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NEUROPSYCHOLOGICAL REHABILITATION 2012, 22 (1), 1 25

Cognitive behavioural therapy and persistent post-concussional symptoms: Integrating conceptual issues and practical aspects in treatment
Seb Potter1 and Richard G. Brown2
Lishman Brain Injury Unit, South London and Maudsley NHS Foundation Trust, London, UK 2 Kings College London, Institute of Psychiatry, Department of Psychology, London, UK
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This paper seeks to integrate research ndings in mild traumatic brain injury (MTBI) around three central themes relevant to psychological therapies for persistent post-concussional symptoms (PCS). These are (1) the relative lack of symptom specicity, (2) the extent to which subjective (but not necessarily objective) cognitive difculties predominate, and (3) the role of psychological (especially cognitive-behavioural) processes in the evolution and maintenance of symptoms. Evidence-based models guiding cognitive-behavioural therapy (CBT) for similar symptoms in other clinical groups are considered in relation to persistent PCS, as well as some of the practical considerations in applying CBT with this client group. Outstanding research issues are identied and discussed, including the opportunities and risks of combining CBT and cognitive rehabilitation approaches. Keywords: Traumatic brain injury; Post-concussion syndrome; Cognitivebehavioural therapy.

Correspondence should be addressed to Dr Seb Potter, Lishman Brain Injury Unit, The Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK. E-mail: s.potter@iop.kcl.ac.uk The authors would like to thank Ionie Lyon for her assistance in preparing this manuscript. The authors acknowledge support from the NIHR Biomedical Research Centre for Mental Health at the South London and Maudsley NHS Foundation Trust (SLaM) and Institute of Psychiatry, Kings College London. # 2012 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business http://www.psypress.com/neurorehab http://dx.doi.org/10.1080/09602011.2011.630883

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INTRODUCTION
The array of cognitive, emotional and physical symptoms reported after some form of traumatic injury involving the head, which improves for many but persists for a few, has long been a topic of clinical interest and debate. The terminology has evolved over the years, from railway spine (Erichsen, 1882, p. 1135), traumatic neurasthenia (Russell, 1932), post-contusional syndrome (Lewis, 1942) to post-concussional disorder (World Health Organization, 1993). Much of the discussion has centred around the extent to which persisting direct effects of traumatic brain injury are primarily responsible for these persistent post-concussional symptoms (PCS) as opposed to other psychological pre-, peri- and post-injury variables. In a paper in 1942 to the Royal Society of Medicine, Lewis (1942) cautioned against polarised viewpoints in this area, suggesting that professionals take care . . . neither to hunt the snark of physiogenesis to death, nor perfervidly to track the red herring of moral obliquity (gold digging, scrim-shanking) to its lair (p. 612). Subsequent biopsychosocial/diathesis-stressor models (Jacobson, 1995; Kay, 1993; Lishman, 1988; Wood, 2004) have attempted to combine the different perspectives, acknowledging potential early effects of brain injury on cognition, whilst emphasising the increasing role of psychological mechanisms should symptoms persist (Figure 1). After mild traumatic brain injury (MTBI) residual direct effects of brain injury may contribute little if anything to persistent symptoms. However, with increasing severity of TBI, so the relative contribution of brain injury on outcome is likely to increase (Schretlen & Shapiro, 2003; Stuss, 1995). Given the debates implications for treatability of these persistent postconcussional symptoms (PCS) following MTBI, it is perhaps surprising that research into treatment beyond prophylaxis has remained limited. Whilst pharmacological interventions for persistent symptoms are available (McAllister & Arciniegas, 2002), much of the focus has been around psychosocial interventions, especially those with cognitive-behavioural components (Kay, 1993; Ruff, Camenzuli, & Mueller, 1996). Although a meta-analysis in 2001 indicated evidence for the effectiveness of early psychoeducation and reassurance in prophylaxis (Mittenberg, Canyock, Condit, & Patton, 2001) a more recent systematic review notes some inconclusive ndings (Al Sayegh, Sandford, & Carson, 2010), and other reviews comment on the shortage of well-designed studies for persistent symptoms (Comper, Bisschop, Carnide, & Tricco, 2005; Snell, Surgenor, Hay-Smith, & Siegert, 2008). Rather than attempt a broad systematic review of MTBI and PCS, this paper seeks to integrate some of the areas of literature relevant to cognitive-behavioural treatment approaches, a process completed in part during the development of a protocol for an ongoing randomised control trial for persistent PCS (Potter, Fleminger, & Brown, 2008, 2010). These are translated

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Figure 1. Model illustrating the changing relative contributions of different factors over time which contribute towards post-concussional symptoms for a hypothetical mild TBI (after Lishman, 1988).

into more general principles and practical applications, drawing on CBT models and practice in potentially related conditions, and reecting the clinical experience of preparing and running the trial. Finally, ongoing issues for research are discussed.

