Symptom Attribution, Injury Severity, and Catastrophic Ideation in Postconcussional Disorder

Background: Previous researchers have suggested that catastrophic misinterpretation of benign experiences or catastrophic reactions to minor injury may be the predominant risk factors for chronic post-concussion symptoms. The “Expectation as Etiology” (Mittenberg et.al., 1992) and “Good Old Days” (Gunstad and Suhr, 2004) models were both developed in support of this view. Despite being widely cited and broadly accepted, neither model has been adequately tested in non-litigating individuals with chronic post-concussion symptoms. The current study investigates the utility of these models in predicting chronic post-concussion symptoms and impairment due to concussive injury. Individuals with a history of concussion reported their current symptoms, and also rated their symptoms prior to the experience of concussive injury. Comprehensive information about emotional and physical health, background information, injury history, health anxiety and anxiety sensitivity were also collected. In contradiction to predictions made by the models, individuals with chronic post-concussion symptoms did not report the experience of fewer symptoms prior to injury than those who had recovered from their injuries. Further, regression modelling indicates that the current emotional distress of the respondent is the strongest predictor of self-rated impairment, over and above all other predictors, including measures of catastrophic ideation. These results are inconsistent with the idea that chronic symptoms are mainly maintained by hypochondriacal traits, catastrophic ideation, or misinterpretation of benign symptoms. As such, the utility of the “Good Old Days”, and “Expectation as Etiology” models for explaining chronic post-concussion symptoms is questioned. These results suggest that current symptom report is not due to misattribution of previously existing symptoms, or catastrophic ideation, and that the strongest predictor of self-rated impairment due to injury is the current emotional distress of the respondent. These findings have clear relevance for the design of treatment protocols, and suggest that targeting current emotional distress may be more efficacious than attempts to address catastrophic ideation in individuals experiencing chronic post-concussion symptoms.