Abstract

The purpose of this study was to examine the influence of the “good-old-days” bias on symptom reporting following mild traumatic brain injury (MTBI). The MTBI sample consisted of 86 patients (51.2% men) referred to a hospital-based concussion clinic in Vancouver, Canada. The majority of patients (83.7%) were evaluated within 3 months following their injury (M = 1.8 months, SD = 1.7, range = 0.2–8.0 months). Patients provided retrospective preinjury symptom ratings on the British Columbia Post-Concussion Symptom Inventory (BC-PSI). Ratings were compared with 177 healthy controls recruited from the community and a local university. MTBI retrospective ratings were significantly lower than the control group on the BC-PSI total score (p < .01, d = 0.27, small effect size) and 6 of the 13 individual items (all p < .05, d = 0.23–0.36, small to small-medium effect sizes). Patients who were currently in litigation reported more post-injury symptoms (p = .009, d = 0.63, medium-large effect size). However, litigation status was not associated with self-reported preinjury retrospective symptom ratings. Consistent with the “good-old-days” bias, patients with MTBI appear to misperceive their preinjury functioning as better than the average person.

Introduction

The post-concussion syndrome remains poorly understood (Bigler & Brooks, 2009; Ruff, 2009). The etiology of the persistent post-concussion syndrome has never been agreed upon (Bigler, 2008; Evered, Ruff, Baldo, & Isomura, 2003; Iverson, 2005; Ryan & Warden, 2003), and the validity of this diagnosis as a true syndrome or disorder has been questioned for many years (Cook, 1972; Lees-Haley, Fox, & Courtney, 2001; Mickeviciene et al., 2004; Satz et al., 1999). When considering a diagnosis of post-concussion syndrome, clinicians must systematically evaluate and eliminate the possible contribution of many differential diagnoses, co-morbidities, and factors that may cause or maintain self-reported symptoms long after a mild traumatic brain injury (MTBI). Researchers have reported that healthy adults report very similar symptoms (Gouvier, Uddo-Crane, & Brown, 1988; Iverson & Lange, 2003; Machulda, Bergquist, Ito, & Chew, 1998; Mittenberg, DiGiulio, Perrin, & Bass, 1992; Sawchyn, Brulot, & Strauss, 2000; Trahan, Ross, & Trahan, 2001; Wang, Chan, & Deng, 2006; Wong, Regennitter, & Barrios, 1994), as do various non-MTBI clinical groups (Dunn, Lees-Haley, Brown, Williams, & English, 1995; Foa, Cashman, Jaycox, & Perry, 1997; Fox, Lees-Haley, Ernest, & Dolezal-Wood, 1995; Gasquoine, 2000; Iverson & McCracken, 1997; Lees-Haley & Brown, 1993; Meares et al., 2008; Mickeviciene et al., 2004; Radanov, Dvorak, & Valach, 1992; Smith-Seemiller, Fow, Kant, & Franzen, 2003). Complicating matters further, the perception and reporting of symptoms long after an MTBI can be influenced by premorbid personality characteristics (Evered et al., 2003; Greiffenstein & Baker, 1992; Hibbard et al., 2000), depression (Iverson, 2006), and a diverse range of social-psychological factors (e.g., expectations, misattribution, and an idealized view of preinjury functioning (Davis, 2002; Ferguson, Mittenberg, Barone, & Schneider, 1999; Gunstad & Suhr, 2001, 2004; Hahn, 1997; Hilsabeck, Gouvier, & Bolter, 1998).

Of primary interest to this study is the “good-old-days” bias. The “good-old-days” bias refers to the tendency to view oneself as healthier in the past and to underestimate past problems. In some studies, patients with back injuries, general trauma victims, and patients who have sustained MTBIs appear to overestimate the actual degree of change that has taken place post-injury by retrospectively recalling fewer preinjury symptoms than the base rate of symptoms in healthy adults (Davis, 2002; Gunstad & Suhr, 2001, 2004; Hilsabeck et al., 1998; Mittenberg et al., 1992). The good-old-days bias seems to occur only following a negative event (Gunstad & Suhr, 2001, 2004). Gunstad and Suhr (2001) reported that although individuals who had experienced a negative event underestimated their pre-event symptoms compared with controls (e.g., depression, chronic headaches, or head injury), normal controls do not differ in their current versus retrospective symptom reporting. These authors suggested that the “experience of any negative event, be it accident or illness, head injury or non-head-injury, may be required for one to focus on the past as ‘better’ than one's current state, for one to think about the ‘good old days’ prior to the negative event” (p. 330). Gunstad and Suhr (2004) further explained that “individuals experiencing any negative event may fall prey to a ‘good old days’ bias as a result of their negative expectations and subjective distress, and, given that PCS symptoms are relatively non-specific, any negative event may result in report of more current PCS symptoms and fewer PCS symptoms in the past” (p. 392). This response bias, combined with an expectation of certain symptoms following MTBI, can have a potent impact on symptom reporting.

