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Sports Psychiatry: An Outpatient Consultation-Liaison Model
Antonia L. Baum, M.D., Strong Memorial Hospital, Department of Psychiatry, Psychiatric Consultation Services, Rochester, NY
TO THE EDITOR: Sports psychiatry is a developing field, designed to address psychopathology and psychological problems in athletes. An awareness that a sound body does not necessarily imply a sound mind is crucial to identifying and caring for those in need of treatment. The discipline of psychology has dominated the world of sports, with a contrasting major focus on performance enhancement.
Athletes are susceptible to the whole gamut of psychopathology, and there are problems unique to the athletic arena. Some are predisposing factors, such as children with attention deficit-hyperactivity disorder (ADHD) who may seek out athletics as an area in which they can excel. Other problems are engendered by the athletic environment, including eating disorders; substance abuse; verbal, physical, and sexual aggression off the field; steroid abuse; and developmental aspects of the generally brief life cycle of an athlete, which range from building self-esteem, to fulfillment of developmental tasks outside of sport, to postathletic career concerns. Achievement by proxy, the phenomenon of a parent or coach obtaining vicarious satisfaction from the success of a young athlete,1 when carried to extremes, can result in the serious injury or death of a child.2
Athletes on psychotropic medications raise unique concerns about their ability to tolerate side effects. Drugs that affect cardiac rate or rhythm, which cause orthostasis, nausea, vomiting, or diarrhea, or whose metabolism is affected by the state of hydration of the patient, may be particularly problematic in athletes. There is also the potential to have an athlete on a banned substance for a therapeutic purpose, such as a patient with ADHD taking psychostimulants, which creates an ethical problem.
Studies of female college gymnasts demonstrate that the prevalence of at least one pathogenic weight-control behavior ranges from 62% to 74%.3,4 Anorexia nervosa was diagnosed in 16.7% of the members of a national rhythmic gymnastics team.5 Drawing attention to these problems is harmful to the image and promotion of the sport and sometimes impedes the diagnosis and treatment of athletes. Published data have found prevalence rates of anorexia nervosa among ballet dancers to be as high as 25.7%6 and of bulimia nervosa to be as high as 19%.7 Eating disorders are not limited to sports emphasizing aesthetics or to female athletes. There are some male-dominated sports that create risk by requiring that athletes be a certain weight for competition, such as wrestling and horse racing.
A survey of male senior high school students not restricted to athletes revealed the prevalence of anabolic steroid use to be 6.6%.8 It is estimated that from 80% to 90% of weight lifters worldwide and about 75% of all professional football players use anabolic steroids.9 The abuse of alcohol and illicit drugs has become a part of the culture of certain sports and a growing problem.10
By using an outpatient consultation-liaison model, I expect that the presence of a psychiatrist in a sports-medicine clinic, in conjunction with regular psychoeducational talks with the staff, will help to identify cases in need of treatment and to ensure follow-up. The stigma often associated with a psychiatric referral frequently leads to noncompliance. This problem is theoretically compounded by the mythology of the sound mindbody dynamic for the athlete.
Our model, currently under study, has the general advantage of having a psychiatrist located within the offices of a specialist who is likely to see psychiatric cases. Case finding, compliance, and satisfaction with care should all improve. I hope to report on the outcome of this consultation-liaison model, evaluating the reasons for referral and the diagnoses made.
REFERENCES
Tofler IR, Katz-Stryer B, Micheli LJ, et al: Physical and emotional problems of elite female gymnasts. N Engl J Med 1996; 335:281283[Free Full Text]
Ryan J: Little Girls in Pretty Boxes: the Making and Breaking of Elite Gymnasts and Figure Skaters. New York, Doubleday, 1995
Rosen LW, Hough DO: Pathogenic weight control behaviors of female college gymnasts. Physician Sportsmed 1988; 16:140144
Rosen LW, McKeag DB, Hough DO, et al: Pathogenic weight control behavior in female athletes. Physician Sportsmed 1986; 14:7986
Sundgot-Borgen J: Eating disorders: energy intake, training volume, and menstrual function in high-level modern rhythmic gymnasts. Int J Sport Nutr 1996; 6:100109[Medline]
Garner DM, Garfinkel PE, Rockert W, et al: A prospective study of eating disturbances in the ballet. Psychother Psychosom 1987; 48:170175[Medline]
Hamilton LH, Brooks-Gunn J, Warren MP: Sociocultural influences on eating disorders in professional female ballet dancers. Int J Eat Disord 1985; 4:465477
Buckley WE, Yesalis CE, Friedl KE, et al: Estimated prevalence of anabolic steroid abuse among male high school seniors. JAMA 1988; 260:34413445[Abstract]
Science 1972; 176:13991401
Benedict J: Public Heroes, Private Felons: Athletes and Crimes Against Women. Boston, MA, Northeastern University Press, 1997
