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Changes in Athletes' Anxiety, Anger, and Impulsiveness following Changes in Athletes' Anxiety, Anger, and Impulsiveness following Concussion Megan Byrd Follow this and additional works at: https://researchrepository.wvu.edu/etd Recommended Citation Byrd, Megan, "Changes in Athletes' Anxiety, Anger, and Impulsiveness following Concussion" (2017). Graduate Theses, Dissertations, and Problem Reports. 5294. https://researchrepository.wvu.edu/etd/5294 This Dissertation is protected by copyright and/or related rights. It has been brought to you by the The Research Repository @ WVU with permission from the rights-holder(s). You are free to use this Dissertation in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you must obtain permission from the rights-holder(s) directly, unless additional rights are indicated by a Creative Commons license in the record and/ or on the work itself. This Dissertation has been accepted for inclusion in WVU Graduate Theses, Dissertations, and Problem Reports collection by an authorized administrator of The Research Repository @ WVU. For more information, please contact researchrepository@mail.wvu.edu. Changes in Athletes’ Anxiety, Anger, and Impulsiveness following Concussion Megan Byrd, M.S. Dissertation submitted to the College of Physical Activity and Sport Sciences at West Virginia University in partial fulfillment of the requirements for the degree of Doctor of Philosophy In Kinesiology With an emphasis in Sport and Exercise Psychology Sam Zizzi, Ed.D, Chair. Anthony Kontos, Ph.D. Edward Etzel, Ed.D Damien Clement, Ph.D., ATC College of Physical Activity and Sport Sciences Morgantown, West Virginia 2017 Keywords: Concussion, Sport, Anger, Anxiety, Impulsivity, Mental Health, Athletes Copyright 2017 Megan Byrd ABSTRACT Changes in Athletes’ Anxiety, Anger, and Impulsiveness Following Concussion Megan Byrd The impacts and effects of sport-related concussion have been considered a major health concern as early as 1999 (Kelly, 1999) and have continued to be a prominent topic of controversy among all levels of sport. Amidst this concern and controversy, the emotional impacts of sport-related concussion, particularly anxiety, anger, and impulsivity are still relatively unknown. The primary purpose of this study was to examine the relationship between sport concussions and anger, anxiety, and impulsivity in collegiate athletes. The secondary purpose of this study was to determine if there is a subset of athletes who are more likely to exhibit certain emotions based on pre-existing risk factors, or the manner in which the concussion was sustained. The study utilized a multi-method, longitudinal design and was sequential in nature. Participants were male and female collegiate athletes and completed the study during three time points: (a) 1 to 10 days post diagnosis (n = 30) (b) 11 to 21 days post-concussion (n = 12), and (c) 30 days post-concussion (n = 10). Slightly more than half (n =16) of athletes reported self or others noticing a difference in their behavior or mood since sustaining a concussion and the mean on all measures were above norms for college aged men and women during time point a. Most notably, 11 out of 30 athletes scored above a 10 on the clinical anxiety measure, indicating a diagnosable level of anxiety for Generalized Anxiety Disorder. Overall, the results indicated that the athletes were experiencing anxiety, anger, and impulsivity following concussion and anxiety seemed to be the mediating factor. The more anxious athletes felt regarding their symptoms and symptomology, the more it seemed to influence their frustration and behavior. Results indicated that the athletes believed they would benefit from education regarding the affective symptoms of concussions and that rehabilitation of concussions should be tailored to each athletes’ symptomology. iii Acknowledgments To say completing a dissertation takes a village would be a vast understatement. Luckily, I have found myself among incredible people who didn’t give up on me, even when I was ready to give up on myself. This dissertation journey began five years ago during my PhD interview with Dr. Sam Zizzi when he asked me what it meant to lose the forest among the trees. So, it’s only fitting that it ends (or starts a new beginning) in a similar fashion. The magnitude of guidance and support provided by Dr. Zizzi is unmeasurable and difficult to convey in words. Thank you for trekking through the literature forest with me and serving as a beacon of light when I found myself traveling too far. You lead by an example I can only hope to follow and are the type of advisor I strive to be. You remind me not to take myself too seriously and to always engage in karmic cleansing. Thank you. I would like to thank Dr. Anthony Kontos for agreeing to meet me in a coffee shop two years ago, and even more so for listening to what I assumed were grandiose ideas for a dissertation. Without your willingness to share your breadth of knowledge and resources, this dissertation does not happen. Thank you for your honest and genuine feedback and suggestions during this process. Your work in concussions is inspiring and I’m grateful to play a small part in improving recovery and rehabilitation for athletes. Thank you. Dr. Etzel is the source of big picture thinking. Thank you for reminding my why the work we do is important and how small gestures can make a huge difference. From sending articles about concussions or baseball to allowing me to sit in your office in the comfy blue chairs when I needed a minute to myself, thank you for showing me what reaching out looks like. Thank you. I’m grateful to Dr. Damien Clement for agreeing to be involved in this project even after the self proclamation, “I don’t mess with concussions.” Thank you for being a stable voice among the instability that has been this project. You provided information in an area I knew very little about and did so with patience. Thank you. To all the help along the way: thank you Trevor Jones, Danielle Funk, Adam Hansell, Brandon Lucke-Wold, Cindy Holland, Valerie Reeves, Jake Manumalo, Alison Pope-Rhodius, and rest the staff, faculty, and students at John F. Kennedy University. When you join a PhD program, you join a family. At WVU, we have a great one. Thank you to all the SPAFers who came before me, who experienced it with me, and who will come after me. Ashley, Chelsea, Pete, and Jesse; thank you for always answering my texts and showing me the way. MegHan, Stefanee, and Tammy; thank you for being my tribe and a source of unwavering love and support. Sharing in the highs and lows along the way makes everything worth it. Thank you to all of my friends near and far, and Drew for keeping me sane during an inconceivably insane situation. Thank you to my exceptional family. Dad, Mom, Adam, Stephen, and everyone else I’m lucky to call part of me. You have provided me the opportunity to grow through and never doubted my abilities. Love you. v Table of Contents Introduction . . . . . . . . . . 01 Concussion Symptoms. . . . . . . . 04 Emotional and Behavioral Responses Following Concussion. . . 04 A New Approach: Concussion Profiles. . . . . . 08 Methods . . . . . . . . . . 09 Research Design . . . . . . . . 09 Participants . . . . . . . . . 10 Instrumentation. . . . . . . . . 12 Procedure . . . . . . . . . 15 Data Analysis: Quantitative Phase. . . . . . . 16 Data Analysis: Qualitative Phase. . . . . . . 17 Results . . . . . . . . . . 18 Quantitative Phase . . . . . . . . 18 Qualitative Phase . . . . . . . . 23 Discussion . . . . . . . . . . 33 Conclusion . . . . . . . . . 53 References . . . . . . . . . . 54 Appendix A – Extended Literature Review . . . . . . 72 Appendix B – Tables and Figures . . . . . . . 148 Appendix C – Consent Form . . . . . . . 150 Appendix D – Assessments . . . . . . . 