To date, there are very few studies examining the “good-old-days bias” and post concussion symptom reporting following MTBI. In one of the most recent studies in this area, Iverson, Lange, Brooks, and Ashton Rennison (2010) examined 90 patients following work-related MTBI who were referred to a concussion clinic for ongoing problems. All were considered temporarily fully disabled from an MTBI and were receiving financial compensation through the Worker's Compensation system. Consistent with the good-old-days bias, injured workers retrospectively endorsed the presence of fewer preinjury symptoms compared with the control group (d = 0.65, medium-large effect size). In addition, patients who failed effort testing (i.e., Test of Memory Malingering) retrospectively reported fewer preinjury symptoms compared with those patients who passed effort testing.

The purpose of this study was to further examine the presence of the “good-old-days” bias in patients who sustained an MTBI. It was hypothesized that (a) patients with MTBIs would endorse fewer preinjury symptoms compared with control participants, and (b) patients in litigation would endorse fewer preinjury symptoms than those who were not in litigation.

Materials and Methods

Participants

Participants were 86 patients who had sustained an MTBI and 177 control participants from Vancouver, BC, Canada. The participants in the MTBI sample (51.2% men) were selected from a larger sample of 110 consecutive referrals (January 2007 to September 2009) to a concussion clinic at GF Strong Rehab Centre, Vancouver, Canada. The concussion clinic is a hospital-based “early intervention” clinic designed to provide educational services regarding the expected symptoms and recovery trajectory following a traumatic brain injury. Patients were included in the sample if (a) they had sustained an MTBI (88.1% of total sample), (b) English was their first language or they had sufficient English fluency to complete the interview and questionnaires (97.3% of total sample), and (c) they had been evaluated within 8 months of injury (98.2% of total sample). A total of 86 patients met all criteria. For many patients, complete medical records were not available for review. For these patients, classification of MTBI was based on (a) self-reported loss of consciousness (LOC) and post-traumatic amnesia (PTA), and (b) self-reported injury information (e.g., witnessed LOC, mechanism of injury, etc.). The diagnostic criteria for MTBI used in this study were from the World Health Organization (WHO) Collaborating Centre Task Force on Mild Traumatic Brain Injury (Carroll, Cassidy, Holm, Kraus, & Coronado, 2004). In brief, the primary features of the WHO operational criteria include: (i) one or more of the following: Confusion or disorientation, LOC for 30 min or less, PTA for less than 24 h, and/or other transient neurological abnormalities such as focal signs, seizure, and intracranial lesion not requiring surgery; and (ii) Glasgow Coma Scale score of 13–15 after 30 min post-injury or later upon presentation for healthcare (seeCarroll et al., 2004, for further details). Demographic and injury severity characteristics of the MTBI sample are presented in Table 1.

Table 1.

Demographic and injury severity characteristics of the MTBI sample

 M SD 
Age (years) 36.9 13.7 
Education (years) 14.0 1.9 
Months tested post-injury 1.8 1.7 
 N Percent 
Ethnicity 
 Caucasian 65 75.6 
 Asian 11 12.8 
 East Indian 3.5 
 Canadian aboriginal 1.2 
 Other 7.0 
Loss of consciousness 
 Positive 68 79.1 
 Negative 10 11.6 
 Equivocal 9.3 
Post-traumatic amnesia 
 Positive 65 75.6 
 Negative 18 20.9 
 Equivocal 3.5 
Glasgow Coma Scale 
 15 11 12.8 
 13–14 27 31.4 
 Missing 48 55.8 
CT scan 
 Negative 34 39.5 
 Positive 24 27.9 
 CT not available 14 16.3 
 No-CT scan undertaken 14 16.3 
Time since injury (months) 
 0–1 39 45.3 
 1–2 23 26.7 
 2–3 10 11.6 
 3 or more 14 16.3 
Personal injury litigation 
 Yes 34 39.5 
 No 52 60.5 
Post-concussion Disordera 
 Yes 81 94.2 
 No 5.8 
 M SD 
Age (years) 36.9 13.7 
Education (years) 14.0 1.9 
Months tested post-injury 1.8 1.7 
 N Percent 
Ethnicity 
 Caucasian 65 75.6 
 Asian 11 12.8 
 East Indian 3.5 
 Canadian aboriginal 1.2 
 Other 7.0 
Loss of consciousness 
 Positive 68 79.1 
 Negative 10 11.6 
 Equivocal 9.3 
Post-traumatic amnesia 
 Positive 65 75.6 
 Negative 18 20.9 
 Equivocal 3.5 
Glasgow Coma Scale 
 15 11 12.8 
 13–14 27 31.4 
 Missing 48 55.8 
CT scan 
 Negative 34 39.5 
 Positive 24 27.9 
 CT not available 14 16.3 
 No-CT scan undertaken 14 16.3 
Time since injury (months) 
 0–1 39 45.3 
 1–2 23 26.7 
 2–3 10 11.6 
 3 or more 14 16.3 
Personal injury litigation 
 Yes 34 39.5 
 No 52 60.5 
Post-concussion Disordera 
 Yes 81 94.2 
 No 5.8 

