By Kim A. Gorgens, Ph.D., ABPP
This short article is meant to draw attention to the demonization of mild traumatic brain injury survivors with persistent symptoms.
70–90% of all traumatic brain injuries are mild (mTBI) and results suggest that the experience of aversive cognitive and emotional symptoms is very common immediately after that kind of injury (see Carroll et al., 2004.) We know that nearly everyone who sustains a concussion or mild traumatic brain injury returns to their baseline function within three months–most people with those injuries report a full recovery within two weeks. I say nearly everyone because we also know that somewhere between 1 and 8% of injured persons do not .
Our understanding of that small group of statistical outliers is growing. To date, there are dozens of studies examining the enduring REPORT of symptoms, the enduring OBSERVATION of symptoms and the enduring EXPERIENCE of symptoms , a patient’s vulnerability to ‘Eriksonian’ suggestions that they may experience on-going symptoms, and growing support for a model that attributes the experience of enduring symptoms to pre-injury psychopathology).
The latter phenomena is troubling—as a field, psychology has a troubling history of assigning pejorative labels to the problems we are obliged to treat as if the assignation of the label confers some additional clarity of understanding or absolves us of our responsibility to provide humane interventions. A noteworthy, albeit historical, example is the explanation of ‘madness’ in female patients as the spontaneous wanderings of the uterus “hither and thither in the flanks” (that being a quote from physician and Hippocrates-contemporary, Aretaeus of Cappadocia). Charcot, a neurologist and early pioneer of psychological sensibilities, coined the term ‘hysteria’ from the word for uterus to describe the presentation of his female patients with traumatic accidents in their past (which he reported to include “a fall from a scaffold or a railway crash”). He wrote that those women suffered, ‘not from the physical effects of the accident, but from the idea they had formed of it.’ Our understanding of human experience is informed as much by cultural zeitgeist as by science.Our understanding of human experience is informed as much by cultural zeitgeist as by science.
But what is there to suggest that there may be more to these statistical outliers than pre-injury melodrama? There has been an exciting proliferation of neuroscience research in this area. Research now suggests a role for persistent dysfunction in the blood-brain barrier and the existence of pre-injury psychophysiological vulnerabilities to poor outcomes (whether conferred by genetics a la APOE ε4 + genotypes, illness exposure, or previous injury). There is also some indication that migraineurs (a lovely French word for people who suffer from migraine headaches) are over-represented in the statistical outliers, as are people with idiosyncratic metabolic and inflammatory responses to injury. David Hovda recently went so far as to say “Both animal models and human studies strongly suggest that there is nothing ‘mild’ about mild TBI at the cellular level.”
Our patients bear the consequences of arrogant or stigmatizing policy (whether athletic, healthcare, or social). We can assume that the persisting symptoms experienced by these statistical outliers reflect the complex and dynamic interplay of physiological, psychological, social and cultural variables. Given the expanse of this area of study, there is no reason to believe that any one variable accounts solely for clinical outcomes. And if we are to benefit from our rising consciousness about the inanity of itinerant reproductive organs as an explanation of emotionality we need to be especially careful when assigning reductionistic motives to a group made up largely of women. When we unwittingly communicate the message that “this is all in your head” (pun intended) we may unintentionally foreclose scientific inquiry, drive persistently symptomatic patients away from the resources meant to proffer support (to them and their families), reinforce ugly gender stereotypes and risk coming up on the wrong side of history (again).
Cancelliere, C., Cassidy, J.D., Li, A., Donovan, J., Côté, P., & Hincapié, J.P. (2014). Systematic
Search and Review Procedures: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of Physical Medicine and Rehabilitation, 95 (3), p. S101–S131,
Carroll, L., Cassidy, J., Peloso, P.M., Borg, J., von Holst, H. & Holm, L. (2004). Prognosis for
mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine, suppl 43, p. 84–105.
Ruff, R. (2011). Mild traumatic brain injury and neural recovery: Rethinking the debate.
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