Interviewing Principles for the Psychiatrically Aware Sports Medicine Physician

The examination

It is essential that the SMP understands the stigma facing many athletes when it comes to admitting that they have an emotional problem or disorder. Indeed, the very word “psychiatrist” in sporting circles can provoke a stigma reaction. Consequently, many athletes suffer needlessly, stoically ignoring their symptoms.

Terry Bradshaw, the Hall of Fame quarterback for the Pittsburgh Steelers, used to sweat profusely and break into tears after a game, but never realized he was suffering from

Depression

Insomnia, weight loss, and fatigue, in particular, should alert the SMP to the possibility of depression, which has a lifetime prevalence of 15% in the general population and 25% in women.

The case of ex-New York Mets pitcher Pete Harnisch illustrates the low index of suspicion that exists in the athletic community regarding the existence of emotional disorder.

Coming off shoulder surgery, Harnisch was expected to be the ace of the 1997 Mets pitching staff. He stopped chewing tobacco in spring

Bipolar disorder

Though bipolar disorder is prevalent in only 1% of the population [9], several high-profile athletes have been diagnosed with this disorder, including Illie Nastase, John Daly, and Muffin Spencer-Devlin. In the hypomanic (less severe) phase, athletes may seem only gregarious, outrageous or “overaggressive.” In the frankly manic or depressed phase, severe behavioral dysfunction occurs, as when Miami Dolphins defensive tackle Dimitrius Underwood took a knife to his neck in 1999.

Pro Bowl center

Anxiety disorder

Generalized anxiety disorder (GAD) is characterized by excessive worry and anxiety, but not by gross panic attacks. It is a common condition, with a 1-year prevalence range of 3% to 8% [12]. Many athletes have normal “state” anxiety—they get anxious during the state of preparedness that precedes a big meet. But some athletes also have “trait” anxiety—from an early age, often beginning in adolescence, they have been worriers, stressed out before examinations and frequently projecting ahead

Panic disorder

There is a lifetime prevalence rate of 5% for panic disorder and panic attacks [13]. Panic attacks are characterized by spontaneous, unexpected bouts of sheer terror, during which patients will state, “I felt totally out of control, like I was going to die, like I was going to go crazy.” They also often feel trapped, and feel they must leave a situation immediately, or they feel that they are having a heart attack and need to call 911. There is often no cue for the first attack.

On history, one

Social anxiety disorder

The best known example of social anxiety disorder is Ricky Williams, star running back for the Miami Dolphins, who, early in his career, gave postgame interviews to reporters while still wearing his helmet with his visor down. In retrospect, Williams always knew he was “wired differently” from his classmates, even in high school. He would recoil from social situations, even from speaking in class, and believes that because he was a football star, his extreme introversion was shrugged off as

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a common psychiatric disorder that, unfortunately, often goes unrecognized by general physicians and psychiatrists alike.

The lifetime prevalence of PTSD is estimated to be about 8% of the general population, but an additional 5% to 15% (up to 23% of the population) may experience subclinical forms of the disorder [15]. Vietnam veterans, of course, have a higher incidence (30% of RVN veterans have experienced PTSD; an additional 25% experienced

Obsessive-compulsive disorder

In obsessive-compulsive disorder (OCD), patients cannot get certain thoughts that bother them or make them anxious out of their minds, regardless of how hard they try. They may have compulsions such as compulsive checking, hand washing, counting, or hoarding. These symptoms have to be inquired about, because the patient will rarely volunteer them. Because OCD is an anxiety disorder, any situation that increases stress will worsen it.

As a senior, Julian Swartz was the Associated Press high

Alcoholism and substance abuse history

Recent evidence indicates that high school athletes, though they get better grades than their nonathletic classmates, are more likely to use drugs and alcohol [25]. Among athletes, particularly at the high school level, male athletes have been found to drink to intoxication significantly more often than female athletes. Since it has been found that 6.2% of Americans have indulged in heavy alcohol use in the past month, if the SMP is the team physician for a football team, it is likely that at

Anabolic steroid abuse

An estimated one million people in the United States have used illegal steroids at least once [30]. Alarmingly, half the users start before the age of 16, and a recent survey [31] showed that 6% of all high school students have used steroids. The highest use is seen among 18- to 25-year-olds, with 26- to 34-year-olds having the next highest rate. Estimates for the rate of use in body builders have ranged from 50% to 80%, and athletes who abuse steroids have, in the past, tended to come from

Muscle dysmorphia

Muscle dysmorphia, also known as “reverse anorexia,” is a disorder of distorted body image. Though the patients are extremely well built and solid, they feel that they are small. They check their appearance dozens of times a day in the mirror, and become anxious if they miss even 1 day of working out in the gym. Their preoccupation with weight lifting costs them social and occupational opportunities. For example, though their bodies are extremely well developed, athletes who have muscle

Supplements and over-the-counter medicines

All athletes should be asked whether they are taking creatine or other over-the-counter supplements. Some supplements, especially those containing stimulants, can precipitate a manic episode in those prone to bipolar disorder. Sometimes athletes will refrain from abusing substances if the SMP stresses strongly enough that the governing body of their sport will disqualify them for continued use.

