Integrated Model of Psychological Response to Sport-Related Concussion Injury and Rehabilitation
According to the Conceptual Model of Psychological Response to Sport Concussion,4 psychological risk factors before concussion (ie, attention-deficit/hyperactivity disorder or other brain-related disabilities, history of life event stressors or post-traumatic stress disorder, coping style, social support, and existing concussion education) are considered important in influencing how an athlete may cognitively appraise and/or physically respond to a sport-related concussion. Experiencing shifts in attentional focus when placed in a potentially stressful athletic situation can predispose an individual to sustaining a concussion. Along with personal (ie, injury characteristics, anxiety, and depression) and situational (ie, sport, social, and environmental) factors, the aforementioned concussion risk factors are also proposed to influence a range of neurobiological, psychogenic, and pathophysiological causes of concussion. In turn, these will influence a bidirectional cyclical cycle of cognitive, affective, and behavioral symptoms and responses to concussion. Along with psychological care following concussion, these cognitive, affective, and behavioral responses will in turn influence the overall psychological outcomes of concussion.4
When placing Seth's case into the conceptual model, it is clear that Seth's family provided him with a sound social support network. It is also clear that Seth's education before the concussion undoubtedly helped him to be open and honest about his symptoms and progress and adhere to his rehabilitation and return-to-play protocol following the concussion. However, his initial cognitive and affective appraisals of the injury (ie, feeling frustrated because it occurred in a practice setting) along with clear neurobiological, psychogenic, and pathophysiological symptoms (ie, headache, confusion, loss of appetite, and sensitivity to light) likely contributed to his inability to cope with the prolonged symptoms following the concussion. More specifically, it appears that Seth found it difficult to cope with his situation. It is also apparent that all of the cognitive, affective, and behavioral symptoms that Seth exhibited point toward Seth's parents suspecting that their son was suffering from depression.
The suspicion by Seth's parents that Seth was suffering from depression is warranted because several studies have reported a prevalence of depression5–8 and other mood disturbances in athletes with post-concussion syndrome.9–11 Although this might appear to support the notion that individuals diagnosed as having concussion have an increased likelihood of developing depression, this may not always be the case. Evidence also suggests that athletes such as Seth who report and display more severe initial physical, cognitive, and affective symptoms and responses to concussion suffer from a prolonged recovery,3 which may or may not be linked with depression, but rather are symptoms of post-concussion syndrome. Indeed, many of the symptoms of post-concussion syndrome (eg, fatigue, irritability, sadness, and sleep disturbances) are parallel to common symptoms of depression. The many overlapping symptoms between post-concussion syndrome and depression also makes the differentiation between the two diagnoses difficult for both the athlete and the health care/sport medicine professional.3,12 Given the seriousness of both conditions and the difficulty in diagnosis, clinicians working with athletes who have a concussion need to be careful in making a clinical judgment without considering and evaluating the role of all possible physical and psychosocial risk factors, symptoms, and responses following concussion thoroughly.
According to the existing literature, some of the pre-disposing risk factors for post-concussion syndrome include having sustained one or more previous concussions, increasing age, concurrent anxiety, range of trauma-related symptoms, life stressors, and pain.13,14 Limited evidence also exists in support of the role of genetics in predicting a prolonged recovery and post-concussion syndrome following sport-related concussion.3 It is advised that athletes such as Seth should be periodically screened for any potential post-concussion syndrome or mental health risk factors because such baseline data can help clinicians to ensure accurate diagnosis and rule out any clinical mental health conditions following concussion.
Including an appropriately constructed demographic survey and psychosocial assessments on an athlete's physical examination before participation in sport can accomplish the aforementioned suggested prescreening.15 Questions related to concussion history and assessments related to trait and state anxiety,16 depression,17 and history and prevalence of major and minor stressors18,19 would be beneficial. Equally, including assessments such as the Profile of Mood States20 or Brunel Mood States21 would be beneficial because it is known that the existence of mood disturbances before an injury is a risk factor of prolonged recovery.22 Because mood disturbances may also cloud the usefulness of baseline testing,23 regular testing throughout the season would be advisable to ensure a valid baseline for the athlete. Additionally, conducting neuropsychological tests prior to any head-related trauma (eg, Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]; ImPact Applications, Inc., San Diego, CA) would be beneficial in the establishment of a baseline for the athlete.24,25
Through clinical and mental health screenings, clinicians can identify any predisposing risk factors prior to the occurrence of a concussion, thus decreasing chances of making an erroneous post-concussion syndrome or depression diagnosis.12 However, there are a couple of things to note regarding the use of neurological and psychological baseline testing. First, it is imperative to note that many of the psychological assessments should be administered and interpreted by a mental health professional who is qualified to do so.26 Therefore, it is encouraged that sport medicine professionals work together with the appropriate mental health professionals to ensure that appropriate psychosocial13 and neuropsychological3 assessment occurs because they are the cornerstones of concussion diagnosis and management. Second, the feasibility of the aforementioned testing can be unattainable for many schools, especially for those that are not affiliated with a large community hospital or concussion clinic.
In addition to screening for potential risk factors and evaluating the presence of symptoms following concussion, it is also important for clinicians to be mindful of how psychosocial factors can exacerbate the reported symptoms3 and complicate the recovery process.27 For example, according to Broshek et al.,27 experiencing a concussion can “create vulnerability to multiple sources of fear” (p. 233). Fear related to isolation, loss of income/scholarship, loss of starting role, and reinjury are somewhat common among athletes who have a concussion, each of which can influence the ways in which an athlete will respond to his or her situation. In Seth's case, due to his ongoing symptoms with memory, attention, and concentration, he clearly experienced increased worry over his position on the team, which led to increased anxiety over his situation. It is also likely that such worries and anxieties contributed to his sleeping patterns and fatigue (and vice versa), all of which exacerbated his issues with memory, attention, and concentration. It can also be assumed that Seth's lack of interaction and communication with teammates and coaches influenced his prolonged symptoms and lack of recovery; external sources can place undue pressure on the athlete, potentially leading to additional stress on an individual who is operating with “reduced cognitive resiliency”27 (p. 233).
Taking the above into account, it is our professional opinion that Seth should be rediagnosed as having post-concussion syndrome. His main cognitive, emotional, and behavioral symptoms point to increased anxiety and worry, with some early signs of depression (evident as avoidant coping, social isolation, and fatigue). It is important to address the symptoms above; if symptoms are left unmanaged, they can lead to clinical depression.