The Polytrauma Clinical Triad Among Women with a History of Intimate Partner Violence

Abstract

Women with a history of intimate partner violence (IPV) are at risk for traumatic brain injury (TBI) with persistent neurobehavioral symptoms, post-traumatic stress disorder (PTSD), and chronic pain, which, together, characterize the polytrauma clinical triad. Among predominantly male Veteran samples, research has suggested that the triad may exacerbate health problems, compared with the presence of any component of the triad alone. The current study is the first to explore the polytrauma clinical triad among a sample of cisgender women who have experienced IPV (N = 198; M = 39.6 years old, SD = 11.9; 83.3% White, 7.1% Hispanic; 59.1% college-educated). Compared with participants without TBI history, participants with IPV-related TBI had higher rates of chronic pain (43.8% vs. 29.0%, p = 0.045, odds ratio [OR] = 1.87 [95% confidence interval: 1.01, 3.43]), PTSD with chronic pain (19.0% vs. 6.5%, p = 0.009, OR = 3.84 [1.41, 10.46]), neurobehavioral symptoms with chronic pain (40.0% vs. 22.6%, p = 0.030, OR = 2.01 [1.07, 3.79]), and the polytrauma clinical triad (19.0% vs. 6.5%, p = 0.009, OR = 3.84 [1.41, 10.46]), after adjusting for age and education. After controlling for IPV severity, however, there were no statistically significant group differences, suggesting that IPV severity may be closely linked to both risk of TBI and elevated symptomatology associated with the polytrauma clinical triad. Additionally, as the number of lifetime TBIs increased, the odds of having chronic pain (p = 0.011, OR = 1.17 [1.04, 1.33]) and chronic pain with concurrent neurobehavioral symptoms (p = 0.007, OR = 1.05 [1.05, 1.34]) also increased. These findings suggest that, especially when comorbid with IPV-related TBI, chronic pain may be a priority treatment target among individuals with a history of IPV. Considering that women with a history of IPV often experience concurrent health conditions, multicomponent interventions that address each condition within the polytrauma clinical triad may benefit this population.

The polytrauma clinical triad describes the co-occurrence of traumatic brain injury (TBI) with persistent neurobehavioral symptoms (i.e., physical, cognitive, or emotional problems lasting at least 3 months post-TBI), post-traumatic stress disorder (PTSD), and chronic pain.¹ These conditions, in tandem, may have a synergistic effect, resulting in magnified cognitive, physical, and behavioral problems.² Researchers have predominantly studied the frequency of the polytrauma clinical triad among U.S. Veterans,^1,3 finding that Veterans who experienced the polytrauma clinical triad had greater suicide and violence risk,⁴ challenges accessing health and disability services,⁵ and sleep disturbance.¹ The polytrauma clinical triad has also been observed in civilian patients at a pain clinic who reported significantly worsened pain, headaches, and sleep quality following a motor vehicle collision.⁶ Notably, prior studies on the polytrauma clinical triad have involved predominantly male samples, ranging from 54% to 94% male.^{3
–5,7

–12}

In contrast to the earliest study on the polytrauma clinical triad,¹ which included persistent neurobehavioral symptoms as a polytrauma clinical triad criterion, other researchers have exclusively used TBI history as a criterion.^{3,4,7

–12} Notably, individuals without a lifetime history of TBI may also experience neurobehavioral symptoms. Neurobehavioral symptoms are non-specific (e.g., difficulties concentrating, headaches, and irritability), can occur due to a myriad of conditions other than TBI,^13
–15 and are present at greater severity among women.¹⁶ Compared with men, women—including Veterans, athletes, and emergency department, trauma center, and concussion clinic patients—have been more likely to report neurobehavioral symptoms at greater severity levels across multiple symptom domains after sustaining a TBI.^{17

–24} Across care settings, women frequently reported higher prevalence and severity of neurobehavioral symptoms, including headaches,^19,20,25 light and noise sensitivity,^20,25 poor coordination and clumsiness,^19
–21 nausea,^19,20 fatigue,^19
–21 difficulties with concentration,¹⁹ and slowed thinking.²¹ In addition to physical and cognitive problems, female Veterans and Servicemembers also presented with more severe emotional symptoms, including post-traumatic stress symptoms,¹⁹ depressed mood,^19,22 and anxiety.²¹

Women remain underrepresented in TBI research^26,27 despite experiencing potentially worse outcomes following TBI.²⁸ One contextual mechanism of TBI, intimate partner violence (IPV), which includes contact sexual violence and physical violence by an intimate partner, such as a current or former romantic or sexual partner,²⁹ disproportionately affects women.^18,30,31 Unlike the amount of research on outcomes of other TBI mechanisms, relatively fewer studies have examined the sequelae of IPV-related TBI. Approximately one in two women (i.e., 47.3%) in the United States have experienced physical or sexual IPV or stalking in their lifetime.²⁹ Estimated lifetime TBI prevalence among samples of individuals who experienced IPV varies widely (i.e., 28–100%), with 31–75% of individuals reporting repetitive TBI involving alteration of consciousness.³² IPV-related head and brain injuries have been associated with greater cognitive (e.g., trouble remembering, concentrating, and solving problems), physical (e.g., headache, sensory problems, imbalance, and sleep difficulties), and emotional symptom severity (e.g., irritability, anxiousness, and depressed mood).^33

–39 Moreover, researchers have found an association between IPV-related TBI and increased risk for pain^40,41 and mental health conditions, including PTSD.^{40,42

–47}

Whereas researchers have looked at TBI, PTSD, and pain separately in relation to IPV exposure,^32,48,49 no studies to date have examined the polytrauma clinical triad among women with a history of IPV, although IPV-related TBIs have been associated with PTSD,⁵⁰ pain,⁴⁸ and worse neurobehavioral symptoms.^36,37 The present study examined the rates of neurobehavioral symptoms, PTSD, and chronic pain among two groups of women who have experienced IPV: women without a lifetime history of TBIs and women with a history of at least one IPV-related TBI. Given the non-specificity of neurobehavioral symptoms,^51,52 individuals with a history of IPV may experience these symptoms even in the absence of IPV-related TBIs⁵³ due to chronic exposure to trauma. IPV-related TBIs, however, may further increase the likelihood of co-occurring neurobehavioral symptoms, PTSD, and chronic pain among women. Study results may provide researchers and clinicians with evidence for concurrently targeting neurobehavioral symptoms, PTSD, and pain symptoms during interventions for women with a history of IPV, especially those who screen positive for IPV-related TBI.

