Neuropsychological deficit sequelae following domestic violence as precursor to suicide attempt by hanging

Dear Editor,

Suicide is a major public health concern. According to the World Health Organization’s 2017 update on suicide prevention, over 800,000 individuals die by suicide worldwide each year.[1] Suicide by hanging is a common method of suicide in adults.[2] Suicide attempts are up to 20 times more common than actual suicides, and India accounts for roughly 30-40% of all suicides worldwide. Domestic and intimate relationship violence is common, accounting for 6.1% of all suicides and suicidal attempts, and limited research explores its impact on neurocognitive deficits and consequences.[3] Hanging injuries can harm the brain and cognition based on duration, weight, ligature location, and pressure. Damage to brain regions can lead to cognitive, behavioral, and psychological problems.

A 23-year-old woman had good academic performance with a well-adjusted premorbid personality, except for occasional anger outbursts. For the past three years, she has been involved in romantic relationships that eventually led to her parents agreeing to her marriage. However, her partner started expressing concerns about her family’s financial support for their wedding, to which her parents disagreed. In February 2023, Patient X married, and then, her partner frequently argued with her about financial matters. Eight days after their wedding, Patient X was found hanging from a ceiling fan in her husband’s home. This prompted her husband and other family members to take her to a local hospital. Following a 16-day hospitalization, Patient X was diagnosed with hypoxic-ischemic encephalopathy. Since her condition did not improve, her parents transferred her to a tertiary hospital. To assess her cognitive impairments resulting from the incident, the NIMHANS Neuropsychological Battery[4] was administered. The results of the neuropsychological evaluations, as shown in Table 1, revealed impairments in attention, mental processing speed, phonic fluency, working and verbal memory, response inhibition, learning, and information processing.

Table 1.

Neuropsychological evaluation findings

Test	Functions	Interpretation	Percentile
Digit Symbol Substitution Test	Mental Speed	Impaired	<3
Color Trials 1 and 2	Focused Attention	Impaired	<3
Digit Vigilance Test	Sustained Attention	Impaired	<5
Controlled Oral Word Association Test	Verbal fluency	Impaired	<5
Animals Names Test	Category fluency	Impaired	<5
Verbal N Back Test	Working memory	Impaired	<5
Digit Span Test	Verbal working memory	Impaired	<5
Spatial Span Test	Visual working memory	Impaired	<5
Stroop Test	Response Inhibition	Impaired	<5
Rey’s Auditory Verbal Learning Test	Verbal learning and memory	Impaired	<15

Patient X experienced cognitive and emotional issues resulting from an ischemic insult caused by post-hypoxic-ischemic encephalopathy, an acquired metabolic condition that leads to reduced blood flow in the brain. The presence of ligature and ventilator disruptions further contributed to cognitive irregularities in the patient. Patient X had a normal cognitive function before the incident, but the deficiencies observed afterward are likely a consequence of the hanging trauma. Survivors of hanging attempts may encounter various neuropsychiatric problems, language difficulties, and neuropsychological impairments. Research has indicated that the severity of the injury, irrespective of the duration of hanging, is closely associated with post-acute cognitive impairment. Specifically, damage to the hippocampal cortex has been identified as a critical factor affecting memory processes and structures.[5] Patient X presented deficits across all cognitive domains, indicating an overall neuropsychological dysfunction, as well as speech and comprehension issues, movement challenges, and neuropathic discomfort. An integrated intervention approach was adopted to address her challenges effectively, with each intervention unit targeting specific problems. The therapist provided a secure space for Patient X to express her emotions during the intervention and focused on inspiring optimism and motivation regarding her concerns. Additionally, the therapist addressed the patient’s anxiety, low mood, and irritability, likely exacerbated by domestic violence. Over four weeks of continuous cognitive remediation sessions, significant improvements were observed in the trained cognitive domains, including attention, processing speed, working memory, visual memory, and verbal memory.

Domestic violence has been established as a significant risk factor for suicide, leading to potential long-term cognitive impairment. The impact of hanging trauma on survivors can result in long-lasting deficits throughout their lives. Consequently, there is an urgent need for neuropsychologists and mental health experts to prioritize the assessment and management of such cases, ensuring prompt and effective intervention to address the associated challenges.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.