Repeated trauma

Sitting in his prison cell, Aaron Hernandez perhaps pondered how he had gone from up-and-coming NFL star to convicted killer. Starting his football career with the Florida Gators aged 18, and going on to play 'tight end' for the New England Patriots aged 21, Hernandez was on the rise, winning various awards and commendations. But in that cell, at the age of 27, he took his own life.

His shocking and unexpected death added yet another element to the already complicated view the public held of Hernandez. How had he gone from a young athlete full of potential to a violent criminal embroiled in multiple homicide cases? There was one thing everyone had suspected about Hernandez since the beginning of his violent behaviour – that he had Chronic Traumatic Encephalopathy (CTE) from the repeated concussions he had received while playing the sport he loved. His suicide made way for the one exam that could confirm this: an autopsy on his brain…

Scans and tragedy

Scans revealed that Hernandez had experienced substantial damage to key parts of the brain, including the hippocampus (central to memory) and the frontal lobe (involved in problem-solving, judgment and behaviour).

Ann McKee, director of the CTE Centre at Boston University, said 'In any individual, we can't take the pathology and explain the behaviour. But we can say collectively, in our collective experience, individuals with CTE and CTE of this severity have difficulty with impulse control, decision-making, inhibition of impulses or aggression, often emotional volatility and rage behaviours.'

And so Hernandez has become somewhat of a poster child for CTE and the horrific impact it can have on its sufferers and those around them. Across the pond, CTE holds a different weight in the public consciousness. Hernandez had joined an ever-growing list of NFL stars who'd met a tragic end. Andre Waters, 44, Adrian Robinson, 25, Dave Duerson, 50, Junior Seau, 43. Each of these men took their own life. All had CTE. Jovan Belcher shot his girlfriend nine times, ending her life before his own. Phillip Adams fatally shot six people before turning the gun on himself. Both were found to suffer from CTE. 

CTE meant nothing to me until I watched the 2020 Netflix documentary 'Killer Inside: The Mind of Aaron Hernandez'. It ignited a morbid curiosity in me – What exactly is this disease? How could it possibly result in such tragic consequences? And most importantly, what are we doing about it?

Symptoms

We have been aware that repeated head trauma, particularly within sports can cause degeneration within the brain. Previous research has focused on 'post-concussion' syndrome, found when recurrent concussions result in cognitive difficulties. CTE is somewhat similar – it's a disorder caused by multiple head traumas – however, its pathology and outcome are more specific. You may think CTE is a relatively new phenomenon, but you'd be wrong. The disease was first noted in 1928 as 'punch drunk syndrome', primarily found in boxers, yet it wasn't until 1949 that CTE was cemented as a medical diagnosis. In CTE, repetitive head trauma, referred to interchangeably as mTBI or concussions, results in a tau-protein build-up in the sulci of the brain. This creates the unique pathology associated with CTE. In fact, this brain pathology is the solitary evidence we have for diagnosing CTE, meaning it can only be identified in death after an autopsy. 

Because the disease is caused by repeated concussions, it's easy to see why CTE is so common in players of contact sports. Instances have been reported in ice hockey, rugby, football, basketball, and boxing. However, the majority of CTE research focuses on American Football. The prevalence of CTE in American football is frightening; in a sample of 202 players, 87 per cent were found to have the disease and in another sample of 246 players, 211 were diagnosed.

CTE symptoms can be separated into three loose categories: physiological, cognitive and behavioural. Reported physiological symptoms include impairments in gait, slowed and slurred speech, as well as difficulty swallowing. Parkinsonism has also been recorded as an uncommon symptom of the disease, with patients demonstrating movement difficulties. 

Secondly, cognitive symptoms have a very high prevalence in CTE sufferers, as they are reported in 85 per cent of cases of those with mild CTE and 95 per cent of those with severe CTE. Symptoms include memory loss, apathy, reduced ability to concentrate, impairments in executive function and dementia. 

Lastly, the behavioural symptoms associated with CTE represent the largest point of contention for the disease, consistently at the heart of media reporting. One study found them to be present in 96 per cent of those with a mild version of the disease and 89 per cent of those with a severe presentation. The list of behavioural symptoms is long and disturbing, including poor regulation of emotion and behaviour, impulsivity, rage, irritability, disinhibition, morbid jealousy, violent outbursts, physical violence, explosivity, depression, paranoia, hopelessness and frequent losses of control. 

CTE as a catalyst

After reading the vast list of symptoms associated with CTE, it's natural to wonder how a 'simple' brain disorder can escalate to such extreme behaviours. Psychology as a discipline can tend towards the simplistic, explaining away things as purely biological or purely social. This is where I suggest CTE research has failed. 

