Current p SYCHIATRY Sport psychiatry How to keep athletes in the game of life, on or off the field Some athletes’ toughest opponents are depression, addictions, and eating disorders. Managing these patients’ mental illnesses is a new niche for psychiatry Antonia L. Baum, MD Clinical faculty Department of psychiatry George Washington University Medical Center Washington, DC port psychiatry—a relatively new subspecialty— emphasizes treating mental illness caused in athletes S by a pre-existing disposition, stressors unique to sports, or use of anabolic steroids or other substances. Sport psychiatrists do not set out to enhance an athlete’s perfor- mance, although effective therapy may produce that outcome. Athletes of all ages and levels, from Little League to the Olympics, are vulnerable to psychiatric disorders. Using real- life examples, let’s look at the practice of sport psychiatry and examine common psychopathologies in athletes. Psychiatry in the gym Psychiatric illness in an amateur or professional athlete may arise from coincidence, a predisposing pathology that first attracted the athlete to the arena, or a psychopathology caused by the sport itself. Some athletes succumb to suicide (Box 1),1 although insufficient data exist to establish the prevalence. Educating athletes, their families, coaches, and trainers about mental illness is key to identifying at-risk athletes and VOL. 2, NO. 1 / JANUARY 2003 51 Sport Psychiatry careers are relatively short because of their physical demands. Box 1 Professional athletes may be so focused on their sports careers NO MORE FOOTBALL, NO MORE MEANING that they are ill-equipped to face life without athletic compe- tition. Retirement, with its abrupt change in emotional sup- n article in Sports Illustrated describes a history port and finances, can be overwhelming. Aconsistent with attention-deficit/hyperactivity Golden Gloves boxer Gerry Cooney recalls a difficult disorder in a young man named “Kenny,” who played descent into retirement, complicated by alcohol. He received high school football and ultimately took his own life. treatment and now runs an organization designed to help In the sportswriter’s words: other boxers through the transition to a life without sports. “…to be in sports, to be active—that was always what motivated him, diverted him from the less active Affective disorders in athletes pleasures of life. His grades were invariably better during Unipolar and bipolar affective disorders occur in athletes, as in the football season. The only time he really floundered any population. Sometimes athletes with depression find tem- was after he finished school, and there was no more porary relief in athletic involvement—in some cases for sub- football to point to in the fall.”1 stantial periods. Depression. U.S. Olympic diver Wendy Williams describes years of denying and coping with depression. Eventually, referring them for treatment. To that end, think of sports and however, her affective symptoms required psychiatric inter- psychiatry in a consultation-liaison model.2 A psychiatrist vention. Refusing medication, she first tried psychotherapy working alongside an orthopedist at the gym would help alone. Several years later, after a worsening of symptoms and remove the stigma of psychiatric illness in sports and allow for several episodes of suicidal ideation, Williams relented to drug timely diagnosis and treatment. therapy to good effect.7 Bipolar disorder. Bipolar mania can cause the same behavioral Special stressors of athletes disturbances in athletes as in anyone else. Stressors in profes- Stressors unique to athletes that may cause, trigger, or worsen sional athletes’ lives can trigger a manic episode, however, and psychopathology include pressure to win, constant risk of the public may witness the episode’s manifestations. When injury, and the specter of sudden retirement at an early age. this occurs, the athlete’s mental illness is generally misunder- Pressure to win. Parents and coaches pursuing vicarious aspi- stood by the public and misrepresented in the media. rations may push a child athlete to physical and emotional In discussing the use of psychological screens for extremes, a dynamic that Tofler calls “achievement by proxy.”3 prospective National Football League players, for example, a These adults may send children away from home for training sportswriter explained the rationale as going for “…the right or remove them from school in the hope that they will excel at mix of on-field aggression and off-field character. No team a sport. Intense training may preclude normal childhood wants to draft the next Dimitrius Underwood.”8 friendships and pursuits and may become frankly abusive.4 Underwood, who reportedly has bipolar disorder, slashed Gymnast Christy Henrich competed in one World Cup his throat under the pressure of being a first-round draft pick gymnastics meet with a broken foot and ultimately died of while a member of the Miami Dolphins. He survived