Sports psychiatry – The lack of an Australian narrative

Sport, play, game, ball, bat, goal, try, team, practice, training, teammates, win, lose …

Since time immemorial, sport has been the stage to show the prowess of our species, superiority of one’s ethnic group, resolve conflicts, test one’s mettle and character, push the boundaries of human ability, sharing individual attributes for the betterment of the team and so on. Although many aspire to become a high-performance athlete, few succeed. Those who do are in a privileged position of representing themselves and their code of sport, team, town or city or rarely their country. The pressure to succeed in these endeavours can also be a burden. Expectations are after all the biggest burdens to carry.

A significant part of an athlete’s performance is the ‘mental’. Traditionally, this was considered to be motivation, character, superior confidence, inner strength, focus, conviction, clarity of purpose and so on – not unlike the desirable traits for a soldier. More recently, considerable effort has gone into looking at the optimal mental state of athletes. Clinical psychologists have been used in sport to manage individual and team performance, and they have become an integral part of many sporting organisations.

There is increasing recognition that athletes can have significant psychological difficulties. Widely publicised instances of substance abuse, cheating, doping, gambling, suicide, disordered behaviours, mood and anxiety disorders and traumatic brain injuries have revealed the hidden toll. The inability of athletes to have a life away from public scrutiny also provides greater insight into their troubles. Psychiatric disorders are as common in this population as in general population, and a large number of these athletes do not avail of treatments due to lack of insight, denial, social stigma and a lack of availability of specialised psychiatric input (Glick and Horsfall, 2005).

Sports psychiatry was initially conceived by Dan Begel, MD, in 1990 as a niche area which he defined as ‘the application of the principles of and practice of psychiatry to the world of sports’ (Begel, 1992). It is increasingly being considered a specialised field as there are nuanced, discrete and specialised interventions.

While there are obvious overlaps between sports psychology and sports psychiatry, in essence, the former deals with performance enhancement, through developing strategies and techniques, as opposed to the latter which primarily deals with assessment and treatment of psychiatric disorders in athletes. Sports psychiatrists also use performance enhancement as a goal to improve engagement in treatments. However, the initial challenge of managing stigma and denial remains a massive impediment.

Non-pathological states and pathological states can be difficult to separate as they exist on a continuum. Non-pathological issues include training rituals, performance anxiety, pre-game behaviours, ‘getting in the zone’ and avoidance behaviours. The role of sports psychiatry is to intervene in pathological states, and thorough assessment and identification of such states are the beginning of the appropriate intervention. Establishing a strong therapeutic alliance with emphasis on privacy is paramount in ensuring trust and treatment adherence.

Pharmacological treatments of athletes have special considerations due to side effects affecting performance as in weight gain, reduction in muscle tone, raised core temperature, involuntary movements and sedation. Non-athletes may be willing to tolerate some of these issues if that meant regaining stability and functioning. However, in athletes, this is a major reason for non-adherence. Selecting the appropriate pharmacological agent should also be undertaken with a comprehensive understanding of the anti-doping guidelines. While most psychiatric medications are generally acceptable, psycho-stimulants are generally prohibited but can be used under strict medical guidance after notification for medical reasons. In-depth knowledge of the prescribing guidelines in sport from World Anti-Doping Authority (WADA) is vital.

Psychological interventions are usually the mainstay of treatment in athletes and widely used treatments include cognitive behavioural therapy, mindfulness and motivational therapy. Presentations of psychiatric illness in athletes can be different to other populations. For example, depression in athletes is very likely to present as overtraining, irritability and substance abuse rather than emotional symptoms. Overtraining syndrome (Glick et al., 2012) can also cause athletes to present with what could be misdiagnosed as clinical depression. Retirement and injury periods are associated with an increased incidence of depression. Understanding these nuances and managing them appropriately are crucial.

Diet, nutrition and exercise play an important role in sports and can be associated with disordered eating and body image issues. The Female Athlete Triad (Birch, 2005) of low energy availability, menstrual dysfunction and reduced bone density due to chronic reduced nutritional intake can have devastating consequencesif not recognised and managed appropriately.

Personality disorders in athletes are another topic of relevance as they have an impact on team performance and cohesion. The most common types of personality traits in athletes are reportedly extraversion, perfectionism and narcissistic traits. Sport provides a stage for exhibiting some of these personality characteristics by being the centre of attention, treating other competitors as objects and compensating for personality deficits by performance, to name a few.

Anxiety disorders are common in athletes; however, the actual prevalence is unknown. Training regimens, pre-performance routines and ritualistic behaviours compensate for some of these symptoms. Substance abuse, underperformance and early retirement can eventuate if the above mechanisms fail and without accurate identification and management.

Psychotic disorders and bipolar affective disorder have also been reported in athletes; however, the prevalence is unknown as there are few studies conducted into the epidemiology of these disorders in this population. Needless to say, this can cause immense difficulties, and there are case reports of famous athletes who have struggled through their careers with these disorders.

Australia has long had the distinction of being an overachiever in sports. The Australia Bureau of Statistics released the Participation in Sport and Physical Recreation, Australia, 2011–2012 report which details Australian involvement and achievements and confirms that our national identity is undeniably intertwined with sport. Australian inroads into conditioning, injury management, diet and nutrition, and an endless list of sport-related activities are impressive and internationally recognised.

However, in the area of sports psychiatry, other than the current discussion about head trauma, there is very little in terms of a narrative. There is a veil of secrecy when discussing the mental aspect of athletes by avoiding and couching it in terms of ‘privacy’, while that same ‘privacy’ is not afforded to athletes who suffer devastating physical injuries. There is polarised commentary ranging from avoidingdiscussion to seeing underperformance as evidence of poor fortitude or temperament. In addition, athletes arestereotyped as people who ought not to have psychological difficulties, and when they do display symptoms, their temperament is questioned while conversely lauding the toughness of their opponents. The veil of secrecy and ‘sensitivity’ hides the true nature and impact of these disorders and may result in poorer outcomes.

Conducting research and providing specialised psychiatric care are happening around the world by establishing collaborations and partnerships between athlete advocates, athletic bodies, psychiatric governing bodies, sports medicine institutes and other stakeholders. Australia, with its legacy of involvement and achievements in sport, should join the effort to develop better understanding and provide better management and outcomes for our athletes, who many of us have dreamed of emulating, at some stage in our life.