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Psychiatric Conditions in Sports

Diagnosis, Treatment, and Quality of Life

JIra D. Glick, MD; Jessica L. Horsfall, MS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO.8 - AUGUST 2001


In Brief: The social stigma surrounding psychiatric illness may prevent athletes from seeking counseling, psychotherapy, medication, or other treatment when needed. Few controlled studies on athletes exist to guide the team physician, clinician, or psychiatrist who must deal with diagnostic issues. Management involves setting realistic goals, educating as well as inducing the patient into treatment, soliciting support from family or significant others, and delivering appropriate treatment (the most difficult task). The objective is to improve performance and quality of life. Confidentiality issues are paramount during diagnosis and treatment. Physicians who understand sports and team dynamics may have more success in helping patients follow through with treatment.

Although much time and money have been invested in treating physical injuries of athletes, their associated psychiatric problems have been minimally addressed (1,2). Even at the most basic level (ie, the gatekeeper level), psychiatric treatment, including psychotropic medication and psychotherapy, has been overlooked. If a condition is diagnosed, patients may still be undertreated. Perhaps this is true in part because, despite some anecdotal evidence, in this population, there have been no controlled studies to suggest that psychiatric intervention improves performance or effectively treats symptoms (3). The usual response is to undertreat (4).

Like anyone else, athletes are at risk for both psychological problems and psychiatric illnesses, including substance abuse. Physicians who work with athletes may perceive that players generally don't seek out or connect with providers to receive appropriate intervention, in part because of the social stigma regarding psychiatric illness (5). Furthermore, to athletes (especially men), treatment denotes weakness among players who, in some cases, do not have mature coping strategies. Others believe they can conquer mental illness without medical help (6). The potential consequences of untreated depression are exemplified in the case of a National Basketball Association player (see "Tragic Consequences of Untreated Depression," below).

Psychiatric Issues in Sports

Psychiatric interventions have been made in sports for many years but, unfortunately, only rarely (7). In 1992, Begel (1) wrote a seminal overview article on sports psychiatry, but few articles have appeared in clinical journals during the past few years (1,6,7).Clearly, sports psychiatry has yet to evolve as a professional specialty (8). In part this is because it lacks a knowledge base, and in part because the incidence and prevalence of psychiatric illness in athletes is generally low. Thus, very few clinicians have the experience—and no one has had a large enough sample—to do systematic surveys of incidence or prevalence, or to do controlled treatment studies with adequate sample sizes.

An excellent overview article (7) on sport psychiatry was published in 1998, but it focused on substance abuse, eating disorders, and brain injury. The sports medicine literature touches on psychiatric issues, and the vast literature on exercise science and performance enhancement addresses different psychologic issues. In 1996, Meyers et al (9) published an extensive review of cognitive behavioral strategies and performance enhancement. In addition, Begel and Burton (10) have published the first textbook on sport psychiatry, Tofler et al (11) have compiled a volume on sport psychiatry in adolescents, and Stryer et al (12) and Eppright et al (13) have published overviews of issues in children and adolescents.

To help address the needs of athletes more completely, we provide a broad overview of psychiatric problems and illness associated with competitive athletes and to discuss diagnosis and psychiatric treatment relevant to physicians, sports psychologists, psychiatrists, or other practitioners of sports medicine as they work with adult athletes (14).

Limited Empiric Data

To review the literature in the field of college and professional sports psychiatry, we conducted Internet searches using Medline and Psychlit for articles from 1980 to 1999 that included, but were not limited to, the terms "athlete, professional, treatment, elite, depression, anxiety, substance, eating disorder, sport, gender, psychiatry, psychology, medication, therapy, counseling, exercise, intervention, brain, basketball, football, Olympic, and boxing." The searches revealed little empiric data relating to characteristics, diagnosis, or psychiatric treatment of college and professional athletes.

To supplement the literature, we have summarized experience from adult sports psychiatry practices at two academic centers (Cornell University Medical College and Stanford University School of Medicine), but our experience is not limited to college settings. The areas covered include problems of living such as difficulties with relationships and work; Axis 1 major depressive disorders such as substance abuse, mood disorder, and anxiety disorders; and Axis 2 personality disorders, such as borderline personality disorder. Salient issues specific to team sports (eg, football, basketball, baseball, soccer) and individual sports (eg, boxing, weight lifting, tennis, track) also are addressed.

