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Bipolar and Psychotic Disorders in Elite Athletes: a Br J Sports Med: First Published As 10.1136/Bjsports-2019-100685 on 16 May 2019

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Bipolar and Psychotic Disorders in Elite Athletes: a Br J Sports Med: First Published As 10.1136/Bjsports-2019-100685 on 16 May 2019 Narrative review Bipolar and psychotic disorders in elite athletes: a Br J Sports Med: first published as 10.1136/bjsports-2019-100685 on 16 May 2019. Downloaded from narrative review Alan Currie, 1 Paul Gorczynski,2 Simon M Rice,3,4 Rosemary Purcell,3,4 R Hamish McAllister-Williams,5 Mary E Hitchcock,6 Brian Hainline, 7 Claudia L Reardon8 1Regional Affective Disorders ABSTRact literature was also reviewed, where there were Service, Northumberland, Tyne Bipolar and psychotic disorders are relatively common gaps in athlete-specific literature, for guidance on and Wear NHS Foundation Trust, diagnosis, prevalence, functional impairment and Newcastle upon Tyne, UK and likely to have a significant impact on quality of 2Sport and Exercise Science, life and functioning which, in the context of elite management. Elite athletes were defined as those University of Portsmouth, sport, includes a potential negative impact on sporting competing at professional, Olympic or collegiate/ Portsmouth, UK university levels. 3 performance. For this narrative review article, the Research and Translation, literature on bipolar and psychotic disorders in elite Orygen, The National Centre athletes was comprehensively searched, and little of Excellence in Youth Mental DIAGNOSIS OF BIPOLAR DISORDER empirical research was found. A diagnosis of bipolar or Health, Melbourne, Victoria, Bipolar disorder is a recurrent and often chronic Australia psychotic disorders may be challenging in elite athletes 4 mental health disorder. It is characterised by Centre for Youth Mental because of complicating factors related to the modifying Health, University of Melbourne, episodes of elevated mood (‘mania’, or when role of exercise and potential precipitating impact of Melbourne, Victoria, Australia less severe, ‘hypomania’) and also commonly 5 substance use. Medications used to treat bipolar and Northern Centre for Mood of depressed mood, with associated change in Disorders, Institute for psychotic disorders may have side effects particularly functioning.2 Neuroscience, Newcastle problematic for elite athletes. Future research should Mania is characterised by an abnormally and University, Newcastle upon be tailored to the specific characteristics and needs Tyne, UK persistently elevated, expansive or irritable mood 6 of elite athletes and to the sporting context in which Ebling Library for the Health and disinhibited behaviour.2 Increased energy and the disorders may arise. Specifically, further research Sciences, University of reduced need for sleep are typical, and insight is Wisconsin-Madison, Madison, is needed on the prevalence and incidence of these frequently diminished. Psychotic symptoms such Wisconsin, USA conditions in elite athletes and the impact of both the 7National Collegiate Athletic as delusions or hallucinations can occur and, if disorders and their treatments on sporting performance. Association (NCAA), present, are usually consistent with the individu- Indianapolis, Indiana, USA al’s elevated mood (‘mood congruent’). Symptoms 8Department of Psychiatry, University of Wisconsin Madison of mania must be present for at least 7 days and School of Medicine and Public INTRODUCTION associated with significantly impaired function to Health, Madison, Wisconsin, The typical age of onset of bipolar and psychotic permit diagnosis of a manic episode. Lesser degrees USA disorders coincides with average peak performance of functional impairment, or simply a change in 1 in elite athletes, yet information on their preva- functioning without impairment, for at least 4 days http://bjsm.bmj.com/ Correspondence to lence in elite athletes and their impact on athletic are consistent with a diagnosis of a hypomanic Dr Alan Currie, Regional 2 Affective Disorders Service, performance is limited. Furthermore, evidence to episode. Episodes of mania and hypomania tend Northumberland, Tyne and guide the clinician who is providing treatment for to be less frequent, and shorter, than depressive Wear NHS Foundation Trust, these conditions in elite athletes is primarily based episodes.3 4 Newcastle upon Tyne NE4 5PL, on ‘expert opinion’ and extrapolation from general Episodes of depression are characterised by some UK; alan. currie@ ntw. nhs. uk (non-sporting) guidelines. or all of the following: low mood; loss of interest Accepted 9 April 2019 The purposes of this narrative review are to: (A) or pleasure; reduced energy; changes in sleep on 8 July 2019 by guest. Protected copyright. Published Online First synthesise the literature on the diagnosis, preva- and appetite; feelings of guilt or worthlessness; 