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Cited by 121Traumatic Brain Injury ResearchLong-Term Effects of COVID-19Mental Health Research Topics

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Network Analysis and Precision Rehabilitation for the Post-concussion Syndrome

Open access
Iverson, Grant L.·2019·Frontiers in Neurology
DOI 10.3389/fneur.2019.00489PMC PMC6548833
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Abstract

Some people experience persistent symptoms following a mild traumatic brain injury (MTBI), and the etiology of those symptoms has been debated for generations. Post-concussion-like symptoms are caused by many factors both before and after MTBI, and this non-specificity is the bedrock of the conundrum regarding the existence of the post-concussion syndrome. A latent model or common cause theory for the syndrome is inconsistent with the prevailing biopsychosocial conceptualization. It is the thesis of this paper that adopting a network perspective for persistent symptoms following MTBI, including the post-concussion syndrome, could lead to new insights and targeted treatment and rehabilitation strategies. The network perspective posits that symptoms co-occur because they are strongly inter-related, activating, amplifying, and mutually reinforcing, not because they arise from a common latent disease entity. This approach requires a conceptual shift away from thinking that symptoms reflect an underlying disease or disorder toward viewing inter-related symptoms as constituting the syndrome or disorder. The symptoms do not arise from an underlying syndrome-the symptoms are the syndrome. A network analysis approach allows us to embrace heterogeneity and comorbidity, and it might lead to the identification of new approaches to sequenced care. The promise of precision rehabilitation requires us to better understand the interconnections among symptoms and problems so that we can produce more individualized and effective treatment and rehabilitation.

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Figure 1 Potentially Amplifying and Reinforcing Persistent Symptoms and Problems and Personal Biopsychosocial Context for Experiencing Persistent Symptoms and Problems. Pre-Injury Vulnerability Factors: personal or family history of mental health problems and associated genetic and environmental vulnerability (childhood abuse or neglect, depression, anxiety, or traumatic stress); prior brain injuries; personal history of, or vulnerability to, migraine or other headache disorder; and history of motion sickness or other visual-vestibular vulnerability factor. Environmental Stressors: financial/occupational stress; academic stress; marital, family, or relationship problems; and litigation, compensation-seeking or maintaining, or other secondary gain issues. Social Psychological Factors: maladaptive coping, catastrophizing, expectations, “good-old-days” bias (tendency to view oneself as healthier in the past and underestimate past problems), nocebo effect, diagnosis threat, cognitive hypochondriasis and preoccupation, lifestyle and family dynamics changes, avoidance behavior, cogniphobia (fear and avoidance of mental exertion out of concern for developing or exacerbating a headache), reinforced illness behavior, anger, bitterness, perceived injustice, justification/entitlement, or iatrogenesis. Personality Characteristics or Disorders: neuroticism (a personality trait characterized by a strong tendency to experience negative emotions such as anxiety, depression, anger, and self-consciousness. Individuals with this trait have considerable difficulty coping with stress), anxiety sensitivity (a trait comprised of physical, psychological, and social pre-occupations and concerns, is characterized by fear of anxiety-related bodily sensations), alexithymia (a cluster of traits characterized by difficulty identifying feelings, difficulty describing feelings to others, externally oriented thinking, and limited capacity for imaginal thinking), perfectionism, egocentrism, Type D personality (personality pattern is characterized by two stable personality traits: negative affectivity and social inhibition), disagreeableness (a personality trait characterized by antagonism, skepticism, and egocentrism), unconscientiousness (a trait characterized by reduced self-discipline and ambition, disorganization, and a more lackadaisical approach to life), narcissistic, dependent, histrionic, or passive-aggressive. Adaptive Personality Characteristics: resilience, grit (passion and perseverance toward long-term goals), and psychological hardiness (personality characteristic consisting of three psychological attitudes and beliefs: commitment, challenge, and control). Copyright © 2019, Grant L. Iverson, Ph.D., Used with Permission.
Figure 1 Potentially Amplifying and Reinforcing Persistent Symptoms and Problems and Personal Biopsychosocial Context for Experiencing Persistent Symptoms and Problems. Pre-Injury Vulnerability Factors: personal or family history of mental health problems and associated genetic and environmental vulnerability (childhood abuse or neglect, depression, anxiety, or traumatic stress); prior brain injuries; personal history of, or vulnerability to, migraine or other headache disorder; and history of motion sickness or other visual-vestibular vulnerability factor. Environmental Stressors: financial/occupational stress; academic stress; marital, family, or relationship problems; and litigation, compensation-seeking or maintaining, or other secondary gain issues. Social Psychological Factors: maladaptive coping, catastrophizing, expectations, “good-old-days” bias (tendency to view oneself as healthier in the past and underestimate past problems), nocebo effect, diagnosis threat, cognitive hypochondriasis and preoccupation, lifestyle and family dynamics changes, avoidance behavior, cogniphobia (fear and avoidance of mental exertion out of concern for developing or exacerbating a headache), reinforced illness behavior, anger, bitterness, perceived injustice, justification/entitlement, or iatrogenesis. Personality Characteristics or Disorders: neuroticism (a personality trait characterized by a strong tendency to experience negative emotions such as anxiety, depression, anger, and self-consciousness. Individuals with this trait have considerable difficulty coping with stress), anxiety sensitivity (a trait comprised of physical, psychological, and social pre-occupations and concerns, is characterized by fear of anxiety-related bodily sensations), alexithymia (a cluster of traits characterized by difficulty identifying feelings, difficulty describing feelings to others, externally oriented thinking, and limited capacity for imaginal thinking), perfectionism, egocentrism, Type D personality (personality pattern is characterized by two stable personality traits: negative affectivity and social inhibition), disagreeableness (a personality trait characterized by antagonism, skepticism, and egocentrism), unconscientiousness (a trait characterized by reduced self-discipline and ambition, disorganization, and a more lackadaisical approach to life), narcissistic, dependent, histrionic, or passive-aggressive. Adaptive Personality Characteristics: resilience, grit (passion and perseverance toward long-term goals), and psychological hardiness (personality characteristic consisting of three psychological attitudes and beliefs: commitment, challenge, and control). Copyright © 2019, Grant L. Iverson, Ph.D., Used with Permission.CC BY · PubMed Central
Figure 2 Hypothetical network of nine symptoms in slow to recover high school and college students with pre-existing anxiety problems. The top figure shows that anxiety (A8) has the greatest degree (eight connections to other symptoms) and strength (three heavier lines) of centrality, followed by headaches (H6) and sleep (S5). Three symptoms are connected to three other symptoms (nodes): irritability (I3), concentration problems (C3), and fatigue (F3). Light sensitivity (L2) is connected to two other symptoms, and nausea (N1) and dizziness (D1) are connected to only one other symptom. The bottom figure illustrates the role of external factors, in the external field, that are amplifying the network of symptoms, such as social stress (E1) and academic stress (E2).
Figure 2 Hypothetical network of nine symptoms in slow to recover high school and college students with pre-existing anxiety problems. The top figure shows that anxiety (A8) has the greatest degree (eight connections to other symptoms) and strength (three heavier lines) of centrality, followed by headaches (H6) and sleep (S5). Three symptoms are connected to three other symptoms (nodes): irritability (I3), concentration problems (C3), and fatigue (F3). Light sensitivity (L2) is connected to two other symptoms, and nausea (N1) and dizziness (D1) are connected to only one other symptom. The bottom figure illustrates the role of external factors, in the external field, that are amplifying the network of symptoms, such as social stress (E1) and academic stress (E2).CC BY · PubMed Central