The major limitations of this article are the lack of scientific literature and paucity of epidemiologic and empiric data. The situation with psychiatric treatment of athletes is similar to that in the field of suicidology: Controlled studies of treatment of elite athletes (1), like controlled studies of those who have suicidal ideation, are relatively rare. Very few mental health professionals have had enough experience to make strong treatment recommendations, although some clinicians have worked with athletes for more than 25 years. Most "problems of living" and many depressive or anxiety disorders can be managed by the nonpsychiatric clinician. In some cases, the nuances of modern psychopharmacology or complicated interpersonal issues may require referral to a psychiatrist who can deliver more extensive psychotherapy, medication, or medication combined with psychotherapy.

Diagnostic Issues

Accurate diagnosis is an essential first step in laying the groundwork for successful treatment. This includes the process and methods of the clinical evaluation and workup, and special issues related to elite athletes. The first step may be to make a referral to a psychiatrist so that a correct diagnosis can be made and medications can be started if necessary.

To establish a trusting rapport with the athlete, the clinician must first evaluate the individual's personality, coping mechanisms, and support system. Psychological status has been found to relate to performance levels (15). It may be difficult to differentiate the person from the athletic "persona." Although not common, emotional maturity may be delayed because of an athlete's "iconization," placing the athlete "on a pedestal" and having others insulate them from the stresses and problems of daily life (9,13,15,16). Childlike attitudes and behaviors (eg, inappropriate anger or inability to follow team rules) may be prominent despite the patient's chronological age (1,7,16).

Second, interpersonal issues must be considered to the extent that personal relationships affect athletic performance. For example, coaches play a large role in determining the impact sports may have on an athlete's mental health (17). The coach's role as a parent-figure, punitive authority-figure, or buddy is important. The roles that family and significant others play may also be relevant (17). And, of course, a major factor directly affecting the interview is whether the athlete is coming voluntarily or involuntarily under pressure from third parties. (See "'Bases Loaded' With Denial," below)

Third, the signs and symptoms of psychiatric conditions (eg, major depressive disorder or alcohol abuse) should be explored. Denial of both psychological difficulty and of pain associated with enhancing performance is common among successful athletes (18). On the other hand, some elite athletes, keenly aware of the capabilities and limitations of their bodies, are less likely to ignore pain and discomfort from physical exertion. If such issues are not addressed, the clinician will have increasing difficulty developing and maintaining a therapeutic alliance.

Methods and Goals of Evaluation

Methods of evaluation include a clinical interview with the athlete, significant others (eg, agents, teammates), and/or family. Laboratory tests (eg, a toxicology screen for illegal substances), other screening tests (eg, a fasting blood sugar for physical illnesses that can cause psychiatric problems), or psychological testing may be indicated (1,6,7,10).

The primary goal is to differentiate the cause of the athlete's difficulties from its effects. Daily functioning and athletic performance go hand in hand; thus, performance may affect interpersonal relationships. For example, some suggest that the professional sports climate may increase the likelihood of athlete violence (19-21). Poor performance may result in aggressive behavior toward a significant other, usually the spouse. Conversely, an interpersonal relationship may improve after a good performance. Monitoring the patient's problem-coping cycle will ideally lead to appropriate interventions and subsequent resolution of relationship difficulties. Therefore, when obtaining a history, the physician must exercise judgment and maintain confidentiality when contacting others. In many cases, depending on the treatment, written informed consent must be obtained (6) before disclosing information crucial for treatment compliance to the coach, other members of coaching staff, other players, agents, family members, or to the team physician.

Special Issues

Athletes develop psychiatric illnesses and have problems, such as violent behavior and substance abuse, that can happen to anyone, not just athletes. Such problems are highly scrutinized by the media, and athletes tend to get stereotyped. Our point here is to present the range of possibilities and emphasize that treatment is often necessary.

Patients who have psychiatric symptoms usually do not present as clearly as patients with fractures present to an orthopedist. Most commonly they present via referral from a third party, such as a family member or teammate in confidence (eg, a substance abuse problem), or after the athletes' complaints or problems with others in their lives are discussed. Sometimes DUI or drug-possession arrests are a factor in bringing substance abuse to light. Substance abuse and antisocial behavior are among the most common issues treated in this population (22,23), but elite athletes may also have mood, anxiety, and eating disorders (6,20,24,25).