Note: N = 86.

aICD-10 Criterion C symptom criteria for Post-concussion Disorder.

The Control group consisted of 177 healthy adults (Age: M = 34.7, SD = 16.3; Education: M = 14.8, SD = 2.5; 59.9% women) that were obtained through two independent studies and were combined for this study. The first study was based at the University of British Columbia and included students and community volunteers (n = 103; Age: M = 23.7, SD = 8.2; Education: M = 14.9, SD = 2.3; 60.2% women). These participants were screened for mental health, substance abuse, and neurological problems through the use of questionnaires. The second study was conducted in the community and the control subjects were part of a clinical trial in psychiatry (n = 74, Age: M = 49.9, SD = 11.7; Education: M = 14.6, SD = 2.8; 59.5% women). These participants were screened for mental health, substance abuse, or neurological problems through the use of questionnaires and by administering the SCID. This control sample is the same sample that was used in the study by Iverson and colleagues (2010).

Procedure and Measures

All participants completed a formal, self-report measure of post-concussion symptoms, the British Columbia Post-Concussion Symptom Inventory (BC-PSI), as part of a larger battery of measures. The BC-PSI is a 16-item measure designed to assess the presence and severity of post-concussion symptoms (Iverson & Gaetz, 2004; Iverson & Lange, 2003; Iverson, Zasler, & Lange, 2007). The BC-PSI was developed based on ICD-10 (World Health Organization, 1992) criteria for Post-concussional Syndrome and requires the test-taker to rate the frequency and intensity of 13 symptoms (i.e., headaches, dizziness/light-headedness, nausea or feeling sick, fatigue, sensitivity to noises, irritability, sadness, nervousness/tension, temper problems, poor concentration, memory problems, reading difficulty, and sleep disturbance) and the effect of three co-occurring life problems on daily living. The participants' ratings of the 13 symptoms were the focus of this study. Individual item scores range from 0 to 4. Item scores of 1 or more are classified as symptoms endorsed at a mild level or greater. Total scores range from 0 to 52. Total scores of 10–14 are classified as “unusually high” and total scores of 15+ are classified as “extremely high”. The internal consistency reliability of the scale in a healthy sample (N = 158) was r = .82 (Iverson et al., 2007) and the test–retest reliability in healthy adults (N = 52), over a 2–6-day retest interval, was r = .61 (Iverson & Gaetz, 2004). The internal consistency reliability (Cronbach's α) in the present sample of controls and the sample of patients with MTBIs was r = .89 for both groups. For the MTBI patient sample, participants were asked to provide both post-injury (current) and retrospective preinjury symptom ratings (1 month prior to their injury) on the BC-PSI. The control subjects were asked to rate their symptoms over the past 2 weeks.

Results

Demographic Variables

There were significant differences between the MTBI and the control group on education (F = 5.936, p = .016, d = 0.32, small effect), but not on gender (χ2 = 2.872, p = .090) or age (F = 1.199, p = .275). On average, the MTBI group had slightly lower education (M = 14.0 years, SD = 1.9) compared with the control group (M = 14.8 years, SD = 2.5). The influence of education on symptom reporting was examined in each group separately using the Pearson product-moment correlations. There were no significant correlations between symptom reporting (i.e., BC-PSI total scores) and education in the MTBI group (r = .09, p = .429) or the control group (r = −.14, p = .058).

