Through sports psychiatry, we have directly witnessed how COVID-19 has not only impacted the general population’s mental health but that of elite athletes too.
My name’s Dr. Amit D Mistry, chair of the Royal College of Psychiatrist’s Sport & Exercise Psychiatry Special interest group (#SEPSIG). We are a nationwide group of psychiatrists interested in improving elite athlete mental health and supporting exercise interventions for those with severe mental illness (SMI). We have grown to over 1000 members within 4 years.
Recently, there has been a surge in evidence demonstrating a robust therapeutic effect for exercise in various mental health conditions. With this in mind, why is it then that elite athletes (who by definition are high level exercisers) have similar prevalence rates of mental illness compared to that of the general population? Latest research shows that the athletic environment contains a combination of unique and generic mental health risk factors. Key sport-specific stressors tend to be multi-dimensional and include frequent surgeries, maladaptive perfectionism traits, performance issues and challenges linked with career transitions (e.g. injuries, de-selection and forced retirement). Also, Paralympians possess additional challenges related to chronic pain, poorly adapted training facilities and travel-related logistical issues.
The regimented nature of athletic training and competition means that if athletes decompensate mentally, there is a higher risk of them developing dysfunctional relationships with entrenched eating and exercise behaviours. Sports with known higher risk of eating disorders include aesthetic, antigravity, weight-category and endurance sports.
When eating disordered behaviours combine with exercise addiction, this can be notoriously difficult to manage and is called secondary exercise addiction. In extremis this can result in systemic changes to body physiology such as osteoporosis (irreversible bone thinning), amenorrhea (loss of menstruation) and generalised hormonal disruption.
These outlined behaviours become particularly challenging when athletes become too invested in their ‘athletic identity’ and use it to manage emotional distress. If an athlete (intentionally or non-intentionally) mismanages their energy intake/expenditure into a deficit for prolonged periods of time, this can result in a situation termed Relative Energy Deficiency in Sport (RED-S). This can lead to performance decrement and a situation called Overtraining Syndrome (OTS). Therefore, it’s imperative for any clinician who meets a patient in “RED-S” to ensure that this is not being driven by an underlying eating disorder (e.g. body dysmorphia, fear of fatness, purging etc).
Anyone interested in promoting nutrition for health (which is a very noble endeavor by the way!) needs to also understand how over-compliance with ‘healthy behaviours’ can turn into a problem for patients too. This is particularly pertinent given professionals working in sport, nutrition and exercise are at higher risk of poor body image and ‘orthorexia’. Orthorexia is when individuals become obsessed with ‘healthy eating’ and this has a detrimental impact on their health and daily function.
Given some of the athlete mental health risks mentioned above, I along with 32 co-authors have released a new book called ‘Case Studies in Sports Psychiatry’ with Cambridge University Press. This is the first ever book to have been jointly written by leading MDT members such as sport medics, dieticians, psychiatrists and professional athletes. Each of the 10 cases runs through an elite athlete experiencing mental illness within their sport. We have created two cases dedicated to RED-S, exercise addiction and eating disorders in competitive swimming and endurance running.
Each chapter outlines a typical psychiatric consultation, biopsychosocial management options and then provides the reader with 5 MCQ’s to help consolidate their learning. To keep up to date with the latest developments within UK Sports Psychiatry and eating disorders you can follow my work on @DrAMistryPsych. Please feel free to get in touch if you wish to learn more and get involved with our rapidly expanding sub-specialty!