153 Appendix E – Interview Guide . . . . . . 160 vi List of Tables and Figures Figure 1 – Using Concussions Clinical Trajectories .. . . Table 1 – Athlete Pseudonyms and Demographics Phase 3 Participants. Table 2- Mean Differences on Paried Samples T-Test Table 3- Descriptive Data Time Point 1 and 2. . . . Table 4 – Bivariate Correlations of Significant Symptoms . . Table 5- Demographics for Phase 1 and 2 Participants . . . . . . . . . . 66 . . . . . 67 67 68 69 72 1 Introduction In the 10-year period from 2000 to 2010, emergency room visits for sports- and recreation-related head injuries among adults and adolescents have increased by 60% (Centers for Disease Control, 2010). In sport, incidence rates per athletic exposure (number of practices and competitions in which an individual actively participates) of all high school sports is 4.9 per 10,000 athletic exposures and collegiate sports is 3.4 per 10,000 athletic exposures (Gessel et al., 2007; Hootman, Dick, & Agel, 2007; Lincoln et al., 2011). A concussion, as defined in the Zurich consensus statement, is a pathophysiological process resulting in functional neurological impairments, as a consequence of forceful biomechanical impacts directly on or transmitted to the head, neck, or face (McCroy et al., 2013). In a retrospective study of 328 collegiate football and soccer players using self-reported symptoms of concussion, Delaney and colleagues (2002) found that 62.7% of soccer players and 70.4% of football players experienced symptoms of a concussion during their previous athletic season. Headache was the most commonly experienced symptom (71%) followed by confusion and disorientation (56%). A history of concussions have been shown to be a significant risk factor for repeat concussions (McCrory et al., 2013) and other neurological conditions, including early-onset Alzheimer’s disease (Graves et al., 1990; Rasmusson, Brandt, Martin, & Folstein, 1995), chronic depression (Holsinger et al., 2002), epilepsy (Langlois, Rultand-Brown, & Wald, 2006) and chronic traumatic encephalopathy (CTE; McCrory, Zazryn, & Cameron, 2007; Omalu et al., 2005). Unfortunately, stories of athletes who have taken their lives are becoming increasingly more common. Many of these athletes who have taken their lives have shown signs of brain injury sustained from concussions in post-mortem brain scans in the form of CTE, a degenerative 2 disease typically caused by multiple hits to the head. CTE can only be diagnosed after death, but patients with CTE often display symptoms such as impulsivity, forgetfulness, depression, and sometimes suicidal ideation (Omalu et al., 2005). While the link between CTE and sport concussion is still being investigated and there are conflicting views on the relationship, it is clear that athletes are experiencing emotional symptoms following concussion. For example, qualitative studies with former professional hockey players detailed suicidal ideations in those who sustained repeated concussions during their career (Caron, Bloom, Johnston, & Sabiston, 2013; Gulli, 2011). In 2014, 22-year-old Kosta Karageorge, an Ohio State football player, and former collegiate wrestler, was found dead from a self-inflicted gunshot wound. He sustained numerous concussions throughout his playing career and in a text to his mother prior to his death Kosta referenced his concussions saying they had his head “all messed up” (Thamel, 2014). While the link between CTE and sport concussion is still being investigated, and there are conflicting views on the relationship, tragedies such as this can be prevented with proper medical attention following concussion. Concussions are a type of traumatic brain injury (TBI) and while the phrases “concussion” and “mild TBI” are often used interchangeably this paper will use the term concussion as a subset of TBI. Concussions may occur from a direct hit to the head, face, neck or elsewhere that results in a force to the head. Rapid functional neurological impairments are often a consequence of concussion that may be short-lived or protracted. Concussion severity ranges from “mild” (i.e., a brief change in mental status or consciousness) to “severe” (i.e., an extended period of unconsciousness or memory loss after the injury), however all brain injuries are serious and may occur without loss of consciousness. 3 Due to the nature and the mechanism of concussion, combined with the physical and psychological symptoms, athletes may be more vulnerable to negative mood states such as depression, isolation, and anxiety, as compared to athletes suffering from musculoskeletal injuries (Chen, Johnston, Petfies, & Pitio, 2008; Hutchison et al., 2009). Therefore, the emotional sequelae following concussion is an area for continued research as a preventative measure against suicide and other mental health issues. By better understanding the manifestation of symptoms following concussion, more specific individualized treatment plans can be developed to aid athletes in their recovery and future health. Collegiate and professional leagues have reformed rules regarding legality of plays, equipment, and return to play protocols to enhance athlete safety. However, even with better detection and stricter rules it has been estimated that as high as 50% of concussions go undiagnosed (McCrea et al., 2004) due to athletes’ unwillingness to report symptoms, and delayed symptom onset (Beckwith et al., 2013; Delaney et al., 2002; Duhaime, et al., 2012). These incident rates do not account for subconcussive impacts, which are characterized as hits to the head that do not cause a concussion to occur, but repeated exposure has been found to be as detrimental as concussions (McKee et al., 2009). Following concussion, and during symptom recovery, an athlete is more susceptible to future head injury, so return to play decisions should be made carefully and with proper testing and screening (Baugh, 2014; McCrory et al., 2013). The American Academy of Neurology has recommended the use of neurological assessment to measure severity and assess treatment, specifically return to play guidelines (Giza et al., 2013). Neuropsychological assessments, such as the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT 2.0; Lovell, 4 Collins, Podell, Powell, & Maroon, 2000), test memory function, reaction time, and speed of cognitive processing. Concussion Symptoms Signs and symptoms following concussion are often characterized into four discrete system clusters: somatic, cognitive, emotional, and sleep-related (Pardini et al., 2004). In 80% of athletes, these symptoms typically resolve in less than three weeks (Iverson, Brooks, Collins, & Lovell, 2006) with 20% of athletes experiencing lingering symptoms. Little is known about how a concussion changes the brain on either a structural or a neurochemical level (Henry, Tremblay, Boulanger, Ellemberg, & Lassonde, 2010) and so it is difficult to determine if athletes’ psychological symptoms are purely emotional, or if they are caused by change within the brain. This unknown factor can lead to difficulties in studying athletes with concussions, specifically the cluster of emotional responses. There is research to suggest that neurobiological and pathophysiological changes associated with brain injury, regardless of severity level, may be directly related to the onset of psychological symptoms (Chen et al., 2008; Hudak et al., 2011; Reger et al., 2012). Concussions and head injuries often damage the prefrontal cortex, ventral frontal lobe and the anterior temporal lobe, which are implicated in recognizing, regulating, and reacting to emotionally relevant stimuli (Etkin, 2010; Etkin, 2012; Kennedy et al., 2007). Emotional and Behavioral Responses Following Concussion There is substantial research documenting the emotional and behavioral responses following injury that include