Psychiatric Sequelae of Concussions 2/1/2018

Concussion, defined as a head injury with a temporary loss of brain function, is the most common type of traumatic brain injury. There is typically not a loss of consciousness associated with most concussions, and the sequelae are typically temporary. Concussion can cause a variety of physical, cognitive, and emotional symptoms. This article is going to focus primarily on the emotional and behavioral symptoms that are associated with concussion. These symptoms may be difficult to recognize if the presentation is subtle, which is highly likely given that most concussions do not have associated loss of consciousness. Diagnosis can be complex also because the symptoms of concussion can overlap with other conditions, which is why a thorough history is so important.

Emotional and behavioral signs of concussion can include irritability, sleep disturbance, loss of interest in favorite activities, tearfulness, restlessness, lethargy, and incongruent affect. Cognitive symptoms can include slowed reaction times, confusion, disorientation, and difficulty focusing attention, difficulty with reasoning, and change in speech pattern. Research shows that these psychologically-based symptoms are most likely caused by reversible pathophysiological changes in cellular function that occur after a concussion, rather than structural changes, which can explain why the dysfunction is temporary in most cases.

Cognitive rest, including reducing activities that require concentration and attention such as school work, video games, reading, and texting, should continue until all symptoms have resolved, which is typically 7-10 days. The recovery time may be longer in children and adolescents. Medications for sleep can be prescribed on a short-term basis if needed. The emotional and behavioral symptoms mostly resolve on their own, but therapy can be provided if the symptoms are impairing in the home and school settings. It is important to provide psychoeducation on the etiology and temporary nature of the symptoms to patients and their families.

In certain cases, symptoms do not resolve for months and may occasionally be permanent. This is called post-concussive syndrome. Psychiatric symptoms of post-concussive syndrome include fatigue, anxiety, memory problems, problems with inattention, sleep problems and irritability. In these cases, there is a debate if the symptoms of post-concussive syndrome are due to underlying structural damage rather than a functional phenomenon and that is why the symptoms last longer than expected.

There are psychiatric sequelae that can occur after repeated concussions, including depression and dementia. Epidemiological research shows depression and dementia occur at a higher rate for people who have suffered more than one concussion, removing other confounding variables. Recent studies have also shown that early exposure to activities like football before age 12 increases the risk of depression and apathy compared to waiting until adolescence to begin these activities. This is also important psychoeducation to provide to patients and families when considering activities that can put children and adolescents at risk for repeated concussions.

It is our hope that this article is a helpful primer on behavioral and emotional concerns related to concussions.

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