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Journal of the Australasian Society for the Study of Brain Impairment
RESEARCH ARTICLE

The role of illness perceptions in post-concussive symptoms in the chronic phase after mild traumatic brain injury (mTBI)

Fleur Vermeer A , Nikita Frankenmolen https://orcid.org/0000-0002-6889-4552 A B * , Tobias Coppes A , Janneke Schuurman A and Dirk Bertens A B
+ Author Affiliations
- Author Affiliations

A Klimmendaal Rehabilitation Centre, Arnhem, The Netherlands.

B Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands.

* Correspondence to: n.frankenmolen@klimmendaal.nl

Handling Editor: Alice Theadom

Brain Impairment 26, IB24038 https://doi.org/10.1071/IB24038
Submitted: 26 April 2024  Accepted: 8 March 2025  Published: 8 April 2025

© 2025 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of the Australasian Society for the Study of Brain Impairment.

Abstract

Background

Maladaptive illness perceptions are known to contribute to the development of persistent post-concussive symptoms 3–6 months after mild traumatic brain injury (mTBI), but it is unclear which role these perceptions play in the chronic phase. This study examined which illness perceptions impact post-concussive and psychological symptoms in the chronic phase post-mTBI.

Methods

This observational study used data from 112 adults who experienced persistent symptoms following mTBI and were referred for multidisciplinary treatment. Measures included a short version of the Illness Perception Questionnaire, the Rivermead Post-Concussion Symptoms Questionnaire and the Brief Symptom Inventory 18.

Results

Specific illness perceptions were unique predictors of post-concussive symptoms (understanding, identity, duration and emotional response) as well as anxiety and depression symptoms (understanding and emotional response).

Conclusion

Although the aetiology of persistent post-concussive symptoms is multifactorial, the finding that specific illness perceptions contribute to experienced symptoms in the chronic phase post-mTBI underline the importance of psychoeducation and psychotherapeutic interventions in this population.

Keywords: anxiety, chronic phase, depression, illness perceptions, mTBI, persistent post-concussive symptoms, RPQ, somatic symptoms.

References

Alharbi AA, Alharbi YA, Alsobhi AS, Alharbi MA, Alharbi MA, Aljohani AA, Alharbi AA (2021) Impact of Illness Perception on the Health-Related Quality of Life of Patients Receiving Dialysis: A Cross-Sectional Study. Cureus 13(6), 15705.
| Crossref | Google Scholar | PubMed |

Anderson JFI, Fitzgerald P (2020) Associations between coping style, illness perceptions and self-reported symptoms after mild traumatic brain injury in prospectively studied pre-morbidly healthy individuals. Neuropsychological Rehabilitation 30(6), 1115-1128.
| Crossref | Google Scholar | PubMed |

Bassi M, Falautano M, Cilia S, Goretti B, Grobberio M, Pattini M, Pietrolongo E, Viterbo RG, Amato MP, Benin M, Lugaresi A, Minacapelli E, Montanari E, Patti F, Trojano M, Fave AD (2016) Illness Perception and Well-Being Among Persons with Multiple Sclerosis and Their Caregivers. Journal of Clinical Psychology in Medical Settings 23(1), 33-52.
| Crossref | Google Scholar | PubMed |

Broadbent E, Petrie KJ, Main J, Weinman J (2006) The Brief Illness Perception Questionnaire. Journal of Psychosomatic Research 60(6), 631-637.
| Crossref | Google Scholar | PubMed |

Broadbent E, Ellis CJ, Thomas J, Gamble G, Petrie KJ (2009) Further development of an illness perception intervention for myocardial infarction patients: a randomized controlled trial. Journal of Psychosomatic Research 67(1), 17-23.
| Crossref | Google Scholar | PubMed |

Carroll L, Cassidy JD, Peloso PM, Borg J, Von Holst H, Holm L (2004) Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine 36(suppl 43), 84-105.
| Crossref | Google Scholar | PubMed |

Carroll LJ, Cassidy JD, Cancelliere C, Côté P, Hincapié CA, Kristman VL, Holm LW, Borg J, Nygren-de Boussard C, Hartvigsen J (2014) Systematic Review of the Prognosis After Mild Traumatic Brain Injury in Adults: Cognitive, Psychiatric, and Mortality Outcomes: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of Physical Medicine and Rehabilitation 95(3), S152-S173.
| Crossref | Google Scholar | PubMed |

