Clinical Sports Psychiatry

An International Perspective

David A. Baron, Claudia L. Reardon, Steven H. Baron

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118404935
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

This book has it all - written by national and international experts and edited by world authorities, it is the first book on sport psychiatry in over a decade. Dealing with psychopathology, mental health problems and clinical management, it differs markedly from sports psychology books that focus on performance issues. Eating disorders, exercise addiction, drug abuse are all problems that are seen in 'everyday' athletes, not just elite performers. This book shows how to help.

This text covers the most important topics in contemporary sports psychiatry/psychology from an international perspective. Chapter authors are experts in the field and global leaders in the related professional organizations, including current and past Presidents/Chairs of the International Society for Sports Psychiatry and of the World Psychiatric Association Section on Exercise and Sports Psychiatry. Authors are mainly psychiatrists: the rest are PhD sport psychologists.

The book comprises representative chapter authors from around the world, to an extent unprecedented in this topic. The authors and editors are well-informed in global perspectives, e.g., having served as consultants to numerous Olympic teams, in addition to service on the International Society for Sports Psychiatry's Board of Directors.

Specifically, this book covers four main categories of topics:

1) mental health challenges faced by athletes (including substance use disorders, exercise addiction, eating disorders, depression, suicide, and concussion),

2) treatment approaches and therapeutic issues with athletes (including different types of psychotherapy for psychiatric disorders, psychotherapeutic performance enhancement approaches, transference and countertransference issues, achievement by proxy, psychotherapeutic issues as applied to a couple of sports that are played around the world, and use of psychiatric medications in athletes),

3) psychosocial issues affecting athletes (including sexual harassment and abuse, cultural issues, and ethics issues), and

4) the field of sports psychiatry (including work within one common sports psychiatry practice setting, and current status of and challenges in the field of sports psychiatry).

There is a growing need for this book. Performance-enhancing drugs, use of psychotropics in impaired athletes, head trauma, sexual abuse, eating disorders, ethics, and depression and suicide in athletes, are just a few of the timely subjects addressed in this text. This is the only comprehensive reference available for those working in the field (or merely interested in it) to consult for current information on these topics. The existing sports psychology texts all focus on performance issues, with little, if any, attention paid to these areas of clinical significance. The book addresses the core differences between sports psychiatry and sports psychology, as well as the areas of overlap. Emphasis is placed on how the disciplines should work together in diagnosing and treating athletes dealing with emotional stress and psychopathology.

Chapters include case examples and specific goals listed at the beginning, along with tables and graphs to highlight key concepts.

Part One

Mental Health Challenges Faced by Athletes

1 Substance Use in Athletes

Eric D. Morse

Carolina Performance, North Carolina State University, USA

KEY POINTS

• A strong, clear, enforceable drug testing policy with frequent, random drug tests would reduce substance use in athletes.
• Assessment of positive drug tests and treatment of substance use disorders and co-­occurring mental illness by sports psychiatrists would help athletes continue to perform at a high level.
• The higher the stakes, the more the risk of doping and the use of performance-enhancing drugs, and the greater the need for sports psychiatrists working with athletes.

BACKGROUND AND SCOPE OF PROBLEM

Despite the risk of negative consequences of loss of performance, pay, and scholarships, elite athletes seem to use most substances at higher rates than age-matched nonathletes in the general population [1–10]. The rates may be lower in some sports, ethnicities, and nationalities [7, 11]. Comparing the National Collegiate Athletic Association (NCAA) survey data from 2005 to 2009, there was a drop in reported use of amphetamines (3.7% of U.S. college athletes reported use), ephedrine (0.9%), and anabolic steroids (0.6%), and increases in cannabis (22.6% reported use), cocaine (1.8%), opioids (3.3%), alcohol (83.1%), and alcohol binges (38.8%) [12]. While sometimes used initially for performance-enhancing reasons, many of these substances can represent gateways to other drug use. There are certainly risks of “stimulant stacking” (energy drinks, excitatory amino acids, caffeine, nicotine, ephedrine, and amphetamines) that can lead to “upper–downer” pairings (adding cannabis, alcohol, or prescription sleeping medications to stimulants) [4]. Sports psychiatrists must be aware of these pairings and patterns of use among their athletes to avoid enabling. Sports psychiatrists must be able to urine drug test their athletes for diagnostic purposes, in a way that would not lead to negative consequences and that would encourage treatment and assistance over penalties. Our elite athletes are role models for our youth; thus, creating prevention and intervention programs to reduce substance use in athletes may have a significant impact on substance use in general.