Method

Participants

Using a retrospective cohort design, the current study used a dataset previously collected from Prolific (www.prolific.com), an online recruitment platform for anonymous research participation.⁵³ This dataset included study participants recruited from the Prolific participant pool, which included 120,140 participants at the time of recruitment. The participant pool was initially filtered by age (i.e., 18–64 years old), sex (i.e., assigned female at birth), gender (i.e., identified as women), language (i.e., fluent in English), current residency (i.e., United States), and head injury history (i.e., “Have you ever had an injury to the head that’s caused you to be knocked out and/or dazed and confused for a period of time?”). These filters resulted in samples of cisgender women participants aged 18–64 years who reported prior head injury (n = 3,562) or did not report prior head injury (n = 10,783), all of whom were eligible to complete the study screener. Participants who completed the screener (n = 1,240) indicated whether they experienced IPV and experienced a head injury due to IPV. Among the screened participants, 384 were eligible, based on self-report of IPV history without brain injury history, and 308 completed the full study. Participants who completed the full study were then excluded based on the following criteria: (1) reported no IPV history (n = 3); (2) were missing data due to data collection error (n = 3); (3) failed any of the attention checks (n = 14); (4) inconsistently reported age (n = 3); (5) reported more IPV-related head or hypoxic-ischemic injury exposures (e.g., non-fatal strangulation) than total injury exposures (n = 19); (6) reported more alteration of consciousness or loss of consciousness episodes than head or hypoxic-ischemic exposures (n = 6); (7) reported only non-IPV-related head or hypoxic-ischemic injuries (n = 34); (8) reported head or hypoxic-ischemic injury within 3 months of study participation (n = 4); (9) reported a neurological disorder or history of brain surgery (n = 15); (10) exceeded the Neurobehavioral Symptom Inventory (NSI) Validity-10 cutoff for potential symptom overreporting⁵⁴ (n = 2); or (11) reported only hypoxic-ischemic brain injuries without co-occurring TBIs (n = 7). The final sample (n = 198) included 93 women with a history of IPV, but no lifetime TBI history, and 105 women with IPV-related TBI history. Participants with IPV-related TBI history reported at least 1 IPV-related TBI but could also report a history of non-IPV TBIs.

Materials

Brain Injury History Questionnaire

Participants responded to a self-report questionnaire applied in prior research⁵³ and based on previous measures developed for brain injury research among women who experienced IPV.^37,55 The questionnaire inquired about lifetime head injuries, injury mechanism (i.e., motor vehicle accident, bicycle crash, other vehicle crash, assault, falling, violently shaken, or another cause), whether the head injury was due to an intimate partner, and time since injury (i.e., in relationship to the most recent blow to the head, such as a TBI: <3 months ago, 3–5 months ago, 6–12 months ago, and >1 year ago). The questionnaire also asked about potential hypoxic-ischemic brain injuries due to non-fatal strangulation, being nearly drowned, being smothered, or another situation involving restricted breathing.

Participants were asked whether injuries resulted in alteration of consciousness, loss of consciousness, or post-traumatic amnesia and whether injuries were due to IPV. Any injury mechanism could be attributed to IPV (i.e., Did any intimate partner cause this injury? Yes or No), with a count of injuries caused by an intimate partner also provided by participants. The total lifetime TBI history included both IPV-related TBIs and TBIs reported by participants that were not attributed to IPV. Participants were provided with definitions of alteration of consciousness and loss of consciousness and estimated the number of times they experienced alteration of consciousness or loss of consciousness post injury. To determine the number of episodes of alteration of consciousness experienced, participants considered times when they felt “dazed and confused” immediately after sustaining a blow to the head, being violently shaken, or being unable to breathe. Examples of alteration of consciousness experiences included “I felt disoriented or confused about what happened or where I was,” “I felt like I could not think clearly,” or “I saw stars.” Participants also reflected on the number of times they experienced loss of consciousness immediately after sustaining a blow to the head, being violently shaken, or being unable to breathe. Examples of loss of consciousness experiences included “I passed out,” “I was knocked out,” or “I was unconscious”.⁵³

Participants were also asked to estimate their longest duration of alteration of consciousness, loss of consciousness, and post-traumatic amnesia to determine TBI severity, characterized using the Veterans Affairs/Department of Defense criteria.⁵⁶ Based on these criteria, a mild TBI requires alteration of consciousness ≤24 h, loss of consciousness of 0–30 min, and post-traumatic amnesia ≤24 h; moderate TBI requires alteration of consciousness >24 h, loss of consciousness of 30 min to 24 h, and/or post-traumatic amnesia >1 day and <7 days; and a severe TBI requires loss of consciousness >24 h or post-traumatic amnesia >7 days.

Neurobehavioral Symptom Inventory

The NSI⁵⁷ is a 22-item self-report questionnaire that queries cognitive, physical, and emotional symptoms. The NSI uses a five-point scale (i.e., 0 = None, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Very Severe), on which participants rate their symptom severity for the last 2 weeks. A symptom was considered endorsed if the participant rated it as 2 or greater. Similar to a previous study on the polytrauma clinical triad,¹ participants who endorsed at least three items met the neurobehavioral symptom criterion for the polytrauma clinical triad. However, the current study did not include the requirement of TBI acquisition and symptom duration of at least 3 months. The TBI requirement would disallow the application of this criterion to participants without prior head injuries, and the duration of symptoms was not evaluated beyond the two-week timeframe of the NSI. That said, participants with TBI were all at least 3 months post injury.

