It is hard to imagine that a sports-related concussion (SRC) or mild traumatic brain injury (mTBI), or any event that triggers significant physical and cognitive symptoms and changes from normal functioning, would not produce some emotional or psychological reactions. However, most of the focus in SRC management has been on tracking physical based symptoms (e.g. headache, balance problems, sleep disturbance/fatigue) and neurocognitive status (e.g. processing speed, attention/concentration, learning/memory) over time until the individual returns to baseline or asymptomatic status. Emotional or psychological aspects, while seen as important factors in prolonged/persistent post-concussive syndrome, have not been discussed or investigated at the same level as the other symptom areas.
Emotional and psychological aspects of SRC can emerge related to a student-athlete’s response to injury and/or their response to recovery. Responses to injury typically produce a sense of loss (loss of control, loss of skills, loss of normalcy), a sense of vulnerability or fear, and anxiety/worry. Student-athletes often describe initial symptoms as “feeling off” or “not like myself,” which can be disconcerting. In some instances, depressed mood or changes in behavior emerge as a direct result of the concussion in the acute recovery phase and can be related to fatigue. Emotional and psychological responses play a crucial role in the athlete’s recovery (Mainwaring, Hutchison, Camper & Richards, 2012); these responses can include depressed mood, anxiety about the future, re-injury fears, frustration or anger (especially if symptoms persist beyond their expected time frame or have impacted their athletic career), sense of loss of team role or identity as an active and contributing student-athlete, significant disruption in social network and negative impact on academic pursuits. After a SRC, some athletes are told by providers to physically rest and have “brain rest” (cognitive rest), which may be appropriate in the initial week of recovery, but can have harmful effects later in recovery. Unfortunately, the terms “brain rest” or “cognitive rest” are not well-defined by providers and student-athletes have often understood it to mean “don’t think.” For some, this prescription creates a fear of thinking and the belief that thinking or cognitive activity will harm their brain. This is similar process to the development of a fear of movement (kinesiophobia) in pain patients, which can further restrict activities (Schmidt, 2003). Removal from, or lessening of, academic demands may be appropriate for a period of time for some student-athletes, but the stress of falling behind and then having to make up and keep up with school assignments can often be significant and make its own contribution to symptoms.
The emotional symptoms that emerge from SRC can prolong recovery and often reflect predisposing or premorbid factors. These factors can include prior depression or anxiety disorders, traumatic stress history, prior head injuries or other neurological vulnerabilities, learning issues, hypervigilance or somatic focus, or personality characteristics or disorders (Silverberg & Iverson, 2011). Psychological factors associated with prolonged or persistent post-concussive symptoms include ineffective and maladaptive coping styles, sleep disturbance often due to mental activation, anxiety and stress/rumination, nocebo effect (adverse effects created or maintained by negative expectations (Hahn, 1997; Scudellari, 2013)) and other expectation effects, and family or social network/support problems. Since the primary tool in the medical management of SRC involves tracking symptoms over time, one must wonder if focusing on symptoms on a daily or regular basis produces hypervigilance to symptoms and can result in reinforced illness behavior and iatrogenic effects resulting in prolonged post-concussion symptoms.
Symptom checklists for concussion are not specific to this condition only. Endorsement of symptoms may reflect other conditions or factors and occur to some degree in non-concussed individuals. These symptom checklists or rating scales are typically used as a general trending tool in recovery, but are largely reflective of self-perceived severity with highly individualized anchor points: are student-athletes rating the symptoms as an average over time since the last appointment or their worst experience of the symptom in the interval, or some other calculation? Psychological and emotional factors, such as being an amplifier/maximizer or minimizer of symptoms, can be strong influences on these symptom ratings and need to be considered when reviewing the ratings during recovery.
Following a SRC, neurocognitive testing results often reflect a decline in certain cognitive areas for a period of time, which can be concerning to athletes and create focused attention to any and all cognitive inefficiencies. In some instances, normal range inefficiencies are seen as evidence of ongoing SRC symptoms and/or slow recovery, which produce more stress and perpetuate the idea of and concern for continued brain-based injury.
