Mental Impairments and CTE


Medical researchers are exploring possible links between the repeated head trauma associated with American football and the development of a variety of psychiatric and neurological impairments. Boston University School of Medicine is currently conducting a study of mental impairment within our group of 500 former Notre Dame players from the 1964-1980 seasons.  The study will include an assessment of links between athletic history and head trauma and Chronic Traumatic Encephalopathy (CTE), a neurodegenerative disease distinct from Alzheimer’s but with similar symptoms. Much is unknown about CTE disease.

Researchers believe that traumatic brain injury from repetitive concussion or repetitive mild hits to the head in football players may lead to CTE.  We know that the brain continues to grow and develop well into a person’s twenties and includes critical changes in the prefrontal cortex, the processing center of the frontal lobe, which is responsible for many complex brain functions.  We also know that at least for the youngest players, the developing brain is more sensitive to physical trauma.  It is not yet clear whether college aged players fall into this sensitive group.  We know that brain changes associated with CTE may begin as early as one year after playing tackle football in players younger than 12 and tend to be cumulative throughout players’ careers. We do know that a number of former college players in their 20s have been recently autopsy-diagnosed with CTE. However symptoms of CTE may not begin for years.  The first symptoms of CTE tend to be mood or behavioral symptoms, in contrast to Alzheimer’s disease where cognitive symptoms usually appear first.

Mood symptoms of CTE include Clinical Depression, which can cause sadness, sleep changes, decreased interest in usual activities, feelings of guilt, decreased energy, decreased concentration, and changes in appetite.  With Depression associated with CTE feelings of worthlessness, helplessness, hopelessness, and misery can be extreme, leading to suicidal thoughts and successful suicides.  Behavioral symptoms of CTE include loss of impulse control, loss of judgment, a short fuse and a hot temper.  These behavioral symptoms can lead to verbal and physical abuse, especially of family members. Cognitive symptoms include short term memory problems, diminished ability to think or plan, attention problems, decreased speed of thinking , Pseudobulbar Affect (uncontrolled laughing and crying without hilarity or sadness), and apathy. Cognitive symptoms are mild at first, and not all players affected will progress to a full blown dementia with severe impairment.

It is important for affected players and their families to know that although there are few studies of treatment for CTE, psychiatric treatment for symptoms other than cognitive ones is most likely worthwhile.  The usual medications for depression as well as cognitive behavioral therapy should be used for depression from CTE.  Treatment for behavioral symptoms is still developing but may include anticonvulsants, antipsychotics, and anger management.  There is no known treatment for cognitive symptoms.

We know that CTE exists and that it is causing problems for a significant number of former football players.  We don’t know how common CTE is. But in a published CBS sports list of “the best 100 high school football players,”  rated as college prospects in 2007, there already is, ten years later, an autopsy-positive diagnosis of CTE in 2 (2%) of those 100 players and possible CTE in a number of  still living players who quit football due to health or other issues. These are players only in their late twenties today. It may be that most players don’t get the disease, but frankly we don’t know yet how high the risk is.

Today, we cannot make a definitive diagnosis except with a postmortem brain autopsy, but we are on the verge of being able to diagnose CTE in living persons. Autopsies of symptomatic former NFL and college football players have a ninety percent positive result for CTE.  Earlier studies linked head trauma to Alzheimer’s, but more recent studies suggest that the cognitive impairment and other symptoms are more likely due to CTE. We don’t know if there are threshold levels of brain trauma that may trigger CTE, if there are other factors such as genetics or lifestyle involved, or what causes early onset of the disease in some players.  

This medical study is also looking for other impairments and brain diseases that may be related to football in general or to repeated head trauma in particular. For example, there is suspicion that Parkinson’s disease and Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease) are implicated. Other possible candidates are bipolar disorder, multiple sclerosis, anxiety, tremor disorders, primary brain tumors, Alzheimer’s, and substance abuse. 

Football remains a popular sport with numerous physical and mental benefits.  We need to know why some players are affected by CTE and others not.  We need to know the level of risk so that participants and parents of young participants can make informed decisions about playing or quitting football, and so that youth football organizations can take the best steps to mitigate risk while preserving positive aspects of the game.  This Boston University School of Medicine study of former ND football players is a significant and needed step in that direction.

For additional details about CTE see


James Ryan MD, ND ‘67, Practice in Psychiatry 

Member, Players Physicians Committee, Independent ND Footballers