Some people experience persistent symptoms following a mild traumatic brain injury (MTBI), and the etiology of those symptoms has been debated for generations. Post-concussion-like symptoms are ...caused by many factors both before and after MTBI, and this non-specificity is the bedrock of the conundrum regarding the existence of the post-concussion syndrome. A latent model or common cause theory for the syndrome is inconsistent with the prevailing biopsychosocial conceptualization. It is the thesis of this paper that adopting a network perspective for persistent symptoms following MTBI, including the post-concussion syndrome, could lead to new insights and targeted treatment and rehabilitation strategies. The network perspective posits that symptoms co-occur because they are strongly inter-related, activating, amplifying, and mutually reinforcing, not because they arise from a common latent disease entity. This approach requires a conceptual shift away from thinking that symptoms reflect an underlying disease or disorder toward viewing inter-related symptoms as constituting the syndrome or disorder. The symptoms do not arise from an underlying syndrome-the symptoms are the syndrome. A network analysis approach allows us to embrace heterogeneity and comorbidity, and it might lead to the identification of new approaches to sequenced care. The promise of precision rehabilitation requires us to better understand the interconnections among symptoms and problems so that we can produce more individualized and effective treatment and rehabilitation.
For nearly 80 years, suicidality was not considered to be a core clinical feature of chronic traumatic encephalopathy (CTE). In recent years, suicide has been widely cited as being associated with ...CTE, and now depression has been proposed to be one of three core diagnostic features alongside cognitive impairment and anger control problems. This evolution of the clinical features has been reinforced by thousands of media stories reporting a connection between mental health problems in former athletes and military veterans, repetitive neurotrauma, and CTE. At present, the science underlying the causal assumption between repetitive neurotrauma, depression, suicide, and the neuropathology believed to be unique to CTE is inconclusive. Epidemiological evidence indicates that former National Football League players, for example, are at lower, not greater, risk for suicide than men in the general population. This article aims to discuss the critical issues and literature relating to these possible relationships.
In the initial autopsy case studies of chronic traumatic encephalopathy (CTE), some researchers have concluded that the proteinopathy associated with CTE is the underlying cause of suicidality and ...completed suicide in former athletes.
A review of the literature on contact sports and risk of completed suicide revealed only one epidemiological study with direct relevant data.
There are no published cross-sectional, epidemiological or prospective studies showing a relation between contact sports and risk of suicide. One published epidemiological study suggests that retired National Football League players have lower rates of death by suicide than the general population. Outside of sports, there is a mature body of evidence suggesting that the causes of suicide are complex, multifactorial and difficult to predict in individual cases.
Future research might establish a clear causal connection between the proteinopathy of CTE and suicide. At present, however, there is insufficient scientific evidence to conclude that there is a strong causal relationship between the presence of these proteinopathies and suicide in former athletes. Additional research is needed to determine the extent to which the neuropathology of CTE is a possible mediator or moderator variable associated with suicide.
To provide a critical review of chronic traumatic encephalopathy (CTE) by considering the range of clinical presentations, neuropathology and the strength of evidence for CTE as a distinct syndrome.
...Seven electronic databases were searched using a combination of MeSH terms and key words to identify relevant articles.
Specific inclusion and exclusion criteria were used to select studies for review. Data extracted where present included study population, exposure/outcome measures, clinical data, neurological examination findings, cognitive assessment, investigation results and neuropathology results.
The data from 158 published case studies were reviewed. Critical differences between the older descriptions of CTE (the 'classic' syndrome) and the recent descriptions (the 'modern' syndrome) exist in the age of onset, natural history, clinical features, pathological findings and diagnostic criteria, which suggests that modern CTE is a different syndrome. The methodology of the current studies does not allow determination of aetiology or risk factors.
The clinicopathological differences between the 'classic' CTE syndrome and the 'modern' syndrome suggest that the new syndrome needs a different nomenclature. Further research is required to clearly define the clinical phenotype of the modern CTE syndrome and establish the underlying aetiology. Future research needs to address these issues through large-scale, prospective clinicopathological studies.
