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Addressing mental health issues in the athlete

This is an excerpt from Medical Conditions in the Athlete 3rd Edition With Web Study Guide by Katie Walsh Flanagan & Micki Cuppett.

Everyone has symptoms of some type of mental health issue at some time in life when one or several stressors overwhelm the person’s ability to self-regulate or repair. The symptoms are usually, and arbitrarily, labeled either physical or mental. This artificial dichotomy usually does not align with the affected person’s reality. Rarely is an athlete with a strained hamstring not also worried about the injury or distressed by the pain. Similarly, the most common initial warning signs of depression are the physical symptoms of tension, restlessness, and disturbed sleep, energy, and appetite. This is because we have overlapping systems of mind, body, spirit, and relationships, each integrally connected to the others. When the homeostasis of one or more systems is disrupted, people instinctively try to correct the problem regardless of its origin. In the mental health domain, signs of distress are emotional, mental, behavioral, and physical.


Framework for Understanding Mental Health

In almost all situations, a variety of overlapping factors contribute to symptom development. The biopsychosocial - spiritual model (BPSS) is a framework for understanding the person’s responses in a given situation and the development of symptoms. Symptom etiology may be conceptualized as a pie. Figure 17.1 shows how these various factors overlap and contribute to well-being. In a given person, the various pieces of the BPSS pie may be larger or smaller at any one time. The relative sizes of the pieces greatly influence the person’s symptoms and ability to adapt.


Figure 17.1 The biopsychosocial - spiritual model is a framework for understanding a person’s responses in a given situation and the development of symptoms.
The biopsychosocial - spiritual model is a framework for understanding a person’s responses in a given situation and the development of symptoms.


For example, two runners may have identical injuries, but the impact of the injury and the course of rehabilitation in these two athletes will usually differ. The amount of pain they have, as well as the length of time until they are ready to compete again, will be influenced not only by the difference in respective levels of physical conditioning and injury history but also by other physical and emotional conditions such as pain tolerance, attitude, perception of the problem, and its implications for life. The situation may also be affected by personality and temperament issues, variable resources for coping, and so on. Another example involves two wrestlers who seem to be equally competitive, but wrestler A, in a struggle to make or maintain weight, develops more obviously disordered eating patterns than wrestler B. Perhaps wrestler A has a family history of obesity and is genetically predisposed toward weight gain more than the other; temperamentally, wrestler A may tend to think more negatively about life challenges, become somewhat self-defeating in the face of adversity, and find emotional comfort in food and the process of eating. Often a variety of factors will help to explain the development of clinically significant problems.


This interplay of variables is the same for athletes as it is for others who are physically active, regardless of whether the symptoms of an injury or condition are physical or emotional. Whereas one athlete may become depressed, another’s symptoms may include anxiety or outbursts of anger and physical aggression. Sometimes one piece of the BPSS pie is so big that it seems to account for virtually the whole reason that someone is symptomatic (e.g., the chemical disequilibrium that comes with bipolar disorder). For this reason, it is a good practice to regularly consider the possibility that an organic cause may be the culprit and refer the person for a medical evaluation.


The treatments that have proven effective for the problems discussed in this chapter are based on the same BPSS approach as the assessment and diagnosis. Different strategies can be useful, depending on the biopsychosocial - spiritual components that are implicated in the assessment process. Practitioners often recommend treatment plans based on their assessment and experience, and then these are negotiated with the patient or family members according to personal preferences. The treatment may be offered on either an inpatient or, more commonly, an outpatient basis.


Treatment may also involve the collaboration of a variety of treatment professionals. For example, eating disorder treatment often involves a physician, a registered dietitian, and a psychotherapist. This will be determined based on the severity of symptoms, the difficulty the athlete has in making changes, the amount of support the athlete has, and other resources that affect care, including financial concerns or insurance benefits. The important first step in treatment is accurate assessment followed by clear and well-timed communication and education with the athlete and family. The athletic trainer can play a valuable role here because people are much more likely to engage in treatment or some type of change process if they become convinced that there is a problem, they know what it is, and they know that something can be done about it. This is because most people will want to know what is going on with themselves, how they "got it," and what they can do to "get rid of it" or at least cope more effectively. Additional treatment recommendations specific to various clinical problems are listed in subsequent sections.


Implications for Participation in Athletics

Early identification and treatment are very helpful in preventing problems from worsening, but sometimes the stigma still associated with mental health conditions prevents people from recognizing these problems in themselves or others. In those cases, functioning in one or more areas of life can be affected, sometimes severely. Restricting participation in a sport, if necessary, will depend on the assessment of the athlete’s level of functioning by the athlete, the coach, and the athletic trainer. Initially, while the medication dosage is being adjusted, the athlete could experience adverse effects that could affect participation or performance, such as nausea, headache, sedation, disturbed balance, or overstimulation. The National Collegiate Athletic Association (NCAA) has no restrictions on the medications typically used to treat these conditions except for pemoline, a medication prescribed to treat ADHD (National Collegiate Athletic Association 2015).


The last general point to be made is that some people experiencing psychological or substance use disorders may consider suicide or become homicidal. Most health care professionals or other professionals are required by law or by a professional code of ethics to report to the authorities if a patient is a danger to self or others. Athletic trainers, too, may encounter an athlete with depression, panic disorder, or substance abuse who is considering suicide or harming someone else. The athletic trainer must seek immediate consultation if in doubt about the need to report. An assessment of whether one is suicidal or homicidal includes determining whether the person has a specific plan, the means to carry it out, the intention to carry it out, and how lethal the plan is. Those with a personal or family history of this type of ideation or action or whose judgment is impaired, perhaps through the use of substances, are more at risk to follow through.

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Learn more about Medical Conditions in the Athlete, Third Edition.