Postconcussive Syndrome Psychiatric Care Clinical Presentation

Updated: Jul 25, 2019
  • Author: Roy H Lubit, MD, PhD; Chief Editor: David Bienenfeld, MD  more...
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Presentation

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.

Symptoms

Physical

Physical symptoms include:

  • Headache

  • Dizziness

  • Fatigue

  • Trouble sleeping

  • Vision problems

  • Discomfort with noise and light

  • Seizures

  • Assaultive behavior

  • Sleep apnea

  • Tinnitus

Cognitive

Cognitive or mental symptoms include:

  • Memory problems

  • Concentration/focusing problems

  • Impulsivity

  • Slowed processing of information

  • Trouble putting thoughts into words

Emotional

Emotional symptoms include:

  • Depression

  • Anger outbursts and quick to anger

  • Anxiety (fear, worry, or feeling nervous)

  • Personality changes

  • Apathy

Rating scales can help assess and track symptoms, including the following:

  • Beck Depression Index or PHQ-9

  • Apathy Evaluation Scale (AES) and Apathy sub-scale of the Frontal Systems Behavior Scale (FrSBe-A) 

  • Global Assessment of Migraine Severity (GAMS) and Migraine Disability Scale (MIDAS)

Obtain information from patients, ambulanc hospital records about the injury, the immediate sequelae including unconsciousness and seizures, and the medical treatment received. [17, 18]

Rates of apathy have been assessed to be occur in 23–71% of patients; it results from disruption of frontal-subcortical pathways. 

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. [19]

    • 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. Lacrosse, football, and soccer are the most dangerous sports. Simply repeatedly heading balls in soccer practice is harmful.

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 include the following:

  • Memory problems

  • Concentration problems

  • Irritability

  • Sleep problems

  • Impaired cognition

  • Impaired multitasking

  • PTSD

  • Anxiety

  • Depression

  • Suicide attempts

  • Subdural and epidural hematomas

  • Seizures

  • Early-onset dementia

  • Personality changes

  • Impulsivity

  • Aggression

  • Exacerbations of preexisting psychiatric disorders, including preexisting dementia

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