and complications of anorexia nervosa. During the girl’s training, went on to play 19 NFL games before being released this sea- her mother was quoted as saying, “A gymnast without a high son by the Dallas Cowboys.9 pain threshold is a gymnast without a career. Their body is a machine, and they are a person. The two are separate.”5 Anxiety disorders Injuries can threaten the athlete’s career and are a major cause Obsessive-compulsive disorder may have unique manifesta- of stress. Olympic diver Greg Louganis was devastated by tions on the baseball diamond, where the batter wears his knee injuries that ended his gymnastics career at a young age, “lucky socks” to every game, spits his tobacco juice in a par- before he switched to diving.6 ticular pattern, or taps his bat on the ground a requisite num- Retirement. Even in the absence of injuries, most athletic ber of times before approaching the plate. It is easy to imagine continued on page 55 52 Current VOL. 2, NO. 1 / JANUARY 2003 p SYCHIATRY Current p SYCHIATRY continued from page 52 that the features of obsessive-compulsive personality disorder, order while attending Georgetown University on a track present in a subset of those with obsessive-compulsive disor- scholarship.13 der, can contribute to athletic success. • Where it is imperative to “make weight,” including Repetition and perfectionism are required for the athlete wrestling, horse racing, and crew. Thoroughbred jockey who aspires to succeed at the elite level. U.S. speed skater Eric Herb McCauley recalls his bulimia developing when he Hayden wore grooves into a wooden board on which he tire- was a high school wrestler, running in rubber suits and lessly practiced the side-to-side motion that hypertrophied his vomiting to keep his weight down. Later he won more quadriceps en route to the Olympic gold medal. than 3,000 races at major horse tracks, using diuretics Social phobia. Some athletes with social phobia appear to express a When prescribing psychotropics to the athlete, consider counterphobic response on the sports-related fluid loss, vo2 max, and cardiac output field or find an escape from their anxiety in this forum. Perhaps Ricky Williams, who has and laxatives on his way to less than 2% body fat.14 acknowledged that he is being treated for social anxiety disor- • Where scoring may be based in part on aesthetics, der, takes refuge behind the armor of his helmet and uniform including gymnastics, figure skating, diving, synchro- as a running back for the NFL’s Miami Dolphins.10 nized swimming, and—though not a competitive Panic disorder. Earl Campbell, a former NFL running back, sport—ballet. developed panic disorder after his retirement from profession- In aesthetic sports, the onset of an athlete’s eating disor- al football. The chest pain and palpitations he experienced der often can be traced to a single, critical comment (Box 2).5 caused him to seek help, but he told a newspaper reporter, “I Psychotic disorders also arise in athletes, sometimes after didn’t realize I was going to a shrink, and when I found out, abuse of anabolic steroids or other substances or in association I almost slugged him.”11 After an initial prescription of with bipolar disorder or schizophrenia. There is nothing more alprazolam, Campbell’s panic symptoms were well managed poignant than treating a first episode of schizophrenia in an through relaxation techniques and exercise. Posttraumatic stress disorder (PTSD). Julie Krone, the cele- Box 2 brated female jockey, developed PTSD after two falls from her mount: a serious spill from which she recovered, and later a ‘YOU’RE SO FAT!’, HE SAID, more minor fall that resulted in two broken wrists.12 Her anx- AND SHE STARTED PURGING iety symptoms were treated, and she went on to race horses n Little Girls in Pretty Boxes—her book about the again before her retirement. She now participates in the Irigors of gymnastics training and competition—news Women’s Sports Foundation-sponsored Minds in Motion columnist Joan Ryan reported that one morning coach Depression Campaign to remove the stigma of PTSD. Bela Karolyi caught gymnast Erica Stokes eating a peach after several hours in the gym. “You’re so lazy!” he Other disorders in athletes bellowed. “You’re so fat! You just come in and pig out ADHD. Children and adolescents with attention-deficit/ after workouts. All you think about is food.” He then hyperactivity disorder (ADHD) may find sports to be adap- made the entire team train an extra 2 hours. tive, even therapeutic. Though this theory is untested, anec- According to Ryan, Stokes began purging after that dotal reports, as in Box 1, are suggestive. tirade: “Like stress fractures and torn muscles, vomiting Eating disorders. Certain athletic environments foster eating was simply another unavoidable insult her body would disorders, especially in athletes who are psychodynamically or have to tolerate if she was going to survive in elite gym- genetically predisposed to disordered eating.