RELEVANT THEMES FROM THE LITERATURE Post-concussional symptoms are non-specic, and comorbidity with psychiatric disorder is high
Descriptions of physical, emotional and cognitive post-concussional symptoms are broadly consistent, with good agreement in symptoms between ICD-10 and DSM-IV (Boake et al., 2004). Factor analyses of PCS questionnaires often identify similar symptom clusters (Potter, Leigh, Wade, & Fleminger, 2006), although single-factor models may also t the data (Lannsjo, af Geijerstam, Johansson, Bring, & Borg, 2009). However, postconcussional symptoms are not specic and overlap considerably with those

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seen in the general population (Chan, 2001), in subclinical depression (Iverson & Lange, 2003), and in other physical conditions (Haldorsen et al., 2003; McCauley, Boake, Levin, Contant, & Song, 2001). Figure 2 shows data from two studies using the Rivermead PCS Questionnaire (King, Crawford, Wenden, Moss, & Wade, 1995), one from participants from the general population without a history of MTBI (Chan, 2001), the other from individuals with persistent symptoms following MTBI or chronic pain (Smith-Seemiller, Fow, Kant, & Franzen, 2003). While symptom severity is elevated in individuals with MTBI compared to healthy controls, their overall level is similar to those in chronic pain. Psychiatric comorbidity is high in individuals with persistent PCS: around two-thirds may meet diagnostic criteria for either DSM Axis I and/or Axis II disorders (Evered, Ruff, Baldo, & Isomura, 2003; Ruff & Jurica, 1999). Comorbid depression may also increase the reporting of both the number and severity of symptoms after MTBI (Lange, Iverson, & Rose, 2011). A co-morbid psychiatric disorder does not necessarily imply that the PCS symptoms themselves are of psychiatric origin: it might reect an epiphenomenal coincidence due to overlapping symptoms, as also suggested in relation to apparent post-traumatic stress disorder (PTSD) after severe TBI (Sumpter & McMillan, 2006) or a reection of the consequences and attempts to manage and compensate for persisting direct effects of brain injury on cognition (Marsh & Smith, 1995; Van Zomeren, Brouwer, & Deelman, 1984).

Figure 2. Mean item ratings on the Rivermead PCS Questionnaire (RPQ) associated with MTBI, chronic pain (Smith-Seemiller et al., 2003), and in healthy controls (Chan, 2001). Data from Chan (2001) were re-calculated using the 00234 scoring system recommended in King et al. (1995).

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However, previous psychiatric difculties may increase risks of persistent symptoms (Luis, Vanderploeg, & Curtiss, 2003), and depression and PTSD may play a role in mediating the relationship between MTBI and persistent PCS in both civilian (Bryant & Harvey, 1999) and military populations (Hoge et al., 2008). For example, symptoms associated with depression, anxiety and PTSD within the rst week to 10 days after MTBI predict subsequent PCS at three and six months post-injury (King, 1996; King, Crawford, Wenden, Caldwell, & Wade, 1999). Acute physical and psychological symptoms may thus predict the presence of subsequent PCS-like symptoms more closely than the nature of the injury itself (McLean et al., 2009). The relationship between psychiatric symptomatology and persistent PCS provides a potential starting point from which to frame a psychological intervention. Overlapping symptoms and other similarities with other conditions provide a range of possible cognitive-behavioural models when formulating possible vicious cycles that contribute to symptom evolution and maintenance, and offers a range of associated evidence-based therapeutic techniques. These may include models and approaches for depression (Beck, Rush, Shaw, & Emery, 1979), anxiety disorders including panic (Clark, 1986), PTSD (Ehlers & Clark, 2000) and health anxiety (Salkovskis & Warwick, 2001), as well as chronic fatigue (Surawy, Hackmann, Hawton, & Sharpe, 1995) and medically unexplained symptoms (Deary, Chalder, & Sharpe, 2007; Nezu, Nezu, & Lombardo, 2001).

Although subjective cognitive complaints are common, the presence and signicance of objective cognitive dysfunction in persistent PCS is ambiguous
Systematic reviews and meta-analyses of neuropsychological functioning indicate that objective impairments can be measured in the initial days and weeks after MTBI, but that effects are not typically apparent beyond 3 months after injury (Belanger, Curtiss, Demery, Lebowitz, & Vanderploeg, 2005; Binder, Rohling, & Larrabee, 1997; Frencham, Fox, & Mayberry, 2005). Meta-analyses may mask heterogeneity and obscure sub-groups that continue to show persistent cognitive decits (Iverson, 2010; Pertab, James, & Bigler, 2009) and some studies do nd evidence of objective impairment (Bohnen et al., 1992; Sterr, Herron, Hayward, & Montaldi, 2006). Nonetheless, objective impairment and subjective complaints can dissociate (Stuss et al., 1985) and any associations tend to weaken over time (Bazarian et al., 1999), whilst functional outcomes, such as return to work, may be more closely associated with subjective symptoms rather than neuropsychological functioning (Nolin & Heroux, 2006). In addition, performance on cognitive tests can be inuenced by a range of other variables often co-occurring with MTBI and persistent PCS (Iverson, 2005; Zasler & Martelli, 2003), from