Pathological gambling and fantasy league involvement

More and more athletes are involved in multiple fantasy leagues. Athletes are not only competing with each other on the field, but also on their computers. In professional sports, ethical conflicts of interest may arise. If you are a defensive tackle or linebacker in football, should you stop an opposing running back cold if he is the mainstay of your fantasy league?

Pathological gambling is present in up to 3% of the general population, and has been responsible for the destruction of several

Attention deficit/hyperactivity disorder

The ADHD athlete will probably not come to you complaining of ADHD, but careful history or history obtained from parents will reveal that the athlete has difficulty finishing projects, often loses things, is forgetful, has difficulty organizing tasks and activities, and is easily distracted. A good question to ask the athlete to tease out the diagnosis is: When you were in grammar school and a fire engine went by, or it started to snow, did you get so lost in the distraction that you forgot

Overtraining

Overtraining [43] refers to a negative response to training stress, often due to chronically high training levels without periods of lower training loads. The overtraining syndrome consists of a variety of psychophysiological signs and symptoms.

Often athletes push themselves to train so intensively because they do not feel as talented as others on their team, but feel they can compensate by intensive, excessive training. The syndrome is dubbed overtraining because despite the lengthy and

Career termination issues

It is often said that a professional athlete dies twice. Certainly retirement is a major problem for a person whose identity is based primarily on athletic prowess. When an athlete ends his or her career, by definition it is premature, and this makes an adverse reaction more likely. Over one third of people in the general population who retire become depressed, and after 2 years 50% are back in the work place in some capacity [50]. Athletes fare even less well. They engage in denial, and one

Learning disabilities

In the course of examining an athlete's thought processes, the interviewer may discover that the athlete has been pushed along in the educational process, not because of academic merit, but because of his or her highly valued athletic prowess. Alan Page [52], the Hall of Fame defensive lineman for the Minnesota Vikings and current associate justice of the Minnesota Supreme Court, related the following: late in Page's career, the Vikings got a new defensive line coach. Though the players were

Dreams

Occasionally a patient may sheepishly relate a dream to the SMP. One does not have to be a psychiatrist to explore what the athlete feels the meaning of such a dream is. Dreams are important to explore because athletes, as a group, tend to be superstitious, and more than a few believe that dreams can foretell their future. For example, before he fought Lou Del Valle in their July 1998 bout, light heavyweight champion Roy Jones dreamt that the soft-punching Del Valle would knock him down. Though

Sports parents interview

When dealing with a child or adolescent athlete, it is important to involve the parents in an assessment of the athlete and the athlete's problem. A meeting with the parents should be held, and parameters of confidentially should be laid out. If the athlete is an adolescent, the teen's permission should be sought before having the parental interview. Child athletes greatly appreciate having their permission sought out as well, and the request shows interest and understanding on the part of the

Transference

Speaking of parents, an athlete's attitude toward a physician is apt to be a repetition of the attitude the athlete has had toward authority figures. It is the set of expectations, beliefs, and emotional responses that a patient brings to the doctor–patient relationship. Transference, therefore, does not necessarily reflect the reality of who a doctor is or how a doctor acts, but rather what persistent experiences the patient has had with all important authority figures throughout life.

The

Countertransference

Physicians, too, have unconscious or unspoken expectations of patients. They might think of patients as “good” when their expressed severity of symptoms correlates with an overtly diagnosable biological disorder. Patients are appreciated when they are compliant and do not challenge the treatment, when they are emotionally controlled, and when they are appropriately grateful [56]. If these expectations are not met, physicians may blame patients and experience them as unlikable, untreatable, or

Psychiatric diagnosis and referral

The SMP may make a formal psychiatric diagnosis, if he is comfortable with doing so, or he can speak to the athlete and family in general terms (“Emily seems down; perhaps she's depressed,” or “Rick's feeling like he's under too much pressure; he may be having anxiety”). Treatment for emotional problems may be undertaken if the SMP is comfortable in that arena, or referral to a sport psychiatrist can be made. At times, if the SMP feels that the athlete might feel a stigma from being diagnosed

Third-party payment

If the SMP decides to undertake psychotherapy, the therapy could be submitted to insurance using the diagnoses of an Axis I disorder, such as anorexia nervosa. Often a DSM-IV Axis I diagnosis of “adjustment disorder” is applicable [57], especially if the athlete's performance problem is causing a “significant impairment in their social (including sports), academic, occupational, or family functioning.” If the athlete has a medical condition (asthma, diabetes, headache) that worsens when she is

Summary

The SMP must function as an important gatekeeper in the diagnosis and prevention of emotional disorders and injuries. The preparticipation physical, the only time all year that many athletes see a physician, provides the opportunity. Examples of psychiatric problems common to athletes, their incidence in the population, and diagnostic tips to ferret them out have been given. Vignettes about well known athletes who have had these problems are included. Each highlights how the lack of diagnostic

Acknowledgments

Deepest appreciation to Judy Brown for research assistance and transcription, and to Ian Tofler, MB, BS, for editing assistance.