PTSD Checklist for DSM-5

The PTSD Checklist for DSM-5 (PCL-5) is a 20-item self-report questionnaire⁵⁸ that uses a five-point ordinal scale (i.e., 0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, 4 = extremely) to query PTSD symptom severity in the past month. The PCL-5 scores can be summed and compared with a cutoff (i.e., ≥33) for a provisional diagnosis of PTSD.⁵⁹

Pain

Women were asked about experiences of bodily pain, including questions on pain frequency and pain duration. The question on pain frequency asked, “In the past 6 months, how often did you have pain?”, allowing participants to respond Never, Some days, Most days, or Every day.⁶⁰ The question on pain duration asked, “How long has pain been an ongoing problem for you?”, allowing participants to respond Less than 3 months, 3–6 months, 6 months–1 year, 1–5 years, and More than 5 years.^61,62 To meet criteria for chronic pain, women must have endorsed pain on most days lasting 3 months or more.^60

–63

Physical and sexual IPV severity

Questions derived and modified from the 2015 National Intimate Partner and Sexual Violence Survey⁶⁴ asked about prior physical and sexual violence experiences. Participants responded whether they were exposed to specific IPV experiences in their lifetime, with their responses weighted according to the severity of the experiences with the weights assigned consistent with prior research.^{36,37,65

–70} The following weights were assigned to the physical IPV items: slapped (1), pushed/shoved (1), pulled hair (1), hit (2), kicked (2), slammed against something (2), choked/suffocated (5), beaten (5), burned (5), used knife (8), used gun (8), thought you might die due to abuse (8). The following weights were assigned to the sexual IPV items, with equivalent weights for sexual assault when unable to consent (i.e., due to alcohol or drugs) and sexual assault due to force or verbal pressure: kissed (1), fondled/groped (1), vaginal sex (3), anal sex (3), perpetrator’s mouth on vagina (3), perpetrator’s mouth on anus (3), mouth on perpetrator’s vagina or anus (3), mouth on perpetrator’s penis (3), fingers or object in vagina or anus (3), and attempted sexual assault (3). Weighted physical and sexual IPV severity item scores were summed to provide overall physical and sexual violence severity scores.

Procedure

As part of a previous research study,⁵³ participants completed an online survey through Prolific (www.prolific.com), a study recruitment platform that connects researchers with prospective participants, who received compensation for study completion. Participants were paid $6.60 for completing an eligibility screener and all study questionnaires. The survey took up to 30 min to complete. Study data were collected and retained using Research Electronic Data capture^71,72 at the University of Kentucky. All participants provided informed consent prior to participation. The data collection procedures were approved by the University of Kentucky Institutional Review Board (Protocol #86320).

Statistical analyses

Logistic regression analyses examined the relationship between IPV-related TBI history and multiple binary outcomes, including neurobehavioral symptoms, PTSD, and chronic pain, along with combinations of these conditions (i.e., neurobehavioral symptoms-PTSD, neurobehavioral symptoms-pain, PTSD-pain, and the polytrauma clinical triad). The first set of analyses involved unadjusted bivariate regression models, predicting each outcome with IPV-related TBI history as a binary variable. Sociodemographic variables (i.e., age, education, race/ethnicity) and physical and sexual IPV severity were examined in relation to IPV-related TBI history and each outcome using t-tests for continuous variables (i.e., age, education, and IPV severity) and χ ² tests for race/ethnicity as a categorical variable. For continuous and categorical variables, effect sizes of Cohen’s d and an odds ratio (OR) were, respectively, calculated, and was reported as an effect size. Any variables significantly related to the outcomes or IPV-related TBI history were included in subsequent models as covariates. Two sets of adjusted logistic regression analyses were conducted. The first controlled for significant sociodemographic covariates, and the second additionally controlled for physical and sexual IPV severity. ORs and R ² were reported as effect sizes for each analysis.

Post hoc analyses

Three post hoc analyses were conducted. The first post hoc analysis replicated the primary sets of analyses after excluding neurobehavioral symptoms that overlap with PTSD symptoms: (1) poor concentration, can’t pay attention, easily distracted; (2) difficulty falling or staying asleep; (3) irritability, easily annoyed; (4) feeling anxious or tense; and (5) feeling depressed or sad. This analysis was conducted to determine whether polytrauma clinical triad rates were attributable to symptom overlap between PTSD and neurobehavioral symptoms, determining if the removal of shared symptoms across these components changed the rates of the PCT. The second post hoc analysis was a binary logistic regression model examining whether the number of lifetime TBIs (i.e., both non-IPV and IPV-related) predicted the rates of meeting criteria for individual conditions, dyads of conditions, and the polytrauma clinical triad. The third post hoc analysis involved just the subsample of women who reported at least one IPV-related TBI, using time since their most recent head injury (i.e., any head injury regardless of whether it was or was not related to IPV) to predict the same outcomes as the second post hoc analysis. SPSS Version 29.0.0.0 was used for these analyses.

Sensitivity analysis

A sensitivity analysis was conducted using G*Power 3.1.9.7.⁷³ Based on a sample of 198 with an approximate 50:50 distribution between groups, the minimum detectable effect size was estimated based on a two-tailed analysis. Assumptions included the following: α = 0.05, 1 − β = 0.80, and about 20% of women without TBI would report any of the clinical conditions of interest. The final assumption was based on the most conservative estimate observed in prior literature estimating ∼17% of women with IPV history have current PTSD.⁵⁰ This analysis also assumed that the relationships between the predictor (i.e., TBI history) and other sociodemographic covariates in the model would be small. The resulting minimum detectable effect size was an OR of 2.51, which is considered moderate in magnitude.⁷⁴

Results

The demographic characteristics of the sample are provided in Table 1. The average age of the women was 39.6 years (SD = 11.9, range: 19–64). Most participants were White (83.3%) and non-Hispanic (82.9%) and reported completing a 2-year, 4-year, or postgraduate college degree (59.1%). Participants with IPV-related TBI were, on average, older (p = 0.045, d = 0.31 [0.02, 0.59]) and had fewer years of education than participants without a lifetime history of TBI (p = 0.014, d = 0.35 [0.07, 0.63]). Overall, many women reported that their most recent IPV-related experience occurred more than 10 years ago (42.9%). Among the subsample of participants reporting at least one IPV-related TBI (n = 105), women, on average, reported 3.5 TBIs (SD = 6.5, Mdn = 2, range: 1–59), with 37.1% reporting one TBI, 28.6% reporting two TBIs, and 34.3% reporting three or more TBIs. Most reported TBIs qualified as mild in severity (n = 95, 90.5%), with 8.6% moderate (n = 9) and 1.0% severe (n = 1). The vast majority of the sample reported that their most recent TBI occurred more than 1 year ago (92.4%). In regard to potential hypoxic-ischemic brain injuries, participants with one or more IPV-related TBIs reported, on average, 1.2 hypoxic-ischemic injuries involving alteration or loss of consciousness (SD = 2.2, Mdn = 0, range: 0–10). Participants without TBI history reported no potential hypoxic-ischemic brain injuries.

