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Forensic Updates

New Data on Persistent Post Concussive Disorder

Dr. Sam Goldstein

One of the most common, acute outcomes of mild to low moderate TBI are a set of physical, emotional and cognitive symptoms currently forming a syndrome known as Post Concussive Disorder. Typically, this condition includes physical or somatic symptoms such as headache, dizziness and visual disturbance, neuropsychological impairments such as difficulty with attention, memory and executive functioning, and emotional or behavioral problems, including irritability, anxiety, depression, emotional ability, apathy and impulsivity. In the DSM-5 diagnostic manual Post Concussive Disorder is now subsumed under the heading of Minor Neurocognitive Disorders.

In most children a Post Concussive Disorder fully resolves in four to twelve weeks following mild head injury. However, up to 30% of children with a mild TBI do not exhibit the typical recovery and develop Persistent Post Concussive Disorder (PPCD). For some children, this lingers for months and even years after injury. Presently defined, PPCD represents symptoms enduring for longer than three months. This phenomena presents in adults as well with up to eighteen months often cited as a typical recovery period.

Perhaps no issue has led to as much disagreement among neuropsychologists as opinions about the nature of, and reasons for, PPCD, typically occurring in individuals suffering from mild to moderate traumatic brain injuries. The persistence of cognitive, emotional and physical symptoms in a small group of individuals suffering from mild to moderate TBI, well beyond the expected time frame, is equally frustrating for patients expecting to recover as well as their treaters. The second group often assuring patients that full recovery is nearly always achieved. Unfortunately, a small percentage of patients do not recover and continue to experience chronic problems. For some, compounding medical or psychological issues offer some explanation for their failure to recover. For others, however, failure to recover is often perplexing and unexplained by available science.

In the last five years, there has been increasing research interest in attempting to understand the variables within the person, immediate environment and extended environment that may contribute to PPCD. In this forensic update, I will briefly summarize a number of recent studies and provide a brief bibliography of relevant research.

Efforts have been undertaken to identify patients with TBI at risk to experience PPCD in an effort to help those who may struggle during the immediate process of recovery. Although most individuals recover fully following a mild traumatic brain injury, a minority (15% to as high as 25% of all adult patients) develop persistent post traumatic complaints that interfere with the resumption of previous activities. In 2015 by Scheenen and colleagues, attempted to compare a group of patients with many post-TBI complaints with patients with few to no complaints in an effort to identify potential, additional discriminating characteristics between them as well as to evaluate which of these factors had the most predictive value for placing an individual at risk. These researchers evaluated coping style, presence of psychiatric history, injury characteristics, mood related symptoms and Post Traumatic Stress Disorder. They studied over 800 patients admitted to three trauma centers with Glasgow Coma Scores of 13 to 15 (lower scores are problematic; 15 is a full score). Two weeks after injury, 60% of patients reported 3 or more complaints. Twenty-five percent reported few complaints. Finally, 15% reported no complaints. Among those with higher initial complaints were more females (78% versus 73% and 52%), a psychiatric history (7% versus 2% versus 5%) and a higher number with depression (22% versus 6% versus 3%), anxiety (25% versus 7% and 5%) and post traumatic stress (37% versus 27% versus 19%) than the low and zero complaint groups. These data provided support that etiological factors such as coping style, depression, anxiety and post traumatic stress symptoms are predictors of slower and/or limited recovery over time. However, in and of themselves, these were insufficient to predict who would and would not recover. It appears that from the acute phase of TBI on, there is a complex interplay of neurogenic, psychological and social factors, including the injury itself, life stress, premorbid health and mental health status, playing a role in the recovery process. These data suggest that at risk to not recover post TBI patients should be identified as quickly as possible and provided with a greater degree of support as well as cautionary guidance that their recovery may not match typical individuals.

A similar study was completed by Murray Stein and colleagues in 2016 following a population of over 800 soldiers suffering from mild TBI during deployment. After adjusting for demographic, clinical and deployment related factors, deployment acquired mild TBI was associated with nearly triple the risk of reporting any post-concussive symptom and with increased severity of post concussive symptoms when present. Among those who sustained mild TBIs, severity of post concussive symptoms at follow-up was associated with a history of pre-deployment TBI, pre-deployment psychological distress, more severe deployment stress and loss of consciousness or lapse of memory as result of deployment acquired mild TBI.

A recent article in the Journal of Physical Medicine and Rehabilitation by John Leddy and colleagues (2016), notes that rest has been the mainstay of treatment for concussion. These authors report that concussion places the human brain in a vulnerable state, placing the brain at risk for more debilitating injury should it sustain more trauma or experience undue stress before metabolic homeostasis has been restored. These authors note that the accepted time frame for recovery after a mild to moderate traumatic brain injury is not scientifically established and depends on a broad range of variables. It is the case that symptoms persisting after many weeks may be contributed to by other etiologies. Cognitive, somatic and behavioral symptoms do not always reliably discriminate between patients with physiological Post Concussive Disorder (defined as those with persisting symptoms who demonstrated exercise intolerance on a treadmill test) from patients with cervicogenic and/or vestibular post-concussion disorders (defined as those with persisting symptoms who had normal exercise tolerance but abnormal cervical and/or vestibular physical examinations). These authors also suggested that recent research indicates that prolonged rest beyond the first couple of days after concussion might hinder rather than aide recovery and a more active approach to concussion management should be considered.

As Maayan, Shorer, & Apter noted in 2016 Editorial in the Journal of Traumatic Stress Disorders and Treatment, it is critical to begin moving towards an integrative view on the relationship between PPCS and psychiatric disorders like Post Traumatic Stress Disorder. These authors suggest that clinicians should attempt to view the patient not via a categorical point of view (e.g., do they have one condition or another) but by looking for reciprocal influences between brain injury and an emotional reaction that may be contributed to by multiple additional variables.

Thus far, research concerning the efficacy of psychological interventions for PPCS are limited. There is preliminary research suggesting that cognitive behavioral therapy can be effective when it is focused on the patient’s expectations, stress management and behavioral activation. Other treatment studies focusing on psychoeducational intervention during the acute phase immediately following TBI, found this to be an effective intervention in reducing the risk later on for PPCS. Very clearly, much more extensive research is needed. For the time being, the debate about the etiology of and the reasons that some patients following TBI developing Post Concussion Disorder progress to experiencing PPCS will continue. In the forensic arena, it is important treaters and forensic evaluators make every effort to refrain from taking sides, selectively interpreting the research or accusing patients of not trying “hard enough” or in the extreme, malingering, absent strong supportive evidence.

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