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nancial incentives to under-perform (Binder & Rohling, 1996), to co-morbid symptoms such as pain and anxiety (Nicholson, Martelli, & Zasler, 2001; Radanov et al., 1999), and even subtle factors such as having attention drawn to a previous MTBI at the time of the assessment (Suhr & Gunstad, 2005). Nonetheless individuals with persistent PCS may report higher levels of subjective cognitive difculties compared with other clinical groups with PCS-like symptoms including chronic pain (Smith-Seemiller et al., 2003), orthopaedic conditions (Gerber & Schraa, 1995) or groups without MTBI (Gordon, Haddad, Brown, Hibbard, & Sliwinski, 2000). Excessive cognitive complaints have been conceptualised as a specic somatoform disorder, labelled cogniform disorder (Delis & Wetter, 2007) or cognitive hypochondriasis (Boone, 2008). Caution is reasonably warranted before assuming that persisting direct effects of brain injury on cognition mediate the relationship between MTBI and persistent PCS. However the subjective experience of perceived cognitive difculties may need to be incorporated in cognitive-behavioural models of persistent symptoms and addressed directly in treatment.

Cognitive-behavioural mechanisms (e.g., around symptom perceptions and coping) can play an important role in the genesis and maintenance of PCS (and PCS-like symptoms)
Involvement in a medicolegal process is recognised as a risk factor for persistent symptoms after MTBI. Although typically framed in relation to nancial incentive (Binder & Rohling, 1996), the ongoing medicolegal claim may inadvertently reinforce maladaptive responses, such as increasing focus on symptoms without associated management, or emphasising issues of blame and responsibility (Jacobson, 1995). In one study of people with mixed but typically more-than-mild injury severity, other-blame (but not self-blame) predicted depression 1 year post-TBI and was associated with maladaptive rumination and pre-occupation about the injury (Hart, Hanks, Bogner, Millis, & Esselman, 2007). In non-MTBI survivors of road-trafc accidents, those who considered others as responsible were likely to demonstrate greater distress at 6 and 12 months post-injury (Delahanty et al., 1997), whilst perceived injustice correlates with pain severity and predicts delayed return to work in chronic pain (Sullivan et al., 2008). A further area of interest has been around expectation as aetiology and the good old days bias. Individuals with head injuries tend to underestimate common pre-injury PCS-like symptoms relative to uninjured controls (potentially increasing attention to similar symptoms post-injury), while uninjured controls are able to anticipate or predict PCS after a hypothetical head injury (Mittenberg, DiGiulio, Perrin, & Bass, 1992). Similar ndings have

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been replicated in some (Gunstad & Suhr, 2004; Iverson, Lange, Brooks, & Rennison, 2009; Lange, Iverson, & Rose, 2010) but not all studies (Gunstad & Suhr, 2002). Although the experimental methodology has been critiqued, especially as to whether controls can predict post-concussional-type symptoms or are responding to methodological biases (Mackenzie & McMillan, 2005; Mulhern & McMillan, 2006), such research suggests that cognitive biases may inuence how individuals perceive and respond to symptoms following injury. Expectation as aetiology has inuenced the development of prophylactic psychoeducational programmes (in the initial hours, days and weeks after injury), emphasising the common nature of post-concussional symptoms and the expectation that the symptoms improve over time, and with some positive results in reducing persistent symptoms (Mittenberg et al., 2001; Ponsford et al., 2002). The relevance of such expectation-based psychoeducational approaches to persistent PCS is unclear. Individuals with persistent symptoms are likely to be experiencing a discrepancy between what they have been told to expect in the acute phase of their injury and their subsequent experiences, leading to uncertainty and potential loss of condence in professional advice. Questions about the causes and implications of persistent symptoms (What does it mean, that they havent improved?) may be both understandable and common. Causal attributions and expectations can affect outcome: individuals 13 weeks after MTBI who anticipated serious negative consequences were more likely to have persistent symptoms 3 months post-injury (Whittaker, Kemp, & House, 2007). In contrast, neither the severity of early post-concussional symptoms, nor other symptoms (such as PTSD and depression), nor injury severity improved the predictive model. Broader cognitive and behavioural responses to symptoms may also be signicant, such as a reduced level of active coping strategies (Bohnen et al., 1992). Although not necessarily generalisable to MTBI, cross-sectional studies in individuals with more severe TBI have shown strategies such as avoidance, worry, self-blame and wishful thinking to be associated with worse outcome (Anson & Ponsford, 2006; Curran, Ponsford, & Crowe, 2000), with avoidance linked to lower self-esteem and reduced perceived ability to cope with the TBI (Riley, Dennis, & Powell, 2010). Longitudinal studies have indicated that emotional well-being may be predicted by selfesteem and perceived impact of TBI (Kendall & Terry, 2009), whilst quality of life was predicted by greater problem-focused and less emotionfocused coping in a mixed acquired brain injury sample (Wolters, Stapert, Brands, & van Heugten, 2010). Research in other clinical groups with similar symptoms may again be informative. In chronic fatigue syndrome, while attributions regarding physical causes for symptoms were unrelated to outcome, attitudes around responses to symptoms (such as avoiding exercise) changed during therapy