depression, tension, anger, anxiety, frustration, and boredom (e.g., Brewer, Van Raalte, & Linder, 1991; Leddy, Lambert, & Ogles, 1994). With the combination of physical and psychological symptoms of concussions, athletes who sustain concussions may 5 experience different emotional responses to injury compared to athletes who have sustained musculoskeletal injuries (Hutchison et al., 2009). Furthermore, concussions have no outward visibility, so concussed athletes may present different responses during rehabilitation and recovery than an athlete who has a visible injury with specific physical limitations. The most frequently cited and studied emotional symptom following concussion is depression (Guskiewicz et al., 2007; Rutherford, 1977). Given the high degree of comorbidity between depression and anxiety (Stavrakaki & Vargo, 1986) and non-concussed injured athletes’ endorsement of anxiety during the rehabilitation process (e.g., Mainwaring et al., 2010; Tracey, 2003) athletes with concussion may be prone to both anxiety and depression after injury. General anxiety disorder (GAD) in persons following a TBI has been reported at rates that are double those found in the general population (Hiott & Labbate, 2002). A retired professional hockey player once described his experience with anxiety following a concussion as, “Anxiety. Absolutely. That year was the worst I’ve ever felt…use the comparison of having your foot on a gas pedal and everything is going too fast. Everything was going too fast for me” (Caron, Bloom, Johnston, & Sabiston, 2013, p. 172). In a prospective cohort study by Yang, Peek-Asa, Covassin, & Tomer (2015), the authors found that among 67 male and female Division I collegiate athletes who sustained a concussion within the 2007-2008 to 2011-2012 seasons, one-fifth of concussed athletes (n = 14, 19.8%) reported experiencing symptoms of depression, and one-third of concussed athletes (n = 24; 33.8%) reported symptoms of anxiety. Post-concussion symptoms of depression significantly co occurred with post-concussion state anxiety (OR = 8.35; 95% CI = 2.09, 33.34). Similarly, Bailey et al. (2010) found that in 47 concussed college football players, 13% of the athletes had 6 elevated anxiety levels as compared to their baseline scores. Additionally, 4% of the athletes had clinically significant levels of anxiety compared to their baseline scores and met the diagnostic criteria for an anxiety disorder. These studies demonstrate that athletes do experience feelings of anxiety following concussion and the findings should be replicated to further understand when in the recovery process athletes feel anxious and how long the feelings linger. Athletes with head injury history who have taken their lives may have done so due to depressive feelings they cannot seem to overcome, although another reason may be due to increased impulsive behavior while feeling anxious or depressed. Impulsivity is a construct that encompasses a multitude of behaviors or responses that frequently result in unwanted or damaging outcomes (Daruna & Barnes, 1993). Impulsivity is a common consequence following head injury (Rochat, Ammann, Mayer, Annoni, & van der Liden, 2009; Starkstein & Robinson, 1997), and is also related to difficulties with emotional regulation, such as irritability and poor temper control (Cattran, Oddy, & Wood, 2011). The prefrontal cortex, a commonly injured region, plays an important role in emotional and behavioral regulation, as well as social awareness. Grafman and colleagues (1996) suggested that the inability to control one’s behavior may result from a loss of frontal lobe inhibition due to damage to the subcortical limbic structures in the brain that are involved in the facilitation of aggression and impulses to act. In athletes, these impulses may lead to risk-taking behaviors after concussion. Research shows that male athletes are more likely to engage in risk-taking behaviors, such as substance abuse, alcohol use, and injurious behavior, than males who are non-athletes (Kokoatlio, Henry, Koscik, Fleming, & Landry, 1996). Thus, impulse control problems and poor emotion regulation after concussion could put athletes at greater risk for additional problems such as re-injury (i.e., 7 returning to sport too soon), self-injury (i.e., suicidal ideation), or dysfunctional behaviors outside of sport. This risk may be greater given the prevalence of irritability following concussion. Eames and Wood (2003) have described a cluster of symptoms characterized by intermittent states of altered affect or behavior called temporolimbic disorders in patients with TBI. They have noted that the change in often sudden, unpredictable, and typically “out of character” for that individual. This type of behavior has been termed an intermittent form of anger following head trauma, and that is closely related to impulse control disorders. Anger has been recognized as a prevalent emotion in sport (Brunelle, Janelle, & Tennant, 1999) and has been endorsed by athletes following sports injury (e.g., Brewer et al., 1991; Leddy et al., 1994). There are theories as to why anger is experienced after sport injury, many centered on frustration that accompanies sport injury. Compared to athletes with musculoskeletal injuries, athletes with concussions have higher reported levels of anger one and two weeks post injury (Hutchison et al., 2009), but this research is limited because it did not follow athletes through return to play. Research has yet to determine if the change in anger was due to removal from play or the concussion itself. Using the State-Trait Anger Expression Inventory-2 (STAXI-2; Spielberger, 1999), Bailie and colleagues (2015) examined the impact of TBI on the experience and expression of anger in a military population. Compared to participants without history of TBI, participants with TBI were four times more likely to have three or more atypical STAXI-2 scale scores than the control group, with the largest difference on the state anger scale (η2 = 0.10). This effect indicates that TBI does 8 have a moderate influence on a person’s anger levels, but these findings have not been replicated in an athlete population. As a way to illustrate the differences in emotions between athletes with concussion and other injuries, Mainwaring (2008) presented the concussion crevice profile using data the short form Profile of Mood States Assessment (Morgan, 1980). It was found that athletes with concussion had elevated levels of fatigue, low vigor, elevated depression, and confusion scores. Likewise, as compared to athletes with other types of injury (Hutchison et al., 2009) and non injured athletes (Mainwaring et al., 2004) concussed athletes had greater mood disturbance, decreased energy, and increased levels of fatigue and confusion. Based on their research of the emotional sequelae of concussion, Mainwaring and colleagues (2012) have advocated for more comprehensive concussion management approaches that include the assessment and management for emotional symptoms. A New Approach: Concussion Profiles As a way for research to unite practice and inform rehabilitation programs, Collins, Kontos, Reynolds, Murawski, and Fu (2014) have developed a conceptual approach to developing clinical profiles to inform the treatment of sport-related concussion (Figure 1). The model suggests using assessment information including a clinical interview and neuropsychological data from athletes to gauge the trajectory of the concussion and to inform the treatment plan. Based on empirical data and clinical experience, the model postulates that symptoms are indicative of the treatment and rehabilitation pathway that would be most beneficial to an athlete’s recovery. For instance, if an athlete presents with cognitive symptoms such as confusion and emotional symptoms, such as sadness, the athlete would likely be on