So-called "characterological" issues, including narcissism and antisocial personality traits (eg, stealing or cheating) may also occur in athletes despite their large incomes (24). One stereotype is a youth from a disadvantaged neighborhood who plays well enough to "go pro" and suddenly finds himself with a six-figure income he has no idea how to handle. He steals because stealing has always been a commonplace part of his everyday life. Other problems may include individual career issues (eg, deciding when and how to retire), transition issues (eg, being out of the spotlight), family issues (eg, marriage, spouse abuse, fidelity concerns), or sports-related issues (eg, difficulties with teammates, owners, league, agents, or fans). Despite these potential problems, considerable literature suggests that athletes, in general, show better emotional health compared with nonathletes (2,26), and the same is true for elite athletes compared with nonelite athletes (27). Changes in mental health over time have also been associated with enhanced or impaired performance (15).

In addition, some evaluation issues are unique to athletes. First, as we mentioned above, clinicians must decide whether and when to contact other sources for the patient history (coaches, team, and family). Understanding the patient's sports environment can increase the success of psychiatric intervention (28).

Second, cross-cultural, ethnic, or racial issues may underlie the athlete's difficulties. A player from one country may misinterpret culturally dictated behaviors or traditions or may be misunderstood by most of the team's players (eg, an American on an Italian basketball team or a Croatian on an American team). Sensitivity to these issues and awareness of the physician's own biases, known as countertransference, are paramount (29).

Third, the physician must consider neurologic issues in searching for the cause of the athlete's problems. Boxers, football players, and soccer players may experience mild head trauma or concussions (30). For example, Matser et al (31) found that among soccer players, heading the ball may impair memory, planning, and visuoperceptual processing. Severe neurologic disorders, such as dementia pugilistica, should be ruled out before psychotherapy is suggested because therapy would be ineffective. Patients who have substance-abuse problems may also present with neurologic difficulties that may or may not subside after detoxification and rehabilitation, and these patients may benefit from neuropsychological testing before entering treatment.

Lastly, developmental level or behavioral status should be evaluated. Athletes with narcissistic, grandiose, or antisocial character traits may use denial or other defense mechanisms that prevent an effective therapeutic alliance (1). Pampered, highly paid professional athletes, especially men, may be developmentally immature in contrast to their "macho adult" presentations, although exactly how common this is remains unknown because systematic studies have not been done.

Encouraging Athletes to Seek Treatment

Unfortunately, college and professional athletes are often very reluctant to seek psychiatric treatment (2,26,32). Athletes' tendencies to deny weakness and assume a macho posture are part of their personalities, resulting in denial of illness and fear of social stigma (6). Constant pressures of competition and performance may lead to dysfunctional coping skills in what is thought to be a small percentage of athletes. Problematic coping mechanisms include reckless driving, sexual promiscuity, and use of recreational and performance-enhancing drugs. The psychology underlying these behaviors involves a variety of mechanisms, some involved with athletic skills and performance (eg, the need to win) and others involved with identity (eg, acceptance by drug-using peers). Providing psychiatric services is paramount for rehabilitation and improvement of quality of life for both the athletes and their families.

Most sports psychiatry clinicians believe that unless athletes present with overt disabling psychiatric symptoms or societal issues (psychomotor retardation, mania, rapid weight loss, agitation, marital difficulties, or legal troubles), traditional referral to a psychiatrist and development of a therapeutic alliance is unlikely. The recent case of a Chicago high school basketball player (33) who attempted to move directly to professional sports and presented at training camp with bizarre aggressive symptoms and suicidal behavior makes this point clear. In our view, the players (and/or their families or teams) must collaborate with a psychiatrist and an intermediary (a peer, former player, or agent) to facilitate treatment. To encourage active participation, the idea of treatment may be reframed as "performance enhancement," similar to individual coaching for improving athletic skills. In addition, the rationale for intervention should appeal to athletes' self-interest, such as increasing skills, money, or quality of life, rather than focusing on a mental illness. Elite athletes usually have great resistance to accepting the diagnosis, especially in its early stages. Lastly, substance abuse problems almost always require collaboration with a consumer organization such as Alcoholics Anonymous, Narcotics Anonymous, or Al-Anon.

