Women and #concussion #TBI – do current treatments make things worse?

Something absolutely critical occurred to me today, as I was scanning the tracking data for a technical website I optimize. Pardon me, if I’m behind the times on this — it just occurred to me, but after some admittedly cursory Googling of terms, I found no evidence that anyone else had made or published about the connection I’m about to discuss.

The Burning Question That Needs To Be Answered:

Do the ways we currently treat concussion / TBI actually work against the women who have been injured?

I’ve been influenced, of late, by a good deal of conversation about women and concussion, including my reading about the “miserable minority” of mild TBI survivors (mostly women) whose symptoms persist past the 3 months they’re expected to last. After decades, we still have double-digit percentages of PCS sufferers who continue to deal with sometimes debilitating symptoms. There is some compelling dialogue going on, and it’s been quite eye-opening.

I’ve also been amazed that only recently have people started studying the differences between male and female concussions. Implausible, but true. It seems logical, that there would be a difference in both the mechanisms and the experiences, yet the discrepancies are just now beginning to be explored. It’s a good change, but I’m surprised it’s this recent.

And after giving this a whole lot of thought for some time, I now have to wonder if we aren’t missing something. Could it be that concussions are worse for women, not only because of their reported heightened susceptibility (this may turn out to be untrue, eventually), not only because they’re “more likely to seek medical care”, but also because of the way concussions are treated?

Gender differences aren’t just about physique and conditioning. They’re also about how men and women respond to the world around them, especially stressors. Some years back, around 2000 or so, my psychotherapist friends were excited to share a new theory that was emerging about how women respond to stress. It’s the “tend and befriend” theory, developed by Shelley E. Taylor, Ph.D. (and others) of UCLA. Dr. Taylor’s publications and news stories about theory can easily be found in a simple Google search for “tend and befriend”.

Essentially, the theory states that:

… human beings affiliate in response to stress.  Under conditions of threat, they tend to offspring to ensure their survival and affiliate with others for joint protection and comfort.  These responses are underpinned by an affiliative neurocircuitry that appears to be based on oxytocin and endogenous opioid peptides.  When close relationships are threatened or one is socially isolated, a rise in plasma oxytocin occurs, a biological marker that may signal a need for affiliation: Oxytocin prompts affiliative behavior in response to stress, in conjunction with the opioid system.  Together with positive social contacts, oxytocin attenuates biological stress responses that would otherwise arise in response to social threats.  These social responses to stress and their biological underpinnings appear to be more characteristic of women than men.

[bold emphasis is mine]

So, under circumstances of stress, women tend to bond more than men. They pull together, forming connections in the face of threat, while men more often resort to fight-flight. Obviously, there will be exceptions, but that’s the gist of it.

Concussion / mild TBI can be a deeply distressing and stressful experience. Especially where no information is given, and no explanations for symptoms are offered, you can end up feeling completely alone. With women, the common impulse might be to reach out and affiliate with others, for support and nurturance and protection.

The only problem is, that’s not how concussion is treated.

If anything, current protocols for concussion treatment involve isolation and strongly curtailed interactivity and stimulation.  According to the Mayo Clinic website:

Rest is the most appropriate way to allow your brain to recover from a concussion. Your doctor will recommend that you physically and mentally rest to recover from a concussion.

This means avoiding general physical exertion, including sports or any vigorous activities, until you have no symptoms.

This rest also includes limiting activities that require thinking and mental concentration, such as playing video games, watching TV, schoolwork, reading, texting or using a computer.

Your doctor may recommend that you have shortened school day or workdays, take breaks during the day, or have reduced school workloads or work assignments as you recover from a concussion.

As your symptoms improve, you may gradually add more activities that involve thinking, such as doing more schoolwork or work assignments, or increasing your time spent at school or work.

Physical and mental rest is a solitary activity. Limiting activities such as texting and computer activity, nowadays, essentially cuts you off from your social circle. Shortened school and work days keeps you out of your customary circle of support.

To me, that means women and girls who are concussed and given the same recovery guidelines as men and boys may actually suffer more short-term stress from concussion than males — specifically as a result of the recommended treatment. Cut off from their affiliations and support networks, women are literally unable to obtain the positive social contacts which produce the oxytocin that attenuates biological stress responses.

According to Taylor (and many others), “men may be somewhat more likely to cope with stress via fight or flight“. So one might reasonably expect the impact of isolation after mild traumatic brain injury to be less disruptive to men’s recovery process. However, for females, it’s a very different story, because their primary means for coping with stress (connecting with others in ways that reduce the biological stress response) has been medically prohibited.

What’s more, since stress is known to increase post-concussion symptoms, it seems likely to me that prescribed isolation and contact deprivation might actually be a contributing factor in the duration and severity of concussion symptoms in females vs. males.

Again, males have been seen to use fight-flight response, so isolation may tie in with that flight impulse and soften the impact of their downtime. Because the deprivation treatment model works for male concussees — and the majority of folks with mild TBI — it’s judged a relative success, with PCS cases being an unfortunate exception. And the unconscious assumptions that “what’s good for the gander is good for the goose” essentially camouflages the inherent shortcomings of concussion treatment protocols for females.

Obviously, more needs to be done to connect the dots and substantiate this unequivocally. I’m sure there are other aspects to this, of which I’m not aware. And it would be helpful if domain experts could weigh in on this.

Who knows? Maybe at the Pink Concussions Summit on Feb 27, this will be addressed. The bottom line is, there are connections to be made that can shed more light on this subject, and the more we keep looking, keep inquiring, keep collaborating, the better chance we have of finding resolutions and approaches that can make life a lot better for a whole lot of people.