Psychiatric and Neuropsychological Issues in Sport Medicine

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Athletes and stress

Across settings, most athletes face a myriad of competing pressures and stressors. At the high school and college levels, student athletes are expected to handle the same full load of classes as their nonathlete classmates while maintaining rigorous practice, competition, and travel schedules. They essentially have two full-time jobs—student and athlete. Although there is variation by sport, practice often occurs in the early morning or late afternoon. Studying and working on class assignments

Prevalence and incidence

Very little research has examined the prevalence of psychiatric/psychological issues in the sports medicine clinic, and how such issues are managed or treated. Early studies clearly revealed that athletes were found to seek psychotherapy less often than nonathlete counterparts [4], [5], [6]. One of the few studies to examine psychiatric symptoms in student athletes compared recreational athletes and National Collegiate Athletic Association (NCAA) athletes at one university [7]. Based on a

Psychiatric issues in the training room

Although there is a dearth of good data on the prevalence of psychiatric disorders in athletes, it is believed that athletes experience these disorders at the same rate as the general population [8]. For some disorders, athletes may have a higher prevalence rate, including substance abuse, eating disorders, and sports performance phobic behavior, because of the interplay between their sport and these behaviors. According to Burton, however, “The athletic community's mental health needs are

Depression

Depression may manifest through a variety of different areas of functioning. Symptoms may include dysphoria; tearfulness; irritability; disruptions in the areas of sleep, appetite, energy, or libido; social isolation/withdrawal; cognitive slowing; difficulty making decisions; attention and memory problems; and in severe cases, may lead to suicidal ideation or attempts at self harm [9]. Depression may have onset at any age, with the most frequent age of onset in the mid-20s. The lifetime risk of

Anxiety

Clinically significant anxiety is defined by excessive worry or apprehension that causes impairment in social, occupational, or other important areas of functioning [9]. Anxiety may result from exposure to a discrete condition or situation, as in the case of specific or social phobias, or may be nonspecific in nature, as is the case with generalized anxiety disorder (GAD). In the case of the latter, symptoms must be present for more days than not during a period of 6 months, and must not be due

Bipolar disorder

Bipolar disorder involves the presence of depressive episodes and at least one manic (Bipolar Type I) or one hypomanic episode without full mania (Bipolar Type II) [9]. Manic episodes can include elevated, irritable, or expansive mood lasting more than 1 week, with accompanying inflated self-esteem, diminished need for sleep, increased or pressured speech, racing thoughts, excessive distractibility, increased goal-directed activity, or excessive indulgence in hedonic activities with a high risk

Psychotropic medication

Anecdotal evidence suggests that physicians working with athletes may have a tendency to undertreat psychiatric symptoms, because of the lack of empirical study verifying the benefits in the athlete population and the fear of adverse side-effects (eg, sedation and cardiac risks) [16]. A 1999 survey of members of the International Society for Sport Psychiatry (ISSP) revealed that the majority of respondents attempted to minimize certain side effects that would be considered problematic in an

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is marked by persistent difficulties sustaining attention, with or without concomitant hyperactive or impulsive behavior that is not age-appropriate [9]. In all cases, evidence of the symptoms must be present before the age of 7, though occasionally the diagnosis may not be made until adulthood. Prevalence rates are 3% to 5% in school-aged children, and prevalence rates in adolescents and adults are unclear at this point. There is a substantial

Substance abuse

Consistent with the general population, alcohol is the most frequently abused substance in athletics [8], [19]. Athletes may also use marijuana, cocaine, or other illegal substances despite random drug testing, and many athletes have developed creative strategies for thwarting drug testing. Despite stringent drug testing requirements at Division I schools and within some professional sports, substance abuse continues to be a pervasive problem.

An NCAA study of substance abuse [19] revealed that

Overtraining

In an excellent review article, Armstrong and VanHeest [22] describe the similarities between overtraining syndrome and major depression. They propose that multiple life stressors may contribute to both in a “dose-response relationship.” Altered serotonin levels are implicated in the etiology of both disorders, and the study authors present anecdotal evidence of an athlete who had severe and chronic overtraining syndrome and who responded rapidly to treatment with fluoxetine. Both the

Concussion

Concussion is the most frequent type of head injury that occurs in athletics [23]. Although it is clear that concussions cause numerous neurological and neurocognitive symptoms, complicated concussions or complicated recovery from concussions can result in numerous psychological symptoms as well, including irritability, depression, anxiety, and impulsivity [24], [25]. After a concussion occurs, the coach, medical staff, and the athlete should review the circumstances of the injury to see if the

Psychological reaction to injury

When athletes sustain an injury that prevents or limits athletic competition, they may also experience psychological reactions ranging from frustration and anger to anxiety, depression, and even grief. Current approaches to injury management emphasize focusing on the emotional and cognitive components of the injury in addition to physical rehabilitation [29]. Rotella and Heyman [30] noted that the stages of psychological reaction to athletic injury are similar to the stages of grief associated

Role of the mental health professional

Given the poverty of research regarding the prevalence of psychiatric distress and treatment in the sports medicine community, there is still much to learn. Foremost, available data do not include diagnoses based upon agreed-upon criteria (eg, Diagnostic and Statistical Manual of Mental Disorders, fourth edition [DSM-IV] [9]), and it is not clear how such diagnoses are made in sports medicine clinics. Second, although knowing how frequently mental health conditions present in clinics is

Summary

Mental health issues may be a significant aspect of patient presentation in the sports medicine clinic, complicating the management of medical issues and independently creating prominent patient care concerns. Depression/mood disorders, anxiety disorders, substance abuse, adjustments to injury, eating disorders, and impulse control disorders may be subtle or obvious, but require good general clinical skills and awareness to assess the complex interplay among personality, medical, and

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