What is Post Concussion Syndrome? By: Bill Brown, Director, The Hidden Epidemic
Each year in the US approximately 2 million adolescents attempt suicide. Suicide is the third leading cause of death for young people ages 15 to 24.
1
Why?
Every year hundreds of thousands of adolescents receive concussions in any number of ways. Many of these concussions are not properly diagnosed, often the victim is “woozy” for a period of time and then they return to normal. But for many the damage is just beginning, for them, Post Concussion Syndrome (PCS) will lead to anxiety and depression. PCS is a result of trauma, injury, to the brain. The body’s natural healing activities usually limit the duration of a PCS incident to a few days or weeks, however many adolescents experience PCS symptoms for much longer. For some they live with the symptoms until they can’t live with them any longer, at that point the decision to live or die is a simple one.
Billy had been alone in his room for only twenty minutes when he decided that he could no longer live with the endless self-doubt and pain the dark thoughts brought to him. Only fifteen, Billy had been living with the pathology of Post Concussion Syndrome for six months. His grades at school had fallen off dramatically since his concussion which led to misunderstandings with his parents and teachers. Everyone seemed to think that he wasn’t trying any longer, that he didn’t care about anything. More and more he began to believe that they were right. He felt alienated from his family and friends and most of all from the Billy he used to be. Now he only wanted relief from the dark thoughts, relief that never came. Relief that was promised from a bottle or in a street drug was no relief at all. He listened to music his Dad called toxic – songs that romanticized death and alienation. Swirling ever downward in a spiral of depression, Billy had convinced himself that the best thing he could do would be to end his life. End it using his grandfather’s 22 caliber rifle that he hid under his bed three weeks earlier in anticipation of this night. The barrel of the rifle was long, too long to aim properly, so Billy had tied a string to the trigger and then to his toe. He had placed the barrel in his mouth and closed his eyes for the last time when he heard his Grandmother’s footsteps coming down the hallway toward his room. Quickly he shoved the rifle under the bed and placed one bare foot over the other so she wouldn’t see the string tied to his big toe. Two gentle knocks on the door, “Billy, can I come in”. He looked to the door and felt a familiar confusion – he was confident in his plan for self-destruction, yet he didn’t want to cause pain to those he loved. That’s why he had decided not to leave a suicide note, it would be better to leave his reasons to himself. “Um, ah - Ok Grandma, what do you want”? His Grandmother opened the door and took a tentative step into the room. “I don’t want anything, Honey. I just felt like I needed to come down and tell you I love you.”
After his Grandmother closed the door and walked away Billy untied the string from his toe. Ashamed, he realized the hurt his Grandmother would endure if he went ahead with his plan. Later that night, in that part of his brain which was still able to think clearly he realized his life had been spared because his Grandmother couldn’t wait to tell him that she loved him. The next day Billy asked his family for help, help that he received. Today Billy is very much alive, well adjusted and teaching school.
Johnny Damon, New York Yankees
Gil Haskell's concussion in Dallas
There are 100 attempts for every death by suicide among adolescents. 700,000 adolescents receive medical attention each year following suicide attempts. The ratio for the elderly is 4 to 1.
Obviously a great many American teens are in pain.
Why?
Here are some facts about concussion from the Ontario Brain Injury Institute:
Someone who experiences a concussion is four times more likely to receive a subsequent concussion. The more concussions an individual has the longer it takes to recover and the symptoms may eventually become irreversible.
The average age for a first concussion is ten. One third of all adolescents will have a concussion before they leave high school.
Some adolescents who have a concussion will end up with learning disabilities2.
What is a concussion?
Any violent blow to the head that causes a brief unconsciousness that lasts only a second or two can result in a concussion. With a concussion the loss of consciousness is caused by a disturbance of the electrical activity in the brain. Although concussions are evidence of a malfunction in the brain they do not result in any visible damage to the structure of the skull. Concussions occur most often when the blow is unexpected. This is because the victim hasn’t tightened the meninges, a covering of connective tissue which protects the brain. Lift your palm up in front of your face – count to three and then slap yourself on the forehead. Did you feel that grunt of exertion just before your hand struck your forehead? That was your reflexive effort to tighten your meninges in order to protect the brain. If someone had hit you by surprise you wouldn’t have had time to tighten the meninges and you would have been much more vulnerable to a concussion. Damage occurs when the brain is able to move within the skull, tightened meninges protects the brain. Concussions have been known to occur after even a minor blow to the head if the brain has been jarred. In most cases rest and acetaminophen is recommended as well as monitoring of the symptoms.