Good-Old-Days Bias

Descriptive statistics, the Mann–Whitney U-tests (due to non-normal distributions), and effect sizes (Cohen, 1988) for the BC-PSI total score and the 13 symptoms for the control group and the two ratings in the MTBI group (retrospective and post-injury) are presented in Table 2. As expected, MTBI post-injury symptoms (i.e., total score and the 13 individual items) were significantly greater than both the MTBI retrospective ratings (all p < .001; d = 0.71–1.90, large to very large effect sizes) and the control group (all p < .004; d = 0.49–1.86, medium to very large effect sizes). Significant differences were also found between MTBI retrospective ratings and the control group. MTBI retrospective ratings were significantly lower than the control group on the BC-PSI total score (p < .01; d = 0.27, small effect size) and 6 of the 13 individual items (all p < .05, d = 0.23–0.36, small to small-medium effect sizes).

Table 2.

Descriptive statistics, the Mann–Whitney U-tests, effects sizes, percentages of symptoms endorsed, and χ2 analyses by group

BC-PSI items Descriptive statistics Mean (SD)
 
Effect size (d) and the Mann–Whitney U-testsa
 
Percentages and χ2 tests: Mild or Greater Symptom Rating
 
 1. MTBI Current 2. MTBI Preinjury 3. Healthy Controls 1 vs. 2 1 vs. 3 2 vs. 3 1. MTBI Current 2. MTBI Preinjury 3. Healthy Control Selected comparison: 2 vs. 3 (p-value)b 
Headache 2.4 (1.5) 0.3 (0.8) 0.4 (0.8) 1.77* 1.86* 0.10 80.2 20.9 26.6 .321 
Dizziness 1.9 (1.5) 0.1 (0.6) 0.3 (0.8) 1.68* 1.56* 0.26** 70.9 5.8 17.5 .010 
Nausea 1.0 (1.3) 0.1 (0.5) 0.3 (0.7) 0.99* 0.78* 0.29*** 45.3 7.0 16.9 .027 
Fatigue 2.3 (1.5) 0.6 (1.1) 0.8 (1.1) 1.32* 1.22* 0.18 76.7 25.6 39.0 .032 
Sensitive to Noise 1.8 (1.6) 0.3 (0.8) 0.3 (0.8) 1.28* 1.41* 0.03 64.0 15.1 15.3 .977 
Irritable 1.9 (1.4) 0.4 (0.9) 0.6 (1.0) 1.30* 1.15* 0.14 74.4 25.6 29.9 .462 
Sad 1.5 (1.4) 0.4 (0.9) 0.5 (1.0) 0.96* 0.88* 0.13 61.6 18.6 25.4 .219 
Nervous/Tense 1.5 (1.5) 0.3 (0.9) 0.4 (0.9) 0.99* 0.99* 0.10 58.1 15.1 22.6 .156 
Temper Problems 1.0 (1.3) 0.3 (0.8) 0.5 (1.0) 0.71* 0.49* 0.23*** 40.7 11.6 23.7 .021 
Poor Concentration 2.2 (1.6) 0.2 (0.7) 0.6 (1.1) 1.75* 1.32* 0.36** 74.4 14.0 27.1 .017 
Memory Problems 2.1 (1.5) 0.3 (0.8) 0.5 (1.1) 1.62* 1.30* 0.25*** 72.1 12.8 23.7 .038 
Difficulty Reading 1.4 (1.5) 0.1 (0.6) 0.4 (0.9) 1.19* 0.92* 0.31** 50.0 3.5 16.4 .003 
Poor Sleep 2.2 (1.6) 0.6 (1.1) 0.7 (1.1) 1.15* 1.16* 0.07 73.3 30.2 32.8 .679 
Total Score 23.0 (12.6) 4.1 (7.4) 6.2 (8.1) 1.90* 1.77* 0.27** 81.4c 11.6c 23.7c .021 
BC-PSI items Descriptive statistics Mean (SD)
 
