Brain Injuries and Soccer

On Sunday, one of the legends of the soccer world was found dead.

Gary Speed was only 42.  He played for clubs in England’s Premiership for 22 years and holds the record for the most appearances representing Wales for an outfield player.  He had recently taken over as the head coach of the national side and Wales, for the first time in years, had begun to look like a genuinely dangerous team.

But on Sunday, it all ended as Speed took his own life, leaving behind a wife and two sons, aged 13 and 14.

In the coming weeks, we will learn more about the circumstances surrounding the death, but one thing that immediately came to mind upon hearing the tragic news was whether there might be a connection to the string of suicides by football players, boxers, and hockey players who had suffered brain injuries.

Chronic traumatic encephalopathy has been documented in autopsies of 20 or so football players who died young, including Dave Dureson, the Pro-Bowl Chicago Bears safety, who shot himself in February.  And there is more general research that shows that people with acquired brain injury are significantly more likely to demonstrate suicidal behaviors than those in the general population.

How might this relate to Gary Speed?

Well, Speed was, as the Guardian noted in its obituary, “an exceptional header of the ball.”  Expertly meeting a gun shot of a cross with his forehead and guiding it in his chosen direction was one of Speed’s special talents.  And he demonstrated that talent for longer than almost anyone: indeed, there are only two players, Ryan Giggs and David James, who played more games in the Premier League.

Although football and boxing have been getting most of the attention lately, we have known for years that there is evidence of chronic traumatic brain injury in professional soccer players.  Indeed, when researchers from the Netherlands looked at a population of professional soccer players in the Netherlands in 1998, the found that they

exhibited impaired performances in memory, planning, and visuoperceptual processing when compared with control subjects. Among professional soccer players, performance on memory, planning, and visuoperceptual tasks were inversely related to the number of concussions incurred in soccer and the frequency of “heading” the ball. Performance on neuropsychological testing also varied according to field position, with forward and defensive players exhibiting more impairment.

We will never know for certain why Gary Speed decided to take his own life, but my hope is that attention will be given to the possibility that the effects of his chosen profession may have contributed to his death.  At present, no one is writing about the role that brain trauma might have played in the tragedy on Sunday, but maybe they should.

In the end, soccer may not be the “safe” alternative to football that so many parents (including my own) have long assumed it to be.

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Related Situationist posts:

• Some Situational Signals of a Suicidal Disposition
• “The Interior Situation of Suicide,”
• Why Goalies Often Dive To The Right
• The Situation of Choosing a World Cup Site
• Manufactured Hype: Can ESPN’s Agenda-Setting Behaviour save Major League Soccer?

Review a collection of sports related Situationist posts by clicking here.

Some Situational Signals of a Suicidal Disposition

From Physorg:

Following the suicide of a relative or close friend, surviving family members and friends are left with a number of painful questions: “What made them do it?,” “Why didn’t they get help?”  The most troublesome question is often, “Is there anything I could have done to prevent this?” People who are contemplating suicide tend to conceal their behavior, or deny they are having suicidal thoughts, so it can be difficult to identify warning signs. Even experienced clinicians sometimes do not catch any warning signs and suicide experts have been searching for a clear behavioral marker of suicide risk.

Psychological scientist Matthew Nock of Harvard University, along with colleagues from Harvard University and Massachusetts General Hospital, adapted the Implicit Association Test (IAT)  to measure associations between life and death/suicide and examined if it could be effective in predicting suicide risk.

The IAT is a widely used test that measures automatic associations people hold about various topics ó participants are shown pairs of words and how quickly they respond indicates if they unconsciously associate those words together. In the IAT version used in this study, participants classified words related to “life” (e.g., breathing) and “death” (e.g., dead) and “me” (e.g., mine) and “not me” (e.g., them). Faster responses to “death”/”me” stimuli than “life”/”me” stimuli would suggest a stronger association between death and self.

People seeking treatment at a psychiatric emergency room participated in this study. They completed the IAT and various mental health assessments. In addition, their medical records were examined six months later to see if they had attempted suicide within that time.

The results, reported in Psychological Science, a journal of the Association for Psychological Science, revealed that participants presenting to the emergency room after a suicide attempt had a stronger implicit association between death/suicide and self than did participants presenting with other psychiatric emergencies. In addition, participants with strong associations between death/suicide and self were significantly more likely to make a suicide attempt within the next six months than were those who had stronger associations between life and self. These results suggest that an implicit association between death/suicide and self may be a behavioral marker for suicide attempt. These findings also indicate that measures of implicit cognition may be useful for identifying and predicting clinical behaviors that tend not be reported.

As Nock explains, “these results are really exciting because they address a long-standing scientific and clinical dilemma by identifying a method of measuring how people are thinking about death and suicide that does not rely on their self-report.”  He adds, “we are hopeful that this line of research ultimately will provide scientists and clinicians with new tools for measuring how people think about sensitive clinical behaviors that they may be unwilling or unable to report on verbally.”

