Sounds like a Concussion, but It's Not

October 26, 2015

Sounds like a Concussion, but It's Not

  1. Jonathan Silver, MD

Symptoms that are relied on for the diagnosis of postconcussion syndrome in high-school athletes are common.

  1. Jonathan Silver, MD

Postconcussion syndrome (PCS) is often diagnosed retrospectively by assessing current symptoms (ICD-10 requires cognitive, somatic, emotional, and sleep problems). However, researchers have questioned the specificity of these. Now, investigators have examined preseason reporting of PCS-like symptoms by over 30,000 healthy high-school students in Maine (boys, 54.1%; mean age, 15.5 years) and analyzed the relationship of symptoms to current or past health conditions (e.g., migraines, psychiatric treatment, substance abuse, attention-deficit/hyperactivity disorder [ADHD]).

Symptoms were rated on a 6-point scale (mild, 1–2; moderate, 3–4; severe, 5–6); to meet PCS criteria, symptoms had to occur in at least three categories. No participant had a recent concussion.

Overall, 19% of boys and 28% of girls met criteria for mild PCS, and 4% and 7% met moderate-PCS criteria. The presence of pre-existing conditions increased symptoms for up to 47% of boys (prior treatment of a psychiatric condition) and 72% of girls (prior treatment of substance abuse). The strongest indicators were, for boys, prior psychiatric treatment, followed by past migraine treatment, and for girls, past treatment of psychiatric disorder/substance abuse, followed by ADHD. Prior concussions were associated with symptom reporting but less strongly so than developmental and psychiatric factors.


In this large study, high-school athletes self-reported all symptoms and prior histories. The findings caution us when diagnosing PCS. Mild symptoms are exceedingly common and easily misattributed to a concussion. Another concern is diagnosis threat (NEJM JW Psychiatry May 2011 and J Int Neuropsychol Soc 2011; 17:219): Telling individuals that symptoms are common after concussion significantly changes their responses. Clinicians need to be cautious in interpreting symptoms that occur after concussions and concluding that these are “new” and result from the brain injury.

Editor Disclosures at Time of Publication

  • Disclosures for Jonathan Silver, MD at time of publication Speaker's bureau American Physician Institute Editorial boards UpToDate Leadership positions in professional societies North American Brain Injury Association (Board Member)


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