**Abstract**

After a traumatic blow to the head, it is common to experience difficulty focusing, disorientation, dizziness, nausea, sensitivity to light and sound, and often loss of consciousness. These symptoms often persist for several weeks following the concussion before diminishing completely. Post-concussion syndrome (PCS) refers to the persistence of concussion symptoms beyond the normal two-week window. For some, symptoms can continue for several months to several years, even further manifesting into depression, anxiety, and substance abuse in time. Though the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) has continued to grow with each new version, PCS has not been included in its most recent iteration. An acquired brain injury rehabilitation specialist can be recommended for TBI, and a clinical psychologist or psychiatrist can be recommended for Acute Stress Disorder. The authors commend this reclassification because it recognizes that brain injuries are to be studied by neurologists and other medical specialists while transformations to one's existence are to be studied by psychologists. Nevertheless, while the present analysis aims at PCS in the latter (psychological) sense, it is worth mentioning that acquired brain injury (ABI) specialists have found it appropriate and even necessary to adopt an existential-phenomenological perspectives to more fully conceptualize this phenomenon. This study utilized the Interpretive Phenomenological Analysis (IPA) and arranged case studies with three athletes who had been forced to retire from sport due to major TBI's and prolonged PCS. Authors identified common themes across each interview and used free imaginative variation to describe the dimensions of the PCS experience. Specifically, the way participants were able to cope with the loss of identity and meaning after sport, as well as their perceived level of social support in the aftermath of TBI and PCS, played major roles in ameliorating and/or exacerbating both somatic and psychological difficulties associated with TBI and PCS.

**Keywords:** traumatic brain injury, post-concussion syndrome, phenomenology, identity, athletic retirement

## **1. Introduction**

After a traumatic blow to the head, it is common to experience difficulty focusing, disorientation, dizziness, nausea, sensitivity to light and sound, and often loss of consciousness. These symptoms often persist for several weeks following the concussion before diminishing completely. Post-concussion syndrome (PCS) refers to the persistence of concussion symptoms beyond the normal two-week window. For some, symptoms can continue for several months to several years.

Though the American Psychiatric Association's (APA) *Diagnostic and Statistical Manual of Mental Disorders* (DSM) has continued to grow with each new version, PCS has not been included in its most recent iteration. The *DSM-5* task force explains, "[s]ymptoms previously termed *postconcussive* (e.g., headaches, dizziness, sensitivity to light or sound, irritability, concentration deficits) can occur in braininjured and non-brain injured populations, including individuals with acute stress disorder" ([1], p. 286). The argument is that the causal linkage between traumatic brain injury (TBI) and PCS breaks down because the symptoms of PCS are either a variation of Acute Stress Disorder or TBI. An acquired brain injury rehabilitation specialist can be recommended for TBI, and a clinical psychologist or psychiatrist can be recommended for Acute Stress Disorder. The authors commend this reclassification because it recognizes that brain injuries are to be studied by neurologists and other medical specialists while transformations to one's existence are to be studied by psychologists.

While the present analysis aims at PCS in the latter (psychological) sense, it is worth mentioning that acquired brain injury (ABI) specialists have found it appropriate and even necessary to adopt an existential-phenomenological perspective as well. American rehabilitation physician and scholar Gary Goldberg [2] explains how "brain injury deeply affect[s] the subjectivity of the person injured—that is, their existence as a human person—because of the potentially significant aspects of personhood impacted […], it can also produce significant problematic impairment of self-awareness" (p. 397). Like neuropsychiatrist Kurt Goldstein [3] argued nearly a century earlier, Goldberg and others have called for a transformation of the philosophical paradigm that has traditionally been used to understand brain injury [4–9]. To this end, the present phenomenological analysis of PCS will be of interest to sport psychologists, clinical psychologists, and rehabilitation specialists working with acquired brain injury.

#### **1.1 Medicalization and DSM**

Since the third edition was published in 1980, *Diagnostic and Statistical Manual of Mental Disorders* (DSM) has used an increasingly biomedical model for explaining psychological disorders (1980). The biomedical model has replaced the psychoanalytic drive-theory model of explanation [10, 11].

The most recent iteration, *DSM-5* [1], continues down the pathway of biomedical explanation. The task-force explains: "The science of mental disorders continues to evolve. However, the last two decades since DSM-IV was released have seen real and durable progress in such areas as cognitive neuroscience, brain imagining, epidemiology, and genetics" (p. 5). They continue, "[s]uch an approach should permit a more accurate description of patient presentations and increase the validity of diagnosis (i.e., the degree to which diagnostic criteria reflect the comprehensive manifestation of an underlying psychopathological disorder)" (p. 5). Here we see that by "psychological disorder" the *DSM-5* task force has in mind an underlying pathogen, and diagnostic validity can be improved with advances in neuroscience, brain imaging, and so forth.

Medicalization, however, has its dissidents. *DSM-5* has been repeatedly criticized for its medicalization and somatization of psychological disorders. American philosopher of medicine Kevin Aho [12] has explained that this has led to a "growing dependence on biological explanations which tend to downplay socio-historical *Social Support, Identity, and Meaning: A Phenomenological Analysis of Post-Concussion… DOI: http://dx.doi.org/10.5772/intechopen.95541*

factors" (p. 3). Peter Kinderman, British psychologist and former president of the British Psychological Association's division for clinical psychology, recommends that a psychosocial model replace the medical model [13]. He suggests, for example, that "an effective way to reduce rates of mental health problems might be to reduce inequality in society" (p. 39). In an open letter to *DSM-5* task force, Division 32 of the American Psychological Association provides four specific examples of how the newer biomedically validated diagnostic criteria have actually lowered diagnostic thresholds, making it easier to receive a diagnosis [14]. In some cases, exclusionary criteria have been removed (such as the bereavement exclusion for depression of Major Depressive Disorder. In others, diagnostic requirements have been reduced (such as with the number of symptoms required for the diagnosis of adult attention-deficit hyperactivity disorder, ADHD).

Former director of the American National Institute of Mental Health, psychiatrist Tom Insel, has complained that the newest version of *DSM*, while *more* biomedical than previous editions, is still inadequately medicalized. On the NIMH website, he explained how "[i]n the rest of medicine, [psychological diagnoses] would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever" ([15]; in [16], p. 522). Indeed, the medicalization of psychological disorders is in presumed etiology only. ADHD, for example, is diagnosed based on patient symptoms which belong to the private world of the patient (e.g., "has trouble waiting his or her turn"). To this diagnosis a biomedical explanation is added. There are no biological tests for depression or ADHD, and the same can be said of a great majority of psychological disorders. It is uncertain what is gained by *explaining* them this way.

While there are many competing hypotheses about what causes depression (even among biomedical psychopathologists; [17]), depression is diagnosed based on behavioral signs and subjective symptoms. In an interview, Insel implores fellow psychiatrists to begin treating psychological disorders as brain disorders, e.g., relying exclusively on brain scans for depression diagnoses [18]. Until that day comes, depression will be diagnosed even in the absence of biomedical evidence.

Another troubling problem arises in addition to diagnostic validity. When biomedical factors are emphasized to the neglect of psychosocial, cultural, political, and historical factors, who benefits? The increasing medicalization of *DSM* has led to a suspicious partnership between the American Psychiatric Association and pharmaceutical companies [12, 19, 20].
