Approximately 20% of concussion/mild traumatic brain injury (mTBI) patients experience persistent post-concussion symptoms (PPCSs) beyond four weeks. Functional neurological disorder (FND) and somatic symptom burden are frequent, overlapping contributors in such cases, yet practical guidance for differentiating and managing these mechanisms remains limited.
We present a clinical framework integrating literature review, neurobiological models (central sensitization, fear-avoidance, predictive processing), and observations from a specialized neuropsychiatry practice. Case prototypes illustrate functional versus somatic presentations. Clinical experience from recent consecutive evaluations (October 2024–October 2025) informed symptom patterns and treatment approaches, including tailored medication, specialized rehabilitation, and cognitive reframing.
Among patients evaluated for PPCS during this period, the majority showed prominent somatic symptom burden, with a substantial minority meeting FND criteria. Functional presentations were associated with greater somatic burden and psychiatric comorbidities. Anecdotally, most of those who engaged in cognitive reframing and individualized care strategies reported improvement at follow-up (as measured by CGI-I), although formal outcome data are needed. These patterns, combined with existing literature supporting the preventive role of early education after concussion, suggest a potential opportunity for targeted early intervention.
Somatic and functional features are prevalent contributors to PPCS. A structured, neurobiologically informed approach can clarify symptom mechanisms and guide care. Differentiating these symptom drivers early and communicating a positive, reversible narrative may improve outcomes. Formal retrospective and prospective studies are warranted. Based on these insights, we are developing a randomized controlled trial to assess whether brief early cognitive framing can reduce PPCS incidence and healthcare utilization. Furthermore, while functional-specific rehabilitation protocols exist, there is a need for validated somatic-focused interventions.