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and were associated with improved outcome (Deale, Chalder, & Wessely, 1998). In a study of individuals with chronic stress symptoms, avoidance of mental exertion was associated with concern about permanent vulnerability to information overload and risk of relapse (Schmidt, 2003). In summary, there is emerging evidence that individuals responses to their injuries and their consequences may be inuential in determining symptoms and outcomes, with pragmatic implications for use of CBT. Treatment may need to extend beyond attributions about the cause of ongoing symptoms to address maladaptive behavioural responses and cognitive appraisals of their injury, associated symptoms, and impact on daily life.

PRINCIPLES AND PRACTICE OF CBT FOR PCS


Structured psychological interventions considering individuals attitudes to injury and promoting a graded return to activities have been recognised as relevant to the treatment of PCS (Lewis, 1942; Russell, 1932). More recently, cognitive-behaviour therapy (CBT) has provided models and methods to treat a range of problems associated with PCS including depression and anxiety, sleep problems, chronic fatigue and pain. More specic approaches have been developed for use in acquired brain injury (Khan-Bourne & Brown, 2003; McGrath & King, 2004), with some focus on PCS (Ferguson & Mittenberg, 1996; Kay, 1993; Ruff et al., 1996). However, the heterogeneity of PCS presentations means a xed session-by-session treatment protocol may be difcult to establish. In this section we outline some of the key principles underlying CBT as it may be applied to persistent PCS. This is informed by the authors experiences in designing and implementing a 12-session formulation-led programme for PCS following predominantly mild TBI (Table 1). The programme is currently being evaluated in a clinical trial with 46 individuals (52% with PTA 24 hours) randomised a minimum of 6 months post-injury (Potter et al., 2008, 2010).

Formulation and engagement: Socialising individuals to a cognitive-behavioural model


Being referred for CBT can be a challenge to a patient if it is perceived as implying that their problems are all in the mind or that they are expected to simply come to terms with their problems (Alexander, 1995). Engaging in debate about the reality of subjective PCS symptoms is rarely productive. Rather, the early process of engagement and socialisation is concerned with helping the client develop an open mind to alternative explanations that can be directly tested through the therapy process. Socialisation often commences with psychoeducation surrounding discussions about PCS. Material developed for early prophylaxis (Mittenberg,

CBT FOR PERSISTENT PCS TABLE 1 Twelve-session formulation-led framework for CBT for persistent PCS

Preliminary investigations (e.g., neuropsychological assessment, results feedback) Session 1 1. Agenda setting 2. CBT rationale for persistent PCS 3. Discussion of CBT format (collaborative, goal-focused, homework, focus on links between thoughts and feeling) 4. Problem and goal list 5. Homework: read Recovery from Post-Concussion Syndrome: A Guide for Patients (adapted from Mittenberg et al., 1993) Session 2 1. Agenda setting 2. Review previous session and homework 3. Discuss probable treatment techniques 4. Identify initial problem area and initiate appropriate techniques 5. Review and homework Session 3 1. Agenda setting 2. Review previous session and homework 3. Identify the days problem area(s) and initiate/develop appropriate techniques 4. Review and homework Sessions 4 12 1. As with session 3 3. Summarise techniques that have worked, and clarify reasons why 4. Summarise techniques that have not worked, and clarify reasons why 5. Introduce other problem areas as applicable Sessions 9 12 1. Increasing focus on relapse prevention/coping with possible symptom are-ups in nal quarter of session series (What happens if. . .?) 2. Focus on continuation of therapy beyond nal sessions: Devising action plans/behavioural experiments for the future 3. Review what has and has not helped, and discuss why

Tremont, Zielinski, Fichera, & Rayls, 1996; Mittenberg, Zielinski, & Fichera, 1993) can be adapted to common persistent PCS; relationships between different symptoms areas can be discussed (e.g., between poor sleep, fatigue, and cognitive difculties), as can factors which make other symptoms better or worse. The idea of vicious cycles can also be introduced during an initial educational phase, ideally using illustrations relevant to the clients own complaints. All cognitive-behaviour treatments involve a collaborative formulation that focuses on target problems and how they are inuenced by a persons thoughts and behaviour (Kirk, 1989; Padesky & Mooney, 1990). This may be especially relevant in PCS if individuals see symptoms solely as direct consequences of their original injury. Identifying factors that improve or worsen symptom experience (e.g., poor sleep exacerbating daytime fatigue or concentration