Effect size (d) and the Mann–Whitney U-testsa
 
Percentages and χ2 tests: Mild or Greater Symptom Rating
 
 1. MTBI Current 2. MTBI Preinjury 3. Healthy Controls 1 vs. 2 1 vs. 3 2 vs. 3 1. MTBI Current 2. MTBI Preinjury 3. Healthy Control Selected comparison: 2 vs. 3 (p-value)b 
Headache 2.4 (1.5) 0.3 (0.8) 0.4 (0.8) 1.77* 1.86* 0.10 80.2 20.9 26.6 .321 
Dizziness 1.9 (1.5) 0.1 (0.6) 0.3 (0.8) 1.68* 1.56* 0.26** 70.9 5.8 17.5 .010 
Nausea 1.0 (1.3) 0.1 (0.5) 0.3 (0.7) 0.99* 0.78* 0.29*** 45.3 7.0 16.9 .027 
Fatigue 2.3 (1.5) 0.6 (1.1) 0.8 (1.1) 1.32* 1.22* 0.18 76.7 25.6 39.0 .032 
Sensitive to Noise 1.8 (1.6) 0.3 (0.8) 0.3 (0.8) 1.28* 1.41* 0.03 64.0 15.1 15.3 .977 
Irritable 1.9 (1.4) 0.4 (0.9) 0.6 (1.0) 1.30* 1.15* 0.14 74.4 25.6 29.9 .462 
Sad 1.5 (1.4) 0.4 (0.9) 0.5 (1.0) 0.96* 0.88* 0.13 61.6 18.6 25.4 .219 
Nervous/Tense 1.5 (1.5) 0.3 (0.9) 0.4 (0.9) 0.99* 0.99* 0.10 58.1 15.1 22.6 .156 
Temper Problems 1.0 (1.3) 0.3 (0.8) 0.5 (1.0) 0.71* 0.49* 0.23*** 40.7 11.6 23.7 .021 
Poor Concentration 2.2 (1.6) 0.2 (0.7) 0.6 (1.1) 1.75* 1.32* 0.36** 74.4 14.0 27.1 .017 
Memory Problems 2.1 (1.5) 0.3 (0.8) 0.5 (1.1) 1.62* 1.30* 0.25*** 72.1 12.8 23.7 .038 
Difficulty Reading 1.4 (1.5) 0.1 (0.6) 0.4 (0.9) 1.19* 0.92* 0.31** 50.0 3.5 16.4 .003 
Poor Sleep 2.2 (1.6) 0.6 (1.1) 0.7 (1.1) 1.15* 1.16* 0.07 73.3 30.2 32.8 .679 
Total Score 23.0 (12.6) 4.1 (7.4) 6.2 (8.1) 1.90* 1.77* 0.27** 81.4c 11.6c 23.7c .021 

Notes: N = 263 (86 MTBI, 177 healthy controls). BC-PSI = British Columbia Post-Concussion Symptom Inventory; MTBI = mild traumatic brain injury; Preinjury symptoms reporting was obtained post-injury, at the time of assessment; SD = standard deviation.

aThe Mann–Whitney U-tests between mean scores on the 13 items; *p < .001, **p < .01, ***p < .001.

bChi-square analyses: p < .001 for all symptoms comparing 1 versus 2 and 1 versus 3 (except Temper Problems; p = .004).

cFor the total score, the percentages of each sample with scores of 10 or greater are reported.

The percentages of participants endorsing each symptom as mild or greater in the control group and the MTBI group (retrospective and post-injury) are also presented in Table 1. In the control group, specific endorsement rates of symptoms ranged from 15.3% to 39.0%. The most frequently endorsed symptoms were fatigue (39.0%), headache (26.6%), and poor sleep (32.8%). In the MTBI group, specific endorsement rates of preinjury symptoms ranged from 3.5% to 30.2%. The most frequently endorsed symptoms were fatigue (25.6%), irritability (25.6%), headache (20.9%), and poor sleep (30.2%). Significant differences in the percentages of endorsed symptoms were found on 7 of the 13 symptoms (all p < .05). The MTBI sample endorsed these symptoms at a lower rate than the control sample. Similarly, a smaller percentage of the MTBI sample (11.6%), compared with the control sample (23.7%), had preinjury total scores of 10 or greater (p = .021). Further comparison of the prevalence of endorsed symptoms was undertaken by considering all symptoms simultaneously. The cumulative percentages of the number of endorsed symptoms in the control group and the MTBI group (retrospective and post-injury) are presented in Fig. 1. When comparing MTBI preinjury ratings and the control group, there were a greater number of symptoms endorsed at a mild level or greater by the control group, compared with the MTBI preinjury ratings, for the majority of comparisons (i.e., 1, 2, 3, 4, 5, 6, 7, and 8 or more symptoms). For example, in the control group, 47.5% endorsed the presence of three or more symptoms, 29.9% endorsed five or more symptoms, and 17.5% endorsed the presence of seven of more symptoms. In comparison, in the MTBI group, 31.4% reported the presence of three or more preinjury symptoms (χ2 = 6.122, p = .013), 14.0% reported the presence of five or more symptoms prior to their injury (χ2 = 7.953, p = .005), and 8.1% reported the presence of seven or more symptoms prior to their injury (χ2 = 4.115, p = .043).

Fig. 1.

Cumulative percentages of the number of symptoms endorsed on the BC-PSI by group: Mild or greater symptoms.

Fig. 1.