The first symptom of PCS is often the loss of short term memory. This makes school especially difficult, because learning is impossible without the ability to remember. Teachers, counselors and parents begin questioning you, they doubt you and then they accuse you of all kinds of things that hadn’t even occurred to you…at least not yet. Your anxiety level grows higher and soon your friends begin to back away from you. You don’t know what’s wrong, but everybody says that something is wrong with you. You’re not the same person you used to be. Then you become more and more anxious – you don’t know what it is that you’ve already forgotten that you will need to remember. You constantly disappoint your friends, family and teachers, and they don’t hesitate to tell you how disappointed they are in you. The more you feel rejected the more you turn inward; your private thoughts become your own reality. You withdraw and become secretive yet that only makes the others accuse you more. Your anxiety never goes away and with that you slide into a state of depression. (Note to teachers: How many of your students fit this description?)
The Brain Injury Resource Center in Seattle Washington has a comprehensive check list used to determine if someone is experiencing PCS. Many of the items on their list are perfect descriptors of troubled teens. For you teachers, I’m sure that you see these impairments on a daily basis.
memory problems
difficulty concentrating
difficulty learning new things
feelings of depression
inappropriate responses to people and things
impaired sense of self
withdrawal or social isolation
mood swings
persistent anxiety3
Suicide Ideation
Cheerleading is the #1 cause of injury in High Schools today
Since these are some of the symptoms of PCS it’s no wonder that thoughts of self-destruction (suicide ideation) are present in many PCS teens. As Dr.Daniel Amen, author of Healing Anxiety and Depression and Change Your Brain – Change Your Life, frequently points out, “Its not that these young people are morally weak, lazy or inferior, the simple truth is that their brain is not in a healthy state.” To further complicate matters, teens; especially teens with PCS are unable to express their condition as “depression.” Instead they complain of poor appetite, boredom, and inability to sleep soundly. Properly interpreted, such symptoms often respond favorably to anti-depressive medication.
Adolescent depression often reveals itself in the clothing, hairstyles, body language, and choice of music that teens select. These choices can be seen as attempts to share mutual feelings with others in similar circumstances while simultaneously closing a door to the rest of the world. Depressive feelings are often described as an overwhelming sense of guilt – yet its guilt for no specific reason. Because these feelings of guilt come from within, its guilt from which there is no escape or source of comfort. The only apparent choice is to withdraw. Oftentimes, in order to keep others out of their private world, they deliberately minimize the outward displays of depression. Dr. Daniel Reidenberg, Executive Director of SAVE, an organization in Minneapolis dealing with teen depression and suicide comments, “Ninety five percent of all parents of suicides say that they didn’t see it coming, they had no idea”. Indeed, a sinister part of the pathology of PCS is secrecy; the victims shut off everyone from their most inner thoughts and plans.
Depression is an incredibly painful condition, and since it’s human nature to seek pleasure and avoid pain, the depressed adolescent frequently turns to illegal drugs and alcohol for comfort. This only compounds the problem. Alcohol makes things worse because it’s a depressant already and illegal drugs provide no relief from the dark thoughts that the damaged brain continues to send. In the logic of depression the only remedy is to stop the pain, and that makes suicide a very desirable option. It’s often remarked that people who attempt suicide seemed happier than normal in the days leading up to it. The reason is that they have finally found a way to stop the pain, for once they can be in control of themselves and their emotions.
Ultimately, some do succeed in ending their pain. At this point blame is often placed on the drugs and alcohol that the victim may have used for comfort. This makes as much sense as blaming wet sidewalks for rain. The real culprit was the concussion, usually months or even years earlier. Many authorities are convinced that much teen angst and the associated negative behavior originate with concussions and the PCS that follows. Not all adolescent PCS results in suicide or even suicidal thoughts. Most of the time the brain, in its wondrous fashion, creates new pathways and circuits and heals itself. When this happens people close to the adolescent say, “I’m sure relieved that he’s grown out of that stage,’ or “she seems to be doing better at school, I’m convinced that our constant nagging helped.” Nothing could be further from the truth.
