It Starts with a Mood Swing
To end the first week of Mental Health Awareness Month, I wanted to write about chronic traumatic encephalopathy [CTE] as some of the first signs may present as mental health related issues. This degenerative brain disease is thought to occur following multiple repetitive brain traumas, and often presents in athletes and members of the military. In those with CTE, the tau protein in the brain malfunctions, misfolds and causes death to surrounding cells, spreading throughout the brain over time. Oddly enough, CTE does not stem from severe concussive head injuries, but rather from receiving hundreds to thousands of sub-concussive head impacts over years of participating in contact sport or military work. Although CTE cannot be definitively diagnosed until brain analysis is performed postmortem, researchers have found early signs and symptoms of CTE in patients as young as 17.
Since there are currently no statistically reliable tests to determine existence of CTE in living patients, doctors must determine diagnosis using classification systems which explore mood/behavior, cognitive ability, dementia and other variables. Those with stage one and two CTE typically present with symptoms related to depression, increased impulsivity, suicidal tendencies, verbal aggression and memory loss. As the disease progresses into later stages, patients may see the addition of neurological impairments such as Parkinson's disease, loss of visuospatial awareness, impaired language abilities, and worsening dementia. The picture below shows cross sections of a control subject brain in comparison to a CTE specimen below it. Atrophy of white and grey matter, and ventricular enlargement is evident.
Mental Health Signs
As previously stated, symptoms such as depression, suicidal thoughts and mood swings are early signs of CTE. Studies have shown that first signs of CTE often include headaches, verbal aggression, changes in short term memory, depression and decreased ability to concentrate. As the disorder progresses, those close to the patient may also observe severe mood swings, suicidal thoughts, explosive or impulsive behaviors, increased aggression and apathy.
If you have ever struggled with mental health related issues, you may know that many of these symptoms overlap, although not always to the same degree. As someone who has personally dealt with depression and anxiety, I can tell you from experience that depending on the day, I may lose my temper due to low tolerance for taxing interactions or I may become completely apathetic because my pleasure hormones are depleted. It is important to recognize that the existence of one of these symptoms does not determine the presence of CTE in a vulnerable patient. A specific set of contributing factors must be present to include CTE as a potential cause of mental or behavioral changes.
Brain Damage or just a Bad Bad Man
As I just mentioned, it is important to recognize that there may be things other than CTE that contribute to the signs listed above. But in the case of media coverage of high profile athletes who have ended their own lives or the lives of others, they are often portrayed as cold blooded killers first, and as people suffering from severe brain damage after the fact. Several high profile cases include those of Chris Benoit and Aaron Hernandez, both of which took the lives of others, followed by their own.
In the case of Chris Benoit, a beloved Canadian wrestler took the lives of his wife and young son and subsequently died by suicide. It was noted in media surrounding the deaths that previous to this incident, Nancy Benoit had filed for divorce and a restraining order after Chris had become alarmingly physical with her. He also had a messy divorce from his first wife after cheating on her to get back at a wrestler he was feuding with as well as years of aggressive arguments. A friend of Benoit described him as entirely unemotional as a person, and during his career as a wrestler, Benoit was one of the only athletes who would willingly take a hit from a chair to the back of the head.
In this case specifically, we have to ask ourselves if this man was simply prone to impulsive and abusive behavior, or if these behaviors stemmed from severe brain damage. In some cases it may be possible that a person's true colors have come out after years in a relationship, and that they truly are an abuser. But with knowledge of the many factors stacked against someone like Chris Benoit that can contribute to CTE, we have to ask if this tragedy could have been prevented had early recognition taken place. This is also not to say that any of the people harmed by Benoit deserved to experience these things. I simply wonder how often shifts in personality and increases in aggression are viewed as inherently abusive behavior, and not as a sign of something else going on. Again, the presence of CTE does not erase the impact or wrongfulness of these actions, but we have to wonder if these things could have been prevented if the signs were recognized sooner.