the 9 mood and anxiety profile. To determine the concussion profile, athletes would be assessed within the first seven days of injury when they experience the highest manifestation of symptoms, then reassessed one to two weeks later. If clinicians can better gauge the trajectory the concussion may take, the rehabilitation and treatment can be geared toward those specific symptoms. Based on the existing literature on the emotional sequelae of concussions, particularly the gaps in understanding of athletes’ experiences over time, the purpose of this study was to explore the relationship between sport concussions and impulsivity, anger, and anxiety in collegiate athletes. The study also seeks to determine if there is a subset of athletes who are more likely to exhibit certain emotions based on pre-existing risk factors, or the manner in which the concussion was sustained. The study’s repeated measures, multi-method design with multiple dependent variables will allow the researcher to track emotional responses over time in an athlete population. Research Design Methods A multi-method, longitudinal design was used to explore the emotional sequelae post concussion in collegiate athletes. The study was sequential in nature as first the participants were given the quantitative assessments, which informed the follow-up interviews. The study was conducted over three time points: (a) 1 to 10 days post-diagnosis, (b) 11 to 21 days post concussion, and (c) 30 days post-concussion. Time points “a” and “b” reflected the quantitative portion of the study and the qualitative interviews took place 30 days post-concussion. In additional to demographic and injury-related items, the participants filled out measures of concussion symptoms, anxiety, anger, and impulsiveness. 10 The benefit of conducting a multi-method study is the opportunity to follow up on quantitative scores, or capture differences that are not represented by the measures (Greene & McClintock, 1985). Furthermore, researchers (e.g., Brewer, 1993; Johnston & Carroll, 1998; Udry et al., 1997) have recommended the need for using qualitative methods early in the injury process and collecting several data points in injury recovery. The data from both sources was used in combination to create a more holistic and detailed description of the experiences of the participants. The data was not combined for analysis, but to aid in making sense of both sets of data. As Denzin and Lincoln (2000) stated, triangulation in this perspective, “is best understood as a strategy that adds rigor, breadth, complexity, richness, and depth to any inquiry’ (p. 5). By simultaneously tracking multiple emotions in one study over time, this study improves upon previous research designs regarding the emotional sequelae of concussions. Participants Participants were recruited through multiple NCAA institutions, a sports medicine center and snowball sampling. Thirty-seven athletes were recruited during the course of two years to participate. Of those 37, a total of 30 collegiate athletes completed the quantitative surveys (81% response rate) 1 to 10 days post-concussion and 12 of 30 athletes completed surveys (40% response rate) 11-21 days post-concussion. Ten of 12 volunteered to complete the qualitative portion of the study 30 days post-concussion (83% response rate). There are two potential reasons as to why the response rate of athletes declined between 1 to days post-concussion and 11 to 21 days post-concussion. First, athletes may have been cleared to play and no longer experiencing concussion symptoms, thus no longer interested in completing a survey on their concussion symptoms. Secondly, participation in all three phases of this study were time 11 consuming and athletes were not compensated for their time. Demographics for athletes who completed Phase 1 or Phase 2, including scores on the Post-Concussion Symptom Scale, can be found in Table 5. Athletes met the inclusion criteria if they were at least 18 years of age and diagnosed with a sport-related concussion by a medical professional. According to the National Collegiate Athletic Association (NCAA) concussion policy (NCAA, 2013) the concussion must be diagnosed by a “physician or physician’s designee.” Concussion diagnosis was based on the following criteria: (1) observed or reported acceleration/deceleration of the head (2) any observable alteration in mental status; and/or (3) observable signs such as confusion, vacant stare, poor coordination, difficulty concentrating, poor balance; and/or (4) any self-reported symptoms such as headache, loss of consciousness, nausea, balance problems, or difficulty reading or concentrating. Participants were male (n = 23) and female (n = 7) collegiate athletes from soccer (n = 3), volleyball (n = 2), football (n = 22), lacrosse (n = 1), diving (n=1), and basketball (n = 1) who sustained a sport-related concussion during the fall 2015 through fall 2016 athletic seasons. Athletes ranged in year in school from freshman to graduate student, with the highest number of participants in their senior year (n = 19). The mean age of participants was 20.47 (SD = 2.01). One fifth (n = 6) of athletes had been diagnosed with more than one concussion during the year. The range of number of concussions sustained during their collegiate careers thus far was 1 to 4, with a mean of 1.6 (SD = .95). Slightly more than half (n =16) of athletes reported self or others noticing a difference in their behavior or mood since sustaining a concussion. Four athletes disclosed being previously diagnosed with a mental illness. Two athletes indicated they had been previously diagnosed with anxiety, one athlete reported having a learning disability, and the 12 fourth athlete did not disclose their mental illness. Only 1 athlete who completed all three phases of the study disclosed previously having a mental illness (anxiety). De Demographic data for the 10 athletes who participated in all three data collections periods differed slightly from the athletes who participated in solely the quantitative portion. Participants mean years of age was similar (M = 20.10, SD = 2.92) to the larger sample. Athletes were male (n = 4) and female (n = 6) collegiate athletes from football (n = 4), soccer (n = 2), volleyball (n = 2), lacrosse (n = 1), and basketball (n =1). The biggest difference in the samples were the number of concussions in their college careers (M = 2.3, SD = 1.16) and 80% of the athletes reported self or others noticing a difference in mood or behavior since their concussion, and one athlete reported having previously been diagnosed with a mental illness (anxiety disorder). The athletes’ pseudonyms and demographics, including scores on the Post-Concussion Symptom Checklist can be found in Table 1. Instrumentation During time periods 1 (1–10 days post-concussion) and 2 (11-21 days post-concussion), athletes were given the following quantitative assessments to assess reported levels of anxiety, anger, and impulse during their recovery period. (1) Demographic questionnaire (time point 1 only) assessing athletic sport history, age, sport type, concussion history, how the concussion occurred, and mental health history. (2) Post-concussion Symptom Scale. Concussion symptoms were measured using the Post-Concussion Symptom Scale (PCSS; Lovell & Collins, 1998) of the Immediate Post Concussion Assessment and Cognitive Test (ImPACT Version 2.0; Lovell, Collins, Podell, Powell, & Maroon, 2000). It is a 21-symptom checklist to document and track concussion 13 symptoms on a 7-point Likert scale (0 = no experience of a symptom to 6 = severe symptom). The items on the scale were developed to represent player report symptoms as opposed to medical verbiage (i.e., feeling “slow”). Iverson, Lovell, and Collins (2003) found evidence of moderate test-retest reliability (r = .65) and pre-to post-season