com at University of Hong Kong Libraries on December 14, 2014
Wong et al.
To our knowledge, no study to date has investigated the
effectiveness of different coping strategies in abused women
to regulate emotions using an fMRI study. However, it is likely
that the interplay between the affective and cognitive division
of the brain underlies the emotion regulation in women experi-
encing IPV. It is recommended, specifically, that future studies
should assess the emotion regulation strategies and enable the
comparison of ACC and amygdala activation or deactivation
among IPV survivors using different emotion regulation strate-
gies by advanced neuroimaging studies. The findings are
expected to be helpful in developing interventions to improve
abused womens mental health outcomes.
Implications for Research, Practice,
and Policy
 Research on neurological damage and neuropsychologi-
cal damage in women survivors of IPV is seriously lack-
ing. Existing studies mainly focused on the target
population of women with PTSD. However, there is a
possibility that abused women might suffer from neuro-
physiological changes associated with cognitive dys-
function but without PTSD symptoms.
 Research on the impact of IPV on abused women, such
as depression, anxiety, poor memory, and inability in
decision making remains at a descriptive level. Current
studies are still unable to explain why some abused
women develop mental health problems, while some
do not. Therefore, future research should aim to gain sci-
entific evidence for the explanations of these phenom-
ena through neuroimaging studies.
 Through the evidence of neuroimaging studies, we can
further understand the neurological damage in abused
women. This can provide relevant information to
develop efficient and cost-effective interventions for
women survivors of IPV.
 Health care professionals or case workers of IPV victims
should receive training about brain function and assess-
ment of neurological functioning, and acquire the skills
of caring for women with neurological or neuropsycholo-
gical damage.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biographies
Janet Yuen-Ha Wong, RN, PhD, is an assistant professor at the
School of Nursing of the University of Hong Kong. She received her
PhD at the University of Hong Kong. Her principal research interest
lies in intimate partner violence and physical, psychological, and cog-
nitive well-being of abused women. During her PhD study, she had
been awarded Fulbright visiting scholarship (20102011) affiliated
with University of Virginia in the United States.
Daniel Yee-Tak Fong, PhD, is an associate professor at the School of
Nursing of The University of Hong Kong. He received his degrees of
BSc in mathematics and MPhil in statistics from The University of
Hong Kong. He then obtained his PhD in statistics from the University
of Waterloo, Canada. He is an experienced biostatistician in health
research. Specifically, he focuses on the application of the best avail-
able methods to scientific research in health-related fields, and to
develop novel methodologies with applications in health research.
Vincent Lai, MBChB (CUHK), FRCR (UK), FHKCR, FHKAM (Radi-
ology), is currently a clinical assistant professor at the Department of
Diagnostic Radiology of The University of Hong Kong. He obtained his
medical degree from the Chinese University of Hong Kong and became
the Fellow of the Hong Kong Academy of Medicine in 2010. He was
awarded the Rohan Williams Medal in the Royal College of Radiologists
examination. He is a specialist neuroradiologists with main research
interest in neuroradiology with use of advanced MR imaging techniques.
Agnes Tiwari, RN, PhD, FAAN, is a professor and head of School of
Nursing at the University of Hong Kong. She is internationally recog-
nized for her work on interpersonal violence prevention and interven-
tion including the validation of the Chinese Abuse Assessment Screen
and several clinical trials of violence prevention models at primary,
secondary, and tertiary levels.