What if Post-Concussive Symptoms Aren’t Really Post-Concussive in Some Cases?
Recently there has been quite a bit of discussion among forensic neuropsychologists about young people who, while considered previously healthy and high achieving, are now reporting quite a bit of decline in functioning following experiencing a single very mild concussion, where in most cases symptom persistence would not be expected. Tales abound of young adults who once active participants in sports and socially outgoing are now housebound and unable to even play video games. The young adults may manifest such symptoms as persistent headaches, visual disturbances, balance changes, and memory complaints. The young adults are quite sincere in their presentation, frequently very high achievers, and there is no obvious secondary gain or litigation in some of these cases. The question to be asked is: Are these physical and cognitive symptoms really a result of concussion? In the cases I am discussing, the bumps to the head are quite minor and did not result in loss of consciousness or posttraumatic amnesia.
One hypothesis posited by forensic neuropsychologists is that the young adults are somaticizing (expressing psychological distress through physical symptoms), possibly because of illness apprehension, health anxiety, and worry around concussion. This may differ from malingering or intentional exaggeration and may be unconscious or unintentional. When you think of the young adult who does not leave the house or participate in everyday activities as in this particular case, think of people who do not exercise for fear they will develop a heart condition when in fact there is no evidence to suggest they will develop a heart condition.
If we dig into the research literature and individual cases, in some cases a thread emerges of iatrogenesis (negative outcomes) because of prolonged activity restrictions (and not necessarily because of injury to brain tissue). A relevant article was produced this week in the journal of Clinical Pediatrics entitled “Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes”? (DiFazio et al., 2015). In the article it is acknowledged that while many clinical practice guidelines advise total (cognitive and physical) rest after TBI, activity restriction itself may contribute to protracted recovery and other complications. A model was proposed in which physical deconditioning and psychological consequences of removal from meaningful life activities led to a psychological reaction which looks like postconcussive symptoms but which in fact is psychological in origin. Another author, Grant Iverson, has written on this topic, and published an important review on this topic suggesting that brief (~72 hours) rest may be the maximum beneficial window of rest after which iatrogenesis can occur (article is available at: http://www.researchgate.net/publication/235906380_The_effects_of_rest_and_treatment_following_sport-related_concussion_a_systematic_review_of_the_literature). It is important to note that in many cases now, the iatrogenesis begins in the ER, where people can be improperly diagnosed with brain injury and informed they may experience lasting side effects. Parents may then read misinformation on the internet and then pass information about intractability of symptoms to the young adult (or the young adult may do this for themselves). This is in contrast to classic research conducted by Mittenberg et al. 2001 (http://www.ncbi.nlm.nih.gov/pubmed/11910547), which suggests that if people are told their concussions will resolve the symptoms do indeed resolve. The preponderance of research to date supports Mittenberg et al.’s (2001) finding. The forensic neuropsychologist might postulate that symptoms may also come along at a time to solve another preexisting life problem such as psychosocial dysfunction related to parental divorce or other conflict; thus, post-concussive symptoms may have a function that maintains them.
From a psychological standpoint, it is important to think about whether, in individual cases, some high achieving people are exhibiting high stress reactivity (highly responsive to stress) as a reason for developing post-concussive symptoms. People who are highly reactive to stress and minor events may be more likely to develop prolonged symptoms. Any kind of functional decline, even if short-lived, can be functionally a bigger deal for such people because of their high standards for achievement. In these high achieving folks we may see a tendency to exhibit depressive features, to underappreciate their cognitive abilities (in a way that is disproportionate to objective test findings), and stress reactivity. Perfectionistic tendencies and high standards play a role here, as these individuals, because of their standards may magnify any slight difference post-injury which may just prolong perception/subjective complaint of the problem. In fact, the cognitive issues may really only be mild or objectively non-existent.
Attorneys and healthcare providers can do their part not to further psychosomatic symptoms by promoting evidence based information to guide diagnosis and case management. In cases where post-concussive symptoms (which are actually post-concussive appearing symptoms) actually have a psychological origin, the forensic neuropsychologist can provide diagnostic clarification (letting them know there really was no brain injury even if they’ve been told this for years), an alternative explanation for symptoms, and emphasizing return to normal functioning (e.g., return to school, sports, socializing, etc.).
With regard to other neurologic complaints such as balance changes, the patient should be evaluated by physical therapy and a neurologist. These professionals can administer objective measurements of balance that try to isolate the cause of subjective balance issues. They can discern whether the symptoms make any sense from a vestibular point of view or whether exaggeration is possible (i.e., patient provides a non-organic response, or, their presentation is not consistent with any known condition).
In terms of reported cognitive, emotional, and behavioral complaints, the forensic neuropsychologist is in a unique position to be able to comment on whether the young adult client’s complaints (reported post-concussive symptoms) are consistent with a known neurologic syndrome or true residual from concussion and are therefore truly post-concussive versus psychological in origin.
About the author. Dr. Messler is a board certified clinical neuropsychologist and licensed psychologist who has provided thousands of evaluations where the question of traumatic brain injury was raised. She has also served as expert consultant and witness. She believes it is critical to provide an objective, scientifically defensible opinion, and to help the jury and court understand the implications of the neuropsychological aspects of cases before them.