Cumulative percentages of the number of symptoms endorsed on the BC-PSI by group: Mild or greater symptoms.

Role of Litigation Status

To examine the role of litigation status on pre- and post-injury symptom reporting, the patients were divided into two subgroups based on their current self-reported litigation status: No-litigation (n = 52) and Yes-litigation (n = 34). The Mann–Whitney U-tests and effect sizes (Cohen, 1988) were calculated for comparisons between the BC-PSI total score and the 13 symptoms in the control group and the MTBI group, stratified by litigation subgroup (i.e., No-litigation and Yes-litigation) and time period (i.e., MTBI preinjury ratings and MTBI post-injury ratings). Only four selected comparisons were undertaken designed to (a) evaluate the association between litigation status on the “good-old-days” bias (i.e., MTBI No-litigation preinjury ratings vs. controls; MTBI Yes-litigation preinjury ratings vs. controls), and (b) evaluate the association between litigation status on PCS symptom reporting both post-injury and retrospectively (i.e., MTBI No-litigation preinjury ratings vs. MTBI Yes-litigation preinjury ratings and MTBI No-litigation post-injury ratings vs. MTBI Yes-litigation post-injury ratings).

Overall, patients who were involved in litigation (personal injury or WCB claims) reported more post-injury symptoms compared with patients in the MTBI group who were not involved in litigation (BC-PSI total score: Yes-litigation: M = 27.6, SD = 12.2; No-litigation: M = 20.0, SD = 12.0; p = .009, d = 0.63, medium-large effect size). On the basis of a comparison of mean scores on each of the individual BC-PSI items, 9 of the 13 items had the Cohen effect sizes greater than d = 0.35 when comparing post-injury ratings (d = 0.35–0.81). Those patients involved in litigation did not tend to be more seriously injured than those who were not involved in litigation. There were no significant differences between the groups in the proportion of patients with abnormal day-of-injury CT scans (17.6% litigants, 28.8% nonlitigants; χ2 = 1.697, p = .428), GCS scores of less than 15 (20.6% litigants, 38.5% nonlitigants; χ2 = 3.050, p = .218), the presence of PTA (76.5% litigants, 75.0% nonlitigants; χ2 = 0.057, p = .972), or the presence of LOC (85.3% litigants, 75.0% nonlitigants; χ2 = 1.886, p = .390). Those patients in litigation were, however, more likely to sustain their injuries in a motor vehicle accident (61.8% litigants, 5.8% nonlitigants; χ2 = 32.039, p < .001).

In contrast, there were no differences in preinjury symptom ratings between the Yes-litigation and No-litigation subgroups (BC-PSI total score: Yes-litigation: M = 4.4, SD = 9.8; No-litigation: M = 3.8, SD = 5.3; p = .221, d = 0.09, very small effect size). Only one of the 13 items had an effect sizes greater than d = 0.35 (i.e., Dizziness, d = 0.48), with the majority of items having very small to small effect sizes (range: d = 0.01–0.22).

Pre- Versus Post-injury Symptom Reporting

The relation between pre- and post-injury symptom reporting was further examined in the MTBI sample. Specifically, those patients who had BC-PSI preinjury total scores of zero or one (n = 42, 48.8%; BC-PSI total score: M = 0.2, SD = 0.4) were compared with those patients who had BC-PSI preinjury total scores of two or greater (n = 44, 51.2%; BC-PSI total score: M = 7.8, SD = 8.9). There was no significant difference in post-injury total scores between these groups (F = 0.005, p = 945; BC-PSI “0–1 group”: M = 23.1, SD = 12.7; BC-PSI “2+ group”: M = 23.0, SD = 12.6).

Complicated Versus Uncomplicated MTBI

The role of injury severity on pre- and post-injury symptom reporting was examined in the MTBI sample. Those patients with complicated MTBIs, characterized by a day-of-injury intracranial abnormality on CT (n = 21), were compared with those with normal day-of-injury CT scans (n = 30) and those who did not undergo day of injury CT (n = 35). A series of three Mann–Whitney U-tests were used to compare the BC-PSI total scores across each of the three groups for each of the pre- and post-injury ratings separately. For the preinjury ratings, there were no significant differences (all p > .05) for all three group comparisons. For the post-injury ratings, there was a significant difference between the no-CT group and the abnormal CT group (p = .006, d = 0.82, large effect size). The no-CT group (M = 25.7, SD = 10.6) had significantly greater post-concussion symptoms compared with the abnormal CT group (M = 16.8, SD = 11.3). There were no significant differences when comparing normal CT versus no-CT groups (p = .802, d = 0.11, very small effect size) and normal CT versus abnormal CT groups (p = .069, d = 0.57, medium-large effect size); though a medium-large effect size was found for the latter comparison. Greater post-concussion symptoms were reported by the normal CT group (M = 24.3, SD = 14.3) compared with the abnormal CT group.

