Clinical Sports Psychiatry – An International Perspective

David Baron, MSEd, DO, DFAPA, FACP, FACN is Professor and Vice Chair of the Dept. of Psychiatry at the Keck School of Medicine of the University of Southern California, and Psychiatrist-in-Chief of Keck University Hospitals of USC. He is the founder and Chair of the Section on Exercise, Psychiatry, and Sport of the World Psychiatric Association, Board member of the International Society of Sports Psychiatrists, and Director of the Center for Psychiatry and Sports at USC. Prof. Baron has published 5 books, over 20 chapters, over 85 papers, and is the executive producer on 2 films related to mental health in youth sports. He has won numerous national and international awards for his work in sports psychiatry over the past 3 decades. Claudia L. Reardon, MD is a Board-Certified psychiatrist and faculty member at the University of Wisconsin School of Medicine and Public Health. She completed her college, medical school, and residency training at the University of Wisconsin. She has special expertise in the diagnosis and treatment of psychiatric disorders in athletes, and in the use of exercise to prevent and treat mental illness. Dr. Reardon writes and speaks widely on these topics. She serves on the Board of Directors of the International Society for Sports Psychiatry and is the American Psychiatric Association Member Expert on sports psychiatry. She is an avid runner and comes from a family of accomplished athletes, including her Olympic gold medalist brother Andrew Rock.

Contributors xi Foreword by Steve Peters xiv Foreword by Thomas Newmark xvi Acknowledgments xviii Preface xix PART ONE: MENTAL HEALTH CHALLENGES FACED BY ATHLETES 1 1 Substance Use in Athletes 3 Eric D. Morse Background and Scope of Problem 3 Reasons for Use 4 Traumatic Brain Injury 5 Recognizing Substance Use 6 Treatment 7 College versus Professional 8 Specific Substances 8 Conclusions 11 2 Addiction in Retired Athletes 13 Pavel A. Ponizovskiy Background 13 Athletic Retirement Always Traumatic? 13 A Model of Adaptation to Athletic Retirement 14 Substance Abuse and Addiction in Retired Athletes 16 Preretirement Predispositions to Addictions 17 Painkillers Misuse 17 Smoking 17 Drinking 18 Conclusion 18 3 Doping in Sport 21 David A. Baron, Claudia L. Reardon, and Steven H. Baron Introduction 21 History of Doping in Sport 22 The Current State of Doping in Sports 23 Controversies of Positive Drug Tests 26 Financial and Business Implications 26 Short- and Long-Term Effects of Doping 27 Gene Doping 29 Cultural Issues Associated with Doping 29 Case Studies 29 Summary 30 4 Exercise Addiction: The Dark Side of Sports and Exercise 33 Tamas Kurimay, Mark D. Griffiths, Krisztina Berczik, and Zsolt Demetrovics Definitions, Symptomology, and Classification 33 Assessment of Exercise Addiction 35 Epidemiology 35 Comorbidity 35 Etiology 37 Conclusion and Implications 40 Acknowledgments 40 5 Eating Disorders in Athletes 44 Antonia L. Baum Introduction 44 Epidemiology 45 The Role of Sports in the Genesis of Eating Disorders and Sports-Specific Eating Disorders 46 Eating Disorders in the Male Athlete 48 The Female Athlete Triad 49 Treatment 49 Future Research 51 6 Personality and Personality Disorders in Athletes 53 Heba M. Fakher M. Hendawy and Ezzat Abdelazeem A. Awad Introduction 53 Personality Traits in Athletes 54 Perfectionism 56 Anger and Aggression 57 Athletic Identity 57 Personality Disorders in Athletes 58 Case Studies 60 Summary 62 7 Assessing and Treating Depression in Athletes 65 David A. Baron, Steven H. Baron, Joshua Tompkins, and Aslihan Polat Introduction 65 Defining Depression 66 Symptoms and Presentation 66 Diagnostic Issues 67 Diagnostic Tools 68 Treatment 69 Special Considerations 71 Conclusion 76 8 Suicide in Athletes 79 Antonia L. Baum Introduction 79 Etiology 80 Retirement 81 Psychological Traits 81 Substance Abuse/Anabolic Steroid Abuse 82 Axis I Psychopathology 83 Pressure to Win 84 Sexual Abuse 85 Homosexuality 85 Firearms 85 Cultural Influences 85 Prevention 86 Sports as Therapy 86 Future Research 86 9 Concussion in Sports 89 David A. Baron, Claudia L. Reardon, Jeremy DeFranco, and Steven H. Baron Introduction 89 What is Concussion and Traumatic Brain Injury? 