Cassidy JD, Boyle E, Carroll LJ (2014) Population-Based, Inception Cohort Study of the Incidence, Course, and Prognosis of Mild Traumatic Brain Injury After Motor Vehicle Collisions. Archives of Physical Medicine and Rehabilitation 95(3), 278-285.
| Crossref | Google Scholar | PubMed |

Chilcot J (2012) The importance of illness perception in end-stage renal disease: associations with psychosocial and clinical outcomes. Seminars in Dialysis 25(1), 59-64.
| Crossref | Google Scholar | PubMed |

Cnossen MC, Van der Naalt J, Spikman JM, Nieboer D, Yue JK, Winkler EA, Manley GT, Von Steinbuechel N, Polinder S, Steyerberg EW, Lingsma HF (2018) Prediction of Persistent Post-Concussion Symptoms after Mild Traumatic Brain Injury. Journal of Neurotrauma 35(22), 2691-2698.
| Crossref | Google Scholar | PubMed |

Crawshaw J, Rimington H, Weinman J, Chilcot J (2015) Illness Perception Profiles and Their Association with 10-Year Survival Following Cardiac Valve Replacement. Annals of Behavioral Medicine 49(5), 769-775.
| Crossref | Google Scholar | PubMed |

Dagher JH, Richard-Denis A, Lamoureux J, De Guise E, Feyz M (2013) Acute global outcome in patients with mild uncomplicated and complicated traumatic brain injury. Brain Injury 27(2), 189-199.
| Crossref | Google Scholar | PubMed |

De Beurs E (2011) ‘Handleiding BSI en BSI 18; Brief Symptom Inventory (revised Dutch Edition).’ (Pearson Assessment and Information B.V.) [In Dutch]

De Raaij EJ, Schröder CD, Kaptein A (2007) ‘Ziekteperceptie Vragenlijst.’ (Vragenlijst IPQ-K.) [In Dutch]

De Raaij EJ, Schröder C, Maissan FJ, Pool JJ, Wittink H (2012) Cross-cultural adaptation and measurement properties of the Brief Illness Perception Questionnaire-Dutch Language Version. Manual Therapy 17(4), 330-335.
| Crossref | Google Scholar | PubMed |

Dutch Federation of Medical Specialists [Federatie Medisch Specialisten] (2010) Licht traumatisch hoofd/hersenletsel (LTH). Richtlijnendatabase. [In Dutch]. Available at https://richtlijnendatabase.nl/richtlijn/licht_traumatisch_hoofd_hersenletsel_lth/afbakening_lth.html

Ford D, Zapka J, Gebregziabher M, Yang C, Sterba K (2010) Factors associated with illness perception among critically ill patients and surrogates. Chest 138(1), 59-67.
| Crossref | Google Scholar | PubMed |

Franke GH, Jaeger S, Glaesmer H, Barkmann C, Petrowski K, Braehler E (2017) Psychometric analysis of the brief symptom inventory 18 (BSI-18) in a representative German sample. BMC Medical Research Methodology 17, 14.
| Crossref | Google Scholar | PubMed |

Gardner RC, Yaffe K (2015) Epidemiology of mild traumatic brain injury and neurodegenerative disease. Molecular and Cellular Neuroscience 66(Pt B), 75-80.
| Crossref | Google Scholar | PubMed |

Hendriks M, Kessels R, Gorissen M, Schmand B, Duits A (2014). ‘Neuropsychologische Diagnostiek: De Klinische Praktijk.’ [In Dutch] (Boom Uitgevers: Amsterdam)

Hou R, Moss-Morris R, Peveler R, Mogg K, Bradley BP, Belli A (2012) When a minor head injury results in enduring symptoms: a prospective investigation of risk factors for postconcussional syndrome after mild traumatic brain injury. Journal of Neurology, Neurosurgery, and Psychiatry 83(2), 217-223.
| Crossref | Google Scholar | PubMed |

IBM Corp. Released 2021) ‘IBM SPSS Statistics for Windows, Version 28.0.’ (Armonk, NY: IBM Corp.)

