Thirty Complexities and Controversies in Mild Traumatic Brain Injury and Persistent Post-concussion Syndrome: a Roadmap for Research and Practice

Abstract

Mild traumatic brain injury (MTBI) is a contentious topic in the field of psychological injury and law, especially in cases in which the symptoms persist in persistent post-concussion syndrome (PPCS). The article reviews 30 points related to MTBI/PPCS that workers in the field need to consider: understanding these syndromes, their symptoms, their prevalence, their causation, the influences and confounds in their diagnosis, best assessment practices, and legal aspects. Evaluators need to know the scientific literature, adopt an unbiased approach, undertake comprehensive assessments, consider all data and factors, and arrive at judicious decisions. The literature indicates few conclusive findings and conclusions related to MTBI/PPCS, except for finding much variability (even in terms of definition), uncertainty, inconclusiveness, and the need for extensive research. The literature supports the view that PPCS is biopsychosocial and that biological factors by themselves cannot account for MTBI/PPCS psychological presentations. The psychological factors can extent into symptom exaggeration, feigning, and malingering, and these confounds need to be assessed carefully before being ruled in or out. Ethically, evaluators should not have preconceived notions either way. When bias is evident in these regards, the weight of testimony or proffered reports in court and related venues will be reduced or they might be deemed inadmissible. As for recommendations, the article proposes that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), creates a new category termed somatic symptom disorder with predominant post-concussion-like symptoms. PPCS should not be considered a syndrome or anything related to the original index concussion/MTBI and should be dropped from the lexicon in the field.