8 May 2019 lence, impact on performance and management of thoughts of death or suicide; psychomotor agitation bipolar and psychotic disorders in elite athletes; or retardation; and poor concentration.2 Symptoms and (B) provide recommendations based on what can last for weeks or more. For diagnostic purposes, is currently known. One of the authors (MEH) a minimum of five symptoms and duration of 2 searched key databases (PubMed, SportDiscus, weeks is specified for a major depressive episode. PsycINFO, Scopus and Cochrane) and repeated If psychotic symptoms are present, they are usually the searches in November 2018 (3 months before congruent with the individual’s depressed mood. intended submission). Figure 1 illustrates the search Features of both hypomania or mania and depres- strategy. Search terms relating to the disorders, sion can be concurrent (described as having ‘mixed sports participation and the elite nature of partic- features’).2 For example, an individual may exhibit © Author(s) (or their employer(s)) 2019. No ipation were combined. We identified 420 poten- increased activation and social disinhibition, but be commercial re-use. See rights tial references and included original studies that: dysphoric in mood. This combination may appear and permissions. Published (A) were written in English; (B) were conducted counterintuitive, but it is more common than often by BMJ. exclusively among current elite athletes; and (C) recognised.5 Individuals in such states are at partic- 6 To cite: Currie A, presented information on bipolar or psychotic ularly high risk for suicide. Gorczynski P, Rice SM, disorders. Twelve references were retained based on Two main specific subtypes of bipolar disorder et al. Br J Sports Med these inclusion criteria. These were then used by the are recognised.2 In bipolar I disorder, there has 2019;53:746–753. other authors to identify related references. Other been at least one manic episode (with or without Currie A, et al. Br J Sports Med 2019;53:746–753. doi:10.1136/bjsports-2019-100685 1 of 9 Narrative review schizophrenia. In schizophreniform disorder, the duration is Br J Sports Med: first published as 10.1136/bjsports-2019-100685 on 16 May 2019. Downloaded from shorter and there is less functional impairment (often a provi- sional diagnosis). In schizoaffective disorder, mood symptoms occur alongside, and sometimes separate from, psychotic symp- toms and may be primarily depressive or manic. Attenuated psychosis syndrome is not an official Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis but is noted within the DSM as a Condition for Further Study,2 with manifestations that reportedly include delusions, hallucinations or disorganised speech in attenuated (or subthreshold) form but still sufficient to be distressing or disabling. A proportion of individuals with attenuated psychosis syndrome will progress to a full psychotic syndrome,8 even when symptoms appear to have resolved.9 Indi- viduals with attenuated psychosis syndrome are at risk for devel- oping many non-psychotic disorders that may need treatment, particularly given their associations with suicidality.10 11 Secondary bipolar and psychotic disorders Substance/medication-induced bipolar disorder and bipolar disorder due to another medical condition are secondary bipolar disorders.2 Similarly, psychotic symptoms may also be substance/ medication induced or due to another medical condition.2 Within the general population, some of these secondary disorders are more commonly a consideration when there is a later age presen- tation12 as they may be associated with conditions such as thyroid disease, multiple sclerosis and right-sided cortical or subcortical brain lesions, which are more common in older populations.13 Of more relevance in sporting populations are traumatic brain injuries, where secondary bipolar disorder is a possible although uncommon sequela,14 and stimulant or anabolic androgenic steroid (AAS) use contributing to depressive or hypomanic symp- toms, an unstable mood or psychotic symptoms.15–17 Sports-specific diagnostic issues A diagnosis of bipolar disorder or a psychotic disorder may be more difficult to make in an elite athlete. Exercise may be an outlet for the excess energy seen in mania or hypomania, which Figure 1 Search strategy. could delay diagnosis. In addition, overactivity may be obscured http://bjsm.bmj.com/ or normalised in the context of athletic training.18 AAS may be misused by athletes for performance reasons16 19; the mood episodes of major depression); in bipolar II disorder, hypomanic disturbance and psychotic symptoms that have been reported and major depressive episodes have occurred, with no periods in association with their use can confuse diagnosis. Impor- of mania. tantly, though, hypomanic symptoms secondary to AAS are Patients with bipolar disorder (especially bipolar II disorder) usually subsyndromal and typically
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