Most important is to understand how the athletes perceive clinicians. One former Olympic swimmer believes that athletes have great difficulty in finding physicians with whom they can feel connected, partly because of the stigma they attach to physicians and especially if the physicians haven't worked with athletes (written communication with Olympic swimmer Katrina Radke, January 2000).

More often than not, athletes only want to hear one answer: that they can perform. For treatment to succeed, the connection and trust built between a physician and an athlete will be a major factor in determining the outcome of treatment.

Principles of Treatment

Make an accurate diagnosis. This includes identifying individual, family, and other interpersonal dynamics, as well as symptoms of psychiatric illness such as major depressive disorder.

Set realistic goals. The primary goal is to differentiate the "person" from the "athlete." The health of the athlete is more important than the sport. The aim is to strengthen the therapeutic alliance, resolve the problem or illness, and maintain or enhance sports performance.

Educate. Routinely, the family and the patient are educated about the psychiatric condition following the initial evaluation. Education entails defining the problem, identifying causes of the problem, explaining the treatment plan, and delivering the prognosis with and without treatment.

Address transference and countertransference. The athlete's feelings and the clinician's feelings must be addressed at this stage of intervention. It is common for an athlete to experience strong initial transference reactions, usually negative, (eg "you don't understand the pressures I'm under"). When contemplating getting help, the athlete often feels scared and believes he or she cannot trust anyone (written communication with professional boxer Gerry Cooney, May 1999). Likewise, "athlete envy" can trigger countertransference for the physician. It is crucial for the physician to follow well-accepted guidelines for treating "VIPs" and to avoid hero worship. Exceptions to this rule may result in inappropriate treatment and poor outcome (1).

Involve the family and significant others. Integration of interpersonal issues into therapy is usually important for successful treatment. Family members may help to support treatment. During this phase, the context in which the athlete lives and functions may also be explored (28). Involving coaches, agents, and team members in the process may be important for the athlete's full recovery, but the process varies greatly depending on the personalities involved. Again, the physician must use this technique judiciously and obtain informed consent (6).

"Do the right thing." This entails delivering appropriate and adequate treatment, including both pharmacotherapy and psychotherapy (34). Typically, athletes will attempt to define their own treatment and make inappropriate requests. For example, if medicine is prescribed, the athlete may suggest a "homeopathic" (ie, very small) dose of the medication. Although treatment must be dictated by the physician, the athlete's input should always be respected (34). The physician must continuously work to maintain the therapeutic alliance to avoid premature dropout and noncompliance (see "Back on Track After Earlier Treatment Dropout," below).

Continue to consult with a psychiatrist as needed. A psychiatrist can oversee management of medications and psychotherapy as needs dictate. The effect of medication on performance is the key therapeutic dilemma for most athletes. Generally, most medications for Axis 1 disorders require several weeks to begin working and at least 6 to 12 months to achieve long-term effectiveness. The usual problem is lack of adherence when patients experience side effects, which are especially prominent in the early phase of treatment. For example, in cases of bipolar mania or most depressive illnesses that interfere with function, patients require mood stabilizers and/or antidepressants. These medications can produce side effects, such as weight gain or ataxia, that may diminish performance. Most athletes will take medication if they believe or discover it will improve their psychiatric disorder and their ability to function, regardless of the medication's side effects (conversation with jockey Julie Khron, May 2000). New strategies and medication for all the psychiatric illnesses are beyond the scope of this article, but are detailed in psychiatric texts (35), consensus guidelines (4), and in a recent overview (36).

Other Treatment Issues

Coercion must be avoided; that is, psychiatric information usually should not be provided to the coach when the patient is being compelled to provide it against his or her wishes. Obviously, the patient's psychiatric status should not be provided as a basis for selecting membership or starting status on a team. However, sometimes team goals contradict the goals of the patient and coaches or team members may ignore the individual needs of the athlete. On the other hand, if the athlete suffers from increased stress (eg, a close pennant race) or an Axis 1 disorder, inducing the athlete into treatment may be difficult. We suggest a technique common to forensic psychiatry. One physician focuses on the needs of the person as a patient, and a second may act as liaison with coaches and the patient's team to address the needs of the person as a team member (20). Involving the second physician or therapist separates the various team needs from the patient's needs.