intraclass correlation (r = .55). Internal consistency reliability on the PCSS in samples of non-concussed high school and college students has ranged from .88 to .94 (Lovell et al., 2006). In high school and college athletes with concussions, Cronbach alphas for men and women were .93 and .92, respectively (Lovell et al., 2006). Symptoms are classified into five categories based on normative data for healthy men and women and categorized by severity (low-normal, broadly normal, borderline, very high, and extremely high). (3) Barratt Impulsiveness Scale-version II. Impulsivity was measured using the Barratt Impulsiveness Scale–II (BIS-II; Patton, Stanford, & Barratt, 1995). The original scale was developed to relate impulsiveness, along with anxiety, to psychomotor efficiency (Barratt, 1959). Through several factor analytic studies (e.g., Barratt, 1965; Barratt, 1985) it was concluded that impulsiveness was not unidimensional and three sub-trait factors were identified, motor impulsiveness, non-planning, and attentional impulsiveness. However, the majority of studies using this scale have reported only the total score, ignoring both the first-and second-factor subscales (Stanford et al., 2009). The scale has 30 questions that are ranked on a 4-point Likert scale (1 = rarely/never to 4 = almost always/always), with 4 indicating the most impulsive response. The higher the summed score for all items, the higher level of impulsiveness. Example items from the questionnaire are “I plan tasks carefully; I say things without thinking; I am restless at lectures or talks.” This 14 questionnaire has shown good internal consistency in college undergraduates (α = .84, Hatfield & Dula, 2014) and test-retest reliability (Stanford, et al., 2009). Total score means for men and women in an adult sample (N = 1577; n = 1178 college students) are 62.8 (SD = 9.2) for men, and 62.1 (SD = 10.6) for women. Previous studies (e.g., Patton et al., 1995) have used a BIS-11 score of one standard deviation above the mean to designate high impulsiveness. (4) State-Trait Anger Inventory-2. Perceptions of anger were assessed using the State Trait Anger Inventory (STAXI-2; Spielberger, 1999). The inventory consists of six major scales and five subscales measuring the experience, expression, and control of anger. The STAXI-2 is comprised of 57-items measured on a 4-point Likert type scale (1 = not at all/almost never, 4 = very much so/almost always). For the purpose of this study, only the State-Anger subscale will be used. State-Anger (S-Anger; 15 items) refers to an emotional state consisting of subjective feelings that vary in intensity from mild annoyance to intense fury, accompanied by muscular tension and arousal of the automatic nervous system. This subscale was chosen for two reasons. First trait anger, as a personality measure, would not likely be effected in a short period of time. Second, research by Bailie et al. (2015) found the largest statistically significant effect on the State Anger subscale when comparing military personnel who had a history of at least one TBI as compared to a control group of persons with no TBI history (η2 = 0.10). Internal consistency reliability has a Cronbach alpha value ranging from .73 to .95 for the total scale and .91 for the S-Anger subscale (Spielberger, 1999). (5) Generalized Anxiety Disorder 7-item. Anxiety was assessed on the generalized anxiety disorder 7-item screening measure (GAD-7; Spitzer, Kroenke, Williams, & Lowe, 2006). It has 7 items answered on a 4-point Likert Scale (0 = not at all sure; 3 = nearly every day). The 15 GAD-7 is a clinical anxiety assessment, with a score above 10 indicating a probable diagnosis of anxiety, and a score above 15 indicating severe anxiety. This measure was developed based on the anxiety disorder diagnosing criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). In the construction of the assessment, patients who were diagnosed with GAD had a mean score of 14.8 (M = 14.8; SD = 4.7), compared to a mean score of 4.9 (M = 4.9; SD = 4.8) of people without GAD. Participants are prompted with “Over the last 2 weeks, how often have you been bothered by the following problems?” Example problems are “feeling nervous, anxious, or on edge” and “trouble relaxing.” Internal consistency was reported as Cronbach alpha α = .92, and test-retest reliability has shown good intraclass correlation of .83. This measure was chosen because it is brief and can be used as a screening tool for athletes. All participants were provided with information to counseling services, in addition athletes who scored above 10 on this measure were followed up with by the PI and encouraged to seek counseling services. Procedure Institutional Review Board approval was obtained at two institutions, a large Mid Atlantic Division I university and a Regional Medical Center. Participants were recruited for voluntary participation via team doctors, head athletic trainers, or through snowball sampling from other participants. Once recruited, athletes gave informed consent via signature or online acceptance prior to taking part in the study (Appendix C). All athletes were assigned a code number and identifier kept separately from the data to protect confidentiality. Athletes completed the surveys in-person or using Qualtrics online software. All data was stored in a password 16 protected computer inside a locked office and on a secure online database (Qualtrics Research Suite, 2014). After athletes completed the questionnaires at time point 2, an interview time was scheduled. At time point 3, the athletes participated in a semi-structured interview with the head researcher via synchronous computer-mediated interviewing on Skype (n = 1), face-to-face (n = 1), or telephone (n = 8). The purpose of the interviews were to capture the athletes’ experiences with their emotional changes that could not be assessed via the quantitative measures. Semi structured interviews were used to provide participants “flexibility to express their opinions, ideas, feelings, and attitudes” (Smith & Sparkes, 2016, p. 103). The majority of interviews lasted approximately 35-40 minutes, were audio recorded and then transcribed verbatim. The interview modality was chosen by the participant depending on travel and their convenience. Non-verbal communication from the two athletes who participated in the Skype and face-to-face interviews were noted. Although phone interviews can lose the physical information provided by face-to face interviews, Hanna (2012) argues that telephone interviews provide safety for participants that may lead to the disclosure of sensitive information they might be hesitant to share in face-to face interviews. The interview guide asked athletes to explain their experiences with the emotional impacts of concussion, by prompting them with their survey scores (e.g., “You scored X on the anxiety measure. Can you tell me more about the anxiety you were feeling regarding your sport concussion?; Where do you think these emotional changes come from?”). Data Analysis: Quantitative Phase Descriptive statistics. Descriptive statistics were used to determine the characteristics of the sample based on (a) gender; (b) age; (c) sport (e) concussion (g) range of scores on 17 instruments, including means, medians, modes, and standard deviation per item and overall scores at 1 to 10 days post-concussion and 11 to 21 days post-concussion. Descriptive data for each time point can be found in Table 3. Inferential Statistics. Three, one way repeated measures ANOVAs were calculated used to answer the first research question: “Do athletes’ measured levels of impulsivity, anger, and anxiety change after sustaining a concussion during their sport season?” It was hypothesized that the athletes will score highest out of the three time points on impulsivity, anger, and anxiety after an