A narrative review of psychiatric features of traumatic encephalopathy syndrome as conceptualized in the 20th century

Abstract

IntroductionSome ultra-high exposure boxers from the 20th century suffered from neurological problems characterized by slurred speech, personality changes (e.g., childishness or aggressiveness), and frank gait and coordination problems, with some noted to have progressive Parkinsonian-like signs. Varying degrees of cognitive impairment were also described, with some experiencing moderate to severe dementia. The onset of the neurological problems often began while they were young men and still actively fighting. More recently, traumatic encephalopathy syndrome (TES) has been proposed to be present in athletes who have a history of contact (e.g., soccer) and collision sport participation (e.g., American-style football). The characterization of TES has incorporated a much broader description than the neurological problems described in boxers from the 20th century. Some have considered TES to include depression, suicidality, anxiety, and substance abuse.PurposeWe carefully re-examined the published clinical literature of boxing cases from the 20th century to determine whether there is evidence to support conceptualizing psychiatric problems as being diagnostic clinical features of TES.MethodsWe reviewed clinical descriptions from 155 current and former boxers described in 21 articles published between 1928 and 1999.ResultsMore than one third of cases (34.8%) had a psychiatric, neuropsychiatric, or neurobehavioral problem described in their case histories. However, only 6.5% of the cases were described as primarily psychiatric or neuropsychiatric in nature. The percentages documented as having specific psychiatric problems were as follows: depression = 11.0%, suicidality = 0.6%, anxiety = 3.9%, anger control problems = 20.0%, paranoia/suspiciousness = 11.6%, and personality change = 25.2%.DiscussionWe conclude that depression, suicidality (i.e., suicidal ideation, intent, or planning), and anxiety were not considered to be clinical features of TES during the 20th century. The present review supports the decision of the consensus group to remove mood and anxiety disorders, and suicidality, from the new 2021 consensus core diagnostic criteria for TES. More research is needed to determine if anger dyscontrol is a core feature of TES with a clear clinicopathological association. The present findings, combined with a recently published large clinicopathological association study, suggest that mood and anxiety disorders are not characteristic of TES and they are not associated with chronic traumatic encephalopathy neuropathologic change.

Applying the Consensus Criteria for Traumatic Encephalopathy Syndrome Retrospectively to Case Studies of Boxers from the 20th Century

“…A recent review of this same case material, including 155 of these 157 boxers from the 20 th century, was focused on whether these men exhibited psychiatric problems, such as depression, anxiety, and suicidality. 15 That review concluded that TES during the 20 th century was described as a neurological condition, including dementia in some cases, and depression, anxiety, and suicidality were not considered to be core clinical features—supporting the decision of the 2021 TES consensus group 20 removing depression from the 2014 preliminary diagnostic criteria 11 for TES. For the present study, we extracted information from these same 155 cases (with two additional identified cases) presented in 21 articles 1 , 2 , 5–7 , 27 , 28 , 30–32 , 34 , 35 , 37–44 , 46 and applied the 2021 TES consensus diagnostic criteria for the three core clinical features (i.e., progressive course, cognitive impairment, and/or neurobehavioral dysregulation), in addition to the supportive features, including whether there was a delayed onset of symptoms, motor signs, or psychiatric features (see the Supplementary Material ).…”

“…These criteria included cognitive impairment and neurological problems, but also diverse psychiatric and psychosocial problems, such as depression, intermittent explosive disorder, anxiety (e.g., obsessive-compulsive disorder and generalized anxiety disorder), excessive gambling, excessive shopping, substance abuse, suicidality, and paranoia. The diverse psychiatric problems that defined the 2014 TES core and supportive diagnostic criteria, however, were not considered part of the clinical syndrome experienced by boxers in the 20th century 15 —and researchers have illustrated the risk of misdiagnosing TES in persons from the general population based on considering the possible psychiatric features. 16–19 …”

Substantia(l) Impacts of Contact Sport Play and Parkinsonism

“…Fast-forward almost a hundred years and RHI through American football participation receives a large share of the spotlight. Parkinsonism remains a recognized symptom in a subset of individuals often decades removed from their RHI exposure, albeit not as consistently reported as in the days of “dementia pugilistica.”…”

“…Parkinsonism remains a recognized symptom in a subset of individuals often decades removed from their RHI exposure, albeit not as consistently reported as in the days of "dementia pugilistica." 7 Historical case reports did not have the benefit of clinicopathological correlation of parkinsonism in individuals with RHI. While the unusual symptom constellations were readily apparent both to observant medical professionals and the keen eyes of boxing fans in the crowd, 4 the underlying cause was not.…”