Headache, dizziness, disrupted sleep, irritability, trouble concentrating. That symptom list belongs equally to post-concussion syndrome and to post-traumatic stress disorder, and the event that caused one is frequently the event that caused the other.
Traumatic brain injury raises the risk of PTSD
A systematic review and meta-analysis found that in civilian populations, PTSD following TBI occurred in 12.2% at three months, 16.3% at six months and 18.6% at twelve months, with a relative risk of 1.67 at three months and 1.70 at twelve — roughly a 70% increase over comparable people without a TBI. In military populations the pooled frequency was 48.2%, relative risk 2.33.
The authors are explicit that between-study heterogeneity was high and their findings should be read with caution. We repeat that rather than quoting the numbers as precise. The direction is nonetheless consistent.
Iljazi A, Ashina H, Al-Khazali HM, Lipton RB, Ashina M, Schytz HW, Ashina S. Neurol Sci. 2020;41(10):2737–2746. doi:10.1007/s10072-020-04458-7
Complex PTSD — the diagnosis that gets missed
Complex PTSD (cPTSD) is recognised as a distinct diagnosis in ICD-11. It requires the core PTSD features — re-experiencing, avoidance, and a persistent sense of current threat — plus three additional disturbances that PTSD alone does not capture:
- Affect dysregulation — emotional reactions that are difficult to modulate, with heightened reactivity or emotional numbing
- Negative self-concept — persistent beliefs about being diminished, defeated or worthless, often carrying shame or guilt
- Disturbances in relationships — difficulty sustaining closeness or feeling connected to other people
cPTSD typically follows prolonged or repeated trauma from which escape was difficult, rather than a single incident. That matters in an injury population more than it might appear. A person’s concussion may have occurred during a single crash — but the years that follow, spent not being believed, cycling through clinicians, fighting a claim, and losing work and role, are themselves a prolonged and inescapable stressor.
Where it goes unrecognised, the affect dysregulation gets attributed to the brain injury, the negative self-concept is read as depression, and the relationship difficulties are treated as a personality problem. Naming it correctly changes the treatment plan, and it changes how the person understands what is happening to them.
Why the distinction is hard to make
Someone irritable, sleeping badly and losing their train of thought after a crash could be describing a concussion, a stress reaction, or both. What separates them is pattern rather than any single symptom: what provokes the symptoms, how they change with cognitive versus emotional load, whether there are objective vestibular or oculomotor findings, and how the picture moves over time.
The instruments we use
- CAPS-5 — Clinician-Administered PTSD Scale, a structured interview against DSM-5 criteria
- PCL-5 — PTSD Checklist for DSM-5, a 20-item self-report for screening and tracking change
- RPQ — Rivermead Post-Concussion Symptoms Questionnaire, 16 symptoms scored for severity
- BC-PSI — British Columbia Post-Concussion Symptom Inventory, frequency and intensity against ICD-10 criteria
Repeating the same instrument over time turns “I still don’t feel right” into a documented trajectory — which matters clinically, and matters again if the injury is connected to a claim.
Treating one and ignoring the other does not work
If the vestibular dysfunction is treated but the trauma response is not, the patient stays symptomatic. If the trauma response is treated while an untreated oculomotor problem keeps producing headaches every time they try to read, the therapy is fighting a physical injury it cannot reach. Both have to be identified before either plan is built.
Where avoidance has become the dominant obstacle, Acceptance and Commitment Therapy is delivered in-house alongside the physical rehabilitation rather than on a separate track.
Common questions
What is the difference between PTSD and complex PTSD?
Complex PTSD, recognised in ICD-11, includes all the core PTSD features plus three further disturbances: difficulty regulating emotion, a persistently negative self-concept, and difficulty sustaining relationships. It usually follows prolonged or repeated trauma rather than a single event.
Could a long injury claim itself contribute to complex PTSD?
The prolonged, inescapable stressors associated with cPTSD are not limited to the original incident. Years of not being believed, repeated examinations, and the loss of work and role are a sustained stressor in their own right, and we assess for it rather than assuming every change is attributable to the brain injury.
Do I need a psychiatrist as well?
Sometimes. We screen with structured instruments and treat the overlap directly, including ACT in-house. Where a presentation calls for psychiatric care we say so and help you get there rather than managing around it.