athlete has been cleared to play. To determine if there is a subset of athletes who are more likely to exhibit certain emotions based on pre-existing risk factors, Pearson correlation coefficients were calculated to show the bivariate relationship between each of the symptoms assessed (i.e., headache, dizziness, fatigue, balance problems, sadness, nervousness) and emotional responses (i.e., anger, anxiety, and impulsiveness). Data Analysis: Qualitative Phase Qualitative data was analyzed using thematic analysis (Grbich, 1999; Braun & Clarke, 2006). Thematic analysis allows for patterns to emerge and be described across an entire data set (Braun, Clarke, & Weate, 2016). First, the researcher familiarized self with the qualitative data by transcribing or reviewing the transcriptions of the interview and then generated initial codes throughout the data set. Initial codes were generated using abductive coding to establish three higher themes based on pre-determined dependent variables of (1) anxiety, (2) anger, and (3) impulsivity. Next, themes were searched for and organized in lower order themes that were coded using InVivo Coding (Strauss, 1987). This type of coding is used to ensure that themes 18 and concepts are as representative of the participants’ words as possible. Themes were then reviewed in relation to the dataset and checked for examples that did not fit within the themes. The code of impulsivity required extensive example checking as the athletes talked about a range of items within this topic. Lastly, themes were refined and links between the themes were created. Reliability of the interviews was established by audio-recording all interviews and transcribing the interviews verbatim. Additionally, quotes have been presented in length with the question that prompted the response included where applicable. Data trustworthiness was established through using specific questions to capture significant experiences related to concussion (Denzin & Lincoln, 2015). Another way to ensure the trustworthiness of findings is through methodological integrity (Levitt, Motulsky, Wertz, Morrow, & Ponterotto, 2017). Levitt and colleagues (2017) describe methodological integrity as a context-driven approach where the research design and procedures support the research goals. As the purpose of this study was to understand how athletes experience emotional effects after concussion, using a sequential design of quantitative assessments to influence qualitative interviews fits this approach. Results Quantitative Phase Descriptive Data. Assessment means were higher during 1 to 10 days post-concussion than 11 to 21 days post-concussion, with the exception of the BIS-II. The athletes mean score on the STAXI-2 was 22.9 (SD = 10). The mean on the STAXI-2 decreased to 19.33 (SD = 6.7) 11 to 21 days post-concussion. The mean score on the BIS-II 1 to 10 days post-concussion was 66.53 (SD = 10.8) and 67.5 (SD = 10) 11 to 21 days post-concussion. On the GAD-7, the mean score 19 was 7.4 (SD = 5.6) 1 to 10 days post-concussion and decreased to 6.25 (SD = 6.6). Eleven athletes scored above a 10 on the GAD-7 1 to 10 days post-concussion, indicating a probable diagnosis of anxiety. Athletes scored a mean of 47.7 (SD = 30.2) on the PCSS 1 to 10 days post concussion and substantially lower 11 to 21 days post-concussion with a mean of 16.0 (SD = 16.3). By gender, women average symptoms were 45.14 (SD = 35) and men scored an average of 16.3 (SD = 19.6) at 1 to 10 days post-concussion. At 11 to 21 days post-concussion, women had an average of 16.3 (SD = 19.6) and men had an average of 15.2 (SD = 15.9). Mean scores and standard deviations for all variables can be found in Table 3. Effect of Time on Outcome Measures. Mean differences in scores on the assessments were only significant on the Post-Concussion Symptom Checklist (PCSS). On the PCSS, athletes selected significantly more concussion symptoms (M = 53.7, SE = 8.26) t(11) = 5.55 p < .05, r= .83 1 to 10 days post-concussion that 11 to 21 days post-concussion. The range of scores 1 to 10 days post-concussion was 1 to 92 (M = 47, SD = 30.1), and the range of scores 11 to 21 days post-concussion was 0 to 42 (M = 16, SD = 16.3). At 1 to 10 days post-concussion, headache was the symptom selected the most often (n = 28) and with the highest intensity (M = 3.2, SD = 1.8). The next most frequently endorsed symptoms were fatigue (n = 23), feeling fogging (n = 23), and difficulty remembering (n = 23) and irritability (n = 21). At 11 to 21 days post-concussion, fatigue (M = 1.3, SD = 2.2, n = 4), excessive sleep (M = 1.8, SD = 2.3, n = 5), irritability (M = 1.8, SD = 2, n = 6), feeling foggy (M = 1.3, SD = 1.8, n = 5), and difficultly concentrating (M = 1.5, SD = 2.1, n = 6), and difficulty remembering (M = 1.2, SD = 1.9, n = 4) were the only symptoms with means above 1.0. 20 When only including the 10 participants who completed all three phases, significant differences were found on the GAD-7. All participants indicated some feelings of anxiety (M = 10, SD = 3.68) 1 to 10 days post-concussion with five of the ten participants scored above a 10 on the GAD-7, a screening tool for anxiety. A score above 10 on this tool is indicates a probable diagnosis of anxiety and of those, one scored 17, indicating severe anxiety. All athletes who scored above a 10 were referred to counseling services. AT 11 to 21 days post-concussion athletes scored an average of 5.5 (SD = 5.7). Athletes endorsed significantly higher feelings of anxiety (M = .2, SD = 3.12) t(9) = 2.32, p < .05, , r = .57 during 1 to 10 days than 11 to 21 days post-concussion. Nine of 10 athletes scored lower at the second point (M = 5.5, SD = 5.68), with the exception being the athlete who indicated previously being diagnosed with an anxiety disorder. Mean differences between 1 to 10 days and 11-21 days post-concussion on the anger and impulsivity measures were not significant with all participants who completed both quantitative phases (n = 12) or with the athletes who completed all three phases (n = 10). All mean differences can be found in Table 3. Correlational Analyses. To determine if there was a relationship between reported symptoms, concussion history, and scores on the three assessments, several point-biserial and bivariate correlations were conducted. Point-biserial correlations were conducted on the dichotomous variables where a response of no was equal to zero, and yes was equal to 1. There was a significant relationship between the variable “Have you or others noticed a difference in your behavior or mood since sustaining a concussion?” and the variable “How many concussions have you been diagnosed with in your college career?”, rpb (28) = .52, (all p<.05. The 21 concussion history variable “Have you been diagnosed with more than one concussion during this year?” was positively correlated with scores on the BIS-II during 11 to 21 days post concussion, rpb (10) = .66 The only other demographic variable with significant correlations was “Have friends or family noticed a difference in your mood or behavior since sustaining a concussion.” This variable was negatively correlated with scores on the STAXI-2 1 to 10 days post-concussion, r pb (28)= -.46 and negatively correlated with scores on the GAD-7 during 1 to 10 days post concussion rpb (28)= -.42. Bivariate correlations supported a significant relationship (all p<.05) between scores on the PCSS and scores on the STAXI-2 r (28) = .72, and GAD-7 r(28) = 64 at 1 to 10 days post concussion. At the 11-21 days post-concussion, scores on the PCSS were significantly correlated to scores on the GAD-7, r (10) = .72. Symptom scores on the PCSS were not correlated with the BIS-II at either time point. To determine which symptoms on the PCSS were related to scores on the GAD-7 and the STAXI-2, follow up analyses were conducted. All significant correlation coefficients are reported in Table 4. The highest correlated symptom with the STAXI-2 was balance problems, r (28) = .7, and loss of sleep, r. = .76. At 1 to 10 days post=concussion, the highest correlated symptoms with the GAD-7 were feeling “foggy,” r (28) = .63 and balance problems, r (28)= .6. During 11 to 21 days post- concussion, there was a significant relationship (all p<.05) between scores on the GAD-7 and most symptoms on the PCSS and the four with the highest correlation were visual problems r (10) = .8, sadness r (10)= .76, excessive sleep r (10) = .75, and irritability, r (10)= .7. 