Jacobs B, Beems T, Stulemeijer M, Van Vugt AB, Van der Vliet TM, Borm GF, Vos PE (2010) Outcome Prediction in Mild Traumatic Brain Injury: Age and Clinical Variables Are Stronger Predictors than CT Abnormalities. Journal of Neurotrauma 27, 655-668.
| Crossref | Google Scholar | PubMed |

Knox L, Goldsmith S, Rushworth N (2017). ‘Understanding the needs of the “miserable minority”: Identifying gaps in the provision of information and support for people experiencing a prolonged recovery after concussion and mild traumatic brain injury.’ (La Trobe University & Sydney: Melbourne, Australia; Brain Injury Australia: Australia)

Lee Y, Baek JM, Jeon YW, Im EO (2019) Illness perception and sense of well-being in breast cancer patients. Patient Preference and Adherence 13, 1557-1567.
| Crossref | Google Scholar | PubMed |

Leventhal H, Diefenbach MA, Leventhal EA (1992) Illness cognition: Using common sense to understand treatment adherence and affect cognition interactions. Cognitive Therapy and Research 16(2), 143-163.
| Crossref | Google Scholar |

Levin HS, Diaz-Arrastia RR (2015) Diagnosis, prognosis, and clinical management of mild traumatic brain injury. The Lancet Neurology 14(5), 506-517.
| Crossref | Google Scholar | PubMed |

Liu QW, Qin T, Hu B, Zhao YL, Zhu XL (2021) Relationship between illness perception, fear of progression and quality of life in interstitial lung disease patients: A cross-sectional study. Journal of Clinical Nursing 30(23–24), 3493-3505.
| Crossref | Google Scholar | PubMed |

Lovette BC, Kanaya MR, Bannon SM, Vranceanu AM, Greenberg J (2022) “Hidden gains”? Measuring the impact of mindfulness-based interventions for people with mild traumatic brain injury: a scoping review. Brain Injury 36(9), 1059-1070.
| Crossref | Google Scholar | PubMed |

Marshall S, Bayley M, McCullagh S, Velikonja D, Berrigan L, Ouchterlony D, Weegar K (2015) Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Injury 29(6), 688-700.
| Crossref | Google Scholar | PubMed |

Mayer AR, Quinn DK, Master CL (2017) The spectrum of mild traumatic brain injury. Neurology 89(6), 623-632.
| Crossref | Google Scholar | PubMed |

McMahon P, Hricik A, Yue JK, Puccio AM, Inoue T, Lingsma HF, Beers SR, Gordon WA, Valadka AB, Manley GT, Okonkwo DO, the TRACK-TBI Investigators (2014) Symptomatology and Functional Outcome in Mild Traumatic Brain Injury: Results from the Prospective TRACK-TBI Study. Journal of Neurotrauma 31, 26-33.
| Crossref | Google Scholar | PubMed |

McMillan TM, Teasdale GM, Stewart E (2012) Disability in young people and adults after head injury: 12-14 year follow-up of a prospective cohort. Journal of Neurology, Neurosurgery & Psychiatry 83(11), 1086-1091.
| Crossref | Google Scholar | PubMed |

Mittenberg W, Tremont G, Zielinski RE, Fichera S, Rayls KR (1996) Cognitive-behavioral prevention of postconcussion syndrome. Archives of Clinical Neuropsychology 11(2), 139-145.
| Google Scholar | PubMed |

Möller MC, Lexell J, Wilbe Ramsay K (2021) Effectiveness of specialized rehabilitation after mild traumatic brain injury: a systematic review and meta-analysis. Journal of Rehabilitation Medicine 53(2), 2751.
| Crossref | Google Scholar | PubMed |

Morgan K, Villiers-Tuthill A, Barker M, McGee H (2014) The contribution of illness perception to psychological distress in heart failure patients. BMC Psychology 2(1), 50.
| Crossref | Google Scholar | PubMed |

Moss-Morris R, Weinman J, Petrie KJ, Horne R, Cameron LD, Buick D (2002) The Revised Illness Perception Questionnaire (IPQ-R). Psychology and Health 17(1), 1-16.
| Crossref | Google Scholar |