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difculties) can encourage a broader perspective. Feedback sessions after neuropsychological assessment (Gass & Brown, 1992) are helpful in starting this discussion in relation to perceptions of cognitive difculties. Lishmans (1988) model (Figure 1) may be used to explain the change in relative importance from brain injury related factors to other factors over time. This allows discussion of the role of psychological factors in maintaining problems and therefore as potential targets of treatment. The role of vicious cycles in maintaining symptoms (Kay, 1993) can be introduced early, possibly using the analogy (cf. Blenkiron, 2005) of a electric starter motor which is needed initially to start a car engine but not to keep the engine going afterwards. Although socialising clients to these ideas can provide hope for improvements in persistent symptoms, clinicians should also be sensitive to the potential impact of challenging previously held attributions and causal beliefs. It is important to stress the formulation as a working hypothesis, not as a statement of fact. It may also be important early in therapy to identify any mixed messages or conicting information that clients have received from health professionals, written materials and the Internet, especially around differing explanations for symptoms and prognosis. Acknowledging the uncertainty and debate, even amongst experts, may be useful in building the therapeutic relationship. It may also be helpful to introduce the notion of persistent post-concussional syndrome as a clinically recognised construct that does not imply a single, specic or particular organic or psychogenic aetiology, and which includes distressing symptoms found also in people without TBI. This can normalise problems and remoralise individuals (Frank, 1982), helping identify therapy targets and possible ways to achieve them.

Behavioural issues: Focusing on making graded increases in levels of activity


Individuals with MTBI and PCS commonly report a restriction of activity over time including work, activities of daily living, hobbies and socialising. Some may have a model of recovery through rest (perhaps inadvertently reinforced by family members), while in others there may be a loss of opportunity due to nancial constraints. Perceived worsening of symptoms (anxiety, fatigue, pain, etc.) following earlier attempts to return to previous activities may have led to avoidance or activity restriction. CBT may aim to tackle such avoidance in its various forms, e.g., kinesiophobia (Todd, 1998) and cogniphobia (Martelli, Grayson, & Zasler, 1999; Schmidt, 2003), travel phobia, social anxiety and agoraphobia, or feelings of demoralisation following perceptions of past failure. Re-engaging the client with rewarding activity through behavioural activation (Jacobson et al., 1996) can also be an important tool in tackling any accompanying depressed mood.

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Of particular relevance to increasing activity is a CBT model for chronic fatigue syndrome (Surawy et al., 1995), describing oscillations between high (boom) and low (bust) levels of activity in association with fatigue and frustration. This may be particularly applicable for clients with PCS who describe marked differences in terms of good (i.e., low symptom) and bad (i.e., high symptom) days. The implication of the boom-and-bust model is to establish a sustainable level of activity which can be built upon. Clients may be encouraged to do gradually more when fatigue levels are higher, and to do somewhat less when fatigue is lower to smooth out activity levels and avoid extreme oscillations. King (1997) suggests titrating levels of activity against symptoms, especially in managing early PCS. However, he notes the risk of symptom-focusing which may exacerbate difculties, as suggested in chronic fatigue (Moss-Morris, Sharon, Tobin, & Baldi, 2005). It may be preferable with persistent PCS to aim for sustainable, gradual increases in activity (in intensity and/or duration) over time.

Cognitive-behavioural issues: Dealing with broader symptom attributions and responses


Whilst CBT models often focus on the beliefs about the causes of symptoms, the precise role of specic causal attributions in PCS is unclear. While clients with persistent PCS might sometimes be characterised as being convinced that their symptoms are solely maintained by an injury to their brain, in our clinical experience many are open to the possibility that psychological mechanisms and variables are involved. They may report, for example, that their headaches are worse when feeling stressed, or that poor sleep and fatigue exacerbate concentration difculties. In approaching therapy and developing formulations, cognitive-behavioural models for health anxiety may be of value. For individuals who remain sceptical about the role of vicious cycles in maintaining symptoms, it may be possible to review the consequences of a solely organic model and to present CBT as a nothing to lose opportunity to discover alternative approaches to managing symptoms (Wells, 1997). Similarly, behavioural experiments may be useful early in therapy to demonstrate, for example, how focusing on symptoms can intensify their experience and distress, or to test the value of established safety behaviours. Such practical demonstrations can help convince sceptical clients of the potential of a CBT approach without confrontationally challenging longstanding causal beliefs. Underestimation of pre-injury symptoms has inuenced early psychoeducational interventions which emphasise the continuity of PCS with normal symptoms (Mittenberg et al., 1992, 1996). Similar applications for persistent PCS may be more challenging, as questions about pre-injury symptoms may