[Situationist Contributor] Mahzarin Banaji, also of Harvard University and a co-author of this study, adds that this work presents a strong argument for the importance of funding basic behavioral research.  “These results are an example of basic research helping to solving a troubling and devastating problem in every society. The method we used was designed to understand the mind, but it turned into a technique that can predict disorders of a variety of sorts. One wonders why funding agencies that should know better about the value of basic research seem so naive when it comes to decisions about what is in the public’s interest,” Banaji explains.

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For a sample of related Situationist posts, see “Race and Implicit American-ness,” and “The Interior Situation of Undecided Voters,” “The Interior Situation of Suicide,” and “The Disturbing Mental Health Situation of Returning Soldiers.”

The Interior Situation of Suicide

The Boston Globe Sunday Magazine included an article by Peter Bebergal, titled “On the Edge.” (The teaser reads as follows: “Can a test reveal if a person has a subconscious desire to kill himself? Peter Bebergal, who lost a brother to suicide, goes inside Mass. General, where Harvard researchers are trying to find out.”) Here are a few excerpts.

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Four years after my brother’s death, Harvard researchers at MGH are experimenting with a test they think could help clinicians determine just that. It focuses on a patient’s subconscious thoughts, and if it can be perfected, these researchers say it could give hospitals more of a legal basis for admitting suicidal patients.

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This missing piece in the suicidal puzzle is what prompted the innovative research study now in its final phase at MGH. The study, led by Dr. Matthew Nock, an associate professor in the psychology department at Harvard University, is called the Suicide Implicit Association Test. It’s a variation of the Implicit Association Test, or IAT, which was invented by Anthony Greenwald at the University of Washington and “co-developed” by [Situationist Contributor] Dr. Mahzarin Banaji, now a psychology professor at Harvard who works a few floors above Nock on campus. The premise is that test takers, by associating positive and negative words with certain images (or words) – for example, connecting the word “wonderful” with a grouping that contains the word “good” and a picture of a EuropeanAmerican – reveal their unconscious, or implicit, thoughts. The critical factor in the test is not the associations themselves, but the relative speed at which those connections are made. (If you’re curious, take a sample IAT test online at implicit.harvard.edu/implicit/.)

The IAT itself is not new – it was created in 1998 – and has been used to evaluate unconscious bias against African-Americans, Arabs, fat people, and Judaism. But critics question whether the test is actually practical, and up until now no one has tried to apply it to suicide prevention. As part of his training, Nock worked extensively with adolescent self-injurers – self-injury, such as cutting and burning, is an important coping method for those who engage in it, though they are often unlikely to acknowledge it. Nock thought that the IAT could serve as a behavioral measure of who is a self-injurer and whether such a person was in danger of continuing the behavior, even after treatment. In their first major study, Nock and Banaji asserted that the IAT could be adapted to show who was inclined to be self-injurious and who was not. And more important, they said, the test could reveal who was in danger of future self-injury.

The next step, Nock realized, was to use the test to determine, from a person’s implicit thoughts, whether someone who had prior suicidal behavior was likely to continue to be suicidal. It would give doctors a third component, along with self-reporting and clinician reporting, and result in a more complete picture of a patient. Nock doesn’t assume that a test like the IAT would be 100 percent accurate, but he believes it would have predictive ability. “It is not a lie detector,” he says. “But in an ideal situation, a clinician who is struggling with a decision to admit a potentially suicidal patient to the hospital, or with an equally difficult decision to discharge a patient from the hospital following a potentially lethal suicide attempt, the IAT could provide additional information about whether the clinician should admit or keep that patient in the hospital.”

Over two years, researchers at MGH asked patients who had attempted suicide if they would be willing to participate in the test. About two-thirds of them agreed (some 200 patients) – even though some had tried killing themselves just hours before – and after answering a battery of questions about their thoughts, sat with a laptop and took the IAT.

During one test, a person was shown two sets of words on a screen, one in the upper left corner, one in the upper right. A single word then appeared in the center, and the test taker was asked to indicate with a keystroke the corner containing the word that connected to the center word. The corner sets were drawn from two groups of words (one group was “escape” and “stay,” and another was “me” and “not me”). In one version, the sets were “escape/not me” and “stay/me,” and the series of words that appeared in the center included, among others, “quit,” “persist,” “myself,” and “them.” The correct answers called for “quit” to be associated with the side that had “escape,” for “myself” to be matched with the side that had “me,” and so forth. In theory, a delay in answering on “quit,” even if the person got it right, could reveal that he was associating the idea of “quit” with the idea of himself. The word sets varied depending on the test, and bias could emerge in a positive or negative way. For example, if the sets were “escape/me” and “stay/not me” and a person hesitated in correctly matching “myself” to the side with “me,” it could reveal that he was associating himself with the idea of “stay.”

