Managing Student-Athletes’ Mental Health Issues

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athletes who suffer from depression after an injury illustrate the relationship between cphysical d and cmental d health. At the same time, some depressed student-athletes are at increased risk of injury. Given the inter- relationship between the physical and men- tal, it might be helpful to think of student- athletes with mental health problems as cinjured d 4 just as you would of a student- athlete who has a physical or medical prob- lem. As with physical injuries, mental health problems may, by their severity, affect athlet- ic performance and limit or even preclude training and competition until successfully managed and treated. This handbook 9s primary purpose is to provide information that you can use to effectively and quickly identify student-ath- letes who are at risk or are experiencing emotional symptoms. Like most medical problems, early identification of mental health problems usually means less disrup- tion to a student-athlete 9s life, fewer severe health complications and a less complicat- ed, quicker recovery. 2 A student-athlete 9s cmental health d might be viewed as secondary to physical health; however, it is every bit as important for healthy performance. 3 Coaches should be involved in identifying mental health problems because you: " Are in an ideal position to identify when your student-athletes are having difficul- ty because you spend so much quality time with them; " Have considerable power and influence with your student-athletes that can increase the likelihood your student-ath- letes will receive timely and effective treatment; " Can minimize by early detection the effects of the disorder on your student- athletes 9 health and performance; and " Can recommend prompt treatment to decrease your student-athletes 9 time away from training and competition. Student-athletes may be at risk for men- tal health problems because: " Their age increases the risk for certain disorders, such as eating disorders or substance-related disorders; " College is a time of transition (significant changes), and psychological disorders often develop or worsen during transition periods (i.e., leaving home for college, changing colleges, significant losses through death or the ending of important relationships, etc.); and " Some mental health problems can be triggered or exacerbated by pressure. These pressures are often unrelated to sport participation, but sport participa- tion may also increase pressure for cer- tain student-athletes. General Signs and Symptoms that May Indicate a Possible Mental Health Problem Some signs and symptoms of possible mental health problems in your student-ath- letes might surprise you. You may notice prob- A stronger case for a referral to a mental health professional can be made as the number of signs and symptoms increases. lems in your student-athletes 9 behavior, cogni- tive/intellectual functioning, physical/medical status, and/or psychological/emotional condi- tion. On this page, there is a list of general signs and symptoms that are present across many, if not most, psychological disorders. The following chapters contain information related to specific mental health problems and their specific signs and symptoms. The cate- gories of cBehavioral, d cCognitive, d cEmotional/Psychological, d and cPhysical/Medical d are not intended to repre- sent separate and exclusive groups. Because many signs and symptoms are related, con- siderable overlap exists among the different categories. These signs and symptoms do not necessarily confirm the presence of mental health problems; however, a stronger case for a referral to a mental health professional can be made as the number of such signs and symptoms increases. Disclaimers This handbook does not cover all mental health problems. Such an undertaking would be well beyond the scope of the handbook. The disorders included were chosen because of their prevalence in the general population and because they are prevalent in the college-age population. The purpose of this handbook is to assist coaches in identifying student-athletes who may be having difficulty and to help coaches learn to respond appropriately and effective- ly with those student-athletes. It should be considered as a very important part of a larger cooperative effort involving other sport and healthcare professionals. The purpose is not to train coaches to be therapists or treat- ment providers. This handbook is a guide. It is not meant to be a substitute for psycho- logical evaluation and treatment by qualified mental health practitioners. 4 Cognitive Symptoms Suicidal thoughts Poor concentration Confusion/difficulty making decisions Obsessive thoughts All-or-nothing thinking Negative self-talk Emotional/Psychological Symptoms Feeling out of control Mood Swings Excessive worry/fear Agitation/irritability Low self-esteem Lack of motivation Physical/Medical Symptoms Sleep difficulty Change in appetite and/or weight Shaking, trembling Fatigue, tiredness, weakness Gastrointestinal complaints, headaches Overuse injuries This is not intended to be an exhaustive list of symptoms, but rather a list of more common symptoms. No one sign or symptom is indicative of a mental health problem, but the need for a referral for an evaluation increases with the number of signs and symptoms reported or observed. Behavioral Symptoms Disruption of daily activities Social withdrawal Irresponsibility, lying Legal issues, fighting, difficulty with authority Decrement in sport or academic performance Substance use Mood disorders sometimes are called Affective Disorders, but more frequently are simply called c depression . d Approximately 10 percent of the American population suf- fers from a mood disorder during any one- year period, which is the same percentage