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be difcult to answer accurately due to a good old days bias, and may be viewed by some clients as trivialising current symptoms. An alternative may be to discuss how clients respond to symptoms, and how these responses differ before and after injury. People may identify that they are now more aware of certain symptoms, that these are more of a source of worry and concern, and are dealt with differently. This may also identify possible unhelpful cognitive distortions such as jumping to conclusions, catastrophising and all-or-nothing thinking, which can then be explored and challenged through verbal reattribution and behavioural experiments (Wells, 1997). Perfectionism may also provide another relevant model for some clients. Perfectionism has been implicated as a risk factor for eating disorders (Fairburn, Cooper, Doll, & Welch, 1999; Lilenfeld et al., 1998), has been associated with poorer outcomes in CBT for depression (Blatt, Zuroff, Bondi, Sanislow, & Pilkonis, 1998), and has been discussed in relation to persistent PCS (Ruff et al., 1996). Although conceptual issues in dening elements associated with normal, positive or dysfunctional perfectionism continue to be debated, a model of clinical perfectionism (Shafran, Cooper, & Fairburn, 2002) echoes clinical experience with some people with persistent PCS. These include concerns about failing to meet certain standards; a focus on selfevaluation of performance with a tendency to view the outcomes in polarised terms; and resulting self-criticism and/or procrastination which maintain these unmet standards and lead to adverse effects on mood and activity. Perfectionism-based formulations may therefore suggest a number of treatment opportunities (e.g., considering standards and expectations for performance, their impact, the options for considering alternatives; monitoring success though positive data logs, and considering where achievements may be minimised by negative automatic thoughts; and addressing procrastination). However, perfectionism remains to be quantitatively studied in relation to PCS, with the possibility that these characteristics may either reect pre-injury personality characteristics or develop in the context of persistent symptoms.

Focusing on cognition: Re-attributing problems, managing perceived mistakes and improving condence in cognitive abilities
As noted above, cognitive symptoms can be prominent amongst persistent PCS. Particular consideration may be given to address those factors affecting both cognitive performance and their perceptions by clients. One particular goal for the therapist may therefore be to reattribute cognitive difculties to causes other than persisting direct effects of brain injury, or at least taking them into account (Kay, 1993). Feedback sessions from cognitive assessments (Gass & Brown, 1992) can provide a useful starting point in identifying relative cognitive strengths and weaknesses, and eliciting discrepancies between how individuals felt they performed on a test compared with their

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test scores. In addition, mechanisms that may contribute to cognitive difculties (and how they are perceived) can be reviewed, along with treatment implications. For example, poor sleep and resulting fatigue may be identied, in turn indicating potential goals around sleep hygiene. Other psychoeducational elements may be useful, such as a discussion of the role of Yerkes-Dodson type curves in illustrating the non-linear relationship between effort or arousal and performance. Although potentially better conceptualised as a rough empirical guide to stressor effects which may over-simplify the different processes involved (Matthews, Davies, Westerman, & Stammers, 2000), they may illustrate the paradoxical effect of an individual trying harder on a particular task (especially if they feel that their ability or performance is impaired), without improving and even potentially harming performance. The concept of reinvestment (Masters, Polman, & Hammond, 1993) may also be helpful in formulating cognitive difculties. This describes the phenomenon where otherwise automatic skills or processes may become deautomatised or break down by reinvesting actions and percepts with attention (Deikman, 1969). An increased awareness of, or focus on, the mechanics of a task may therefore interfere with performance, especially where the task is a previously automatic one and where an individual is stressed or under pressure. Much of the experimental evidence of this proposed personalityrelated dimension has been focused around motor performance actions especially in sport, which may facilitate explanation using parallels with phenomena such as the yips in golf (Smith et al., 2000): however, research into the effects of reinvestment in more cognitively-orientated tasks is limited. Rather than improving cognitive functioning per se, CBT strategies may focus more on limiting the impact of perceived errors or mistakes and on improving condence in memory and other cognitive domains. The cognitive model in Figure 3 outlines a potential process by which challenges to memory or attention are responded to, before, during and after a task. Borrowing from the cognitive model of social anxiety (Clark, 2001), it outlines roles for anticipatory anxiety, performance anxiety and subsequent self-critical postmortems, all mediated by associated negative automatic thoughts. The combination of these stages, with associated increases in rumination, focus on task mechanics, and attention to evidence of difculties encountered and errors made, may lead to impairments in task performance (Teasdale et al., 1995; Teasdale, Proctor, Lloyd, & Baddeley, 1993). However, the ultimate impact of this spiral is to increase distress, reduce condence in cognitive abilities and promote avoidance of situations or tasks that are viewed as cognitively challenging. The model yields a number of potential targets for therapy. Negative automatic thoughts representing expectations or perceptions of performance (and in particular performance failures) can be addressed through verbal

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Figure 3. Outline of CBT model for conceptualising subjective cognitive difculties.

