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This troublesome and frequent sequela of head injury has been mentioned above as well as in the chapter on headache (page 158) When the syndrome is protracted, neurologists are vexed by the condition a problem intensi ed by worried patients and family It has also been called the posttraumatic or postconcussion syndrome, posttraumatic headache, traumatic neurasthenia (Symonds), and traumatic psychasthenia, among many other names Headache is the central symptom, either generalized or localized to the part that had been struck The headache is variously described as aching, throbbing, pounding, stabbing, pressing, or band-like and is remarkable for its variability The intensi cation of the headache and other symptoms by mental and physical effort, straining, stooping, and emotional excitement has been mentioned earlier; rest and quiet tend to relieve it Such headaches may present a major obstacle to convalescence Dizziness, another prominent symptom, is usually not a true vertigo but a giddiness or lightheadedness The patient may feel unsteady, dazed, weak, or faint However, a certain number of patients describe symptoms that are consonant with labyrinthine disorder They report that objects in the environment move momentarily, and that looking upward or to the side may cause a sense of unbalance; labyrinthine tests may show hyporeactivity; far more often they disclose no abnormalities McHugh found a high incidence of minor abnormalities by electronystagmography both in concussed patients and in those suffering from whiplash injuries of the neck; but we nd some of the data dif cult to interpret Exceptionally, vertigo is accompanied by diminished excitability of both the labyrinth and the cochlea (deafness), and one may assume the existence of direct injury to the eighth nerve or end organ

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These symptoms clear up in several weeks in the majority of patients When the symptoms persist, however, the patient is intolerant of noise, emotional excitement, and crowds Tenseness, restlessness, fragmentation of sleep, inability to concentrate, feelings of nervousness, fatigue, worry, apprehension, and an inability to tolerate the usual amount of alcohol complete the clinical picture The resemblance of these symptoms to those of anxiety and depression and to other forms of posttraumatic stress disorder is quite apparent In contrast to this multiplicity of subjective symptoms, memory and other intellectual functions show little or no impairment, although this has been disputed Leininger et al, for example, found that most of their 53 patients who suffered minor head injury in traf c accidents performed less well than controls on psychologic tests (category test, auditory verbal learning, copying of complex gures) The fact that those who were merely dazed did as poorly as those who were concussed and that litigation was involved in some cases would lead one to question these results A further discussion of cognitive sequelae is found below The syndrome of posttraumatic nervous instability complicates all types of head injury, mild and severe Once established, it may persist for months or even years, and it tends to resist all varieties of treatment Eventually, the symptoms lessen Strangely, this syndrome is almost unknown in children Characteristic also is the augmentation of both the duration and intensity of this syndrome by problems with compensation and litigation, suggesting a psychologic factor In countries where these matters are a less prominent part of the social fabric, the occurrence of posttraumatic syndrome is far less frequent The constitution of the patient appears to be important Stable, athletic, tough- bered individuals take a concussive injury in stride, while the sensitive, nervous, complaining types may be so overwhelmed by such an accident that they are unable to expel it from their minds Environmental stress assumes importance as well, for if too much is demanded of the patient soon after injury, irritability, insomnia, and anxiety are enhanced In this connection, an interesting experiment was conducted by Mittenberg and colleagues A group of subjects with no personal experience or knowledge of head injury were asked to select from a list those symptoms that they would expect after a concussive head injury They chose a cluster of symptoms virtually identical to that of the postconcussion syndrome An approach to treating such patients is given further on, in the section on treatment, under Patients with Only Transient Unconsciousness Other Posttraumatic Cognitive and Psychiatric Disorders In all patients with cerebral concussive injury, there remains a gap in memory (traumatic amnesia) spanning a variable period from before the accident to some point following it This gap is permanent and is lled in only by what the patient is told In addition, as stated in the introduction to this section, some degree of impairment of higher cortical function may persist for weeks (or be permanent) after moderate to severe head injuries, even after the patient has reached the stage of forming continuous memories During the period of deranged mentation, the memory disorder is the most prominent feature; in that respect the state resembles the alcoholic form of the Korsakoff amnesic state and has some resemblance to the state of transient global amnesia (page 379) It has been repeatedly asserted that this amnesic state is a constant feature of every prolonged traumatic mental disorder, but to the authors it re ects in part the ease with which memory can be tested With more careful testing, other cognitive disorders are evident Concussed pa-.

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