Reframing Postconcussional Syndrome as an Interface Disorder of Neurology, Psychiatry and Psychology

Camilla N. Clark; Mark J. Edwards; Bee Eng Ong; Luke Goodliffe; Hena Ahmad; Michael D. Dilley; Shai Betteridge; Colette Griffin; Peter O. Jenkins


Brain. 2022;145(6):1906-1915. 

In This Article

Recommendations on how to Implement Assessment and Treatment

The use of PCS as a diagnosis remains pervasive despite its removal from the latest iterations of the DSM-5 and ICD-11.[77,78] As discussed above, this syndromic diagnosis belies the complexity of the underlying condition and its use acts to close off diagnostic and treatment pathways. In addition, misinformation or lack of understanding about the nature of the condition can lead to unrealistic expectations, frustration with the medical process and symptom amplification.[79] Therefore, a conceptual change, brought about by the abandonment of these syndromic terms, is important to improve understanding and to facilitate the additional assessments and treatments needed.

Given the incidence of mTBI, it is not feasible for all patients to be seen by specialist interdisciplinary teams. We argue that by abandoning syndromic diagnostic labels and reframing the conceptualization of persistent symptoms as described above, primary care and non-specialist professionals would be more alert to potential diagnoses for symptoms, be able to counsel patients more effectively and instigate relevant treatments. Furthermore, it would allow the selection of those patients who would benefit most from referral to a specialist service. For example, rather than attributing dizziness following a head injury to 'PCS', without this diagnostic label further assessment for the cause of the dizziness would be required. This would allow, for example, the identification of potentially treatable causes such as benign paroxysmal positional vertigo. It would also improve the initial education process for patients, with early education recognized to reduce persistent symptoms following mTBI.[80]

For those patients referred for a specialist opinion, given the potential of this disorder to span neurology, psychiatry and psychology, the clinician must be trained to assess the biological and psychological elements within a patient, in addition to considering ecological factors such as social and economic circumstances.[53] This interface across disciplines is not unique to mTBI, with increasing recognition that the assessment and management of many 'neurological' and 'psychiatric' disorders would benefit from expertise across these specialties.[81,82]

The aim of this assessment would be to map the cause for an individual's symptoms to a pathophysiological or psychopathological process, or both (Figure 1). This should allow:

  1. An individualized treatment plan which could be based within primary care with appropriate support and training (e.g. migraine treatment, psychological treatment and medication for neuropsychiatric disorders, management of sleep disturbance or vestibular manoeuvres for benign paroxysmal positional vertigo).

  2. Appropriate explanation and psychoeducation for the patient to understand the cause of their symptoms, including an understanding of the key role that somatic hypervigilance and emotional conditioning play in the chronicity of symptoms.[83]

  3. A specialist multidisciplinary service which can provide specialist assessment and treatment for a subset of patients with high symptom complexity/severity, treatment resistance or diagnostic uncertainty.

  4. Development of clinical trials and experimental research studies within a properly stratified group of patients.

Finally, there must be capacity for patients to be reviewed if required beyond their initial appointment to allow modification of interventions by monitoring the symptom trajectory and response.