Concussions: A Growing Psychiatric Epidemic
Mar 29, 2018

Grace Armstrong
Core Spirit member since Dec 24, 2020
Reading time 3 min.

Also known as “concussion,” chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disease believed to be the result of multiple mild traumatic brain injuries (mTBIs).

CTE was first described by Martland in 1928 as being “punch drunk,” a syndrome of confusion and ataxia in boxers having suffering repeated blows to the head.1 In 1937, Millspaugh described “dementia pugilistica,” symptoms of cognitive and motor dysfunction, once again mainly observed in boxers.

The term “chronic traumatic encephalopathy” was first coined by Miller in 1966 to encompass the mood, cognitive, and motor dysfunctions of dementia pugilistica.3 In 1973, Corsellis introduced a pattern separating CTE from other neurodegenerative diseases.

The modern definition of CTE was brought to the national spotlight by the case studies of Omalu et al. that highlighted neuropsychiatric and neuropathologic changes in National Football League (NFL) players,5 inspiring the movie “Concussion.” This article focuses on CTE in American football and why it is of importance to psychiatrists and mental health professionals.

Epidemiology and Risk Factors

The most common risk factor across case studies of CTE is a history of at least one mTBI. Onset generally occurs in mid-life, usually after retirement from professional play.6 Timing is variable, given the heterogeneity of career length among NFL players; many begin their careers in junior high school, but some start at the tender age of 6.

Of 1.2 million interscholastic football players in any given year, up to 5.6% sustain an mTBI. The majority (53%) of cases, however, remain unreported to medical personnel.

Although the literature supports a correlation between repeated mTBIs and CTE, definitive causation has not been determined.9 Still, 63% to 71% of players with repetitive mTBIs eventually develop CTE.

Among NFL players, the reported prevalence of CTE ranges from 3.7%6 to 90%.10 This disparity is largely due to disagreement among clinicians regarding what constitutes an mTBI, and the consequences faced by NFL players, their coaches, equipment managers, and team clinicians reporting them.

Players who are running-backs, begin play before age 12, and have a history of previous mTBI are at a high risk of re-injury.12 A relationship between number of years played, development of CTE, and the stage of phosphorylated Tau (pTau) pathology has also been suggested.

Retired NFL players who have had 3 or more mTBIs have a 5-fold increased risk for mild cognitive impairment, and 3-fold higher risk for depression. The APOE ε4 genotype increases the risk for cognitive impairment in CTE.

Pathophysiologic Features

Evidence suggests that repetitive disturbance of axons along with altered neurotransmission is linked to widespread glutamate release, ionic fluxes, and metabolic uncoupling.15 These changes may generate a chain of events leading to CTE.

Animal models have shown decreased serum and cerebrospinal fluid (CSF) levels and activity of tissue-nonspecific alkaline phosphatase (TNAP), an enzyme that dephosphorylates the p-Tau protein essential for microtubule assembly. Accumulation of p-Tau eventually causes neuronal death.

A recent consensus conference defined the irregular pattern of p-Tau immunoreactivity deposition surrounding microvasculature in the depths of cortical sulci as pathognomonic for CTE, a distinction from other tauopathies.

Supportive features include abnormal p-Tau neurofibrillary tangles (NFTs) distributed in layers I-II of the cortex; p-Tau thorn-like astrocytes in the subpial and periventricular regions of the cortex; pretangles, extracellular tangles, or NFTs; and dendritic swellings in the hippocampus.

Also supportive of CTE are dot-like structures and TDP-43 immunoreactive neuronal inclusions in the antromedial temporal cortex, amygdala, and the hippocampus, as well as septal abnormalities, atrophy of mammillary bodies, and third ventricle dilation.17 Staging for CTE pathology has been proposed.

There are some similarities between Alzheimer’s disease (AD) and CTE, suggesting a separate classification of CTE-AD; the presence of Aβ plaques correlates with more severe p-Tau pathology and advanced stages and clinical presentations.