For about the next five months, Nock and his research team at Harvard will analyze all the data collected from MGH. If they think their findings show promise, they will follow up and run their experiment again to see if it yields similar results. If it does, they may seek to implement the test at an area hospital. For now, following up with patients will be pivotal in assessing the test’s effectiveness. Tragically, though, the only way researchers will know for sure whether the test can predict behavior is if a key number of patients attempt suicide again.

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Nock says it’s still too early to tell how well the test will predict someone’s likelihood of engaging in suicidal behavior. But he says the hope is that the IAT will be able to record subtle distinctions between those who are at risk and those who aren’t by measuring how “positively or negatively people value the option of suicide as a potential response to their intolerable distress.

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We recommend the entire article, which you can link to here. For a collection of Situationist posts about implicit associations, click here.

The Disturbing Mental Health Situation of Returning Soldiers

The military conflicts in Iraq and Afghanistan have led to over 4,700 deaths of U.S. soldiers (in addition to over 1.2 million deaths of Iraqi and Afghan people) and tens of thousands of physical injuries to U.S. soldiers. As we know too well, some of those injuries are catastrophic.

The mental health of returning soldiers has received much less attention, no doubt in part because those injuries are less apparent, because many people still view mental illness as less serious than physical illness, and because of choice myth in the context of mental illness: there is a common presumption that mental illness reflects a weak will (as opposed to biological impairment) of the person and that it can be corrected by the person, if the person so chooses.

Given the horrific conditions of warfare, however, perhaps the mental illness of soldiers will receive more credibility. New revelations about the number of veterans attempting suicide will certainly draw attention to the issue: although the Veterans Health Administration recently claimed that 800 veterans are attempting suicide each year, newly-uncovered e-mails from government officials indicate the actual number of veterans attempting suicide each year is closer to 12,000.

Just released data about the number of soldiers who have returned, and will return, from Iraq and Afghanistan with very serious mental health-related problems should also raise public consciousness. A new study by the RAND Corporation entitled “Invisible Wounds of War,” indicates a truly jaw-dropping figure: 1 out of every 5 returning soldiers–or about 300,000 total soldiers to date–suffers from either post-traumatic stress disorder or major depression. Below we excerpt an article by Lizette Alvarez of the International Herald Tribune on this topic.

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One in five service members who have returned from Iraq or Afghanistan report symptoms of post-traumatic stress disorder or major depression, but little more than half of them have sought mental health treatment, according to an independent study of United States troops.

The service members and veterans who reported these symptoms represented about 19 percent of the 1.6 million service members who have deployed to war in the last five years, a figure consistent with the most recent findings by military researchers. A 2007 survey of combat army soldiers who had been home for several months found that 17 percent of active-duty troops and 25 percent of reservists had screened positive for symptoms of stress disorder.

The study, released on Thursday by the RAND Corporation, reported that about 19 percent of the troops said they might have experienced a traumatic brain injury, usually the result of powerful roadside bombs, yet a majority of those troops had never been evaluated for such an injury.

The 500-page study is the first exhaustive, private analysis of the psychological and cognitive injuries suffered by service members. The study sought to determine the prevalence of these injuries, gaps in treatment and the costs of treating, or failing to treat, the conditions.

RAND researchers conducted a telephone survey from last August to January 2008 with 1,965 service members, reservists and veterans who had deployed to Iraq or Afghanistan in the last five years. Some respondents had deployed more than once. The researchers also gathered data from focus groups. The survey was conducted in 24 communities with high concentrations of service members, reservists and veterans.

The Defense Department said that it was heartened that the data reflected its own findings on the prevalence of mental injuries, and that the study helped highlight the hurdles the military faces in helping veterans.

“We’re on a long journey, and we’ve come a long way, but we’ve got a long way to go,” said Colonel Loree Sutton of the army, head of the new Defense Center of Excellence for Psychological Health and Traumatic Brain Injury.

Lisa Jaycox, a senior behavioral scientist at RAND and a co-author of the new study, “Invisible Wounds of War,” said the findings also served to underscore the barriers, some of them self-imposed, that troops face in getting help. War veterans say they are often reluctant to seek treatment, in part out of fear that their medical information will be used to derail their careers. Commanders typically have access to a service member’s military medical records.

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For the rest of the article, click here. To access “Invisible Wounds of War,” click here. For related Situationist posts on the military conflicts in Iraq and Afghanistan, see The Situation of Soldiers, “Our Soldiers, Their Children: The Lasting Impact of the War in Iraq,” “The Situation of a “Volunteer” Army,” “From Heavens to Hells to Heroes – Part I,” and “Looking for the Evil Actor.” For related Situationist posts on mental health, see “The Situation of Racial Health Disparities” and “Guilty or Not Guilty? Law & Mind Meet Hamlet.”