Adverse childhood experiences (ACEs) are associated with mental health and cognitive problems, and mental health problems are associated with perceived cognitive difficulties among adolescents. The ...unique contribution of ACEs to cognitive difficulties after adjusting for poor mental health is not well understood and represents the purpose of this study.
The Adolescent Behaviors and Experiences Survey was conducted in 2021 with high school students in the United States. Cognitive difficulty was assessed with: 'Because of a physical, mental, or emotional problem, do you have serious difficulty concentrating, remembering, or making decisions?' Four ACEs were examined: sexual violence (lifetime and past 12 months), parental emotional abuse, and parental physical abuse. Students were asked about feeling sad or hopeless (past year), considering suicide (past year), and having poor mental health (past month). Binary logistic regressions examined the association between ACEs and cognitive problems, adjusting for mental health.
Participants were 6,945 students. Students reporting poor mental health were very likely to endorse difficulty concentrating, remembering, or making decisions (girls = 81% and boys = 67%). Cognitive difficulty was uncommon among students who denied poor mental health (girls = 17% and boys = 12%). For boys
< 0.001;
= 0.22 and girls
< 0.001;
= 0.31, after adjusting for mental health problems, independent predictors of cognitive difficulties included parental verbal abuse and physical abuse. For girls, lifetime forced sexual intercourse and sexual violence during the past year were also independently associated.
ACEs are associated with perceived cognitive difficulty in both adolescent girls and boys, even after adjusting for poor mental health.
Introduction
Some youth experience cognitive difficulties that interfere with their ability to learn and function well in a school environment. We examined correlates of perceived cognitive ...impairment among high school students who completed a national survey conducted by the United States Centers for Disease Control and Prevention (CDC) in 2019.
Methods
Participants were high school students (grades 9–12) who completed the Youth Risk Behavior Survey (YRBS) in 2019. The CDC uses this survey to monitor risk behaviors. Students answered the following question ‘Because of a physical, mental, or emotional problem, do you have serious difficulty concentrating, remembering, or making decisions?’ as either ‘yes’ or ‘no.’ Student responses to this question were analyzed in relation to demographic variables and variables pertaining to adversity, mental health problems, and drug use.
Results
The sample included 8,349 students between the ages of 14 and 18, with 4,093 boys (49%) and 4,256 girls (51%). A large proportion reported having serious difficulty concentrating, remembering, or making decisions due to physical, mental, or emotional problems (38%). A significantly larger proportion of girls (45%) than boys (30%) reported experiencing cognitive impairment
χ
2
(1) = 212.23,
p
< 0.001; Odds Ratio = 1.95, 95% confidence interval = 1.78–2.13. Youth who exercised regularly were significantly less likely to report cognitive impairment. Binary logistic regression was used to examine the associations between perceived cognitive impairment and adversity, mental health, and lifestyle variables separately for boys
χ
2
(11) = 569.158,
p
< 0.001; Nagelkerke
R
2
= 0.212 and girls
χ
2
(11) = 1,026.189,
p
< 0.001; Nagelkerke
R
2
= 0.321. Being bullied, feeling unsafe or threatened at school, getting very low grades, insufficient sleep, and using illicit drugs were independently associated with perceived cognitive impairment in both boys and girls—after controlling for associations with depression and suicidality. Youth who denied mental health problems, psychosocial adversities, and using illicit drugs reported much lower rates of perceived cognitive impairment (boys = 13%, girls = 15%).
Conclusion
A remarkably large proportion of high school students in the United States reported experiencing serious difficulty with their cognitive functioning over the past year. Girls were significantly more likely to endorse perceived cognitive difficulties compared to boys. There was a strong association between perceived cognitive impairment and the experience of psychosocial adversity.
Systematic review of possible long-term effects of sports-related concussion in retired athletes.
Ten electronic databases.