It’s impossible to accurately estimate the number of concussions adolescents suffer in a day, month or year. Many are not diagnosed or treated due to the manner in which they occurred. Billy’s concussion happened during a routine high school water polo practice, a ball unexpectedly hit him from behind and he was told to sit out for five minutes. Think of the number of youth sports programs – soccer, little league, pee wee football, hockey, all of these activities result in concussions to some of the participants. Then there are non-organized sports like skate boarding, surfing, skiing, horse back riding as well as play ground fights, falls and mishaps. It soon becomes clear that a great deal of teen misbehavior might originate with a trauma to the brain. Dr. Amen notes the following brain areas that are especially vulnerable to injury:
Temporal lobes, which house memory, receptive language, temper control and mood stability
Deep limbic system, which can cause problems with depression, negativity and libido
Prefrontal cortex, where judgment, concentration, attention span, impulse control, organization, planning and expressive language are centered
Anterior cyngulate gyrus, the brain’s gear shifter, where damage causes people to get stuck repeating negative thoughts or behaviors
(Note to teachers: Again, how many of your students fit these descriptions?)
Renewed focus on education under the No Child Left Behind Act has revealed that the nationwide high school dropout rate is much closer to 30% than the 4% or 5% figures that states had been reporting in previous years. While there are many reasons for a student to drop out, Focus on Adolescent Services reports the following as the top four reasons teens drop out of school:
1. Were failing, getting poor grades, or couldn’t keep up with school work. 2. Had disciplinary problems, were suspended or expelled. 3. Didn’t get along with teachers and other students. 4. Had a drug or alcohol problem.
Matt Hasselbeck, Seattle Seahawks
Victims of PCS usually don't realize what's wrong with themselves
Please note that all of these reasons for dropping out are also the symptoms of Post Concussion Syndrome, and that one out of three adolescents will have had a concussion prior to leaving high school. One out of three. The common factor between teen suicide and the discouragingly high drop-out rate is PCS. It’s time we look at various elements of negative teen behavior as symptoms of an underlying condition, not the problem itself. When we take this approach we will begin to heal our children instead of labeling and isolating them into confusion, fear and pain. Many young people are clinically depressed, suicidal, substance abusing and dropping out of school because those are the symptoms of a disease, and the disease can be treated.
Twelve percent of adolescents suffer depression at any given time.
Only one in five adolescents ever receives mental health treatment.
What is Post Concussion Syndrome?
The symptoms that usually immediately follow a concussion may include headache, sleepiness, dizziness, confusion, lack of emotion, blurred vision, vomiting, and an inability to remember events prior to the injury. In most cases a person will recover from a concussion within a few hours or days. The adolescent with a more severe concussion might experience these symptoms for several weeks. Basically PCS is one or more symptoms that persist beyond one week. The concurrent difficulties that last over time have to do with what Adolescent Psychology Technician Bob Jones calls “the downward spiral of depression.” Mr. Jones describes the spiral as follows: “Memory loss and confusion result in anxiety. Anxiety that doesn’t go away creates a state of depression which can then lead to suicide.” Fortunately not all adolescents descend into a suicidal state. Many heal at some point during the spiral, either with medical intervention or due to the body’s natural healing ability. However, there are countless teens who suffer the ravages of PCS unnecessarily. It goes without saying that their families and friends are also secondary victims of this insidious condition which robs our youth of the inherent joy and exuberance in life to which they are entitled.
Not everyone who is depressed from PCS experiences every symptom. Some will experience a few symptoms and some many. Parents need to watch their teens for the following symptoms of PCS induced depression:
- Loss of memory and/or disorientation - Persistent sad, anxious, or empty “mood” - Feelings of guilt, worthlessness, helplessness - Change in sleep patterns - Decreased energy or fatigue, being “slowed down” - Loss of interest or pleasure in hobbies and activities that were once enjoyed
According to the National Institute of Mental Health the severity of the above symptoms varies with individuals and also varies over time.
The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as viral infection can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview and lab tests. If a physical cause for the depression is ruled out, a psychological evaluation should be done.
Treatment choice will depend on the outcome of the evaluation. There are a variety of antidepressant medications and psychotherapies that can be used to treat depressive disorders. Depending on the patient’s diagnosis and severity of symptoms, the therapist may prescribe medication and/or one of the several forms of psychotherapy that have been proven effective for depression.
By seeking appropriate help you will have done a wonderful thing for your son or daughter. The Billy you read about earlier is my son and today we are closer than ever before, both of us ever more appreciative of the joy that life offers. My wish is simple, that the teens now struggling with PCS receive proper treatment and become healthy once again. Then, in the words of Poet Mary Anne Radmacher, they’ll be able to “….know the greatness of their spirit and their hopes fly on the wings of possibility.” As it should be.
1 Reidenberg, Dr. Daniel J., Executive Director – Suicide Awareness –Voices in Education. Minneapolis, Mn.
