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Postconcussive Syndrome Psychiatric Care Clinical Presentation

  • Author: Roy H Lubit, MD, PhD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: May 09, 2016
 

History

Rapid improvement of head injury typically occurs within the first 6 months and often continues for 18 months. Problems continuing after 18 months usually continue indefinitely. Headache, dizziness, memory impairment, and fatigue are present in 30-50% of people during the first month after a mild head injury. In a prospective study of mild CHI conducted in Belfast, these symptoms disappeared within 6 months in 52% of cases and persisted in 16%. Of survivors, 32% reported a worsening of symptoms between 6 weeks and 6 months.

Significant functional impairment, marked by unemployment and marital dysfunction, typically accompanies postconcussive syndrome. In research populations, involvement in litigation plays a relatively small role in either the genesis or the resolution of patients' complaints.

Patients treated for sequelae of head injury should be screened for the development psychiatric[11] or neurologic problems, including the following:

  • Irritability
  • Sleep problems
  • Concentration and attention issues
  • Headaches
  • Dizziness
  • Apathy and depression: Rates of apathy have been assessed to be occur in 23-71% of patients; it results from disruption of frontal-subcortical pathways. Apathy can be measured by the Apathy Evaluation Scale (AES) and Apathy sub-scale of the Frontal Systems Behavior Scale (FrSBe-A)
  • Anxiety disorders, such as panic disorder, agoraphobia, and generalized anxiety
  • Impulsivity and social inappropriateness
  • Seizure disorder
  • Suicide risk
  • Homicide risk: Because of their impulsivity and impatience, persons with head trauma can be combative to others, including family members and caregivers.

Standard rating scales, especially the Hamilton Depression Rating Scale and the Positive and Negative Symptom Scales, are sometimes useful.

Also inquire about subsyndromal complaints and nonspecific somatic distress, especially fatigue and headache. These, along with irritability, anxiety, apathy, and dysphoria, are cardinal features of postconcussive syndrome. Seizure phenomena, especially partial-complex seizures, should be explored specifically.

The nature and severity of head trauma affect the nature and severity of sequelae. Obtain information from patients and usually from their hospital records about the injury, the immediate sequelae including unconsciousness and seizures, and the medical treatment received.[10, 12]

Neuropsychological testing is the most sensitive means of characterizing the cognitive deficits of survivors of head injury.

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Physical

Neurologic examination should include special attention to the following:

  • Cranial nerves: Anosmia stems from damage to the olfactory tracts, confirming injury to the limbic system. Visual-field mapping may identify damage to the optic nerves. Nystagmus may reflect subtle labyrinth injury.
  • Weakness: Hemiparesis may reflect diffuse axonal injury (DAI).
  • Cerebellar signs include dysmetria and nystagmus.
  • Signs of parkinsonism, including tremor, cogwheeling, and abnormal gait, confirm damage to the basal ganglia.
  • Mental status examinations should be conducted repeatedly, with the date and time carefully noted, to follow changes over time.
  • Mental status:
    • Orientation: Patients with postconcussive syndrome may or may not be oriented to time and place. Disorientation is a very serious sign.
    • Appearance: Grooming and hygiene are usually intact, but in severe cases self-care declines.
    • Affect and mood: Depression, anxiety, labile mood, irritability or apathy may be present.
    • Speech: Fluidity may be impaired.
    • Concentration: Concentration is often significantly impaired.
    • Memory: Short-term memory and ability to learn new things is often impaired. Remote memory is intact.
    • Psychomotor activity: Patients are often slowed up but could be agitated from lack of control and stress.
    • Energy: Patients are easily fatigued.
    • Sleep: Patients are often disordered.
    • Headache: Headache is often present.
    • Dizziness or vertigo: Dizziness or vertigo is often present.[13]
    • Suicidal ideation: Suicidal ideation is a significant consideration in severe cases.
    • Homicidal ideation: Homicidal ideation is not typically associated with patients with postconcussive syndrome.
    • Delusions and hallucinations: Delusions and hallucinations are not part of the syndrome.
    • Comprehension: Comprehension may be impaired in severe cases.
    • Insight: Insight is variable.
    • Judgment: Patients with postconcussive syndrome may have impaired judgment from impaired cognitive abilities.
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Causes

Causes of head injury in civilian populations include the following:

  • Car accidents (50%)
  • Falls (21%)
  • Assault (12%)
  • Recreational activity (10%)

Roughly 50% of these injuries are associated with alcohol use.

In children, bicycle accidents are a significant cause of head injury, a clear indication for the need to wear a helmet when riding a bicycle.

Among infants, most injuries reflect child abuse.

Elderly patients are especially vulnerable to falls.

Increased survival following severe injury contributes to the increasing overall number of people in need of treatment for late sequelae.

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Complications

Complications of postconcussive syndrome includethe following:

  • Subdural and epidural hematomas
  • Seizures
  • Early-onset dementia
  • Personality change
  • Impulsivity
  • Aggression
  • Exacerbations of preexisting psychiatric disorders, including preexisting dementia
  • Memory problems
  • Concentration problems
  • Sleep problems
  • Impaired cognition
  • Impaired multitasking
  • Anxiety
  • Depression
  • Suicide attempts
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Contributor Information and Disclosures
Author

Roy H Lubit, MD, PhD Private Practice

Roy H Lubit, MD, PhD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Jennifer S Morse, MD Associate Medical Director, Optum Health

Jennifer S Morse, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Aerospace Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Julia Frank, MD to the development and writing of this article.

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