Original research; incidence, risk factors or causation related to ...long-term mental health or neurological problems; individuals who have suffered a concussion; retired athletes as the subjects and possible long-term sequelae defined as
10 years after the injury.
Study population, exposure/outcome measures, clinical data, neurological examination findings, cognitive assessment, neuroimaging findings and neuropathology results. Risk of bias and level of evidence were evaluated by two authors.
Following review of 3819 studies, 47 met inclusion criteria. Some former athletes have depression and cognitive deficits later in life, and there is an association between these deficits and multiple prior concussions. Former athletes are not at increased risk for death by suicide (two studies). Former high school American football players do not appear to be at increased risk for later life neurodegenerative diseases (two studies). Some retired professional American football players may be at increased risk for diminishment in cognitive functioning or mild cognitive impairment (several studies), and neurodegenerative diseases (one study). Neuroimaging studies show modest evidence of macrostructural, microstructural, functional and neurochemical changes in some athletes.
Multiple concussions appear to be a risk factor for cognitive impairment and mental health problems in some individuals. More research is needed to better understand the prevalence of chronic traumatic encephalopathy and other neurological conditions and diseases, and the extent to which they are related to concussions and/or repetitive neurotrauma sustained in sports.
Abstract
Objectives
Empirically informed neuropsychological opinion is critical for determining whether cognitive deficits and symptoms are legitimate, particularly in settings where there are ...significant external incentives for successful malingering. The Slick, Sherman, and Iversion (1999) criteria for malingered neurocognitive dysfunction (MND) are considered a major milestone in the field’s operationalization of neurocognitive malingering and have strongly influenced the development of malingering detection methods, including serving as the criterion of malingering in the validation of several performance validity tests (PVTs) and symptom validity tests (SVTs) (Slick, D.J., Sherman, E.M.S., & Iverson, G. L. (1999). Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13(4), 545–561). However, the MND criteria are long overdue for revision to address advances in malingering research and to address limitations identified by experts in the field.
Method
The MND criteria were critically reviewed, updated with reference to research on malingering, and expanded to address other forms of malingering pertinent to neuropsychological evaluation such as exaggeration of self-reported somatic and psychiatric symptoms.
Results
The new proposed criteria simplify diagnostic categories, expand and clarify external incentives, more clearly define the role of compelling inconsistencies, address issues concerning PVTs and SVTs (i.e., number administered, false positives, and redundancy), better define the role of SVTs and of marked discrepancies indicative of malingering, and most importantly, clearly define exclusionary criteria based on the last two decades of research on malingering in neuropsychology. Lastly, the new criteria provide specifiers to better describe clinical presentations for use in neuropsychological assessment.
Conclusions
The proposed multidimensional malingering criteria that define cognitive, somatic, and psychiatric malingering for use in neuropsychological assessment are presented.
Abstract
Objective
Some researchers have claimed that former National Football League (NFL) players are at increased risk for suicide as a clinical feature of chronic traumatic encephalopathy (CTE). ...This review examines the literature on risk for suicide in former professional football players, and the association between suicide and CTE.
Method
A narrative review of the literature published between 1928 and 2018.
Results
Between 1928 and 2009, suicide was not considered to be a clinical feature of CTE in the literature. The best available evidence from epidemiological studies suggests that former NFL football players are at lesser risk for suicide, not greater risk, compared to men in the general population. However, surveys have revealed that a substantial minority of former NFL players have depression and other mental health problems, chronic pain and opioid use is relatively common, and those with depression and chronic pain also have greater life stress and financial difficulties. That minority would be at increased risk for suicidal thoughts and behaviors.
Conclusions
Researchers and clinicians are encouraged to be cautious and circumspect when considering the clinical presentation of former athletes, and to not assume that depression and suicidality are caused by specific types of neuropathology. This represents a reductionistic and Procrustean view. Some former football players have mental health problems, but it should not be assumed uncritically that the underlying cause is an inexorably progressive neurodegenerative disease. Providing evidence-informed and evidence-supported treatments for depression and suicidality might reduce suffering and improve their functioning.