Table 1.

Demographic Characteristics and IPV Experiences

	Total sample (n = 198)	Women with IPV-related TBI (n = 105)	Women without TBI (n = 93)	Statistic	p	d; OR [95% CI]
Age, M (SD), range	39.6 (11.9), 19–64	41.3 (11.7), 19–64	37.7 (11.9), 21–64	t = 2.14	0.034	d = 0.31 [0.02, 0.59]
Race/ethnicity, n (%)
White	165 (83.3%)	84 (80.0%)	81 (87.1%)	χ ² = 1.31	0.252	OR = 0.67 [0.33, 1.34]
Black	13 (6.6%)	9 (8.6%)	4 (4.3%)
Native American	1 (0.5%)	1 (1.0%)	0 (0.0%)
Asian	5 (2.5%)	0 (0.0%)	5 (5.4%)
Native Hawaiian/Pacific Islander	1 (0.5%)	1 (1.0%)	0 (0.0%)
Multiracial	10 (5.1%)	8 (7.6%)	2 (2.2%)
Other	3 (1.5%)	2 (1.9%)	1 (1.1%)
Hispanic, n (%)				χ ² = 0.77	0.381	OR = 1.65 [0.53, 5.11]
No	184 (92.9%)	96 (91.4%)	88 (94.6%)
Yes	14 (7.1%)	9 (8.6%)	5 (5.4%)
Education, n (%)				t = 2.48	0.014	d = 0.35 [0.07, 0.63]
<12 years	3 (1.5%)	2 (1.9%)	1 (1.1%)
High School	27 (13.6%)	14 (13.3%)	13 (14.0%)
Some college	51 (25.8%)	36 (34.3%)	15 (16.1%)
2-year college degree	32 (16.2%)	18 (17.1%)	14 (15.1%)
4-year college degree	65 (32.8%)	27 (25.7%)	38 (40.9%)
Postgraduate degree	20 (10.1%)	8 (7.6%)	12 (12.9%)
IPV recency, n (%)				χ ² = 1.60	0.206	OR = 0.68 [0.37, 1.24]
Within the last year	10 (5.1)	6 (5.7)	4 (4.3)
1–5 years ago	52 (26.3)	31 (29.5)	21 (22.6)
6–10 years ago	51 (25.8)	27 (25.7)	24 (25.8)
More than 10 years ago	85 (42.9)	41 (39.0)	44 (47.3)
IPV severity, M (SD)
Physical IPV	20.0 (16.1)	30.0 (13.9)	8.8 (9.8)	t = 12.60	<0.001	d = 1.76 [1.43, 2.08]
Sexual IPV	12.9 (11.3)	8.5 (8.0)	16.7 (12.4)	t = 5.57	<0.001	d = 0.77 [0.48, 1.06]

Bold values indicate significant findings (p < 0.05). Each racial category includes the count of participants with that single racial identity. Multiracial includes participants reporting one or more racial identities. The χ ² test for group comparison by race compared the rates of non-Hispanic White participants against the rates of participants with other racial/ethnic identities. The t-test comparison by education was based on education as a continuous variable. These categories were coded as: <12 years (1), high school (2), some college (3), 2-year college degree (4), 4-year college degree (5), and postgraduate degree (6). IPV recency refers to the time since the participant’s most recent IPV event. The χ ² test for group comparison by IPV recency compared the rates of participants experiencing IPV in the last 5 years against the rates of participants with IPV most recently experienced 6 or more years ago. The Mann-Whitney U test for group comparison based on IPV severity compared the mean ranks of severity between the IPV-related TBI and no TBI groups, with the effect size r calculated as z/√N.

IPV, intimate partner violence; SD, standard deviation; TBI, traumatic brain injury.

The distributions of participants with and without IPV-related TBI meeting criteria for neurobehavioral symptoms, PTSD, or chronic pain are presented in Figure 1. Women most commonly met criteria for neurobehavioral symptoms, independent of all other conditions. Across both groups of participants, a similar number of women reported chronic pain independent of all other conditions (i.e., 3.8% of women with IPV-related TBI; 4.3% of women without TBI history). All women who screened positive for PTSD also reported neurobehavioral symptoms or reported co-occurring neurobehavioral symptoms and chronic pain (i.e., the polytrauma clinical triad); no participants met criteria for PTSD independent of neurobehavioral symptoms or chronic pain. The co-occurrence of neurobehavioral symptoms and chronic pain was the most common dyad of conditions among both participants with and without IPV-related TBI (i.e., 21.0% and 18.3%, respectively).

FIG. 1.

Distribution of participants meeting criteria for neurobehavioral symptoms (NBS), PTSD, and chronic pain among subsamples of women survivors reporting at least one IPV-related traumatic brain injury (left) or no lifetime history of traumatic brain injury (right). IPV, intimate partner violence; PTSD, post-traumatic stress disorder.

Frequencies of meeting criteria for neurobehavioral symptoms, PTSD, chronic pain, and combinations of these three conditions are summarized in Table 2. Participants were included in the rates of each condition even if they met criteria for more than one condition. For example, women meeting criteria for the polytrauma clinical triad (i.e., concurrent neurobehavioral symptoms, PTSD, and chronic pain) would also meet criteria for each individual condition and condition dyads (i.e., neurobehavioral symptoms with PTSD; neurobehavioral symptoms with chronic pain; PTSD with chronic pain).

Table 2.