Previous research into CTE has focused on one particular area: How does CTE evolve into the extreme, violent behaviours seen in the media? Well, maybe it doesn't, alone. Despite the media presenting a clear and straightforward link between CTE and violent behaviour, it's almost impossible to ignore the lifestyle of these athletes and how their environment potentially impacts their CTE presentation. 

The issues that these athletes suffer from in CTE often reflect wider issues that men face in society. Men are ultimately at a greater risk for homicidal and suicidal behaviours; for example, in the majority of countries, suicide rates are often three times higher for men than women and it is a commonly accepted fact that men commit more murders per year, in the United States alone, men are responsible for 85.3 per cent of murders. Therefore, is it better to consider the symptoms of CTE as a contributing factor that predisposes athletes to extreme behaviour, rather than the casual factor?

Furthermore, the social environment and expectations placed on men should also be considered. It is undeniable that the NFL is a heavily male-dominated sport, breeding an environment of hypermasculinity. One research paper proposed that an atmosphere of toxic masculinity and a lack of openness for men to discuss their mental health is a contributing factor to violent and extreme behaviours, similar to those associated with CTE. 

By only focusing on the biological/neurological aspect of CTE and ignoring the 'social' part of these athletes' lives, it's impossible to form a whole picture of the disease and its consequences. I propose that CTE is a catalyst for existing issues already present in athletes. For example, a player already suffering from depression may experience some cognitive difficulties associated with CTE, such as an inability to suppress their emotions. This, alongside the environment of the NFL, where perhaps open discussions of mental health are discouraged, may all combine and lead to extreme behaviours. Future research into CTE should focus on the interaction between the social and the biological to gain a fuller understanding of the disease. 

CTE and women

You may have noticed that this article has focused mainly on CTE in men, as this is where most of the research and attention lies. However, there are some interesting angles on women. Those with CTE can experience rage, and the girlfriends and wives of the sufferer are often the target of these violent outbursts.One paper noted the instance of the 'Punch-drunk boxer' referring to boxer's suffering from CTE, and the 'battered wife' detailing this association. Researching the association between CTE and inter-partner violence is of utmost importance: only then can we attempt to assess and treat the sufferers and their partners, hopefully reducing the negative consequences associated with the disorder. 

A quick skim of the research demonstrates the little interest it shows in women, despite them having higher concussion rates than men. In July of this year, Australian rules footballer Heather Anderson became the only female athlete with confirmed CTE, after taking her own life last November, aged 28. 

Interestingly, although confirmed cases of CTE in women are low, the majority of female sufferers obtained the disorder due to repeated head trauma from domestic abuse. This adds another intriguing layer to the enigma that is CTE. Male CTE sufferers are more likely to abuse their partners, who in turn are likely to develop CTE. 

A global call to action

CTE as a disease needs more attention and more research. Up until 2016, the NFL denied the existence of CTE. Only as recently as 2022 did the US National Institute of Health publicly acknowledge the causal link between contact sports and CTE. Despite the NFL's reluctance to accept CTE as a part of their sport, it is becoming harder to ignore. In recent years, the NFL brain bank has been created, whose main focus is to investigate CTE in the brains of its players. Tragically, when ex-NFL star Dave Duerson died by suicide at age 50, he chose to shoot himself in the chest, preserving his brain for study. Duerson left a note specifically requesting his brain be donated to the bank and examined for CTE. Junior Seau took his own life using the same method. Both were found to be CTE sufferers. 

Only with further research and the full cooperation of contact sports bodies will we be able to fully understand CTE, and hopefully treat it before it becomes extreme. As recently as July this year, an international team of experts studying issued a 'global call to action to sports organisations, government officials, parents and the military to immediately implement CTE prevention and mitigation efforts'. Simply educating amateur to professional-level players on CTE and its symptoms may help them better understand what to look out for. Encouraging open and honest conversations about mental health will provide players with the support they need. Sports bodies monitoring and assessing concussion risks for their players. These are small changes that could make a world of difference. 

Complexity and challenge

As I begin a career in clinical psychology, I learn about the complexity of the brain and the potential for damaging influences on it. I now find it almost impossible to turn off my 'psychologist' brain when watching any contact sports, whether that be rugby, boxing or the NFL. Any enjoyment for me is always undermined by the concern of repeated head trauma and what that may result in. As a field, we know the impact head trauma can have on a person, whether that be an array of mental health disorders to cognitive issues to CTE. But is the public really aware of the risks of head trauma? Does Psychology as a discipline do enough to assess and treat the risk before the damage is done?

As I write, former NFL star Sergio Brown has been taken into custody and charged following his mother's death. These athletes deserve a chance before they're just another news report in an endless sea of tragic stories. 

• Anya Greenhalgh is studying for a Masters in Clinical Psychology at the University of York. She wrote this piece while on her placement at The Psychologist.