Psychosocial Factors to Consider in the Treatment of Concussion and Postconcussive Syndrome
To fully and appropriately treat a patient with a concussion, or mild traumatic brain injury, a clinician needs to take into account the impact of psychosocial factors. Psychosocial factors include previous psychological health disorders (e.g., depression, anxiety, substance use, etc.), insomnia, social support systems (e.g., family, school, community, etc.), psychosocial stressors, and coping strategies, to name a few. These are important to consider for differential diagnosis between the symptoms of concussion and other comorbid factors which might provide a broader context for evaluating and treating symptoms.
Possible cognitive symptoms of concussion include deficits in attention, memory, executive functioning, complex problem solving, word finding, and pragmatic or social skills difficulties. Typically, a patient having sustained a concussion will experience a full recovery within 2-3 weeks; atypical recovery, with symptoms progressing a month or longer is typically labelled post-concussion syndrome (PCS). In many cases, PCS is consistent with an underlying psychological health disorder or other non-brain injury related influences. Patients experiencing symptoms continuing past a month should consider a comprehensive a comprehensive biopsychosocial approach to evaluation in order to accurately target underlying factors which might be maintaining symptoms. Concussions often occur in the setting of a traumatic event (e.g., assault, motor vehicle accident, fall) ; as such, the psychological impact may effect recovery. Psychological health disorders, such as depression, anxiety, attention-deficit hyperactivity-disorder, and bipolar disorder, may have similar symptoms to concussion. Broshek, Marco, and Freeman (2015) note that “pre-morbid and concurrent anxiety increases the risk for prolonged concussion recovery.” Other potential influences on prolonged recovery from concussion include a somaticizing coping style, the presence of secondary gain or financial incentives.
Symptoms of PCS are non-specific and include fatigue, dizziness, poor concentration, memory problems, headache, and irritability. For those diagnosed with PCS, studies show that the prevalence of a pre-morbid anxiety or psychological health disorder are high (Meares et. al, 2008). Meares and colleagues (2008) also show that a diagnosis of PCS may not always be associated with a brain injury, but can be a result of trauma exposure, so again, differential diagnosis is important in treatment. In contrast, the misattribution of diffuse symptoms (some of which might predate the concussion) exclusively to brain injury risks iatrogenesis and a poor prognosis for recovery for long-term functional recovery.
When evaluating and possibly beginning treatment for a patient having sustained a concussion, it is ideal (albeit rare) to have an interdisciplinary team comprised of neurology, speech pathology, occupational therapy, physical therapy, neuropsychology and psychiatry and social work. The inclusion of psychological health providers on concussion teams maximizes the chances that comprehensive evaluation and differential diagnosis of premorbid psychological health disorders, comorbid concussion and psychological health disorders, and/or PCS will occur.
- Broshek, D. K., De Marco, A. P., & Freeman, J. R. (2015). A review of post-concussion syndrome and psychological factors associated with concussion. Brain Injury, 29(2), 228-237.
- Meares, S., Shores, E. A., Taylor, A. J., et al. (2008). Mild traumatic brain injury does not predict acute postconcussion syndrome. Journal of Neurology, Neurosurgery & Psychiatry, 79(3), 300-306.