Frequencies of the PCT and Its Components by IPV-Related TBI Status Among Women with a History of IPV

	Women with IPV-related TBI (n = 105)		Women without TBI (n = 93)		Unadjusted				Adjusted for age and education				Adjusted for age, education, and IPV severity
Outcome	n	%	n	%	β	p	OR [95% CI]	R ²	β	p	OR [95% CI]	R ²	β	p	OR [95% CI]	R ²
PCT	20	19.0	6	6.5	1.23	0.012	3.41 [1.31, 8.91]	0.07	1.34	0.009	3.84 [1.41, 10.46]	0.10	0.63	0.300	1.89 [0.57, 6.25]	0.14
NBS-PTSD	31	29.5	21	22.6	0.36	0.269	1.44 [0.76, 2.73]	0.01	0.52	0.139	1.69 [0.84, 3.38]	0.10	0.01	0.980	1.01 [0.42, 2.45]	0.13
NBS-Pain	42	40.0	23	24.7	0.71	0.023	2.03 [1.10, 3.74]	0.04	0.70	0.030	2.01 [1.07, 3.79]	0.04	−0.35	0.426	0.71 [0.30, 1.66]	0.15
PTSD-Pain	20	19.0	6	6.5	1.23	0.012	3.41 [1.31, 8.91]	0.07	1.34	0.009	3.84 [1.41, 10.46]	0.10	0.63	0.300	1.89 [0.57, 6.25]	0.14
PTSD	31	29.5	21	22.5	0.36	0.269	1.44 [0.76, 2.73]	0.09	0.52	0.139	1.69 [0.84, 3.38]	0.10	0.01	0.980	1.01 [0.42, 2.45]	0.13
Chronic Pain	46	43.8	27	29.0	0.65	0.032	1.91 [1.06, 3.44]	0.03	0.62	0.045	1.87 [1.01, 3.43]	0.04	−0.35	0.412	0.71 [0.31, 1.62]	0.13
≥3 NBS	77	73.3	63	67.7	0.27	0.389	1.31 [0.71, 2.42]	0.01	0.36	0.286	1.44 [0.74, 2.79]	0.12	−0.89	0.067	0.41 [0.16, 1.06]	0.23

Bold values indicate significant findings (p < 0.05). PTSD symptom endorsement involved individual symptom severity rating of 2 (i.e., moderate) or greater. Participants could meet criteria for more than one condition. Provisional PTSD diagnosis criteria required the following symptom endorsements: at least one symptom related to intrusion; at least one symptom related to avoidance of stimuli associated with the traumatic event; at least two symptoms related to negative alterations in cognition and mood; at least two symptoms related to marked alterations in arousal and reactivity. Pain and chronic pain are used synonymously in this table, such that chronic pain is defined as pain lasting most days for 3 months or more. NBS criteria involved at least three neurobehavioral symptom endorsements (i.e., each symptom rated as 2, moderate severity, or greater). IPV severity was calculated using the weighted severity of physical and sexual IPV. Age, education, and IPV severity were included in the adjusted models as separate covariates.

IPV, intimate partner violence; NBS, neurobehavioral symptoms; PCT, polytrauma clinical triad; PTSD, post-traumatic stress disorder; TBI, traumatic brain injury.

Neurobehavioral symptoms, PTSD, and chronic pain

Overall, a majority of the sample met the neurobehavioral symptom criterion. There were no group differences in rates of meeting the neurobehavioral symptom criterion. Approximately one in four participants screened positive for PTSD, and rates of meeting a provisional PTSD diagnosis did not statistically differ across groups. However, compared with participants without TBI, participants with IPV-related TBI were more likely to report chronic pain. Group differences for meeting criteria for chronic pain (p = 0.045, OR [95% confidence interval] = 1.87 [1.01, 3.43]) remained significant after controlling for age and education. After additionally controlling for IPV severity, however, groups did not significantly differ in rates of chronic pain (p = 0.412, OR = 0.71 [0.31, 1.62]).

Condition dyads

Women with at least one IPV-related TBI were more likely to meet criteria for two dyads: (1) chronic pain with concurrent neurobehavioral symptoms and (2) chronic pain with concurrent PTSD. Group differences for meeting criteria for chronic pain with concurrent neurobehavioral symptoms (p = 0.030, OR = 2.01 [1.07, 3.79]) and chronic pain with concurrent PTSD (p = 0.009, OR = 3.84 [1.41, 10.46]) remained significant after controlling for age and education. After additionally controlling for IPV severity, however, groups did not significantly differ on meeting criteria for chronic pain with concurrent neurobehavioral symptoms (p = 0.426, OR = 0.71 [0.30, 1.66]) or chronic pain with concurrent PTSD (p = 0.300, OR = 1.89 [0.57, 6.25]). The rates of meeting criteria for neurobehavioral symptoms with concurrent PTSD were not statistically different across groups.

Polytrauma clinical triad

Compared with participants without a lifetime history of TBI, women with IPV-related TBI were more likely to meet criteria for the polytrauma clinical triad (p = 0.012, OR = 3.41 [1.31, 8.91]). This group difference remained statistically significant even after controlling for age and education (p = 0.009, OR = 3.84 [1.41, 10.46]). However, after additionally controlling for IPV severity, the groups did not significantly differ in rates of the polytrauma clinical triad (p = 0.300, OR = 1.89 [0.57, 6.25]).

Post hoc analyses

Distributions of participants meeting criteria for neurobehavioral symptoms, PTSD, and/or chronic pain, after the exclusion of neurobehavioral symptoms that overlapped with PTSD symptoms, are presented in Table 3. Despite the exclusion of certain neurobehavioral symptoms, the number of participants who met criteria for the polytrauma clinical triad remained unchanged. Because there was no change in PTSD and chronic pain criteria, there was no change in rates of PTSD with concurrent chronic pain, PTSD, and chronic pain. Across both groups of participants, fewer women met the new neurobehavioral symptom criterion. Fewer women with IPV-related TBI met criteria for condition dyads including neurobehavioral symptoms. The only change in significant group differences pertained to the dyad of chronic pain and neurobehavioral symptoms, which no longer significantly differed across groups.

Table 3.

Post Hoc Analysis of Frequencies of the PCT and Its Components by IPV-Related TBI Status Among Women with a History of IPV after Removing Neurobehavioral Symptoms That Overlap with PTSD Symptoms