During evaluation and treatment, one must distinguish the symptoms of the illness from the pressures of competing. For example, anxiety associated with a game is normal and requires no treatment. However, severe anxiety that persists and prevents functioning may indicate an anxiety disorder that requires intervention (1). It is important for the physician to treat the illness and psychiatric issues, while the patient's sports team focuses on athletic performance (37). That the patient always comes before the sport is a principle worth reiterating.

Finally, the physician must avoid collusion in denial—agreeing with the athlete that there is no problem when one exists. This most commonly occurs when the athlete or team attempts to rationalize antisocial behavior and substance abuse. Axis 1 and 2 personality disorders must be clearly defined for appropriate treatment, and the psychiatrist must maintain boundaries with the patient at all times to ensure a successful outcome (38).

Finding the Right Balance

The fear of social stigma and mistrust of physicians often prevent athletes from seeking treatment for psychiatric problems. Therefore, clinicians may need to enlist the help of coaches, teammates, and significant others to encourage athletes to seek treatment. Diagnosis and treatment maximize elite athletes' talents and improve their life function by addressing psychiatric illnesses or problems. The ultimate aim is to improve patients' health and performance; team needs are less important.

Consultation with a psychiatrist is useful to determine an accurate diagnosis, prescribe medications if needed, and guide psychotherapy. Athletes are usually reluctant to take medications that may interfere with performance, so undertreatment is common. Therefore, to achieve maximal efficacy, we recommend that the primary physician provide at least the minimal effective dose and duration of medication and psychotherapeutic intervention as dictated by patient needs. Further reports of psychiatric intervention for both male and female athletes are needed, as are scientific studies of different treatment strategies.

References

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Tragic Consequences of Untreated Depression

Mr X was in his mid-30s and had a 13-year career in the National Basketball Association. He had a history of lowered mood or "depression" since his teens for which he had never sought treatment. Throughout his career he used alcohol, but never to excess, as a way of coping with the lowered mood. On being released by his team, he felt that his life had no future. He drank steadily for several months and refused therapy or help from former players. He died of a self-inflicted gunshot wound within a year of his release.


'Bases Loaded' With Denial

Mr Y was a professional baseball player in his mid-20s. He had a lifelong history of lowered mood and also had one family member who likely had what was probably a major depressive disorder. During spring training, he noted the onset of irritability, anhedonia, and lowered mood. His wife encouraged him to seek treatment, but he felt that there was nothing wrong. He became more isolated from his teammates and less motivated to go to the ballpark. A discussion with his manager resulted in the patient being blamed for his illness; he "wasn't trying hard enough."

On the urging of his agent, he sought help from the psychiatrist working with his team. He was started on an antidepressant and felt better within 6 weeks. He still was not well enough to pitch and returned only late in the season. He continued medication the following season and returned to prior form.


Back on Track After Earlier Treatment Dropout

Mr Z, a jockey in his mid-40s, had been highly successful throughout his career. During one of his races he was thrown from his horse and was severely injured, with multiple fractures to his face and body that required extensive surgery. Following the injury, he developed signs and symptoms of posttraumatic stress disorder and subsequently had a major depressive episode. He was unable to ride.

He was reluctant to try psychotherapy but tried it briefly and then quit. After he was unable to work for 2 years, his friend convinced him to consult a psychiatrist. He tried individual psychiatry, which helped a little regarding self-esteem issues, but he still felt depressed. While in therapy, he refused medication for 2 years but finally, in desperation, agreed to try it. He was started on an antidepressant and made a "miraculous" recovery. He returned to riding and was able to return to his previous form. He reported feeling better than he ever had in his life—he had apparently suffered from a low-grade mood disorder for many years.


We are indebted to many people who reviewed this manuscript and made suggestions, but particularly to Dan Begel, MD, Janet Taylor, MD, Robert Lipsythe, David Stern, Jeff Mishkin, and Katrina Radke.

Dr Glick is a professor of psychiatry and behavioral sciences and Ms Horsfall is the project coordinator of Psychoses Research in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine in Stanford, California. Address correspondence to Ira D. Glick, MD, Dept of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd, Suite 2122, Stanford, CA 94305-5723; e-mail to [email protected].


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