Depression, anxiety, and stress as predictors of postconcussion-like symptoms in a non-clinical sample
Introduction
For most individuals, the postconcussion symptoms experienced in the acute stage of a mild traumatic brain injury (mTBI) resolve within a few days to a few months (Schretlen and Shapiro, 2003, Belanger et al., 2005, Belanger and Vanderploeg, 2005). However, some individuals continue to report a set of physical, cognitive, and affective difficulties beyond the typical recovery period (King and Kirwilliam, 2011). This atypical recovery profile is often referred to as Postconcussion Syndrome (PCS; Williams et al., 2010). PCS (or Postconcussive Disorder) is recognised in formal diagnostic systems, such as the Diagnostic and Statistical Manual Fourth Edition (DSM-IV-TR; American Psychiatric Association (APA), 2000) and the World Health Organization's (WHO) International Classification of Diseases (ICD-10; WHO, 1992).
PCS is a disabling condition characterised by symptoms and difficulties that persist beyond one (WHO, 1992) to three months (APA, 2000) of the injury. The symptoms experienced by people with PCS include but are not limited to headaches, dizziness, sensitivity to noise, irritability, and difficulties with memory (World Health Organization, 1992, American Psychiatric Association, 2000). Whilst the aetiology of the persistent symptoms that comprise PCS remains uncertain (Prigatano and Gale, 2011), a substantial body of research has now identified that factors independent of brain injury status are associated with ongoing symptomatology.1
The symptoms associated with PCS are not specific or unique to the syndrome. Postconcussion-like symptoms are also reported by people with chronic pain (Iverson and McCracken, 1997, Smith-Seemiller et al., 2003), or people who receiving psychological treatment for other conditions (Fox et al., 1995, Iverson, 2006). Postconcussion-like symptoms are also reported in community and student samples (Chan, 2001, Iverson and Lange, 2003, Wang et al., 2006, Garden and Sullivan, 2010, Edmed and Sullivan,). The non-specificity of PCS symptoms presents a major diagnostic challenge for clinicians.
In 2007, Iverson and colleagues (2007) presented a conceptualization of the factors that influence PCS symptom report. This model included both biological and psychological factors. The newer incarnation of this model is described as a “biopsychosocial model” of poor outcomes from mTBI (Iverson, 2012). Both of these models identified a role for depression, anxiety and stress. In the 2007 conceptualisation, depression was identified as a contributing factor in its own right, whereas anxiety and stress were grouped together with ‘somatic preoccupation’ (Iverson et al., 2007). In the more recent model, depression remains on its own, but anxiety, stress, and worry are grouped together as a factor that influences poor mTBI outcomes (Iverson, 2012).
Of these three factors, the relationship between depression and PCS has been the most extensively researched (e.g., Sawchyn et al., 2000, Trahan et al., 2001). Iverson and colleagues (2007) suggest that depression is not only a challenging differential diagnosis for PCS, but that it may also form the predominant aetiology of PCS for some patients. A considerable body of base-rate research has found that higher levels of depression or depressive symptoms are associated with higher levels of postconcussion-like symptoms (e.g., Suhr and Gunstad, 2002, Iverson and Lange, 2003, Iverson, 2006, Garden and Sullivan, 2010). In one study, Iverson (2006) found that 90% of patients with depression and no history of head injury, met liberal self-report criteria for PCS.
There are fewer studies of the the relationship between PCS symptoms and anxiety or stress. Nevertheless those that have been conducted have revealed a positive association between PCS and anxiety or stress. For example, among college students with and without mTBI histories, greater PCS/postconcussion-like symptomatology was reported by those individuals who: (a) reported a greater number of, and being more impacted by, stressful events (as measured by the Daily Stress Inventory; Gouvier et al., 1992), (b) had higher levels of subjective stress (as measured by the Perceived Stress Scale; Machulda et al., 1998), and (c) were exposed to higher levels of experimentally induced acute stress (measured physiologically and subjectively following completion of cognitively demanding tasks; Hanna-Pladdy et al., 2001). Less commonly reported in the literature, but nevertheless present, is the finding that anxiety (as measured by the Beck Anxiety Inventory) and postconcussion-like symptomatology were positively correlated in neurologically normal young adults and people with “recovered” mTBI (Trahan et al., 2001).
With a few exceptions, this past research has largely explored these variables (i.e., depression, anxiety, or stress) and their relationship to PCS and postconcussion-like symptoms either in isolation or independently. Studies that have considered these factors together have found that mTBI outcomes are predicted by scores on the Hospital Anxiety and Depression Scale (HADS), the Impact of Events Scale, duration of posttraumatic amnesia, and some neuropsychological measures (King, 1996, King et al., 1999). Specifically, King (1996) found that PCS symptom report at 7–10 days was predicted by intrusive thoughts about a stressful event, and at three months, PCS symptom report was predicted by HADS anxiety. The King et al. (1999) study found that depression as measured by the HADS predicted PCS symptom report at 7–10 days, and HADS anxiety predicted PCS symptom report at six months. However, these studies had an inadequate sample size to generate a reliable regression model (N=50–52, with 7–17 predictors). Furthermore, these studies did not include a control group. Thus, it is difficult to determine if these predictions hold for mTBI samples only or if they might also be demonstrated in a non-clinical sample. Additional research that addresses these concerns and considers the influence of depression anxiety and stress on postconcussion-like symptom report is clearly needed.
This exploratory study sought to investigate the relationship between postconcussion-like symptoms and the reporting of symptoms of depression, anxiety, and stress, respectively. To address one of the limitations of past research, this study aimed to have an adequate participant-to-variable ratio. A non-clinical sample was used to determine if relationships demonstrated previously in clinical groups would hold outside of this context.
Section snippets
Participants
The participants were 71 undergraduate students (74.6% female) from Queensland University of Technology. Participants were aged from 17–54 years (M=24.27, S.D.=8.93) and had no history of head injury or neurological impairment. Four participants indicated that they spoke a language other than English at home. These participants were retained in the sample because sufficient English proficiency was assumed on the basis of current student status at an Australian university. Volunteers received
Results
The data were examined for accuracy of data entry, missing values, and breaches of relevant statistical assumptions. All statistical test assumptions were met unless otherwise specified. A missing values analysis revealed that there were no variables with more than 1.5% of missing data. Seven cases had missing data on the DASS (0.8%); these cases were retained and the missing items were resolved by averaging over the remaining items for that scale (as per Lovibond and Lovibond, 1995a). There
Discussion
The purpose of this study was to examine the influence of depressive symptoms, anxiety and stress on postconcussion-like symptoms in a non-clinical sample. There was a strong positive relationship between postconcussion-like symptoms and DASS subscale scores at the bivariate level of analysis. This finding is consistent with previous reports of a significant positive association between postconcussion-like symptoms and depression or depressive symptoms (Suhr and Gunstad, 2002, Iverson and
Acknowledgements
The Human Research Ethics Committee of Queensland University of Technology (QUT-HREC #1000000311) approved this research. This project was granted an occupational workplace health and safety clearance. Funding for this project was provided by the School of Psychology and Counselling, Queensland University of Technology. The authors thank Lauren Cunningham for assistance with manuscript formatting, and Dr Janine Beck for comments about statistical methods.
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