	Women with IPV-related TBI (n = 105)		Women without TBI (n = 93)		Unadjusted				Adjusted for age and education				Adjusted for age, education, and IPV severity
Outcome	n	%	n	%	β	p	OR [95% CI]	R ²	β	p	OR [95% CI]	R ²	β	p	OR [95% CI]	R ²
PCT	20	19.0	6	6.5	1.23	0.012	3.41 [1.31, 8.91]	0.07	1.34	0.009	3.84 [1.41, 10.46]	0.10	0.63	0.300	1.89 [0.57, 6.25]	0.14
NBS-PTSD	29	27.6	21	22.6	0.27	0.416	1.31 [0.69, 2.50]	0.01	0.43	0.233	1.53 [0.76, 3.09]	0.10	−0.10	0.819	0.90 [0.37, 2.21]	0.13
NBS-Pain	38	36.2	23	24.7	0.55	0.083	1.73 [0.93, 3.20]	0.02	0.54	0.097	1.71 [0.91, 3.24]	0.02	−0.26	0.552	0.77 [0.33, 1.80]	0.08
PTSD-Pain	20	19.0	6	6.5	1.23	0.012	3.41 [1.31, 8.91]	0.07	1.34	0.009	3.84 [1.41, 10.46]	0.10	0.63	0.300	1.89 [0.57, 6.25]	0.14
PTSD	31	29.5	21	22.5	0.36	0.269	1.44 [0.76, 2.73]	0.09	0.52	0.139	1.69 [0.84, 3.38]	0.10	0.01	0.980	1.01 [0.42, 2.45]	0.13
Chronic Pain	46	43.8	27	29.0	0.65	0.032	1.91 [1.06, 3.44]	0.03	0.62	0.045	1.87 [1.01, 3.43]	0.04	−0.35	0.412	0.71 [0.31, 1.62]	0.13
≥3 NBS	67	63.8	56	60.2	0.15	0.603	1.17 [0.66, 2.07]	0.002	0.26	0.417	1.29 [0.70, 2.40]	0.10	−0.54	0.216	0.59 [0.25, 1.37]	0.15

Bold values indicate significant findings (p < 0.05). PTSD symptom endorsement involved individual symptom severity rating of 2 (i.e., moderate) or greater. Participants could meet criteria for more than one condition. Provisional PTSD diagnosis criteria required the following symptom endorsements: at least one symptom related to intrusion; at least one symptom related to avoidance of stimuli associated with the traumatic event; at least two symptoms related to negative alterations in cognition and mood; at least two symptoms related to marked alterations in arousal and reactivity. Pain and chronic pain are used synonymously in this table, such that chronic pain is defined as pain lasting most days for 3 months or more. NBS criteria involved at least three neurobehavioral symptom endorsements (i.e., each symptom rated as 2, moderate severity, or greater). In this post hoc analysis, NBS that overlap with PTSD symptoms were excluded from the PCT criteria: (1) poor concentration, can’t pay attention, easily distracted; (2) difficulty falling or staying asleep; (3) irritability, easily annoyed; (4) feeling anxious or tense; (5) feeling depressed or sad. IPV severity was calculated using the weighted severity of physical and sexual IPV. Age, education, and IPV severity were included in the adjusted models as separate covariates.

IPV, intimate partner violence; NBS, neurobehavioral symptoms; PCT, polytrauma clinical triad; PTSD, post-traumatic stress disorder; TBI, traumatic brain injury.

Results from the remaining post hoc analyses are reported in Table 4. As the number of lifetime TBIs experienced increased, women were more likely to report chronic pain and chronic pain with concurrent neurobehavioral symptoms. Women who experienced IPV-related TBI with greater time since their most recent injury were less likely to have three or more neurobehavioral symptoms. Neither the number of lifetime TBIs nor time since last injury predicted rates of meeting criteria for PTSD, any dyad including PTSD, or the polytrauma clinical triad.

Table 4.

Post Hoc Analyses with TBI Count and Time Since Last Head Injury as Independent Predictors of Outcomes Related to the PCT

	Women with IPV-related TBI (n = 105)		Women without TBI (n = 93)		TBI count (n = 198)				Time since last head injury (n = 105)
Outcome	n	%	n	%	β	p	OR [95% CI]	R ²	β	p	OR [95% CI]	R ²
PCT	20	19.0	6	6.5	0.04	0.185	1.04 [0.98, 1.11]	0.02	−0.02	0.496	0.98 [0.93, 1.04]	0.01
NBS-PTSD	31	29.5	21	22.6	0.03	0.298	1.03 [0.97, 1.10]	0.01	−0.03	0.186	0.97 [0.92, 1.02]	0.03
NBS-Pain	42	40.0	23	24.7	0.17	0.007	1.05 [1.05, 1.34]	0.08	−0.01	0.521	0.99 [0.95, 1.03]	0.01
PTSD-Pain	20	19.0	6	6.5	0.04	0.185	1.04 [0.98, 1.11]	0.02	−0.02	0.496	0.98 [0.93, 1.04]	0.01
PTSD	31	29.5	21	22.5	0.3	0.298	1.03 [0.97, 1.10]	0.01	−0.03	0.186	0.97 [0.92, 1.02]	0.03
Chronic Pain	46	43.8	27	29.0	0.16	0.011	1.17 [1.04, 1.33]	0.01	0.00	0.999	1.00 [0.96, 1.04]	0.00
≥3 NBS	77	73.3	63	67.7	0.18	0.054	1.20 [1.00, 1.43]	0.04	−0.07	0.005	0.94 [0.89, 0.98]	0.11

Bold values indicate significant findings (p < 0.05). PTSD symptom endorsement involved individual symptom severity rating of 2 (i.e., moderate) or greater. Participants could meet criteria for more than one condition. Provisional PTSD diagnosis criteria required the following symptom endorsements: at least one symptom related to intrusion; at least one symptom related to avoidance of stimuli associated with the traumatic event; at least two symptoms related to negative alterations in cognition and mood; at least two symptoms related to marked alterations in arousal and reactivity. Pain and chronic pain are used synonymously in this table, such that chronic pain is defined as pain lasting most days for 3 months or more. NBS criteria involved at least three neurobehavioral symptom endorsements (i.e., each symptom rated as 2, moderate severity, or greater). TBI count refers to the number of reported lifetime TBIs, both IPV-related and non-IPV related, and was analyzed using the full sample (n = 198). Time since last head injury corresponds to the number of years since last blow to the head and was assessed only among women with IPV-related TBI (n = 105).

IPV, intimate partner violence; NBS, neurobehavioral symptoms; PCT, polytrauma clinical triad; PTSD, post-traumatic stress disorder; TBI, traumatic brain injury.

