A controlled historical cohort study on the post-concussion syndrome

A controlled historical cohort study on the post-concussion syndrome

D. Mickevi ienea, H. Schraderb, K. Nestvoldc, D. Surkiened, R. Kunickase, L. J. Stovnerb and
T. Sandb

In Lithuania, expectation of chronic symptoms after minor head injury is less

than in western countries and possibilities for monetary compensation are
minimal. Therefore, an opportunity exists to study the post-concussion
syndrome (PCS) without several confounding factors present in western
societies. We sent questionnaires about symptoms attributed to PCS to 200
subjects who had a concussion with loss of consciousness between 35 and
22 months before the study. For each study subject, a sex- and age-matched
control person with minor non-head injury was identified. These controls
received similar questionnaires. All the responding post-concussion patients
stated that they had had acute headache after the trauma but this headache had
disappeared in 96% of cases within 1 month. Headache and dizziness at the
time of the questioning were not significantly more prevalent in the patients
with concussion than in the controls, and there was no significant difference
concerning subjective cognitive dysfunction. Scores of visual analogue scales
of symptoms attributed to PCS showed no significant differences except for
depression, alcohol intolerance and worry about brain injury, which were
more frequent in the concussion group. No specific effect of the head injury
was detected when various definitions and different constellations of core
symptoms of PCS were used. These findings question the validity of the PCS
as a useful clinical entity

“Expectation as etiology” versus “the good old days”: Postconcussion syndrome

symptom reporting in athletes, headache sufferers, and depressed individuals

JOHN GUNSTAD a1 and JULIE A. SUHR a1 c1

a1
Psychology Department, Ohio University, Athens, Ohio

Abstract

The present study explored the explanatory power of Mittenberg's “expectation as etiology”
theory for the persistence of postconcussion syndrome (PCS) complaints. One hundred
forty-one participants completed a PCS symptom checklist under 2 conditions. Normal
controls, healthy athletes and depressed individuals reported current symptoms and
symptoms expected following a hypothetical mild head injury. Head-injured athletes,
chronic headache sufferers, and a 2nd sample of normal controls reported current
symptoms and retrospective symptoms (prior to their injury/illness or from some point in
the past). Depressed individuals reported more current symptoms than normal controls and
healthy athletes, demonstrating that “PCS” symptoms are not specific to PCS. All groups
expected more symptoms following mild head injury than currently experienced,
supporting the idea that individuals expect negative consequences following head injury.
However, healthy athletes expected fewer symptoms than normals or depressed individuals,
possibly due to preexisting expectations for speedy recovery. Both head-injured athletes
and headache sufferers reported more current symptoms than the past, but not at a rate
lower than baseline of normal controls. Results suggest that the “expectation as etiology”
hypothesis may be too specific, and that, following any negative event, people may
attribute all symptoms to that negative event (the “good old days” hypothesis). (JINS, 2001,
7, 323–333.)

Classifying
MHI based on physical signs and symptoms at the time of the injury reduces the
confounding factors of compensatory coping mechanisms, development of emotional
symptoms, the stress of litigation, and psychosocial factors that affect functioning several
weeks to several months or years after the injury. However, at the time of an initial
assessment, the presence of alcohol in many cases of MHI causes the degree of alteration of
consciousness to look more severe than itactually is (Dikmen, S., & Levin, H.S. (1993).
Methodological issues in the study of mild head injury.
Journal of Head Trauma Rehabilitation, 8, 30-37.).