reattribution. This might include a focus on jumping to conclusions and expecting possible failure (e.g., Theyll think Im stupid, Im not going to be able to do this), catastrophising possible mistakes (e.g., I couldnt have got that more wrong) or focusing on them with a degree of selective abstraction (e.g., That didnt go perfectly, I made several errors); elements of all-or-nothing thinking (e.g., Ive got it wrong, Ive failed completely) or overgeneralisation (e.g., I made a mistake, Im never going to be able to do this). These possible distortions and their impact on mood and activity can be identied using conventional CBT techniques such as thought records and Socratic questioning, and challenged accordingly. Behavioural experiments can provide a counterpoint to verbal reattribution by illustrating the emotional impact of some of these thoughts as well as providing a further means to challenge them and provide some relief from symptoms (Wells, 1997). For example, beliefs about the need to identify problems in advance or reect on mistakes can be identied, with a goal to ban postmortems of perceived failures (Clark, 2001). Behavioural experiments can be used to test the value of beliefs about the perceived need to try harder or concentrate on what Im doing. The client can be encouraged to put less effort into a task and see the impact, on both task performance and associated difculties such as fatigue. Similarly, the effect of focusing attention on a relatively automatic task can also be examined: e.g., an individual might be asked to walk up and down a corridor as normal, then to repeat the task while focusing on the particular muscles involved in walking and their coordination. Afterwards, they can be encouraged to reect on the impact that this manipulation has on perceived task performance, complexity and uency.

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Improving more general metacognitive beliefs may also be useful. In older adults, beliefs in poor memory have been shown to be associated with increased dependence, avoidance of memory challenges, helplessness and demoralisation (Elliott & Lachman, 1989). Cognitive continua (Wells, 1997) can be used to address dichotomous success or failure thinking and highlight ways in which this may over-simplify individuals experiences or cause them to overlook more positive experiences by discounting partial successes. Positive data logs (Padesky, 1994), recording when individuals have concentrated or remembered successfully, can illustrate and correct processing biases that may lead individuals to overlook or discount achievements and contrast with less constructive post-mortems of events. Other strategies from positive psychology (Seligman, Steen, Park, & Peterson, 2005) and managing low self-esteem (Fennell, 1998) may also be relevant in this domain.

OUTSTANDING ISSUES IN THE TREATMENT OF PERSISTENT PCS


The previous section suggests that CBT can provide a framework for the conceptualisation and treatment of post-concussional symptoms. However, there are a number of outstanding issues in addition to broader conceptual and methodological issues around the denitions of MTBI and PCS (Carroll, Cassidy, Holm, Kraus, & Coronado, 2004).

Is CBT an effective treatment for persistent PCS? Can its effectiveness be enhanced?
Whilst interventions with psychosocial components are viewed as potentially benecial in surveys of various professional groups (Davies & McMillan, 2005; Evans, Evans, & Sharp, 1994; Mittenberg & Burton, 1994), research into psychological treatment of persistent PCS is largely limited to early prophylactic interventions. However, studies using either single case designs or trials with limited controls have demonstrated that psychosocial treatment with cognitive-behavioural components may be effective in addressing particular persistent symptoms after mixed-severity TBI, including dizziness (Gurr & Moffat, 2001), headache (Gurr & Coetzer, 2005; Martelli, Grayson, & Zasler, 1999), depression (Bradbury et al., 2008), anger (Medd & Tate, 2000), PTSD (McGrath, 1997; McMillan, 1991; Williams, Evans, & Wilson, 2003), and other anxiety disorders such as obsessive-compulsive disorder (OCD) (Williams, Evans, & Fleminger, 2003). There is also some evidence for broader improvements in activities of daily living (Ho & Bennett, 1997) and post-concussional symptoms (Cicerone et al., 1996) in uncontrolled studies of cognitive rehabilitation for MTBI with cognitivebehavioural elements.

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The most relevant randomised controlled trial (Tiersky et al., 2005) assessed the impact of an intensive 11-week programme in a small group (N 20) of individuals with mild to moderate TBI, seen on average between 5 and 6 years post-injury. Treatment combined cognitive-behavioural elements with cognitive remediation (the latter including both compensatory and remediation/retraining elements) with one-to-one sessions occurring twice a day for three days per week. When compared with waiting-list controls, the treated group showed improvements in overall symptoms as well as in some neuropsychological measures, but not subjective cognitive complaints. Gains were maintained at 3 months post-treatment, although community integration did not improve signicantly. Such results suggest that persistent difculties after predominantly mild TBI can respond to psychosocial treatment with cognitive-behavioural elements, and that randomised controlled trials can be conducted in this client group. However, it remains unclear the extent to which CBT improves broader aspects of outcome such as quality of life, return to work or decreased utilisation of medical services. It is also unclear how any impact of CBT is inuenced by TBI severity, length of time elapsed since injury, the presence of co-morbid or pre-injury psychiatric diagnoses or previous/ongoing medicolegal claims. A better understanding of the role of psychological factors in persistent symptoms would also assist in rening CBT protocols for PCS. King (2003) notes a number of windows of vulnerability where different mechanisms may have a different emphasis at different points during recovery. The role of broader personality traits (such as clinical perfectionism and reinvestment) have been noted, as have other more specic event- or symptom-related processes, such as illness perceptions or aspects of coping and avoidance. Again, similarities with other conditions may be relevant: perceptions of injustice (of particular relevance in relation to medicolegal aspects of PCS) have been associated with symptoms in chronic pain (Sullivan et al., 2008), whilst the perceived unacceptability of experiencing and expressing negative emotions has been implicated in chronic fatigue and other disorders such as irritable bowel syndrome and somatisation (Rimes & Chalder, 2010; Surawy et al., 1995). Cross-sectional studies demonstrating associations with symptoms and differences between individuals with persistent PCS and controls (or other clinical groups) can be useful in identifying possible variables of interest, with experimental or longitudinal designs providing more convincing evidence of their direct role in maintaining symptoms over time. Practical aspects of CBT provision also deserve consideration in future research, with implications around its effectiveness. These include the number, frequency and length of sessions; the advantages and disadvantages of guided self-help through bibliotherapy or computerised CBT, individual therapy or group treatment; the value of including family members as

