When The Lights Go  Out: Why are football players struggling once they leave the game?
By Lawrence V. Tucker, M.D. & Michael D. DeVine, MS, LPC
On May 2, 2012, Junior Seau, 43, was found dead in his home in Oceanside, California. It has been confirmed that he took his own life and many speculated that Chronic Traumatic Encephalopathy (CTE) — a degenerative brain condition caused by head trauma may have contributed to his demise. His death has once again sparked conversation about the deleterious effects of repetitive head trauma on the long-term health of athletes who play contact sports, regardless of age or level of competition.
However, as true with many post concussion syndrome, especially repetitive concussions, there were warning signs. Seau drove his car off a cliff in late 2010 after a physical confrontation with his girlfriend. At that time he claimed the road mishap was an accident when he fell asleep at the wheel and not a suicide attempt. It has been know, by those close to him, that he experienced financial problems and depression.
Unfortunately, Seau wasn’t known for having a concussion history while he played. He wasn’t part of the pending lawsuits filed by more than 1,200 former players against the NFL claiming the league didn’t properly treat or advise them on concussion-related matters. What makes this condition all the more disabling is that many players may not experience loss of consciousness. Many multiple sub clinical mild concussions are not reported. A slew of dead NFL players have been diagnosed with this progressive degenerative disease known as CTE. One of them was former Chicago Bears safety, Dave Duerson, who took his life in February 2011 in the same fashion that Seau did, by shooting himself in the chest. Duerson did so deliberately so his brain could be studied postmortem.
Junior Seau was the third suicide among former professional football players in the past 15 months, and the previous two – former safeties Dave Duerson and Ray Easterling – were thought to have suffered from CTE acquired over their years in the NFL. Researchers continue to make progress in their understanding of what can lead to memory impairment, loss of impulse control, depression, and dementia.
CTE results in behaviors similar to Alzheimer’s disease, but differs in that it has a clear environmental cause (repeated brain trauma) rather than a genetic cause. The condition is characterized by a number of neurological and physiological changes in the brain, most importantly the buildup of an abnormal protein called tau. With continued traumatic brain injury, as occurs in concussions or even with injuries that do not lead to concussive symptoms, tau protein congregates in clumps in and around the brain, disrupting its function. Its effects on behavior can take place over a span of months to decades, making CTE nearly impossible to diagnose until the patient has died and the brain itself can be inspected for changes suggestive of the condition.
The clinical symptoms associated with CTE vary in severity depending on which of three clinical stages the individual is experiencing. In the first stage, which may take place over months to years, a patient may suffer from a number of symptoms including headaches, dizziness, confusion, depression, and psychosis. As the disease progresses to the second stage, the individual may suffer from social instability, erratic behavior, memory loss, and the initial symptoms of Parkinson’s disease. The final stage consists of a progressive deterioration to dementia and may have other symptoms including those associated with Parkinson’s disease.
Because repetitive closed head injuries seem to be the cause of CTE, athletes involved in contact sports may be at highest risk. However, while athletes in collision sports such as football and boxing may sustain higher numbers of concussive and pre-concussive brain injuries, an athlete in any sport who may have sustained more than one concussive injury may be at risk for CTE.
Fortunately, there are Single Photon Emission Computed Tomography (SPECT) scans that measure regional cerebral blood flow (rCBF), and can reveal:
- Areas of healthy brain
- Areas of relative brain inactivity (“cold spots†on the surface scans, which appear as holes or dents on the rainbow looking scans).
- Areas of relative brain over-activity (“hot spots†on the deep scans with red being hot and white the hottest).
Unfortunately, at this time there is not wide spread use of this technology. SPECT scans can show areas of decrease activation and where damage has occurred. This technology can and has been used to see early, repetitive, and long term encephalopathic changes in the brain, allowing specific treatments to be undertaken early so athletes and other people who have head trauma, to be treated and not to suffer unnecessarily.
SPECT scans and Head Trauma
*SPECT images courtesy of The Mind Matters Clinic of TexasÂ
Physical Brain Trauma Patterns
Brain trauma can show in many different ways on scans. Typically, there is:
- Focal areas of decreased activity in the prefrontal cortex, temporal lobes, parietal lobes, occipital lobes
- Decreased prefrontal pole
- Decreased anterior temporal poles
- Decreased anterior and posterior temporal lobes
- Focal areas of increased activity
- Off center anterior cingulate activity
- ·Contra coup injuries (one side plus the opposite side)
It is unfortunate that anyone has to needlessly suffer and have a similar outcome that Junior Seau and other athletes, pro and college, have had. CTE is indeed widespread and we do not hear about the common everyday people, who have experienced car accidents, and other type of head trauma, that have also had similar outcomes. We have used SPECT scans on athletes as well as other kids and adults who have had single or repeated head traumas, to improve their outcome and decrease the likelihood of declining disability. Hopefully this technology will become more wide spread and used throughout profession sports and the general public, to prevent any more deaths and disability.
Career Identity, Career Transition, and Personality
While the role of the brain injury in the suicides of players like Junior is clearly chronicled above, we cannot squarely put all of the blame on it. What we have learned in psychology/psychiatry is that several factors play a role in human behavior; most influential are environmental and personality factors. To further understand the issue, we must understand the very nature of a football player’s personality and the environment that they live/play in.
