Understanding Post-Concussion Syndrome

I spend most of my professional time as a general psychiatrist. However, I also practice forensic psychiatry, the subspecialty of psychiatry that deals with mental health issues and the law. A frequent request from an attorney involves examining a claimant who asserts mental health issues after suffering a concussion. A percentage of these individuals suffer from post-concussion syndrome.

Dr. “A” was injured in a motor vehicle accident when the Lyft she hired was rear-ended. Subsequently, she complained of neck and back pain as well as cognitive disturbances. These included headaches, problems with memory and concentration, and a lack of a “filter,” so she often spoke before thinking, saying hurtful things to her friends, coworkers, and family, all of which is out of character. She has a Ph.D. in one of the natural sciences.

At the time of my evaluation, she was seeing a psychiatrist for medication management due to depression. She described her current mood as “not too bad.” At times, she was very irritable. She had a “complete breakdown” in her sleep cycle following her injury. This resolved when a sleep specialist prescribed medication that allowed her to sleep 6-7 hours per night.

She told me that her memory was “terrible,” and she was having difficulty concentrating. The neuropsychological testing report ordered by her attorney noted “intellectual functioning that remained very strong across both verbal and nonverbal abilities. However, weaknesses noted included ‘difficulty initiating tasks and problems, recalling complex geometric designs not consistent with her level of education.’”

What Is Post-Concussion Syndrome?

According to the Concussion Legacy Foundation, a concussion is a type of traumatic brain injury, or TBI, caused by an impact on the body resulting in a rapid back-and-forth movement of your brain inside your skull. This sudden movement can stretch and damage brain tissue and trigger a chain of harmful changes that interfere with normal brain activities. Since your brain is your body’s control center, the effects of a concussion can cause disability in all of your brain functions. These may include but are not limited to vision, hearing, balance, memory, a feeling of “fogginess,” mood changes, problems with temperature and blood pressure, and sleep disorders.

For most people, symptoms will clear in a matter of days or weeks, depending on the severity of the injury. However, for 10-30 percent of people, an extended recovery with persistent symptoms will develop a post-concussion syndrome. Headache is the most common and long-lasting symptom. Over 50 percent of individuals experience this symptom even one year after the initial injury. Patients with post-concussion syndrome often describe problems with sleep, memory, concentration, increased irritability, and mood changes. Up to 75 percent of TBI patients suffer from major depressive disorder.

When you have a concussion, your immune system responds to the injury by causing inflammation near the injury site. The affected parts of your brain experience a temporary breakdown of structures in and around those cells. This results in an oxygen deficit your brain typically uses to accomplish a task. Because of neuroplasticity, other parts of your brain attempt to take over. However, this process is less efficient, resulting in the deficits described by sufferers.

Treatment Options

Current treatment recommendations for post-concussion syndrome involve multiple modalities.

• Rest: The most common recommendation following a concussion is symptom-limited cognitive and physical rest for at least 24-72 hours. This includes sleep, low levels of light and noise, and limited screen time. Rest is recommended because your brain is vulnerable after an injury.
• Physical therapy: The idea of exercise after a head injury may sound counterintuitive. Indeed, a period of rest is recommended. However, prolonged rest may worsen your symptoms. After a concussion, there may be damage to a part of your nervous system that is not under voluntary control. This is called the autonomic nervous system, a part of which (sympathetic) is involved in the “fight or flight” response during a perceived threat, and also the parasympathetic, which is involved in relaxation after the danger is over. After a concussion, your body may remain in the “fight or flight” mode, leading to an elevation in your heart rate, slowed digestion, and increased anxiety. Exercise stimulates your parasympathetic nervous system.

An article published in The International Journal of Sports Physical Therapy reviewed multiple studies on physical exercise of varying degrees after a head injury. The results of this systematic review indicate there is evidence supporting the use of physical therapy interventions, including aerobic or multi-modal treatments, for patients after a concussion.

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• Vestibular therapy: Vestibular rehabilitation therapy involves exercises that help you manage dizziness and balance. Exercises may include eye movement control, balance retraining, stretching, and strengthening your muscles.

A recent study published in Healthcare reported the positive effects of vestibular therapy for patients with traumatic brain injuries. Specifically, the researcher noted decreased reports of dizziness, improved gait, and self-reported improved quality of life.

• Cognitive behavioral therapy: CBT is based on the idea that how we think, feel, and act are all closely related and can be helpful for people who have suffered a traumatic brain injury. Many people with TBI struggle with depression or anxiety because of fear of further injury or loss of functioning. Someone with a brain injury might be anxious about situations that present the possibility of another injury occurring. CBT would help identify this fear and develop alternative ways of thinking and coping.
• Medication: A common complaint in those who have experienced a brain injury is memory loss and poor concentration. Many of the patients I see after this type of injury look as if they have attention deficit disorder even though they have no prior history. Short-term use of stimulant medications that are used to treat those who suffer from ADD also works for patients with post-concussion syndrome. These medications can aid in improving daytime energy and can assist with cognitive skills. They work quickly, often within 30 minutes, and do not last more than a few hours, so their effectiveness is predictable and timed to accommodate individual patient’s needs and schedules.

Depression is the most common psychiatric disorder after a TBI, with a prevalence of over 25 percent. A 2022 study published in Cureus found a significant proportion of people who had a mild traumatic brain injury (MTBI) later developed depression or anxiety. The current literature regarding antidepressants for those who have suffered a TBI is mixed. A study published in The Journal of Neuropsychiatry suggests that pharmacological treatment may be mild to moderately effective in treating depression following a TBI. Nevertheless, untreated depression in this population is associated with worse psychosocial functioning, cognition, and reintegration into the community. Some studies of antidepressant treatment after TBI indicate that certain classes of medication are more effective. These are the selective serotonin reuptake inhibitors (SSRIs), with Zoloft and Celexa having the fewest side effects.

As many as 3.8 million concussions occur each year, and almost half of concussions that occur go undetected and untreated. The good news is that most deficits are not permanent, and with appropriate diagnosis and treatment, many can be reversed with a multiple-disciplined approach.