90 Pathophysiology of Concussion 91 Diagnosis of Concussion 91 Epidemiology and Etiology of Concussion 93 Prevention of Concussion 93 Post-concussion Syndrome 94 Second Impact Syndrome 94 Chronic Traumatic Encephalopathy 95 Future Research 98 10 Posttraumatic Stress in Athletes 102 Thomas Wenzel and Li Jing Zhu General Aspects 102 Risk Factors 105 Other Research on Diagnosis of Posttraumatic Stress Symptoms in Athletes 107 Further Specific Reactions to Extreme Stress in Sport 107 Relevance 109 Clinical Considerations and Interventions 110 Conclusions 111 PART TWO: TREATMENT APPROACHES AND THERAPEUTIC ISSUES WITH ATHLETES 115 11 Psychotherapeutic Treatment of Athletes and Their Significant Others 117 Mark A. Stillman, Eva C. Ritvo, and Ira D. Glick Introduction 117 The Athlete-Patient 118 Psychotherapy with the Athlete-Patient: Unique Challenges 121 Conclusion 122 12 Mindfulness, Attention, and Flow in the Treatment of Affective Disorders in Athletes 124 Brandon J. Cornejo Introduction 124 Mindfulness 125 Flow 126 Attention in Sports 127 Mindfulness, Exercise, and Mental Health 128 Bridging the Gap between Flow and Mindfulness Developing a Treatment Approach 128 Conclusions 129 13 Performance Enhancement and the Sports Psychiatrist 132 Michael T. Lardon and Michael W. Fitzgerald Introduction 132 Motivation and Goal Setting 133 Maximizing Cognition and Emotion in Competitive Environments 136 Attentional Focus and Mental Imagery 139 Positive Psychology, Peak Performance, and the Athletic Zone 140 Summary 145 14 Applied Sports Psychology in Worldwide Sport: Table Tennis and Tennis 147 Kathy Toon, Dora Kurimay, and Tamas Kurimay Introduction 147 Tennis and Table Tennis: Examples of Worldwide Sports 148 The Game Face Routine 149 The Game Face Pyramid 153 Recommendations and Conclusions 155 15 The Use of Psychiatric Medication by Athletes 157 Claudia L. Reardon and Robert M. Factor Introduction 157 Antidepressants 158 Anxiolytics and Sedative-Hypnotics 159 Stimulants 161 Mood Stabilizers and Antipsychotics 162 Recommendations and Conclusions 162 PART THREE: PSYCHOSOCIAL ISSUES AFFECTING ATHLETES 167 16 Sexual Harassment and Abuse in Sport 169 Saul I. Marks What is Sexual Harassment and Abuse in Sport? 169 Prevalence of Sexual Harassment and Abuse in Sport 170 Perpetrators of Sexual Harassment and Abuse in Sport 170 Risk Factors for Sexual Harassment and Abuse in Sport 170 Physical and Psychological Consequences of Sexual Harassment and Abuse in Sport 173 Physical Consequences and Medical Presentations of Sexual Harassment and Abuse in Sport 173 Psychological Consequences of SHA in Sport 174 Specific Psychological Consequences and Medical Presentations Seen in Sport in General 175 Prevention by Understanding the Coach Athlete Relationship 175 The Team Doctor s Role in Prevention of SHA 176 Leadership from the International Olympic Committee 176 Clinical Approach to Disclosure 176 Conclusion 177 17 The Role of Culture in Sport 179 Claudia L. Reardon, David A. Baron, Steven H. Baron, Bulent Coskun, and Ugur Cakir Multiculturalism 181 Specific Examples of Important Cultural Issues in Sport 181 Stigma and Access to Psychiatric Treatment Around the World 182 Epidemiology of Mental Illness in Athletes Across Different Cultures 183 Women, Sport, and Culture 184 Conclusions 186 18 Ethical Issues in Sports Psychiatry 188 David A. Baron, Joshua Tompkins, Sally Mohamed, and Samir Abolmagd Introduction: The Evolution of Medical Ethics 188 Modern Medical Ethics 189 Medical Ethics Around the World 190 Ethical Issues in Psychiatry 191 Mental Health in the Athletic Arena 192 Sports Psychiatry: A Newcomer to the Field 193 Ethics of other Sports Health-Care Professions 193 Ethical Challenges for the Sports Psychiatrist 195 Conclusion 197 PART FOUR: THE FIELD OF SPORTS PSYCHIATRY 201 19 Sports Psychiatrists Working in College Athletic Departments 203 Eric D. Morse Background 203 Design 204 Budget 204 Who is Being Served 205 Confidentiality 205 Boundaries 205 Improving Utilization with a Team Assistance Program Model 206 Treatment Issues 209 Part of the Sports Medicine Team 211 Location 211 Conclusion 213 20 Sports Psychiatry: Current Status and Challenges 215 Ira D. Glick, Thomas Newmark, and Claudia L. Reardon Background 215 Evolution of the Field 216 Challenges for the Field 216 The Role of Professional Sports Psychiatry Organizations 217 Index 219