eMedicine Specialties > Psychiatry > Psychosomatic

Postconcussive Syndrome: Follow-up

Author: Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice
Contributor Information and Disclosures

Updated: Oct 1, 2008

Follow-up

Deterrence/Prevention

• Primary prevention of head injury involves the use of protective gear in contact sports, seat belts, bicycle and motorcycle helmets, and hard hats in appropriate jobs.
• For elderly patients, altering the environment to minimize the risk of falls is important.
• Protecting children from child abuse helps prevent head injuries.
• Patients who have had one head injury are at risk for others.
• Identification and treatment of substance abuse makes subsequent injury less likely.
• Some patients with head injury are parasuicidal. They may benefit from treatment of depression, character disorders, and other conditions associated with suicide.
• Restricting return to play for athletes prevents SIS.
• Prevention of sequelae in patients once they have been injured is an active area of research. Recent reviews of the subject suggest hypothermia during the period of coma may mitigate tissue damage. Prophylactic use of anticonvulsants is not recommended.

Complications

• Reactions to anticholinergic, analeptic, and parkinsonian adverse effects of medication
• Subdural and epidural hematomas
• Hydrocephalus
• Partial complex or grand mal seizures
• Exacerbations of preexisting psychiatric disorders, including preexisting dementia
• Conversion symptoms
  • Conversion symptoms typically occur when a person feels trapped in a threatening situation, especially if he or she is unable to openly talk about the dilemma with others who are trusted.
  • Patients with head injury often face such dilemmas, being forced to return to work when they feel unable, being expected to perform normal family roles despite significant problems of cognition or mood, and being subject to hostile legal scrutiny. Moreover, the head is a symbolically significant part of the body. For all of these reasons, some of the nonspecific distress of patients with head injury and, more rarely, some of their focal complaints may be understood as conversion symptoms or somatization.

Prognosis

The prognosis of mild or moderate dementia and PCS remains difficult to provide with certainty. Some patients recover fully from severe injuries with prolonged coma; others remain disabled for long periods after much milder insults.

Patient Education

Patients with dementia

• These patients need simple explanations of their impairments. While they may be aware of cognitive dysfunction, they may lack insight into impairments in judgment, changes in personality, elevated mood, or paranoid symptoms. Education should include the expected course of improvement, with the greatest improvement expected in the first 6 months but delayed improvement possible as long as 5 years after injury.
• Caretakers of patients with dementia need a great deal of ongoing education and support. Importantly, the patient's environment must be neither tedious nor overstimulating. Maintaining consistent routines of light and dark, eating, sleeping or lying in bed, performing bathroom activities, and participating in therapeutic or recreational activities help patients remain emotionally balanced and minimize caregiver burden.
• Keeping the environment safe by eliminating area rugs to reduce falls, providing tub bars, and putting child locks on cabinets or stove knobs also is important in the care of patients with dementia. If the patient is capable of going out alone, the caregiver should ensure that he or she knows the routes well, carries identification, wears a medic alert bracelet, and knows how to use phones (especially cell phones) and busses.
• Caregivers for patients with mild dementia need to decide whether the person should continue to have access to checking accounts or credit cards. If the person is willing and competent, the caretaker should consider getting power of attorney, in order to monitor the person's use of financial resources. If the patient has markedly poor judgment or seems seriously incompetent, the caregiver should seek formal conservatorship, to have legal authority to manage the person's resources.
• Caregivers should be included in the patient's relationship with health care professionals. They should be specifically told to seek help if the patient has very disrupted sleep; does not eat a balanced diet; or is incontinent, aggressive, or sexually inappropriate. Any marked change in behavior should prompt a call to the clinician. Because patients with dementia do not always show typical symptoms when acutely ill, taking the patient's temperature and looking for signs of infection is a particularly important step if the patient shows a change.
• Clinicians, in turn, must be accessible to caregivers. Meeting with more than one family member to stress the importance of having family members and friends share the burdens of providing care often is an overlooked step. Although one particular friend or relative may know the most about a patient and assume most of the responsibility, sharing this with others reduces the likelihood of the caregiver becoming isolated or depressed, an otherwise common outcome of providing long-term family care.

Patients with postconcussional syndrome

• Patients with PCS need to know that headaches, dizziness, fatigue, irritability, poor concentration, and decreased memory are common in the first 3-6 months after injury. These symptoms fully resolve in most patients after mild injury. However, persistent impairment is possible. Patients should know that anxiety, depression, decreased concentration, and other persistent symptoms may improve with rehabilitation, psychological support, and medication.
• Caregivers need to adopt a posture of encouragement and expectation that the patient will try to be as independent and productive as possible. At the same time, caregivers need to be patient and tolerant. They should accept that the patient may have real limitations and that these will likely worsen if the person is tired, ill, or acutely stressed. Emphasizing what the person can still do, rather than what seems to be lost, is generally helpful.

Online resources

• The traumatic brain injury page of the National Institutes of Health contains links to other organizations providing education and support (see National Institute of Neurological Disorders and Stroke).
• CDC, What is Traumatic Brain Injury?
• MayoClinic.com, Traumatic Brain Injury
• WebMD, Dementia in Head Injury
• For excellent patient education resources, visit eMedicine's Dementia Center and Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Dementia in Head Injury, Dementia Overview, Dementia Medication Overview, and Concussion.

Miscellaneous

Medicolegal Pitfalls

• In treating patients with head injuries, the physician needs to know if the patient is involved in litigation related to the injury.
  • Anticipate having to testify in depositions or court proceedings.
  • Document impairment and objective findings clearly, quantifying symptoms and progress in recovery whenever possible.
  • When called to testify, be aware of personal attitudes towards patients who are dependent, not improving quickly, not functioning to their ability, or expressing undesirable attitudes of resentment or entitlement. None of these factors should blind the physician to the reality of patients' distress and impairment. Testifying for either the defendant or the plaintiff in a head injury case requires honesty, humility, and awareness of the uncertainty surrounding the causes and the outcomes of the symptoms that patients develop.
• Involvement in litigation does not reliably predict the severity or extent of symptoms after head injury. Settlement of pending lawsuits also does not cause resolution of symptoms.
• When people have prominent severe problems of information procession or frontal lobe deficits manifested by impulsivity and poor judgment, they may be incompetent to make medical decisions or handle their own affairs. Guardianship, conservatorship, or some other protective legal arrangement may be needed. Physician evaluation typically is required, unless the person is competent enough to sign a power of attorney or designate a substitute payee.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Julia Frank, MDto the development and writing of this article.

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