Plaques in CTE-AD are more likely to be found within the sulci, contrasting with the gyral depositions observed in AD. Death tends to occur 10 years earlier, suggesting that repetitive mTBI may accelerate and change the deposition and accumulation of Aβ; presence of Aβ plaques may correlate with CTE progression and may speed up the aging process of the brain. The presence of Aβ plaques is believed to increase the odds of developing cognitive dysfunction in CTE by 4.5 times in individuals with Aβ pathology.

Although CTE cannot currently be diagnosed via imaging, there are a few PET ligands for p-Tau that show some promise. DPA-713 has detected TBI-related neuronal inflammation in 9 former NFL players with clinically-suspected CTE. The PiB amyloid ligand is also being investigated for utility in PET neuroimaging.

Image 1 depicts the different stages of CTE.

Neuropsychiatric Symptoms

The average age of symptom onset is between 30 and 64 years of age. Within the first 48 hours to 2 weeks after an mTBI, cognitive deficits are common.20 Four stages of neuropsychiatric symptoms were proposed in 201310, and are similar to the posthumous progression described in 2011 by Omalu et al.5

Stage I symptoms include memory loss, executive dysfunction, difficulty concentrating, inattention, aggression, depression, explosivity, and suicidality. Headache is fairly common. At this stage, very few individuals will see a psychiatrist.

by Psychiatry Advisor

Leave your comments / questions for this practitioner

To write a comment please
Category filter
Concern filter
Type filter

All categories

Personality Psychology
$80 USD
therapy session
Individual Counselling Session (60 minutes)

I offer a compassionate counselling service that is unique to every woman and her situation. Allowing you to feel heard and understood in a safe environment free from shame and judgement.

My aim is to support and empower women through periods of change and emotionally difficult times. Empowering women to navigate their life and the mess that it can sometimes feel like it’s in with insight, respect, hope and strength.

I believe you have the desire and the capacity to grow towards fulfilling your true potential, and that you’re the expert on your own life. Counselling is a way of assisting you to identify and define your emotional issues and to help you better understand yourself.

Therefore, I don’t give advice. I will work with you to help you understand yourself more fully and to find your own inner resources. With greater self-awareness and trust in yourself, I hope that you will be able to make constructive changes, leading to a more satisfying and meaningful life.

I apply an integrated approach to counselling, meaning that I combine different but complementary counselling methods that have been taken from different models of therapy. These are Person-Centred Therapy, Cognitive Behaviour Therapy and Solution Focused Therapy. Using an integrative approach allows me to be flexible in providing a service that suits your situation.

I offer face-to-face and online individual counselling sessions, allowing women to openly talk about their emotional challenges.

Hayley Fualau
Personality Psychology
$150 USD
therapy session
Individual Psychotherapy

Are you seeking a therapist that sees you as a whole person - mind, body, and spirit, in the context of your lived experience and culture? Do you need someone to meet you where you are, without assumptions? Are you seeking help in your personal growth and healing?

All clinicians and support options are not the same. I am guided by a core philosophy that all human beings have an innate desire for balance, healing, and growth. Your definition of these concepts and your journey to achieve them is unique to you, your child, or your family.

Contact me to discuss scheduling.

Maybe you have specific complaints, stressors, or goals that you would like help navigating; perhaps you feel ready to strive for the next level of personal growth. Holistic Psychotherapy can offer the comprehensive tools and support you need to overcome personal challenges, interpersonal challenges, and to reach a healthier state of being. With the help and support of your therapist, you will be able to utilize your innate strengths to find yourself reaching the goals and understanding you seek in a safe and nonjudgmental space.

Stacey Wright
Personality Psychology
$750 USD
healing session

Finding it hard to get over that last relationship? Loving someone who is bad for you? These 4 hourly sessions will help place you into a mentally healthier place leaving behind the negative relationship and its lingering thoughts.

Jane Nash
Personality Psychology
$15 USD
therapy session

Facing difficulty in concentrating, relationships, academics, emotional concerns, stress etc. Counselling helps resolve these by aiding you with the necessary skills and cope up with these. Get in touch with our expert and professional counsellors/ psychologists.

Emotional well being helpline

Related Articles

View All
Registered individuals enjoy all the possibilities of Core Spirit.