Discussion

In the current study, women with IPV-related TBI met criteria for the polytrauma clinical triad (19.0%) more often than women with a history of IPV, but no lifetime history of TBI (6.5%). Rates of neurobehavioral symptoms and PTSD—two components of the triad—were not statistically different between groups. Conversely, rates of chronic pain differed significantly across groups, in that women with IPV-related TBI were more likely to meet criteria for chronic pain. Furthermore, the only condition dyads that differed across groups included chronic pain (i.e., chronic pain with concurrent neurobehavioral symptoms; chronic pain with concurrent PTSD). Women with IPV-related TBI were more likely to meet criteria for chronic pain, condition dyads including chronic pain, and the polytrauma clinical triad, even after controlling for age and education. Given that chronic pain was associated with all significant group differences, the current findings indicate that chronic pain may be the primary driver of the polytrauma clinical triad among women with a history of IPV. That said, the inclusion of IPV severity in the model attenuated these associations such that there were no significant group differences for any outcomes, suggesting that IPV severity may be closely linked to both IPV-related TBI history and conditions that comprise the polytrauma clinical triad. This finding could also indicate no meaningful association between the presence of IPV-related TBI and the polytrauma clinical triad, independent of IPV severity. Neurobehavioral symptoms, PTSD, and chronic pain may occur more frequently among women survivors with IPV-related TBI simply because they have greater IPV exposure in general, which results in greater cumulative emotional trauma and repeated physical injury to the body.

A post hoc analysis examined whether the number of lifetime TBIs (i.e., both non-IPV and IPV-related) predicted each condition, dyad, and the polytrauma clinical triad among the full sample of participants, who, on average, experienced 3.5 lifetime TBIs (range: 0–59). This analysis found that greater chronic pain and chronic pain with concurrent neurobehavioral symptoms were associated with the number of lifetime TBIs. In contrast, neurobehavioral symptoms, both independent of other conditions and with concurrent PTSD, were not associated with repetitive lifetime TBIs. These results suggest that a greater number of lifetime TBIs is related to increased likelihood of having chronic pain, a relationship researchers are beginning to explore among other populations.^75,76 Previous studies, however, have not examined this relationship among women with a history of IPV. The relationship between the number of lifetime TBIs and chronic pain among women with a history of IPV may also reflect cumulative bodily injury due to extensive physical trauma. Of note, women with IPV-related TBIs had significantly higher lifetime physical IPV severity in the current sample, and bodily injuries resulting from abuse can intuitively result in chronic pain. Researchers hypothesize that TBI may alter pain modulation^77,78 and have reported increased pain sensitivity among individuals with a history of psychological trauma.⁷⁹

The current study supports previous research suggesting that chronic pain often follows TBI^78,80
–82 or IPV-related abuse^48,83,84 and may persist years after injury.⁸¹ Following TBI, chronic pain has been associated with elevated suicidal ideation,⁴ anxiety,⁸⁵ and sleep disturbance^85,86 among other populations—such as Veterans. Considering women with a history of IPV may already report elevated rates of depression,^87,88 PTSD,^83,89,90 and sleep disturbance,⁹¹ researchers could examine how chronic pain relates to other domains of mental and behavioral health among women with IPV-related TBI.

Contrary to previous studies,^{30,33,36,37,92} the current study did not find an association between TBI history and neurobehavioral symptom frequencies among women with a history of IPV. Previous studies reported differences in neurobehavioral symptom severity based on head or brain injury history among women with a history of IPV.^{33,36,37,41,66} Compared with women without IPV exposure or women survivors without a history of TBIs or head injuries, women with IPV-related TBIs reported greater levels of cognitive (e.g., difficulties with memory and concentration) and physical symptoms (e.g., dizziness, vision and hearing problems).^{30,33,36,38,92} These studies suggest that women survivors with a TBI or head injury history generally report more neurobehavioral symptoms, which contrasts with the current findings.

One potential explanation for differences in study results on the association between neurobehavioral symptoms and IPV-related TBI is the recency of IPV experiences. In previous studies, women reported abuse from a current or recent partner (i.e., within the past 2 years),^33,37,66 or a greater percentage of the sample (26.5%) disclosed a history of IPV within the past year.³⁰ In contrast, 5.1% of women in the current study reported past-year IPV experiences. IPV is associated with TBI,⁹² and, as reported in the current study, women were less likely to report neurobehavioral symptoms as time since last head injury increased. Therefore, given that many women reported that their most recent IPV experiences occurred 6 or more years ago, participants in the current study may be less likely to report neurobehavioral symptoms than women in prior studies, who reported more recent IPV experiences.^30,33

The current study also did not find an association between IPV-related TBI history and screening positive for PTSD. In contrast, previous studies found that IPV-related TBI was associated with greater severity of PTSD symptoms.⁴⁴ Differences in study results may be attributable to differences in study samples. Participants recruited online, as with the current study, may not experience the same level of IPV-related trauma severity as participants in previous studies. In prior research, women may have experienced more severe physical abuse, considering that they were recruited from a fracture clinic,⁹² the courthouse after obtaining protective orders against their intimate partners,^36,37 or domestic violence shelters.^93
–95 Individuals who seek health care, legal, or IPV recovery services may have different IPV experiences than individuals recruited online from the general population, who, on average, likely experience less severe IPV. As such, the relationship between IPV-related TBIs and PTSD symptoms may be attenuated, because the overall trauma exposure of the current sample may be lower, compared with prior studies. Additionally, online recruitment methods may not capture responses from participants who do not wish to disclose sensitive information, such as injury history, in an online survey.

Another notable consideration pertains to the overlap between some neurobehavioral and PTSD symptoms. Considering the same symptoms across components of the polytrauma clinical triad could artificially increase rates of comorbidity if, for example, certain symptoms solely attributable to PTSD are also considered neurobehavioral symptoms. To address this concern, a post hoc analysis excluded overlapping symptoms from the neurobehavioral symptom criterion. As expected, given fewer symptoms were considered, rates of meeting criteria for neurobehavioral symptoms decreased across both groups. This change was also reflected in group differences for one condition dyad, neurobehavioral symptoms with concurrent chronic pain. Among the primary analyses, the magnitude of the group difference for this dyad was modest. However, based on the post hoc analysis excluding some NSI items, rates of neurobehavioral symptoms with concurrent chronic pain did not significantly differ across groups. These results may be due to a slightly greater reduction in meeting the neurobehavioral symptom criterion among the IPV-related TBI group. That said, women with IPV-related TBI were still more likely to meet criteria for the polytrauma clinical triad, suggesting that group differences for the triad were not attributable to symptom overlap between PTSD and neurobehavioral symptoms.