REASONS FOR USE

Athletes often use substances to objectively or subjectively assist performance. McDuff lists the most common reasons for elite athletes to initially use substances: to fit in, boost self-­confidence, produce pleasure, escape problems, and have fun. Reasons for continued use may include: stress relief, psychological dependence, negative emotions reduction, and tolerance/withdrawal [4]. In this author’s and others’ experiences, a leading reason for athletes to use substances is to get high. Looking at the reasons for an individual athlete can help in the development of a treatment plan. Developing new coping mechanisms other than substance use is vital.

Enhancing performance with substances may involve getting bigger, stronger, or faster. For some athletes, substances are used to get thinner or to pay better attention. Relieving pain with opioids may lead to an iatrogenic addiction. Some athletes compete using opioids. A recent study by the National Institute on Drug Abuse and the National Football League (NFL) of 644 former NFL players found that 52% used pain medication while playing. Of those players, 63% received medication from a nonmedical source; 15% of the retired players are still misusing pain medications [5].

Substance use to celebrate wins or console losses may be done on an individual or team level. Particularly in individual sports, individual athletes may deal with the stress of winning (and higher expectations) or losing (and disappointment) with substances. It seems to be acceptable in many societies to celebrate a tough win with alcohol, as evident from many sports-related television commercials. Champion teams and athletes pop open and shower each other with champagne to celebrate. When substance use is part of the team culture through peer pressure, hazing rituals, or even as part of the team’s recruiting process, it can be propagated from class to class or from old professional veterans to rookies.

Career termination

Of all the challenges with which athletes must contend, the termination of their athletic career certainly ranks among one of the most difficult [13]. When athletes recognize that professional sports participation is no longer an option, they may be reluctant to give up the identity of athlete. For many athletes whose identity has been drawn from athletic participation, anticipation of life after athletics can be scary. It is common for athletes experiencing the termination phase of their career to deal with the anxiety and fear by using substances [14]. Unexpected, early career termination due to injury, poor academic performance, or positive drug tests are even more challenging and may lead to more substance use. Unresolved physical pain may lead to substance use as well. The loss of identity and remaining stuck in the past may be seen in reunions, alumni functions, and frequent unexpected visits to the training room long after athletic careers are over. Substance use at these times may peak. Sports psychiatrists need to screen, warn, and treat their athletes of these common occurrences. Athletes often do not like to discuss what they would do if their athletic careers were over tomorrow, but discussing the subject and developing a Plan B may help prevent maladaptive behaviors in the future and should be part of the work of the sports psychiatrist.

Weight management

Most athletes are concerned with weight management at one time or another, to enhance performance, make specific weight classes, or appear attractive for judges [15]. For some, the focus on weight management becomes obsessive and eating disorder behaviors develop. While misusing substances like diet pills, stimulants, or laxatives is expected with eating disorders, some athletes may develop a co-occurring substance use disorder [16]. Suspecting an eating disorder should be probable cause for a urine drug screen within athletic drug testing policies. While there is a sport-specific prevalence for eating disorders, no sport or individual should be considered exempt from developing an eating ­disorder. Anabolic steroids may be used to trim down and reduce body fat, or to bulk up and gain weight. Some athletes use cannabis to improve their appetites and gain weight for their sport.

Performance effects

Athletes may use substances for performance-enhancing effects. When sports psychiatrists refer to performance-enhancing drugs, we may think of anabolic steroids and stimulants. However, athletes may see some initial improvement in their game with alcohol, cannabis, or benzodiazepines if they are too energized or have difficulties with intensity regulation when competing. They may pair uppers (steroids, stimulants, or cocaine) with downers (alcohol, benzodiazepines, or cannabis) as they continue to use and require assistance with resulting insomnia or fatigue. Continued use or abuse may lead to dependence and/or a drop-off in performance. Tolerance develops and higher doses must be consumed to gain the same performance or euphoric effect. An athlete may have a difficult time deciding if continued use is for performance-enhancement reasons or for relaxation and coping with the deterioration in performance. Substance use usually increases during the off-season and on days off [5].

Athletes, coaches, trainers, or administrators may ask sports psychiatrists to prescribe performance-enhancing medications to athletes. Importantly, proper testing, diagnosing, treatment planning, and prescribing appropriate medication for mental illness should not be considered performance enhancing, but performance enabling [17]. Sports psychiatrists help athletes return to their previous level of functioning and performance with the use of psychiatric medications. However, sports psychiatrists must be aware of the psychiatric medications that are on the banned list of the sport in which their athlete-patient participates (particularly stimulants, modafinil, and beta-blockers) and, if a prescription of one of these medications is appropriate, submit the proper documentation for Therapeutic Use Exemptions (TUE) for most professional and Olympic sports [18]. The NCAA also has certain guidelines [19]. Medications to treat addictions, such as methadone or buprenorphine, may be on some banned lists as well.