Table 1 Adjusted relative risk of traumatic brain injury (TBI) by indicators of psychiatric
illness in the year before TBI diagnosis or reference date
Controls
Cases (n=1440)(n=4320) (n Adjusted
Psychiatric illness indicator (n (%)) (%)) relative risk* 95% CI

Psychiatric ICD-9-CM diagnosis

Acute reaction to stress or 48 (3.3) 62 (1.4) 1.9 1.3 to
adjustment reaction 2.9
Alcohol or drug intoxication, 34 (2.4) 51 (1.2) 1.6 1.0 to
withdrawal, or dependence 2.6
Anxiety 26 (1.8) 38 (0.9) 1.5 0.9 to
2.6
Depression 54 (3.8) 87 (2.0) 1.4 1.0 to
2.0
Hyperkinetic disorder 14 (1.0) 48 (1.1) 0.7 0.4 to
1.3
Malaise or fatigue 44 (3.1) 64 (1.5) 1.7 1.1 to
2.6
Organic non-psychotic 10 (0.7) 6 (0.1) 4.4 1.6 to
disorders 12.5
Organic psychotic disorders 15 (1.0) 11 (0.3) 3.7 1.6 to
8.7
Schizophrenia, hallucination, or 17 (1.2) 26 (0.6) 1.9 1.0 to
paranoia 3.7
Somatoform disorders 19 (1.3) 14 (0.3) 2.8 1.3 to
5.8
Other 70 (5.0) 124 (2.9) 1.3 1.0 to
1.9
Psychiatric medication
prescription
Anxiolytics 27 (1.9) 25 (0.6) 2.4 1.3 to
4.2
Antidepressants 57 (4.0) 89 (2.1) 1.5 1.1 to
2.2
Antipsychotics 18 (1.3) 19 (0.4) 2.7 1.3 to
5.5
Lithium 6 (0.4) 11 (0.3) 1.6 0.6 to
4.4
Psychostimulants 3 (0.2) 13 (0.3) 0.5 0.2 to
1.9
Major psychiatric illness
indicators
Psychiatric ICD-9-CM 262 (18.2) 420 (9.7) 1.7 1.4 to
diagnosis 2.0
Psychiatric medication 85 (5.9) 136 (3.2) 1.6 1.2 to
prescription 2.1
Psychiatric service utilisation 151 (10.5) 307 (7.1) 1.3 1.0 to
1.6
Psychiatric diagnosis and 66 (4.6) 94 (2.2) 1.7 1.2 to
medication 2.3
Psychiatric diagnosis and 73 (5.1) 126 (2.9) 1.3 1.0 to
utilisation 1.8
Psychiatric medication and 42 (2.9) 76 (1.8) 1.3 0.8 to
utilisation 1.9
Diagnosis, medication, and 32 (2.2) 51 (1.2) 1.3 0.8 to
utilisation 2.1
Any psychiatric illness 349 (24.2) 618 (14.3) 1.6 1.4 to
1.9

*Relative risk adjusted for age, sex, reference date, and Ambulatory Care Group. Reference
group is made up of those without each specific indicator.
Lower limit rounded down to 1.0.
Determined by psychiatric ICD-9-CM (International Classification of Diseases, 9th
revision, clinical modification), diagnosis, psychiatric medication prescription, or
psychiatric service utilisation.
CI, confidence interval.
94). Moreover,
the diagnosis post-concussion disorder (PCD), by the American Psychiatric Association
( DSM IV) (95) demands specific criteria with 3 or more symptoms present for at least 3
months following the head injury and evidence from neuropsychological testing of
difficulty in attention or memory (DSM IV) (95).
There are studies which have identified several general risk factors of persistent symptoms
and slow recovery after MTBI. Some of these factors are female gender, age over 40 years,
prior MTBI, malingering, alcohol abuse (73, 96-98). The WHO collaborating centre task
force on mild traumatic brain injury reported that litigation/compensation was consistently
identified as a prognostic factor for delayed recovery, and little consistent evidence for
other predictors was found
Alcohol intoxication indicative of hazardous alcohol drinking (i.e. dependent drinking
and frequent binge drinking) is a common finding in trauma patients, and more
common in head injury patients than in those with other types of trauma. Binge drinking
is the predominant pattern of alcohol drinking in trauma patients, and particularly
in head trauma patients.

EFNS guideline on mild traumatic brain injury: report of an EFNS task force
European Journal of Neurology 2002, 9: 207–219