Study limitations

The current study had limitations. Based on a sensitivity analysis, the study only had sufficient power to detect moderate effects; as such, this study would not be able to detect small effects that may be clinically meaningful. Additionally, most participants were highly educated, non-Hispanic White women, and findings based on this sample may not generalize to populations of different educational and racial/ethnic backgrounds. Discrepancies in internet accessibility may also play a role in participant sampling. For example, affluent, urban, and well-educated communities are more likely to have access to the internet.^96,97 Given that the current study was conducted online, the sample may include more participants from urban settings and those with greater socioeconomic status.

Furthermore, this study relied solely on self-reported measures. These measures also queried symptoms across different timeframes (e.g., past month PTSD symptoms, past 2-week neurobehavioral symptoms). These timeframes reflect the original instructions used when psychometrically developing and evaluating these instruments, but still notably vary across constructs considered when operationalizing the polytrauma clinical triad. Survey measures included one embedded symptom validity scale, the NSI Validity-10,⁵⁴ to determine whether participants potentially overreported symptoms. However, the NSI Validity-10 has been validated with military and Veteran samples^54,98 but not with women with a history of IPV. That said, few participants were excluded from this study based on the NSI Validity-10 (n = 2). Data collection did not include informant-reported information on health or TBI history. There were also no medical records available to confirm TBI history or verify the clinical characteristics of past injuries, such as duration of loss of consciousness or alteration of consciousness, which help determine the presence and severity of TBIs. Certain TBI diagnostic criteria (e.g., alteration of consciousness, post-traumatic amnesia) may also overlap with the acute effects of trauma on orientation and memory (e.g., peritraumatic dissociation, PTSD-related amnesia). Considering IPV-related TBI inherently corresponds with trauma and often relies on retrospective report for diagnosis, future research should further examine methods to tease apart the acute clinical signs of TBI and trauma in this population. Finally, individuals with a history of IPV may also experience other forms of brain injury, such as hypoxic-ischemic events due to non-fatal strangulation and attempted suffocation or drowning, in addition to TBIs; future research may study other acquired brain injury mechanisms, separate from TBIs, to examine the relationships between IPV-related hypoxic-ischemic brain injuries and the polytrauma clinical triad.

Conclusion

In an online sample of women with a history of IPV, the polytrauma clinical triad, meaning the co-occurrence of neurobehavioral symptoms, PTSD, and chronic pain, occurred more often among women with IPV-related TBI. These co-occurring conditions may result in additive effects and potentially lead to worsened health outcomes, as observed in prior Veteran samples.^1,4,5 Additionally, an increased number of IPV-related TBIs was associated with greater chronic pain and chronic pain with concurrent neurobehavioral symptoms, suggesting that repetitive IPV-related TBI also corresponds with worsened health outcomes. Nonetheless, even without a history of TBI, many individuals with a history of IPV experience problems across multiple domains of mental, physical, cognitive, and behavioral health. Given the high frequencies of neurobehavioral symptoms, PTSD, and chronic pain among the current sample of women with a history of IPV, simultaneously addressing these conditions during treatment could benefit this population. Furthermore, future research could examine other comorbid conditions associated with IPV, such as depression, anxiety, or substance use disorders,^44,50,99,100 potentially expanding the breadth of disorders considered in the polytrauma clinical profile of women who have experienced IPV.

Future research may identify other important considerations for working with individuals who have experienced IPV. First, researchers may consider recruiting from other settings, such as rural communities, health care clinics, and domestic violence shelters, to determine whether the polytrauma clinical triad occurs at similar frequencies among individuals from these different settings. Second, researchers may consider the association between IPV-related TBI and social determinants of health, such as financial and housing stability. Prior studies have suggested that increased economic and housing stability may be associated with decreases in experiencing abuse.^101
–103 However, studies have not examined the potential relationships between IPV-related TBI or its sequelae and these social determinants of health. Given that economic and housing statuses may change over time among individuals with a history of IPV, longitudinal studies on this topic may help researchers begin to identify protective factors against IPV-related TBI, and potentially, repetitive IPV-related TBI, along with variables associated with improved health and functioning following injury. Finally, including community partners, such as individuals with a history of IPV and social service providers, in research teams may be beneficial, considering that these community partners can provide insight into research that could most benefit individuals who have experienced IPV.^104,105

Transparency, Rigor, and Reproducibility

This study was not pre-registered. The analysis plan was not formally pre-registered, but the team member with primary responsibility for the analysis certifies that the analysis plan was pre-specified. Participants, recruited from Prolific, were screened prior to data collection. At the time of recruitment, the original participant pool included 120,140 participants and was filtered based on eligibility criteria, as described in the article. Based on these criteria, 14,345 participants were eligible to complete the study screener, and 1,240 completed the screener. After application of exclusion criteria, the final study sample was 198, including 93 women with a history of IPV, but no TBI, and 105 women with IPV-related TBI history. Given that this study involved secondary data analyses, a sensitivity analysis was conducted using G*Power. Assumptions included: α = 0.05, 1 − β = 0.80, approximately 17% of participants meeting criteria for clinical conditions of interest, and a small relationship between the predictor variable with sociodemographic covariates. Based on a sample size of 198 with approximately equal distribution between groups, planned two-tailed analyses, and the listed assumptions, per sensitivity analysis, the sample had sufficient power to detect a medium effect size. Data were collected online from June to July 2023. The measures used, described in the text, have established evidence for reliability and validity. Data were analyzed using SPSS by investigators who were aware of the relevant characteristics of the participants. There were no missing data in the analyses. Effect sizes and confidence intervals have been reported in the abstract for primary outcomes and main text for all outcomes. No replication or external validation studies have been performed or are planned/ongoing at this time. The data from this study will not be shared due to the sensitivity of the participant population.

Footnotes

Authors’ Contributions

S.E.L.: Conceptualization (lead), formal analysis (lead), writing—original draft (lead), writing—review and editing (equal). T.K.L.: Supervision (equal); writing—review and editing (equal). C.L.B.: Supervision (equal); writing—review and editing (equal). J.E.K.: Conceptualization (supporting); formal analysis (supporting); writing—original draft (supporting); writing—review and editing (equal); funding acquisition (lead).

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Author Disclosure Statement

The authors have no competing interests or conflicts of interest to report.

Funding Information

This work was supported, in part, by a Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) grant (#K12-DA035150) from the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH). This publication was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH, through GrantUL1TR001998.

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