Nijs J, Roussel N, Van Oosterwijck J, De Kooning M, Ickmans K, Struyf F, Meeus M, Lundberg M (2013) Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice. Clinical Rheumatology 32(8), 1121-1129.
| Crossref | Google Scholar | PubMed |

Ontario Neurotrauma Foundation (2018) ‘Guidelines for Concussion/Mild Traumatic Brain Injury & Prolonged Symptoms, Healthcare Professional Version’, 3rd edn. Available at https://braininjuryguidelines.org/concussion/fileadmin/pdf/Concussion_guideline_3rd_edition_final.pdf

Ośmiałowska E, Staś J, Chabowski M, Jankowska-Polańska B (2022) Illness Perception and Quality of Life in Patients with Breast Cancer. Cancers 14(5), 1214.
| Crossref | Google Scholar | PubMed |

Plass AM, Van Praag D, Covic A, Gorbunova A, Real R, Von Steinbuechel N (2019) The psychometric validation of the Dutch version of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) after traumatic brain injury (TBI). PLoS One 14(1), e0210138.
| Crossref | Google Scholar | PubMed |

Ponsford J, Lee NK, Wong D, McKay A, Haines K, Alway Y, Downing M, Furtado C, O’Donnell ML (2016) Efficacy of motivational interviewing and cognitive behavioral therapy for anxiety and depression symptoms following traumatic brain injury. Psychological Medicine 46(5), 1079-1090.
| Crossref | Google Scholar | PubMed |

Ruff RM (2011) Mild traumatic brain injury and neural recovery: Rethinking the debate. NeuroRehabilitation 28, 167-180.
| Crossref | Google Scholar | PubMed |

Ryan LM, Warden DL (2003) Post concussion syndrome. International Review of Psychiatry 15(4), 310-316.
| Crossref | Google Scholar | PubMed |

Sander AM, Clark AN, Arciniegas DB, Tran K, Leon-Novelo L, Ngan E, Bogaards J, Sherer M, Walser R (2021) A randomized controlled trial of acceptance and commitment therapy for psychological distress among persons with traumatic brain injury. Neuropsychological Rehabilitation 31(7), 1105-1129.
| Crossref | Google Scholar | PubMed |

Sararoudi RB, Motmaen M, Maracy MR, Pishghadam E, Kheirabadi GR (2016) Efficacy of illness perception focused intervention on quality of life, anxiety, and depression in patients with myocardial infarction. Journal of Research in Medical Sciences 21, 125.
| Crossref | Google Scholar | PubMed |

Scharloo M, Kaptein AA, Weinman J, Hazes JM, Willems LN, Bergman W, Rooijmans HG (1998) Illness perceptions, coping and functioning in patients with rheumatoid arthritis, chronic obstructive pulmonary disease and psoriasis. Journal of Psychosomatic Research 44(5), 573-585.
| Crossref | Google Scholar | PubMed |

Segal O, Goldzweig G, Tako E, Barzilai A, Lyakhovitsky A, Baum S (2021) Illness Perception, Perceived Social Support and Quality of Life in Patients with Pemphigus Vulgaris: What Should Dermatologists Know? Acta Dermato-Venereologica 101(4), adv00441.
| Crossref | Google Scholar | PubMed |

Silva STC, Freitas PD, Lunardi AC, Xavier RF, Barbosa RCC, Stelmach R, Carvalho CRF (2023) Association between illness perception and clinical control, quality of life, physical activity, and psychosocial status in subjects with moderate to severe asthma: a cluster analysis. The Journal of Asthma 3, 115-122.
| Crossref | Google Scholar | PubMed |

Silverberg ND, Panenka WJ, Iverson GL (2018) Fear Avoidance and Clinical Outcomes from Mild Traumatic Brain Injury. Journal of Neurotrauma 35(16), 1864-1873.
| Crossref | Google Scholar | PubMed |

Snell DL, Siegert RJ, Hay-Smith EJ, Surgenor LJ (2011) Associations between illness perceptions, coping styles and outcome after mild traumatic brain injury: Preliminary results from a cohort study. Brain Injury 25(11), 1126-1138.
| Crossref | Google Scholar | PubMed |