The story of Aaron Hernandez is nothing less than shocking. The 27 year old tight end was convicted for the murder of Odin Lloyd and was a person of interest in one other murder case, and at least two other shootings. Following his conviction, Hernandez ended his life in prison. Upon studying his brain, it was found that the condition was comparable to the brain of an 85 year old with Alzheimer's disease. Scientists claimed that Hernandez would have been classified as stage three CTE, and that until this time a brain of this condition had not yet been observed in anyone under the age of 46. Although they could not be sure that this was not a typical brain for a 27 year old NFL player, scientists did state that living with CTE of this stage would have caused decreased impulse control, increased aggression and increased displays of rage behaviors.
Examination of this brain showed remarkable damage at the frontal lobe, the area responsible for impulse control, social behavior and judgment. The amygdala of Hernandez's brain, responsible for emotional regulation and behavior as well as management of fear and anxiety, was also severely affected. In viewing timelines of events in the life of Aaron Hernandez, we can view ongoing actions displaying poor impulse control and aggressive over-reactivity. Tom Brady recalled having to pull Hernandez off of a man at a bar that he assaulted at the age of 17. Shootings were also a regular occurrence in the time line of crimes committed by Hernandez. Following his conviction, Hernandez assaulted a fellow inmate and was penalized for witness intimidation in relation to one of his charges.
Again we have to ask ourselves, could anything have been done if someone recognized the signs sooner? In my opinion it is not normal behavior for someone to continually participate in casual shootings and multiple murders. In cases like this, we also see that celebrities are sometimes given a slap on the wrist for initial offences. Others involved are typically concerned with preserving the reputation of the celebrity in question, but why was no one trying to get him help? I would also argue that this was not a case of fame overcoming him, as he stated in interviews prior to his death that playing under Bill Belichick meant that he could not act recklessly. The irony in this statement is now fully apparent, as years of Hernandez's life were colored by reckless behavior.
In both of these cases, the media addressed the fact that these men suffered from severe brain damage, but the verbiage in articles concerning them was still quite often defamatory in nature. Chris Benoit was accused of "slaying" his wife and child and will never be placed into the WWE hall of fame due to the nature of his passing. Both Hernandez and Benoit are frequently covered in documentaries and YouTube videos about killers. In the case of Phillip Adams, news articles asked if the presence of CTE is a reasonable argument to dispute murder charges. In an article titled "Is CTE an Excuse for Murder" we view more gross details about wrongdoings of those involved, headings such as "Why did he Snap?" and autopsy information about those who were killed. When reading the short explanations of the nature of CTE in these articles, the lack of understanding of the writers can also become apparent. More often than not, they describe severe concussive events as the cause of CTE when this is not really accurate. I understand that details of a murder investigation are probably more click worthy than a discussion of a brain disorder, but misinformation or half truths are not productive. No, we cannot remove these people from the responsibility of their actions. But I also do not believe that it is fair to reduce them to murderers. Sensationalizing tragedy and glossing over the impact that CTE has had on people who have been described as family oriented and selfless seems unreasonable to me, as these people were suffering from an invisible disease.
What can be Done?
At this time, researchers are continually looking for ways to identify protein markers in living subjects that may indicate the presence of CTE. Since we are limited to subjective testing to determine the diagnosis and situational factors (exposure to repetitive sub-concussive impacts) must be present to diagnose, education is the best way to promote early recognition. Limiting head and body contact before the age of 14 has been proposed to decrease the likelihood of harmful exposure. The NFL has been dinged for placing misinformative posters about head injury in stadium locker rooms. Scientists also continue to research interventions that may slow the onset of CTE. Unfortunately, this disease as well as diseases such as Alzheimer's are still not fully understood. If you are involved in areas that create high risk factors for CTE, the most you can do is educate those around you and keep an eye out for early signs. If someone is displaying depressive symptoms, difficulty with anger or impulse control do the best you can to address the situation. Even if someone is presenting with mental health issues that do not align with CTE, starting a conversation may be the biggest impact you can have on that person's life.
Kristen Huber, BaKin, CAT(C)
Owner, the Gentle Athletic Therapist