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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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tients, during the period of posttraumatic amnesia, rarely confabulate and usually have an impaired ability to register events and information, an abnormality not ordinarily observed in patients entering the chronic phases of Korsakoff psychosis Apart from disorientation in place and time, the head-injured patient also shows defects in attention as well as distractibility, perseveration, and an inability to synthesize perceptual data Judgment may be mildly impaired, rarely severely, during the amnestic epoch A perseverative tendency interferes with both action and thought As a general rule, the lower the score on the Glasgow Coma Scale immediately after injury (Table 35-1) and the longer the posttraumatic gap in the formation of memories (anterograde amnesia), the more likely the patient is to suffer permanent cognitive and personality changes Abnormalities in these spheres were found in only 12 percent of head-injured patients who had been in coma for longer than 24 h (Sazbon et al) If respiration and motor function were normal (except for early decorticate posturing) and there was no extraneural trauma, 94 percent of the patients recovered According to Jennett and Bond, patients with good recovery achieved their maximum degree of improvement within 6 months Others have found that detailed and repeated psychologic testing over a prolonged period, even in patients with relatively minor cerebral injuries, discloses measurable improvement for as long as 12 to 18 months There are other mental and behavioral abnormalities of a more subtle type that remain as sequelae to cerebral injury As the stage of posttraumatic dementia recedes, the patient may nd it impossible to work or to adjust to his family situation Such patients continue to be abnormally abrupt, argumentative, stubborn, opinionated, and suspicious Unlike the traumatic mental disorder described above, in which there is a certain uniformity, these traits vary with the patient s age, constitution, past experience, and the environmental stresses to which he is subjected Extremes of age are important The most prominent behavioral abnormality in children, described by Bowman et al, is a change in character They become impulsive, heedless of the consequences of their actions, and lacking in moral sense much like those who had recovered from encephalitis lethargica Some adolescents or young adults show the general lack of inhibition and impulsivity that one associates with frontal lobe disease In the older person it is the impairment of intellectual functions that assumes prominence In most instances these more serious behavioral changes can be traced to contusions in the frontal and temporal lobes The tendency is for all such symptoms to subside slowly though not always completely, even in those in whom an accident has provoked a frank outburst of psychosis (as may happen to a manic-depressive, paranoid schizophrenic, or neurotic patient) These forms of traumatic insanity were carefully analyzed for the rst time by Adolf Meyer Hysterical symptoms that develop after head injury, both cognitive and somatic, appear to be more common than those following injury to other parts of the body These symptoms are discussed in Chap 56.