Behavioral Symptoms-CTE Link Needs Long-Term Study

Their paper, “Behavioral Health Symptoms Associated With Chronic Traumatic Encephalopathy: A Critical Review of the Literature and Recommendations for Treatment and Research,” has been published in the Journal of Neuropsychiatry and Clinical Neurosciences.

Media reports link aggression, violence, depression and suicide with CTE in former football players. However, the relationship between CTE and behavioral changes is an extremely complex and poorly understood issue, according to the UB research.

To establish a causal relationship between CTE and behavioral changes, “this phenomenon needs to be systematically studied over a long period in a large sample of contact and non-contact sports athletes, ideally starting early in their careers,” says Daniel Antonius, PhD, lead author and assistant professor of psychiatry. 

Discussion of these symptoms has evolved as new technologies have helped identify specific brain changes after blows to the head result in forces being transferred to the brain, the researchers say.

However, the absence of “research-accepted diagnostic criteria for identifying individuals considered at risk for CTE” hinders scientists’ understanding of the causal relationship between CTE and behavioral health symptoms, the researchers conclude.

“According to the research community, there is a need for more empirical evidence,” Antonius emphasizes.

So far, Antonius notes, peer-reviewed literature on CTE consists primarily of individual case review studies and post-mortem research.

“Case studies are illuminating and important, but they cannot be used to properly establish clinical criteria for diagnosing a medical or psychiatric condition,” he says.

The UB paper traces the reporting of neuropsychiatric symptoms now associated with CTE to the 1928 paper, “Punch Drunk,” by H.S. Martland in the Journal of the American Medical Association.

Martland discussed the similarity of these symptoms to other brain disorders involving encephalitis, inflammation of the brain.

To better understand CTE and behavioral symptoms, an appropriate animal model also needs to be developed. Yet, this is a challenging task, as experiences with traumatic brain injury (TBI) models suggest, Antonius notes.

“Coming up with an animal model will be difficult and take years,” he says.

For decades, for example, researchers have been using animal models to study TBI, and they still do not have a perfect model, he says.

Like CTE, traumatic brain injury involves multiple factors, including brain deficits and abnormalities affecting different areas of the brain, as well as various behavioral manifestations, Antonius explains.

The paper’s co-authors also are involved with UB’s Healthy Aging Mind Project, a comprehensive multidisciplinary research and treatment study. The study assesses how former professional athletes — including football and hockey players — age, while helping them maintain quality of life.

“We wanted to see what happens to their minds, brains and mental health, while helping them and their families identify treatment and counseling opportunities,” says Antonius, who led the project’s behavioral health committee.

The project has a strong service component, providing education, assistance and, where possible, treatment for the athletes.

Developed by two of Antonius’ co-authors — John Leddy, MD, associate professor of clinical orthopaedics, and Barry S. Willer, PhD, professor of psychiatry — the project is based in UB’s Concussion Management Clinic, which Leddy directs. 

It involves researchers —  including UB medical students, residents and post-doctoral researchers — from the medical school’s departments of psychiatry and orthopaedics, as well as faculty members from other UB health sciences schools.

In addition to Antonius, Leddy and Willer, co-authors on the paper are: 

• In the Department of Psychiatry: Alex Cogswell, PhD, assistant professor; Josie L. Olympia, MD, associate professor of clinical psychiatry; Victoria L. Brooks, MD, assistant professor; and Michael Digiacomo, MD, a fellow in UB’s Child and Adolescent Fellowship Program
• Andrea Hinds, PhD, a postdoctoral associate in the Department of Orthopaedics and research assistant in the Department of Psychiatry
• John Baker, PhD, in the School of Social Work and the departments of nuclear medicine, orthopaedics and psychiatry
• John Picano, a fourth-year UB medical student
• Nickie Mathew, MD, who completed a psychiatry residency at UB, and is now a clinical assistant professor at the University of British Columbia

Research leading to the publication was partially supported by grants from:

• National Football League Charities
• Buffalo Sabres Foundation
• Robert Rich Family Foundation
• Ralph Wilson Foundation
• Program for Understanding Childhood Concussion and Stroke