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Mind, Body and Sport: The psychiatrist perspective

An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness

By Todd Stull

Many changes are taking place in our culture that influence the mental and emotional well-being of today’s student-athletes. The pressure associated with student-athletes’ daily routine can create intense emotional responses. The time, energy and effort put into developing skills in a given sport can result in imbalances in other areas of life. Developmental and environmental influences shape emotional, motor and social aspects of the brain. Eating patterns, impulse control and interpersonal relationships are also affected.

While many colleges and universities have employed sport psychologists – or at least have access to such services – to help student-athletes navigate their unique stressors, it’s also helpful from a psychiatrist perspective to describe factors contributing to adolescent brain development and mental health and substance problems in today’s student-athletes.

The psychiatrist’s role in working with student-athletes is to optimize health, improve athletics performance and manage psychiatric symptoms while operating within an interdisciplinary team. Medical problems and substance-induced conditions need to be ruled out before the psychiatric diagnoses are made.  

The most common psychiatric disorders in student- athletes are represented in the following categories:

  • Anxiety disorders
  • Mood disorders
  • Personality disorders
  • Attention deficit hyperactivity disorder
  • Eating disorders
  • Body dysmorphic disorder
  • Adjustment disorders
  • Substance use disorders
  • Impulse control disorders
  • Psychosomatic illnesses

Anxiety Disorders are among the most common psychiatric problems in student-athletes. Performance anxiety, panic disorder and phobic anxiety after an injury are more likely to be sports-related. Generalized anxiety disorder and obsessive-compulsive disorder are less likely to be sports-related but are still common.  

Many athletes can experience anxiety that is either related to a medical problem or induced by a medical problem or substance use. The typical presentation is with physical symptoms and the psychological symptoms of worry and obsession. Feeling “overwhelmed” or “stressed” are frequent terms used at the time of presentation.

Performance anxiety is connected to the anticipation of the act and becoming overwhelmed during specific components of performance. Panic attacks are intense feelings of being overwhelmed with many physical symptoms such as racing heart, shortness of breath, shakiness and sweating that surface quickly. Phobias may be related to an injury, recovery and return to play.

Generalized anxiety disorder often presents with excessive worry or apprehension that is difficult to control. Obsessive-compulsive disorder presents with intrusive ideas, thoughts, urges or images that come into one’s mind with a ritualized behavior to try to undo or dissipate the obsession.

Mood Disorders include major depressive disorder (clinical depression), bipolar disorder, substance-induced depression (such as alcohol) and a mood disorder secondary to a medical problem (for example, thyroid disorder).  

Fifteen to 20 percent of the population will suffer an episode of depression in their lifetime, and it is among the most common conditions a sports psychiatrist will treat.  

The average age for onset of depression is approximately 22, but it is decreasing. Symptoms of depression include depressed mood, loss of interest, sleep and energy disturbance, appetite and weight changes and impaired concentration. Anxiety is a common symptom. A low frustration tolerance, isolation from teammates and lack of enjoyment with deterioration in performance is a part of the presentation with depression as well. Males are more likely to present with anger and excessive alcohol use.

To meet the diagnosis of bipolar disorder, an individual must have had some degree of mania in his/her life. Initial presentation for bipolar is an episode of depression. Other defining features of bipolar disorder include a strong family history of a mood disorder, chronic sleep problems, irritability, erratic performance, stormy relationships and impulsivity. A substance use disorder commonly co-occurs with bipolar disorder.

Personality Disorders are fairly common in athletes. The most common personality traits in student-athletes associated with performance are extraversion, perfectionism and narcissism. Individuals with personality disorders experience interpersonal difficulties, impulse control problems, misperception of comments or situations and affective instability. Individuals with personality disorders have maladaptive coping skills.

Attention Deficit Hyperactivity Disorder (ADHD) is common in athletes and presents with problems focusing, concentrating, learning, attention shifting and sustained attention. ADHD is probably the most common psychiatric condition that sport psychiatrists treat. Males tend to be more hyperactive. Females more likely will have the inattentive type.

The number of student-athletes with ADHD appears to be increasing and may be related to the influences of social media and a rewiring of the brain. This condition carries over into adulthood in about half of the cases. The symptoms can change with age and can be temporary.

The severity of the symptoms can result in limitations in a number of areas of life and result in performance slumps or interpersonal conflict. Males often present with denial, while females present tired and exhausted.