Discussion

The purpose of this study was to examine the influence of the “good-old-days” bias on post-concussion symptom reporting in patients following MTBI. On the basis of earlier research by Gunstad and Suhr (2001) and Iverson and colleagues (2010), it was hypothesized that patients with MTBIs would endorse fewer preinjury symptoms compared with community control subjects. Overall, the results support this hypothesis. The MTBI group had lower preinjury BC-PSI total scores than the community control subjects. The MTBI group had lower preinjury mean scores on multiple symptoms, and they endorsed fewer preinjury individual symptoms than the control group. These findings are consistent with, and expand upon, other studies in this area (Davis, 2002; Gunstad & Suhr, 2001, 2004; Hilsabeck et al., 1998; Iverson et al., 2010; Mittenberg et al., 1992).

It is important to note that the total score effect size between controls and MTBI retrospective preinjury ratings reported in this study (d = 0.27, small-medium effect size) was much lower than that reported by Iverson and colleagues (d = 0.65, medium-large effect). It is difficult to determine why these differences occurred. There are many similarities between the current study and the Iverson and colleagues study. For example, both studies (a) evaluated patients at the same time post-injury (% within 2 months: Iverson = 76.5%, Current = 72.0%); (b) used the same post-concussion symptom inventory, control sample, statistical methods, and inclusion/exclusion criteria; (c) recruited the MTBI samples from the same city; (d) included MTBI samples that had similar ethnicity composition (Caucasian: Iverson = 73.6%, Current = 75.6%) and gender composition (Men: Iverson = 64.4%, Current = 51.2%); and (e) had a similar number of MTBI patients that met ICD-10 Criterion C for Post-concussional Syndrome (Iverson = 95.6%, Current = 94.4%).

Nonetheless, there are some differences between the two studies. The sample in this study (a) was younger and had more years of education (Current: Age: M = 36.9 years, SD = 13.7; Education: M = 14.0 years, SD = 1.9; Iverson: Age: M = 41.5 years, SD = 11.5; Education: M = 12.6 years, SD = 1.9), (b) had a greater proportion of patients with more serious injuries as indicated by the presence/absence of PTA and LOC (Current = 75.6% and 79.1%, respectively; Iverson = 33.3% and 30.0%, respectively) and day-of-injury CT abnormalities (Current = 27.9%; Iverson = 0%), and (c) had a lower proportion of patients who were in litigation at the time of evaluation (Current = 39.5% personal injury or WCB claims; Iverson = 100%, WCB claims). In the present study, age and education were unrelated to preinjury symptom reporting, so these variables seem unlikely to explain the differences. The present sample appeared to have more serious MTBIs compared with the previous study. Theoretically, having a more serious injury should be considered a greater adverse event which should result in a stronger good-old-days bias phenomenon—as such, the present findings run counter to the theory.

The key difference, therefore, appears to be compensation-related. In the previous study, 100% of patients had an active WCB claim and none had returned to work. They were receiving financial compensation at the time they were assessed. A subset underwent neuropsychological screening, including effort testing. Those injured workers who failed effort testing reported virtually no preinjury symptoms and greater post-injury symptoms. Therefore, poor effort was clearly related to pre- and post-injury symptom reporting (Iverson et al., 2010). In the present study, there was no difference between those in litigation versus those not in litigation in regard to preinjury symptom reporting, but there was a difference between groups in post-injury symptom reporting (litigation > non-litigation). The post-injury symptom reporting difference could be explained, at least in part, by a greater percentage of litigants being involved in motor vehicle accidents. This would put them at risk for greater soft tissue injuries and increased symptom reporting relating to those injuries. No effort testing was done in the present study, so this important moderating variable could not be investigated. Moreover, in British Columbia people have 2 years to initiate litigation following injury. Because our sample was evaluated within a few months post-injury, some of the nonlitigants might, in the near future, initiate an action. Therefore, these were not necessarily “clean” litigation subgroups. It is important to highlight that the results from this study are related to a much broader literature on self-perception and response bias. Positive and negative impression management (e.g., social desirability, defensiveness, and under-reporting and over-reporting of psychopathology) have been studied for many years. This study relates to the broader literature on self-perception and response bias in that patients evaluated following MTBI might be influenced by social desirability and defensiveness in regards to their preinjury symptoms and over-reporting in regard to their post-injury symptoms. For example, Greiffenstein, Baker, and Johnson-Greene (2002) noted that adults who report significant symptoms and problems long after an MTBI overestimate their past level of academic achievement. Other researchers examining non-MTBI populations have found that (a) high-school students with learning disabilities tend to overestimate their academic skills (Stone & May, 2002), (b) abused children are more likely to overestimate their academic abilities (Kinard, 2001), (c) personality characteristics can influence a persons' self-assessment of their intelligence (Furnham & Chamorro-Premuzic, 2004), (d) estimates of humor, grammar, and logic are overestimated by young adults who score in the bottom quartile on these measures (Kruger & Dunning, 1999), and (e) people tend to overestimate the likelihood that they would act in generous or self-less ways (Epley & Dunning, 2000).