Recognition that post-concussion syndrome is best managed in a multidisciplinary approach (NCAA Sport Science Institute) is crucial in being able to address these prolonging factors. While post-concussion syndrome and neurocognitive symptoms can initially be determined by the concussive event, at some point in time, these symptoms may become more maintained or prolonged by non-brain-based factors (or a combination of factors). Continuing to discuss symptoms as concussion-related some months post injury may perpetuate a brain injury focus which can contribute to activation of prolonging factors, a greater sense of disability and longer recovery times. Ideally, management and treatment of SRC should include opportunities to evaluate/address psychological or emotional factors or responses, which are likely activated in student-athletes to varying degrees. As a member of the sports medicine team, clinically trained sport psychologists have the expertise to provide support to these injured student-athletes and address both their responses to injury and recovery, and be helpful in dealing with maladaptive coping strategies and recalibrate expectancies. The clinical sport psychologist can provide support in dealing with temporary or extended challenges to identity, athletic identity, self-esteem, and future plans and goals. These interventions often provide opportunities to deal with the fear of reinjury, address potential concerns over long-term consequences of concussions, and add to their general problem solving and resilience skills.
The depression and anxiety that can emerge in recovery may track positively with the improving physical symptoms in many instances, but it may be important to assess and address these emotional dimensions independently, as the concussion experience may trigger other issues. Application of cognitive-behavioral therapy interventions for persistent post-concussion syndrome have shown positive results, with early brief intervention reducing prolonged recovery (Snell, Surgenor, Hay-Smith & Siegert, 2009). Components seen as effective include education about post-concussion symptoms, reattribution of these symptoms to benign causes, reassurance of favorable prognosis, and gradual resumption of pre-injury activities (Mittenburg, Tremont, Zielinski, Fichera & Rayis, 1996; Mittenburg, Canyock, Condit & Patton, 2001).
It is important to recognize the role that psychological and emotional factors play in the response to injury and the course of recovery in SRC. While the initial focus may be on physical based symptoms and reaching a physiologically-based return to play status (e.g., exertion without symptoms, game level stamina), psychological and emotional factors can be crucial in understanding and managing the student-athlete as they recover cognitively and emotionally, and return to pre-injury levels of performance. Clinical sport psychologists can play an important role in the management of SRC. They have the expertise to assess and intervene and be an integral part of the student-athlete’s recovery..
Hahn, R. (1997) The Nocebo Phenomenon: Concept, Evidence and Implications for Public Health. Preventive Medicine, 26, 607-611.
Mainwaring, L., Hutchison, M., Comper, P. & Richards, D. (2012) Examining emotional sequelae of sport concussion. Journal of Clinical Sports Psychology, 6(3), 247-274.
Mittenburg, W., Tremont, G., Zielinski, R., Fichera, S. & Rayls, K. (1996) Cognitive-Behavioral Prevention of Postconcussion Syndrome. Archives of Clinical Neuropsychology, 11(2), 139-145.
Mittenburg, W., Canyock, E., Condit, D. & Patton, C. (2001) Treatment of post-concussion syndrome following mild head injury. Journal of Clinical and Experimental Neuropsychology, 23, 829-836.
Schmidt, A. (Oct 2003) Does ‘mental kinesiophobia’ exist? Behavior Research and Therapy, 41(10), 1243-1249.
Scudellari, M. (July 1 2013) Worried Sick. The Scientist Magazine (www.the-scientist.com/articleNo/136126).
Silverberg, N. & Iverson,G. (2011) Etiology of the post-concussion syndrome: Physiogenesis and psychogenesis revisited. NeuroRehabilitation, 29, 317-329.
Snell, D., Surgenor, L., hay-Smith, E. & Siegert, R. (2009) A systematic review of psychological treatments for mild traumatic brain injury: An update on the evidence. Journal of Clinical and Experimental Neuropsychology, 31(1), 20-38.
About David Coppel, Ph.D.
Dr. David Coppel is a Professor in the Department of Neurological Surgery and the Director of Neuropsychological Services and Research at the University of Washington Sports Concussion Program, located at both Harborview Medical Center and Seattle Children’s Hospital. He works as a Clinical Psychologist, Clinical Neuropsychologist and Sport Psychologist in his current positions. He is a Clinical Professor in both the Department of Psychiatry & Behavioral Sciences and the Department of Psychology at the University of Washington. Since 1996, Dr. Coppel has been the Consulting Neuropsychologist and Clinical/Sport Psychologist for the Seattle Seahawks. In his work at the Sports Concussion Program, he provides consultation regarding sports concussions to a number of high school, college and professional sports teams. Over the past 30 years, Dr. Coppel has specialized in clinical sport psychology and performance psychology and provided consultation to athletes, performers, and coaches at the amateur, collegiate, Olympic, and professional levels of competition.