Eating Disorders occur in both sexes but are more common in females, and in sports in which lower body weight/fat improves performance or weight is divided into classes. The triad of impaired eating, amenorrhea and osteoporosis are the classic features in females.  

Full-symptom presentation usually occurs as the eating disorder progresses; however, disordered eating is more common at presentation. As the condition worsens, more impairment occurs. Individuals affected with eating disorders have decreased energy and a special relationship with food.  

Eating disorders are more common in gymnastics and swimming/diving, which are judged on aesthetics, and in wrestling, cross country and distance running. Eating disorders can be life-threatening, especially anorexia nervosa.

Body Dysmorphic Disorder is a preoccupation with an imagined defect in appearance that causes distress. It is more common in males. Muscle dysmorphia is a subtype that is characterized by an unhealthy preoccupation with muscularity, mirror checking and dieting. Student-athletes in sports in which large physical size and physique are emphasized are more susceptible to the disorder.

Adjustment Disorders are emotional and behavioral responses to a perceived stressful situation that exceeds the athlete’s ability to adapt. The most common emotions are anger, anxiety, sadness and guilt. The most common behaviors include aggression, arrests, insomnia, social isolation, substance use, relationship conflicts, quitting and poor performance.

Substance Use Disorders in student-athletes are different than in the general population. Student- athletes most commonly use alcohol, marijuana, opiates, stimulants (such as Adderall), caffeine, tobacco and performance enhancers.  

Alcohol and drug use is more common in males and more common in the offseason for all student-athletes. Some of the consequences related to substance use include academic problems, vandalism, assault, injury, driving under the influence, sleep deprivation, sexual abuse and, in severe cases, death.  

The brain pathways involved can be reinforced from use and create fundamental changes in the brain. Over time, the effects can hijack the brain. Alcohol and drug use commonly co-occur with mental health problems. Since alcohol is difficult to detect on a drug screen, the effects of alcohol often present with performance problems. Cannabis can be perceived as “safe,” but is detectable for longer periods of time on a drug screen.

Stimulant use [for example, amphetamine/dextroamphetamine (Adderall), methylphenidate (Concerta and Ritalin)] is an increasing problem for student-athletes, especially since they are used for a number of non-medical reasons. Student-athletes who begin using an opiate [for example, hydrocodone (Vicodin), oxycodone (Percocet and Oxycontin)] may continue to use it after their medical problems have been resolved.

Impulse Control Problems can manifest in erratic behavior and performance. An individual who suffers from an impulse control problem might exhibit episodes of aggression, fighting, and risky sexual behavior.

Psychosomatic Illnesses and presentations include pain without supporting evidence, prolonged recovery from injury, frequent injuries and performance problems. Symptoms are often manifestations of an emotional issue and occur more commonly in collision sports.  

Individuals with pain are at increased risk for depression, post-traumatic stress disorder, substance use problems and adjustment reactions. A serious injury that leads to chronic functional impairment (or pain) in a student-athlete may manifest as a psychosomatic condition.

In addition to all of these, pain presents another challenge with today’s student-athletes. There may be pressure to play through the pain for fear of loss of a position or status. An athlete who is injured may experience a loss of identity.

Pain, injury and recovery, sleep, traumatic brain injury, suicidal ideation, transition and ending one’s athletics career bring challenges that have multiple associations to physical health, mental health and emotional well-being and substance use.  

Over-training can look like clinical depression. Sleep disturbances are associated with decreased performance and mental health problems (like depression and ADHD).  

Suicide presents another challenge and often is a part of a psychiatric illness with a strong connection to substance use, mental illness and perfectionism. Many warning signs emerge before suicide attempts that are often missed. More than two-thirds will have alcohol in their system at the time of the suicide attempt.

The challenge for any athletics department is to be aware of mental health issues and be trained to spot them when they emerge. Emotional well-being is important to any athlete’s success academically, athletically, socially and spiritually. Untreated mental health problems result in undue suffering, diminished positive affect and balance in life.  

Most psychiatric disorders in student-athletes improve and resolve with proper treatment. Early recognition is important to shorten the time between illness onset and treatment, thus improving the mental health and emotional well-being for our student-athletes.

Todd Stull, founder of Inside Performance Mindroom, holds an M.D. from the University of Nebraska Medical Center and is a board-certified psychiatrist in addiction medicine as well as general and addiction psychiatry. He is a former high school and college football quarterback (Hastings College) and has spent a number of years working with college student-athletes while serving as consulting sport psychiatrist at the University of Nebraska. He serves as the treasurer for the International Society for Sports Psychiatry.