The direct clinical implications of this study are modest. Clinicians might choose to have patients complete a post-concussion symptom scale based on their recall of symptoms in the month prior to getting injured and their current symptoms. If a person rates all preinjury symptoms as zero, that might reflect a bias. It is important to appreciate, however, that a sizeable minority of the healthy population will endorse none of these symptoms. Questionnaire results can be combined with interview findings to draw a clinical inference about the presence of recall bias. Some patients emphasize, in a rather extreme and implausible way, that they had no symptoms whatsoever prior to being injured (e.g., virtually never experienced fatigue, irritability, difficulty concentrating, or a headache). This, combined with the questionnaire results, might lead the clinician to conclude a possible recall bias—and this can actually be used, carefully and diplomatically, in treatment via cognitive restructuring.

This study has several limitations. First, this sample should not be considered generalizable to all people who have sustained MTBIs. This is a highly selected, non-representative, yet homogenous sample. The vast majority of these patients were referred to the concussion clinic because they had been identified as “at risk” of poor outcome following MTBI. Consequently, the large majority of the patients (94.2%) met ICD-10 criteria for post-concussion disorder. It would be informative to evaluate the presence of the “good-old-days” bias in those patients with versus without post-concussion symptoms. Unfortunately, the composition of our sample did not allow us to make these comparisons. Future studies are encouraged to compare pre- and post-injury ratings in PCD present and PCD absent groups. Second, the control group did not provide retrospective ratings of post-concussion symptoms in this study. It is possible that the endorsement of fewer preinjury symptoms in the MTBI group may not be related specifically to the “good-old-days” bias per se (i.e., as a consequence of the injury event), but may be a result of a more general retrospective bias. However, researchers have found that healthy control participants do not report more current than past symptoms when asked to provide retrospective ratings 2–3 years prior (Gunstad & Suhr, 2001, 2004). Nonetheless, it would be informative for future studies to compare retrospective self-reported symptoms in both MTBI and healthy controls to more comprehensively evaluate these issues. Third, there was no measure of effort administered to the patients. The relation between effort test failure and elevated symptom reporting has been established for some time (Iverson et al., 2010; Kreutzer, Seel, & Gourley, 2001; Seel et al., 2003). Of particular relevance, Iverson and colleagues have reported that failure on the TOMM is associated with increased post-concussion symptom reporting following MTBI. It is possible that some patients have exaggerated their symptoms in this study. Although it was possible to compare patients who are seeking/not seeking financial compensation for their injuries in this study, we could not, however, examine the issue of effort or exaggeration separately from litigation status. In conclusion, there is accumulating evidence that some patients with a post-concussion syndrome misperceive and/or inaccurately report their preinjury functioning. They likely underestimate and/or underreport the number of symptoms they were experiencing prior to sustaining an injury. In this study, this misperception and underestimation of problems prior to their injury is consistent with the “good old days” bias, but this quasi-experimental, cross-sectional research design does not allow a confident conclusion as to whether this social-psychological phenomenon was, in fact, operative. That is, we cannot differentiate this nocebo-related, presumably subconscious recall bias from deliberate under-reporting of past symptoms. Nonetheless, the “good-old-days” bias can potentially have a negative impact on a patient's (a) perception of current problem severity, (b) (mis)attribution of most or all current symptoms and problems to the injury, and (c) duration of recovery from injury.

Conflict of Interest

Grant Iverson, PhD is the author of the British Columbia Post-Concussion Symptom Inventory, a scale used in this study. He has a clinical practice in forensic neuropsychology involving individuals who have sustained mild TBIs.

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Author notes

A portion of these data were presented at the International Neuropsychological Society Conference, February 2010, Acapulco, Mexico. This research was granted ethical approval by the University of British Columbia Behavioral Research Ethics Board.