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co-therapists and the role of booster sessions after a treatment block. CBT may also be offered in different settings, e.g., through specialist post-concussion clinics, or community brain injury teams, or more generic mental health or psychological therapy services. Scope also exists for integrating CBT into broader multidisciplinary care, such as collaboration with neuropsychiatry around the use of medication (Arciniegas, Anderson, Topkoff, & McAllister, 2005; McAllister et al., 2002), or integration with physiotherapy around managing dizziness (Gurr & Moffat, 2001). Potential difculties also exist in applying CBT to persistent PCS. The heterogeneity of the client group, due in part to the lack of symptom specicity and the potentially wide range of applicable cognitive-behavioural models, make it difcult to dene a particular, highly-specic CBT for PCS protocol. This may make training therapists more challenging and runs the risk of non-formulation-driven, unstructured and unfocused CBT techniques being applied by therapists lacking experience of clients with (mild) TBI or PCS. Clearer replicated demonstrations of specic psychological factors and their role in the genesis and maintenance of persistent PCS could also assist in targeting CBT strategies more effectively.

What is the role of cognitive rehabilitation/remediation in the treatment of persistent PCS, and what is its relationship with CBT?
A number of authors have discussed CBT in conjunction with cognitive rehabilitation or remediation techniques that seek to compensate for cognitive impairments or improve cognitive functioning. The two approaches are both goal-orientated, active, collaborative and focused on current concerns and issues (Mateer, Sira, & OConnell, 2005) and are potentially complementary, as in the use of combined remediation and CBT to help subjects cope with feelings of loss related to decreased cognitive and physical functioning (Tiersky et al., 2005). Indeed, a combination of both cognitive restructuring and memory skills training may have additive or synergistic effects on metacognitive beliefs (Lachman, Weaver, Bandura, Elliot, & Lewkowicz, 1992). Where different treatment rationales may be more acceptable to different individuals, similar tasks can also be presented in various ways: attempting a series of attentionally demanding tasks might be framed as exercises to boost attention (a cognitive remediation perspective), or as systematic desensitisation to improve tolerance to fatigue (a behavioural perspective), or to test and challenge concerns regarding metacognitive abilities and improve condence (a cognitive-behavioural perspective). However, there are risks in explicitly combining cognitive remediation/ rehabilitation with CBT approaches. Their rationale may iatrogenically neurologise non-neurological disability, implying a need to come to terms with

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or grieve a loss of function (Alexander, 1995) whilst diverting attention away from other possible causes of complaints and their treatment (Paniak, TollerLobe, Durand, & Nagy, 1998), Teaching compensatory strategies for cognitive difculties may inadvertently train maladaptive safety behaviours that maintain problems through heightened self-focus and awareness of the possibility of making errors, decreasing uency, reinforcing a subjective sense of impaired abilities and interfering with evidence that might help rebuild condence (Veale, 2003). Caution about remediation also may be warranted given the debate about the neuropsychological sequelae of MTBI noted previously and the more general effectiveness of cognitive remediation techniques (Cicerone et al., 2005). For these reasons, a formulation-based CBT intervention may be preferred after MTBI which remains catholic and wide-ranging but without making potentially iatrogenic assumptions. With increasing severity of TBI, where the relative contribution of brain injury on cognition (Stuss, 1995) and postconcussional symptoms is likely to be greater, there may be a better rationale for cognitive remediation/rehabilitation as an explicit adjunct to CBT. Questions persist about which techniques or treatment components work best, how they work, and for whom they are most effective. However, these questions remain open to experimental scrutiny (Cicerone et al., 1996).

SUMMARY
The extent to which direct effects of brain injury are responsible for persisting symptoms after MTBI remains contentious, although there are reasonable grounds to be cautious in making this link. Whether a denite answer to this question would assist in improving clinical care is also open to discussion. Perhaps more important than the sterile debate concerning the psychological vs. organic origins of symptoms (Wood, 2004, p. 1135) is the degree to which persistent symptoms or associated impaired functioning can be improved by a particular treatment. Whilst the notion of using psychological treatment in such instances is itself not novel, CBT provides a bridge between much of the current literature on persistent PCS and broader developments in psychological therapies in recent years, as well as offering several targets for future research and larger scale clinical trials.

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