John Holland speaks volumes in his career theory about how a person’s career choice is rooted in their personality style and that a person’s happiness can be rooted in their search for a work compatible environment with their personality. When a person finds a career choice (i.e. type of work, work environment, co-workers, etc.) that matches their personal style, then people tend to be passionate about their work and equates to higher levels of happiness and job satisfaction. When people choose a career path that is incongruent with their personality style, then people report higher levels of job dis-satisfaction and unhappiness.
So what happens when a football player retires from the game? We have seen over the past 20 years a significant problem with football players experiencing personal, professional, interpersonal, and financial problems after they leave the game. When we apply Holland’s theory to football players who have played professional football for a majority of their adult lives, we see several factors that explain why these problems are occurring. First, football players who have had the luxury of playing professional football for several years have been playing the game not only for that time but also college, high school, and Pop Warner football. The majority of their lives have literally been about being a football player.
During the season, their free time is spent studying playbooks, practicing, working out. When football players are in the offseason, they have their off season training programs that guide what they do and when they do it. A football player is consumed with trying to become a better football player and their personal and professional identity develops around being a football player. Moreover, a player’s self-esteem is based on how good of a football player they are and for many players; the admiration of the masses (i.e. coaches, players, fans, owners, family, friends, media, etc.) is a huge source of self-esteem and self-identity. When a player leaves the game of football, the thing that has defined then for the past 20-30 years is taken away. With their career being taken away, their sense of self-worth, identity…basically the thing that helps them define themselves is taken away.
If this itself was not a huge hit to a player’s psyche, also take in to account the camaraderie and emotional/interpersonal connections that they made with their teammates over that time period. Many football players liken the gridiron to a battlefield and feel as though their teammates are fellow soldiers goring to war together. Each person has each other’s backs. When the game is put in to the rear view mirror of a player, all of those battle experiences are gone as well…the feeling of standing shoulder to shoulder with a team mate are long gone. Many football players have tighter relationships, more close and intimate relationships with team mates than they do their own family. When they leave the game, it’s not only the game that they lose, it’s also a built in family.
The suicides of Junior Seau, Dave Duerson, etc., have all brought to light the effects of CTE on former players and will no doubt make all of us to view the game of football in a different light. The deaths have shed light on the effects of chronic traumatic brain injury on these players and experts like us will be left to question what factors are contributing to these suicides. If we take a player with no brain injury and define retirement from football in the above light, it would be difficult for any of us to not deal with depression, loss of identity, boredom, and feelings of helplessness/hopelessness. When we add in CTE in to the mix, we really start to understand why suicides are happening with former players.
Interplay of Brain Injury and Career Identity, Career Transition, and Personality
As Dr. Lawrence Tucker explained above, CTE can cause damage to the pre-frontal cortex (PFC) of the brains of football players. The PFC is especially important when looking at the post-football lives of players for a few reasons. First, the PFC is largely responsible for human’s abstract thinking, attention, focus, and advanced problem solving. When damage is done to this area of the brain, we tend to see problems in these areas, sometimes significant impairment in functioning. When a player is trying to figure out what to do with his life after football, how to find a new identity, new career, learning how to spend his free-time (i.e. no team practices, game prep, working out, etc.), these already difficult decisions are compounded by a brain that just is not working as good as it should. Simple problems that usually would not pose any problems could be more difficult for players with damage to this region of their brain, let alone difficult life defining decisions.
Secondly, recent research has identified the PFC to play a major role in the regulation of human emotions. Pathways have been discovered that send signals to out emotional centers of the brain to shut down, allowing people to cope with intense emotions better as well as learning how to make better decisions when in an emotionally intense state. When damage is done to PFC, a person has a reduced ability to control the emotional centers of the brain and is often overwhelmed with their emotions; often tending to make poor/impulsive decisions in emotionally agitated states. In football players with CTE, this region of the brain is damaged and with that comes an inability to deal with the intense emotions of a post football playing career. With this usually results in intense depressive episodes, poor anger management, periods of intense rage, and anxiety. We have seen the early warning signs of these emotional states with several football players and from our experience with suicidal clients, leads us to believe that intense emotional states, impulsive decision making, poor coping skills,  in addition to feelings of helplessness/hopelessness that leads  up to the suicide attempts of former football players.
Possible Solutions
So when we look at everything we know about psychology, psychiatry, neuroscience, and the lives of football players, we can come to a likely decision that the rash of player suicides is caused by the difficult life transition of retiring from football and exacerbated by the significant effects of CTE. So what can we do about the problem? If these factors account for the majority of former player suicides, what can be done to prevent these deaths from happening?
In our opinion, many things can be done to protect players. First, when a player retires from the NFL, mandatory counseling and regular psychiatric evaluations must be established by the NFLPA. The counseling must be mandatory to help them until their career transition is complete with further counseling being made available as well. Players must also get regular psychiatric evaluations including brain imaging to determine the extent of any neurological damage to their brain as well as establishing a treatment plan to help reduce any further deterioration. Evaluations must be completed regularly over time to identify any problems that may occur further down the road. Regular counseling will also help players develop better coping skills as well as utilize research validated strategies (i.e. Cognitive Behavioral Counseling, Dialectical Behavior Counseling, etc.) that will help increase their cognitive abilities. Secondly, the NFL and the NFLPA must develop programs to keep players involved in football, albeit it through internship programs, coaching/athletic training programs, etc. This will enable players to stay involved in the game, maintain close relationships with players/organizations, and help guide a player to develop a new professional identity while still being close to the game.