22 Qualitative Phase Codes were developed based on a thematic analysis and an abductive approach (a combination of inductive and deductive coding). The semi-structured interview guide was influenced by the quantitative results, such as asking about their reported concussion history and athletes were provided scores on the quantitative assessments when applicable (i.e. “You scored x on this anxiety measure, which decreased between time points”). Theme 1: Anxiety “The unknown.” A theme emerged around the notion that each athlete was experiencing something unique and different from other athletes and how many facets of concussions are still unknown. They talked about how they tried to make sense of their anxious feelings surrounding the unknown factors of being able to complete school work, their recovery, and most concerning was not being able to regulate their own emotions. Snow White talked extensively about feeling alone and wondering how other athletes felt after their concussions, “Was I different? Did everyone else feel this weird? Why couldn’t I stop crying and just…chill out.” Ariel had a similar experience and discussed being alone on campus as her concussion occurred shortly before holiday break and also wondering how others with similar injuries dealt with their feelings: Knowing how other people can relate is always helpful because um, like now it’s winter break at (school) and only the basketball teams and uh hockey teams are here…I’m always alone it feels like and sometimes I have those nights where I just feel I don’t want to say almost depressed, but almost lonely and emotional and like, why is this going on? So it would be nice to have an outlet to go to someone and be like hey, have you had this 23 feeling before? I don’t know how to get out of this, can you suggest anything? Do you have any recommendations or advice? Many athletes talked about the anxiety associated with not knowing when they would feel “normal” again or the severity of their injury. Belle commented on the interplay of her injury, her school work, and the process of returning to sport, “I was pretty anxious because it was also exam period and didn’t really know, um, the severity of it either, and then additional to that, you know, just the daily symptom check reminder like, ‘Oh, do I really feel better?’ or ‘Is it just the same?” you know, like trying to identify with the numbers as well as possible.” Naveen expressed his anxiety surrounding the severity of his concussion: Now when you hear concussion you think about all your friends who have trouble remembering things and the stories on ESPN or whatever on CTE. I just wanted to know when I could play again and it seemed like no one could tell me. I thought that meant I was bad off, but I guess it just meant they didn’t know. Cinderella shared, “Who’s going to say I’m not going to have headaches for the rest of my life?” Jasmine had a similar thought as Naveen and Cinderella, “One night before I went to bed I was begging my headache to go away so I could sleep. I just wanted it to go away and I was so anxious that I would have a headache for the rest of my life.” She was emotional when recalling this memory, specifically how scared she was about lingering symptoms. Like Naveen, Jasmine mentioned previous teammates and their battles with post-concussion symptoms. Belle had a comparable experience, “you’re getting anxiety in the middle of the night and it’s like, “Oh 24 my god,” and “I can’t sleep” and I have, you know, to be at training in the morning. Stuff like that, and going on just an emotional roller coaster, to say the least.” Mulan seemed to have the most difficulty understanding her spike in anxiety scores during her first 20 days of concussions recovery. For her, it led to frustration with her mental health provider as well as her athletic training staff: I am already an anxious person. I know that about myself and take medication regularly because I have anxiety. But, when I talked to my doctor he didn’t say anything about how my concussion may have made it worse. It felt way worse. Like, I remember, I remember when I filled out the survey the second time, I think, I felt really bad so that makes sense it was higher. I couldn’t concentrate on anything because I felt so anxious all day. My headaches didn’t really go away for a while so maybe that’s why I was anxious? That kinda makes me mad, why wouldn’t my doctor think to ask me about my concussion when I complained my anxiety was worse? Or maybe it was my fault for not bringing it up. In Mulan’s case, she had a pre-existing anxiety disorder that may have been exacerbated by her concussion symptoms, particularly her headaches. In terms of her medical staff, Cinderella introduced the idea of lasting impacts and her fear surrounding her length of recovery that led her to feel anxious: I was pretty concerned that I was taking a long time to recover...I was concerned that there might be something that might show up on the CT. I was concerned about going to see a neurologist. I was concerned about what the doctors would say about my head and what I’m always concerned about: doctor’s telling me I couldn’t play sports anymore but 25 I kinda make that decision for myself...I was concerned about my cognitive functioning for, for a long time like not being able to remember things, not being able to keep up in conversations, um yeah, and then that was definitely very noticeable after this last concussion and I started to notice it after the previous one as well so that was very scary for me. For some athletes this unknown factor was so intense that it resulted in the lack of sleep or other negative mental health outcomes. They expressed how having more education on both the emotional symptoms and recovery of concussion would likely help lessen the feelings of anxiety they experienced. “Fear of not being able to play again.” The second theme to emerge under anxious feeling was directly related to their sport. This was the only theme in which all ten athletes had something to discuss regarding their fears around not being able to return to their sport for the remainder of the season and two participants discussed not being able to play their sport again. Eric was a senior when he sustained two concussions, with the second one occurring eight days after he was cleared to return. He stated: After that second one there was a lot more emotion and knowing that I wasn’t sure that I’d play again like my senior year or more in terms of the concussion itself, but like definitely felt more emotional after that second one…I guess I was just clouded by that kind of thought like it was just at the end, you know. If I could have the opportunity to like do what I wanted you know and sat on the bench for a couple of years and it’s finally my turn and it’s just the fear of not being to play again. 