In stage II, symptoms begin to progress — cognitive features worsen, and language dysfunction appears. Behavioral symptoms progress to include impulsivity; mood symptoms become more prominent, and lability appears.

By stage III, approximately 75% of individuals show cognitive decline with the development of visuospatial difficulties; difficulty concentrating and inattention become more severe. Behavioral symptoms continue to worsen and become more extreme. Mood symptoms worsen as well.

By Stage IV, up to 100% of individuals are symptomatic. Cognitive impairment is severe; many individuals are described as having “severe memory loss with dementia,” “profound” inattention and loss of concentration, and dysarthria. Paranoia may develop. Mood symptoms can be severe, with approximately 31% of individuals studied having contemplated suicide. Of those diagnosed with pure stage III or IV CTE, 26% had suicidal tendencies, and 14% completed suicide.10


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Additional observations made by Omalu included decreased information processing speed, increase in religiosity, lack of insight, poor judgment, involvement in obviously illegal activities, substance abuse, indiscretion, sexual inappropriateness, verbal and physical abuse, problems with interpersonal relationships, isolation, restlessness, hyperactivity, and somatic complaints. He also noted hopelessness, social phobia, anxiety, agitation, mania, labile mood, insomnia, explosivity, and suicidal ideation, attempt, and completion.5

Through interviewing next-of-kin, it was suggested that some individuals diagnosed with CTE had exhibited mood and behavioral changes before developing cognitive impairment, and the rest exhibited cognitive impairment first.

The group with behavior and mood changes first tended to be more violent, explosive, depressed, out of control, and showed symptoms at a significantly younger age than the cognitive impairment group.  The group that developed cognitive impairment first was more likely to progress to dementia.21

See Table 1 for staging of both neuropathologic and neuropsychiatric sequelae of CTE.

Prevention and Treatment

Prevention and management of mTBI includes pre-participation counseling: education of coaches, trainers, players, and families about the risk of mTBI during play and the need for close monitoring when an mTBI is suspected.12 

Promising technologies include the Head Impact Telemetry System; and the Integrated Concussion Examination, a cloud-based system that captures players’ baseline pre-season neurocognitive functioning, history of concussions, balance, and coordinate performance data for comparison after an mTBI.8

Assessment for mTBI involves standardized sideline assessment tools, with the caveat of being adjunctive to proper evaluation of suspected TBI. Management of mTBI involves immediate removal of the player from play, restriction from training/practice/gameplay to avoid further injury.12

Because head impacts are a major concern in football, there has been a race among manufacturers to provide the most advanced and protective helmet technology. However, early evidence suggests that helmets may only be providing players with a false sense of security.