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Are Post-Concussional Symptoms Unique to Neurologic Impairment? Likely Not.

Dr. Sam Goldstein

Complimentary Service of the Neurology, Learning and Behavior Center

The Neurology, Learning and Behavior Center provides multi-disciplinary, clinical and forensic assessment, case management, trial consultation and treatment services for children and adults with brain injury and dysfunction, Attention-Deficit Hyperactivity Disorder, language disorders, learning disability, developmental delay, Autism, emotional disorders and adjustment problems. The Center is dedicated to the provision of treatment services.

ARE POST-CONCUSSIONAL SYMPTOMS UNIQUE TO NEUROLOGIC IMPAIRMENT?… LIKELY NOT

In the seventh issue of this legal update, I provided an overview of Post-concussion Syndrome (PCS). This is a collection of symptoms, including problems with thinking, physical impairments involving fatigue, dizziness, headache and sensory sensitivity as well as mood changes. Fifty to 80% of individuals during an acute period following a mild head trauma exhibit some of these symptoms. Approximately 50% of affected individuals experience symptoms for at least three months with 10% to 15% complaining of persistent post-concussive symptoms beyond that period. Less than 10% of individuals experiencing mild head injury demonstrate measurable neuropsychological deficits. The subjective nature of PCS symptoms and the overlap with other physical and psychological conditions has made accurate assessment, interpretation and litigation difficult.

The text revision of the Fourth Edition of the Diagnostic and Statistical Manual of the American Psychiatric Association was published last summer. Post-concussional Syndrome remains in the Appendix of this manual. This diagnosis for some clinicians has languished in the Appendix despite the fact that there is a fairly robust literature suggesting a commonality in symptoms presenting in individuals experiencing head injury sufficient to produce a loss of consciousness exceeding five minutes or post-traumatic amnesia exceeding twenty-four hours. Diagnosis of PCS remains in the Appendix of this diagnostic manual because the symptoms defining this condition appear characteristic individually or in combination with other conditions, in particular depression and anxiety. One of the most daunting tasks facing neuropsychologists in the forensic arena is the connection of specific symptoms to certain conditions. Many clinicians find it difficult to ascribe symptoms or percentage of symptoms to one condition or another for individuals experiencing mild closed head injury accompanied by depression or anxiety. Thus, it is common in forensic settings for two neuropsychology experts to disagree, with one pointing to psychiatric reasons for post-concussion like symptoms while another pointing to traumatically induced neurologic reasons.

This issue has also been one of the challenges facing neuropsychology researchers. Fortunately it has quickly moved to the forefront of research interest. In this Legal Update I will briefly review the post-concussional literature and relationship of PCS symptoms to depression and anxiety. Most importantly I will summarize a study published this month in the Archives of Clinical Neuropsychology, whose Editorial Board I sit on. Though the results of this study need to be replicated, the findings may surprise some of you, particularly in regards to the percentage of individuals with psychiatric problems reporting PCS symptoms.

During the early stages of recovery from closed head injury or brain trauma, individuals report a variety of symptoms, including headache, dizziness, nausea, sleepiness, visual problems, impulsivity, irritability, anxiety, moodiness, problems with concentration, sensory changes, difficulty thinking clearly and problems with daily cognitive efficiency. In some situations individuals with seemingly mild head injury may experience these symptoms for many years. The issue as to whether these prolonged symptoms are due to the subtle neurological effects of injury or related to issues secondary to life change, psychiatric problems or even litigation continues to be debated.

It has been well accepted that many PCS symptoms are reported by adults with no history of head trauma or other neurological illness. A number of these studies are cited in the references at the close of this update. Taken in combination, these studies suggest for example that individuals seeking psychotherapy report as many if not more PCS symptoms than individuals without medical problems or those seeking help for other medical issues. These studies reveal that the frequency, intensity and duration of PCS symptoms are often correlated positively with daily stress. However convincing these studies appear on first read, many require replication or suffer from methodological and statistical problems.

In a recent issue of the Archives of Clinical Neuropsychology, Donald Trahan and colleagues evaluated the relationship between post-concussional type symptoms, depression and anxiety in neurologically normal adults and victims of mild brain injury. The sample included nearly 500 individuals with no history of neurologic problems, 56 individuals with clinical depression and 40 individuals with a history of mild head injury. The results revealed moderate to high correlations between reports of PCS, depression and anxiety symptoms. This finding is consistent with previous research. Interestingly, individuals with clinical depression scored significantly higher for self-report of PCS symptoms than either normal adults or for that matter, mild head injury victims.

It appears likely that depression often co-exists with other clinical conditions including head trauma. Depressed individuals, even those with no established health problems, often report more frequent and more severe health symptoms than those who are not depressed. This appears true for a wide range of symptoms, including those that do not appear in any logical way related to the syndrome of depression. It would appear that in individuals experiencing minor closed head injury subsequently reporting prolonged post-concussive symptoms appearing out of proportion to what is known about the nature and severity of their injury, an escalation of symptom problems may be the result of depression. It remains to be determined whether affective changes following head injury such as those related to depression might also be the result of neurologic impairment combined with chronic pain and life style change. Very clearly, additional research needs to be conducted and will be over the coming five to ten years. However, in the interim, the prudent, science-based forensic neuropsychologist must provide a reasoned and reasonable theory of etiology when evaluating individuals experiencing chronic symptoms of minor closed head injury presenting with psychiatric changes, including depression and anxiety.

References

Gouvier, W.D., Cubic, B., Jones, G., Brantley, D., & Cutlip, Q. (1992). Post-concussive symptoms and daily stress in normal and head injured college populations. Archives of Clinical Neuropsychology, 7, 193-211.

Fox, D.D., Lees-Haley, P.R., Earnest, K., & Dolezal-Wood, S. (1995). Base rates of post-concussive symptoms in health maintenance organization patients and controls. Neuropsychology, 9, 606-611.

Lees-Haley, P.R. & Brown, R.S. (1993). Neuropsychological complaint base rates of 170 personal injury claimants. Archives of Clinical Neuropsychology, 8, 203-209.

Oddy, M., Humphrey, M., & Uttley, D. (1978). Subjective impairment and social recovery after closed head injury. Journal of Neurology and Neurosurgery and Psychiatry, 41, 611-616.

Trahan, D.E., Ross, C.E., & Trahan, S.L. (2001). Relationships among post-concussional -type symptoms, depression and anxiety in neurologically normal young adults and victims of mild brain injury. Archives of Clinical Neuropsychology, 16, 435-445.