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Citations

Cites

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Research works printed but not linked: 5

  1. Heilbronner, 1993, Factors associated with postconcussion syndrome: neurological, psychological, or legal?, Trial Diplomacy J., 16, 161
  2. 1992, The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines
  3. 1994, Diagnostic and Statistical Manual of Mental Disorders. 4th ed
  4. Iverson, 2012, A biopsychosocial conceptualization of poor outcome from mild traumatic brain injury, 37
  5. Ruff, 1999, Mild traumatic brian injury, 315

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Metadata

Authors
Iverson, G. L.
Affiliations
Harvard University (US)
Corresponding author
Iverson, Grant L.
ORCID
Iverson, Grant L.
Venue
Frontiers in Neurology
Publisher
Frontiers Media SA
Published
2019-05-29
Volume
10
Pages
489-489
ISSN
1664-2295 (ISSN-L)
DOI
10.3389/fneur.2019.00489
PMC
PMC6548833
OpenAlex
W2947325756
Cited by
121
References
165
Citations by year
2026: 20 · 2025: 9 · 2024: 10 · 2023: 19 · 2022: 25 · 2021: 18 · 2020: 17 · 2019: 2
FWCI
2.26
Type
journal article
Language
en
Open access
Licence
Locations
  • Frontiers in Neurology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
Spaulding Research Institute
Topics
  • Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury Research
  • Health Sciences › Medicine › Clinical Neurology › Long-Term Effects of COVID-19
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
Keywords
post-concussion syndrome, mild traumatic brain injury, symptom networks, symptom co-occurrence, precision rehabilitation, biopsychosocial model, symptom heterogeneity, comorbidities, personalized treatment

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