TRAUMATIC BRAIN INJURY

Athletes with traumatic brain injury (TBI) are more susceptible to the intoxicating effects of substances and may get in trouble more easily due to the disinhibiting effects of the brain injury. Cognitive impairments may become more pronounced. Athletes with postconcussive symptoms or syndromes may rely on substances to help manage the headaches and frustrations of not being able to practice or compete. The risk of suicide may be magnified when TBI is complemented with substances. Athletes with TBI may become more impulsive, have more emotional dysregulation, have less cognitive reserve, and require more time to clear from substances, particularly from longer-acting benzodiazepines, which may be inappropriately prescribed for sleep by some physicians.

RECOGNIZING SUBSTANCE USE

Prior to or besides urine drug testing, how might sports psychiatrists recognize substance use in athletes? First and foremost, sports psychiatrists might not recognize substance use unless they ask. Other members of the sports medicine team might not feel comfortable or have much training in asking the questions. Asking yes/no questions such as “Do you drink alcohol?” often leads to a quick “no” from the athlete. On the other hand, asking “How much alcohol do you drink in a typical week?” usually results in a response of some number of drinks. When the answer is “zero,” the sports psychiatrist should probe why the athlete does not drink. The same series of questions should continue for other commonly used ­substances – stimulants, cannabis, anabolic steroids, cocaine, and others depending on the location and what substances are popular in that region or campus. To find out what other substances are popular in your region or campus, the sports psychiatrist may simply ask, “What are your teammates usually using?”

Besides responses to direct questions, students having difficulty reporting to practice, study hall, or class on time might be a clue to substance use problems. There may be a drop-off in their academic or athletic performance. Other odd behaviors or changes in attitude or work ethic are common. Sometimes substance intoxication is more obvious than substance withdrawal. More specific signs and symptoms of substance use are listed in Table 1.1.

For universities and teams, a good substance use prevention or drug testing policy will allow drug testing for cause. Discovering some of the signs mentioned previously should prompt someone to order a drug test. A good substance use prevention or drug testing policy is not designed to punish the athlete, but rather to help the athlete get the assistance she may need. Treatment and education should be emphasized over suspensions. There should be a “treatment track” that may allow an athlete who tests positive to return to play sooner if the athlete is compliant with treatment recommendations.

Table 1.1 Signs and symptoms of substance use.

Substance	Signs and symptoms of use	Signs and symptoms of withdrawal
Stimulants	Dilated pupils, anxiety, jitteriness, increased heart rate/blood pressure, mood, somnolence, dry mouth, nasal problems, restlessness, insomnia, talkativeness, loss of appetite, tics	Fatigue, headaches, anxiety, depression
Cannabis	Smell on clothes, bloodshot eyes, memory problems, lack of motivation, paranoia, increased appetite, use of eyedrops, drowsiness, giggling, slowed responses, cough	Insomnia, cravings, irritability, anxiety, reduced appetite
Alcohol	Sedation, disinhibition, slurred speech, euphoria, ataxia, blackouts, memory problems, flushing, impulsiveness, vomiting, fights, legal problems, nystagmus	Increased heart rate/blood pressure, tremor, seizures, irritability, insomnia, fatigue, depressed mood, headache, sweating
Anabolic steroids	Acne, rapid weight gain, irritability, rage, gynecomastia or hair loss in males, deepening of voice and facial hair in females, injection sites, cysts, bloating, night sweats, joint pain, insomnia, mood swings	Depressed mood, weakness, fatigue, aches, insomnia, weight loss, restlessness

TREATMENT

Individual treatment

Sports psychiatrists may be asked to assess and intervene when an athlete tests positive on a random urine drug test from a team, university, NCAA, or professional league. Teams, universities, or leagues must have a very clear, fair drug testing policy that allows for assessment, treatment, and enforceable consequences for positive drug tests with little wiggle room for exceptions for more talented athletes in money-generating sports or for influential coaches. The best deterrent for drug use in sports is frequent, accurate, very closely observed, truly random urine drug testing. Masking agents must be tested for as well. If athletes know they will...

Table of contents

• Cover
• Title page
• Copyright page
• Contributors
• Foreword by Steve Peters
• Foreword by Thomas Newmark
• Acknowledgments
• Preface
• Part one: Mental Health Challenges Faced by Athletes
• Part Two: Treatment Approaches and Therapeutic Issues with Athletes
• Part Three: Psychosocial Issues Affecting Athletes
• Part Four: The Field of Sports Psychiatry
• Index