26 Three athletes discussed their conversations with coaches and trainers about their ability to return to sport. Aladdin sustained his concussion during his sophomore year and questioned if he should red shirt his junior year in order to fully recover, but a position coach said that he would “have to fight really hard” for his spot back, so ultimately decided not to sit out. Jasmine had a different experience, and explained, “my assistant coach told me my health was more important than the season and to take a break, but I was too anxious to take off the rest of the season. I know we are bringing in a good freshman who also plays keeper and so I needed to play as soon as I could.” Mulan feared that her captain status could be taken away if she stayed out of the lineup for too long, “I knew I needed to come back, my team needed me whether my head was ready or not!” Simba talked about his realization with concussions when it impacted his playing time: I felt fine. I was ready to go, and then (athletic trainer) told me I probably wasn’t going to play. If I felt fine, but my scores on that test weren’t good enough, when was I going to get to play? It didn’t seem fair. I also didn’t think concussions were a big deal until I couldn’t play. It really just wasn’t fair that I missed two games for something I couldn’t even feel… I was worried that I would be out even longer and there wasn’t nothing I could do about it. There was a general theme surrounding losing their position but also how their health could impact their future and so the athletes were left in a place of dissonance between their recovery and their future. The unknown aspect of when they could return seemed to lead to anxiety, which often stirred feelings of anger or frustration. 27 Theme 2: Anger “Frustration towards myself and irritability towards others.” Feelings of anger were described mostly through frustration with self and others and irritability. Athletes discussed their frustrations in explaining their symptoms and recovery to peers, professors, coaches, and teammates. They felt like most of their support system generally wanted to help, but the athletes did not know how to explain how they were feeling or what help they needed. This inability to explain led to frustration and a halt to asking for help from others. Jasmine explains: My friends would ask if I was okay, but I don’t think they really understood, you know? I would say that I felt weird, cause I didn’t know how else to explain it, and they would just nod. I kinda wanted them to stop asking… I felt frustrated because I know I needed help. I would get irritated with little things, but just couldn’t explain it. So them asking to help frustrated me, and then I got frustrated with myself and how I felt. It was like, never ending. Although concussions have received more attention in the last five years in terms of medical advancements and the seriousness of the injury, some athletes still felt as if they had to justify their injury to others which led to frustration. Eric states, “I’m not like limping around and stuff and I’d say that was the hardest part, trying to get people to understand.” Cinderella had a similar experience. Her concussion happened with such force that she was left with a visible mark on her face: It was swollen a little bit and there was a little bit of um bruising but I think the next day I was kinda like happy. Kinda like showing off my war wound… once the bruising and the 28 swelling kinda went down, the way people usually view concussions kinda took over I guess like people kinda forgot cause it wasn’t visible. Belle also spoke about her frustrating encounters with teammates and other athletes who did not seem to understand her recovery, “People are like, ‘oh, you’re just babying it.’ But they’ll be like, ‘it’s been already so long,’ like, ‘you should be fine.” So I mean there was just a lot of questioning, or and a lot of, you know, and, ‘you’re just trying to get out of it,’ and so that was kind of hard to hear.” Attempting to complete school work and explain to professors that they may need extra time to for assignments and exams was another source of frustration for the athletes. Many athletes talked about the difficulty balancing their recovery with keeping up with school demands. Additionally, they spoke about the added obstacle of completing homework while experiencing symptoms such as headache, dizziness, or nausea. Cinderella stated, “I was having trouble just like reading a paragraph in a text book. I got really, like I said, angry, upset, frustrated, irritated. I got really nervous like, if I can’t do this, then like what’s going to happen to my school.” Similarly, Belle discussed her difficulties with school and how to navigate exams period, “It was more difficult because I was entering exam period, so trying to get my professors to understand the situation was frustrating.” When asked how this injury differed from other injuries sustained in sport, Simba discussed his difficulty going to class based on his restriction: [Team doctor] told me not to be in front of screens for at least 5 days. I was taking a computer class. How was I supposed to do that? (Professor) said I could miss, but I don’t think he believed me. They always think athletes are trying to get out of class for like this thing or the other. But I couldn’t sit in front of a screen. So I couldn’t do the assignment 29 and missed class. It just isn’t like that with other injuries, you know? If my leg was broke I could go to class. Some athletes had experienced injuries previously in sport that kept them out of playing or practicing with their team, but discussed how the concussion was different. It was explained that the concussion was not only different in terms of recovery, but also in how others treated them as their injuries were not visible. In the above quote Simba highlights the difference between his concussion and if he had a musculoskeletal injury. Other injuries experienced by the athletes were hip, knee, and back injuries and no athlete recalled being as frustrated or irritable with those injuries. All seven athletes who sustained more than one concussion in their college careers discussed their anger with the injury itself. This led to anger over the recovery period, not being able to play, and their future health problems. Naveen discussed his anger about sustaining his second concussion of his career: I knew as soon as stood up that I had a concussion. And all I could think was [expletive] not again. I was mad that it was happening again. I was mad that I got hit from a helmet. I was mad that he wasn’t ejected for hitting me. I was just mad. I stayed mad, too. I told [head coach] as I walked off the field, ‘it’s a concussion. I won’t be back’ and didn’t even bother with [athletic trainer]. His anger was related to the injury as well as knowing what the recovery process would look like. He appeared to be agitated as he relived the experience and thinking about what it meant moving forward. He was a sophomore, but discussed how taking time out of sport or being labeled as “concussion prone” could impact his future playing time at his position. Mulan mentioned that she “at least felt better prepared” for this concussion since she had one during her senior year of high school, but also felt like this one was worse even though the hit seemed “way 30 less severe than the last time. That was annoying, if I’m going to get a concussion at least let it happen on a big play.” Cinderella also mentioned her anger with sustaining another concussion, particularly because this was her 4th concussion. She stated, “I was just really angry that I got a concussion again…I think I was partially sad and angry about the fact that I probably won’t be playing soccer for a very long time if ever again and I mean I’ve been playing soccer my entire life.” The second part of this theme that emerged under anger was the endorsement of feeling irritable. Participants discussed being irritated by stimuli that normally would not have bothered them as well as feeling a general sense of irritability. When asked where her irritability may have stemmed from Belle said, “I think just not feeling myself because of the head injury, so, you know, waking up with a hea