Snell DL, Hay-Smith EJ, Surgenor LJ, Siegert RJ (2013) Examination of outcome after mild traumatic brain injury: The contribution of injury beliefs and Leventhal’s Common Sense Model. Neuropsychological Rehabilitation 23(3), 333-362.
| Crossref | Google Scholar | PubMed |

Snell DL, Surgenor LJ, Hay-Smith EJ, Williman J, Siegert RJ (2015) The contribution of psychological factors to recovery after mild traumatic brain injury: Is cluster analysis a useful approach? Brain Injury 29(3), 291-299.
| Crossref | Google Scholar | PubMed |

Snell DL, Martin R, Surgenor LJ, Siegert RJ, Hay-Smith EJC, Melzer TR, Anderson TJ, Hooper GJ (2020) Wrestling with uncertainty after mild traumatic brain injury: a mixed methods study. Disability and Rehabilitation 42(14), 1942-1953.
| Crossref | Google Scholar | PubMed |

Spain LA, Tubridy N, Kilpatrick TJ, Adams SJ, Holmes AC (2007) Illness perception and health-related quality of life in multiple sclerosis. Acta Neurologica Scandinavica 116(5), 293-299.
| Crossref | Google Scholar | PubMed |

Stålnacke BM (2007) Community integration, social support and life satisfaction in relation to symptoms 3 years after mild traumatic brain injury. Brain Injury 21(9), 933-942.
| Crossref | Google Scholar | PubMed |

Tiersky LA, Anselmi V, Johnston MV, Kurtyka J, Roosen E, Schwartz T, DeLuca J (2005) A Trial of Neuropsychologic Rehabilitation in Mild-Spectrum Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation 86(8), 1565-1574.
| Crossref | Google Scholar | PubMed |

Van der Horn HJ, Out ML, De Koning ME, Mayer AR, Spikman JM, Sommer IE, Van der Naalt J (2020) An integrated perspective linking physiological and psychological consequences of mild traumatic brain injury. Journal of Neurology 267, 2497-2506.
| Crossref | Google Scholar | PubMed |

Van der Naalt J, Timmerman ME, De Koning ME, Van der Horn HJ, Scheenen ME, Jacobs B, Hageman G, Yilmaz T, Roks G, Spikman JM (2017) Early predictors of outcome after mild traumatic brain injury (UPFRONT): an observational cohort study. The Lancet Neurology 16(7), 532-540.
| Crossref | Google Scholar | PubMed |

Verhage F (1964) ‘Intelligentie en Leeftijd; Onderzoek bij Nederlanders van Twaalf tot Zevenenzeventig Jaar.’ [In Dutch] (Van Gorcum: Assen)

Vlaeyen J, Linton SJ (2012) Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain 153(6), 1144-1147.
| Crossref | Google Scholar | PubMed |

Waldron B, Casserly LM, O’Sullivan C (2013) Cognitive behavioural therapy for depression and anxiety in adults with acquired brain injury. What works for whom? Neuropsychological Rehabilitation 23(1), 64-101.
| Crossref | Google Scholar | PubMed |

Wäljas M, Iverson GL, Lange RT, Hakulinen U, Dastidar P, Huhtala H, Liimatainen S, Hartikainen K, Öhman J (2015) A Prospective Biopsychosocial Study of the Persistent Post-Concussion Symptoms following Mild Traumatic Brain Injury. Journal of Neurotrauma 32, 534-547.
| Crossref | Google Scholar | PubMed |

Whitnall L, McMillan TM, Murray GD, Teasdale GM (2006) Disability in young people and adults after head injury: 5-7 year follow up of a prospective cohort study. Journal of Neurology, Neurosurgery & Psychiatry 77(5), 640-645.
| Crossref | Google Scholar | PubMed |

Whittaker R, Kemp S, House A (2007) Illness perceptions and outcome in mild head injury: a longitudinal study. Journal of Neurology, Neurosurgery & Psychiatry 78(6), 644-646.
| Crossref | Google Scholar | PubMed |

Wijenberg MLM, Stapert SZ, Verbunt JA, Ponsford JL, Van Heugten CM (2017) Does the fear avoidance model explain persistent symptoms after traumatic brain injury? Brain Injury 31(12), 1597-1604.
| Crossref | Google Scholar | PubMed |