Controversies of mild traumatic brain injury
The experimental and scientific understanding
of mild traumatic head injury (MTHI) has evolved over
the past twenty years, with a plethora of research
being generated and documented within the scientific
literature. At the same time, clinical experience
across multidisciplinary lines has increased as health
care professionals have continued to interact with
this population of patients. It has recently been
estimated that approximately two million people annually
in the United States experience closed head injury
(Brown, & Fann, 1994). Closed head injury represents
a significant cause of morbidity and mortality, especially
within the younger populations. This has resulted
in a considerable increase in health problems associated
with the residual sequelae of closed head injury.
Epidemiological studies have documented
that within the incidence of closed head injury in
general, injuries that are classified as mild or minor
typically account for the greater percentage of cases
evaluated in emergency room and out patient settings
(Goodwin, 1989). This is also the case outside the
United States, where estimates range as high as eighty
percent (Cohadon, Richer, & Castel, 1991).
While the current body of research
literature and experience from clinical practice has
provided a greater understanding of MTHI, there continues
to be controversy with respect to definition and classification
(Kibby, & Long, 1996). Any approach for neuropsychiatric
and/or neuropsychological evaluation of MTHI must
take into account the confusion that exists in understanding
this injury as it is differentiated from more severe
injuries and from other neuropsychiatric disorders.
Earlier attempts at defining the parameters of MTHI
have been seen in the research literature (Colohan,
Dacey, Alves Rimel, Jane, 1986, Davidoff, Kessler,
Laibstain, & Mark, 1988). The Mild Traumatic Brain
Injury Committee of the Head Injury Interdisciplinary
Special Interest Group of the American Congress of
Rehabilitation Medicine has proposed definitive guidelines,
which have been utilized by the research community
in more recent studies (Kay, et al, 1993). More current
proposals for classification of the spectrum of MTHI
have also been suggested (Esselman & Uomoto, 1995).
Despite the clearer definitive guidelines,
there continues to be clinical confusion in evaluating
and understanding the pathophysiology, symptomatology,
and differential diagnosis of MTHI. The use of the
terms postconcussive syndrome (PCS)and posttraumatic
syndrome (PTS) has been used to describe the pattern
of symptom presentation seen in this population of
patients. However, this has not led to a clearer understanding
of MTHI with respect to evaluation and assessment.
In addition, there have been suggestions that mild
head injuries should be differentiated from mild brain
injuries. Furthermore, there is often the development
of secondary psychiatric disorders that may have a
physiological and/or psychosocioenvironmental basis,
typically referred to among clinicians as psychological
overlay, that complicate the clinical presentation
of MTHI and make the evaluative process more complex.
Clearly, the greatest scientific and
clinical controversy has been associated with the
postconcussive nomenclature (Binder, 1986, Lowden,
Briggs & Cockin, 1989, Alves, Macciocchi, &
Barth, 1993, Kibby & Long, 1996). In general,
PCS has been understood to represent the synergistic
and interactive effects of physical, cognitive and
psychological symptoms seen upon clinical presentation.
The assumption is made that there may be physiologic,
pharmacologic, psychologic, socioenvironmental, circumstantial,
and medicolegal bases underlying the perpetuation
of symptomatology. There is also typically a presentation
of chronic pain syndrome that may have both physical
and psychological factors contributing to the pattern
of symptoms and complaints. Neuropsychiatric and neuropsychological
evaluation of these patients presents the clinician
with a complex task of deciding how to explain the
nature of PCS and more importantly what to recommend
with respect to treatment.
There is also disagreement among researchers
and clinicians as to the duration of PCS and what
factors predispose individuals to developing a persistent
PCS. Within this context, the issue of premorbid factors
such as personality characteristics, past psychiatric
history, previous substance abuse, prior incidence
of MTHI, and general health problems certainly appears
to have an influence on the chronicity of symptoms
(Goodwin, 1989).
Because of the confounding issues inherent
in the diagnostic assessment of the MTHI patient,
a comprehensive time based neuropsychiatric evaluation
is proposed to clinically deal with the complexities
seen in this patient population. Such a time based
evaluation process may not always be necessary, but
in cases where there are confusing diagnostic differentials,
a time based approach will be helpful in guiding the
clinician through the evaluation process. The time
based approach will be presented later on in this
chapter.
We further propose a neuropsychiatric
nomenclature and classification based on the practical
aspects of evaluation, which are more meaningful to
the clinician in everyday practice. These clinical
distinctions should not be considered distinct entities,
but rather as clinical aspects of a dynamic post head
trauma spectrum that can be useful in guiding the
clinician in the evaluation process. We will attempt
to integrate current research findings and clinical
experience into a methodology for neuropsychiatric
evaluation that is first of all useful to the patient
and secondly reflects clinical acumen and multiclinical
diversity.