of depression in college students as reported by the National Mental Health Association. Certainly, most people will feel depressed for short periods from time to time for various reasons. However, when the depression becomes more severe, lasts longer and occurs more frequently, evalua- tion and treatment are warranted. Although most mood disorders primarily involve low mood or depression, bipolar disorder con- sists of episodes of abnormally elevated (high) moods, in addition to the character- istic low moods. Signs and Symptoms/Identification Typically, mood disorders (or depression) are characterized by: " Low or sad moods, often with crying episodes. " Irritability or anger. " Feeling worthless, helpless and hope- less. " Eating and sleeping disturbance (reflect- ed in an increase or decrease). " A decrease in energy and activity levels with feelings of fatigue or tiredness. " Decreases in concentration, interest and motivation. " Social withdrawal or avoidance. " Negative thinking. " Thoughts of death or suicide. " In severe cases, intent to commit suicide with a specific plan, followed by one or more suicide attempts. 5 Chapter 1 Mood Disorders " Depression Effects on Health and Performance You can tell from these depressive symptom descriptions that most aspects of a person 9s life are negatively affected by the disorder. Athletic performance is no exception. In fact, poorer performance would be expected. If a student-athlete is not eating or sleeping well and feels tired or fatigued, you would expect performance to decrease from a physiological perspec- tive. Add in emotional and cognitive com- ponents of low mood, decreased motiva- tion, poor concentration, and negative thinking, and you could not expect a stu- dent-athlete to perform well. Poor sport performance can increase a student-ath- lete 9s depression and the pressure to per- form better. Depression may also increase a student-athlete 9s risk of injury. Causes of Depression There are many different types of depression and a variety of causes. A thorough discussion of the causes of depression is beyond the scope of this handbook. However, you should be aware of the three most common causes of depression in the general population and one type that is unique to student-athletes. " Depression can occur in response to a specific event in a person 9s life (i.e., death of a family member, break-up of a significant relationship). When these situ- ational factors become intense or an individual feels out of control with his or her life, depression may follow. " Depression also can occur without any specific precipitant (trigger). Some depressions are believed to be more bio- logical or neurobiological in nature. That is, there appears to be a genetic vulnera- bility or predisposition to depression that runs in some families. Also, depression 6 Case Illustration Sam, a member of a college swim team, had been missing his morning swim practices. Although his coaches were angry and made him make up the prac- tices and perform additional work as a punishment for missing practices, he still had difficulty getting out of bed in the morning. He could not explain to them why he could not get up and get to practice, other than to say that he was tired because he kept wak- ing up between 3 and 4 a.m. and could not get back to sleep until it was time for him to get up. His academic and athletic perform- ance dropped off, and he appeared less motivated to per- form well. Teammates had remarked that Sam was less talk- ative and was turning down offers to join them socially. One team- mate reported that Sam told him that he felt so bad that he would rather be dead than feel the way he was feeling. for some people appears to involve an imbalance in brain chemicals called neu- rotransmitters. These individuals may need or benefit from antidepressant medication. Antidepressant medications can have numerous side effects (i.e., weight changes, sedation, etc.). As a consequence, athletic performance may be affected. " Another cause of depression involves negative thought patterns that many depressed individuals have. Individuals with this type of depression constantly make negative self-statements that maintain their depressed mood. " Although most depressions probably occur from the aforementioned causes, student-athletes may get depressed from their sport participation . For example, some student-athletes become depressed in response to an injury . Their self-esteem and identity may be nega- tively affected by their inability to do the thing that they do best and enjoy most- play their sport. Other student-athletes may become depressed as a result of covertraining syndrome d or cstaleness. d This syndrome sometimes follows heavy training and can include physical (i.e., decreased performance, fatigue, muscle soreness, weight loss, sleep disturbance, etc.) and psychological (i.e., depression, anxiety, irritability, decreased concentra- tion, etc.) symptoms. The decrease in performance as a result of this syndrome can further depress a student-athlete. Depression and Risk of Injury A student-athlete may become depressed after an injury, but the relation- ship between depression and injury may also occur in reverse order. Depression can precede an injury and may increase a stu- 7 Difficulty in Identification of Depression Although depressive symptoms appear to be fairly straightforward and easy to recognize, identifying depression can be difficult for several reasons: 1. Depressed people often with- draw socially. Thus, you may have less opportunity to notice a problem. 2. Many depressed individuals do not believe they cdeserve d your time and attention. In fact, they often do not want to cbother d others with their diffi- culties. 3. Others may hide their symp- toms by smiling and acting as though nothing is wrong. 4. Some depressed individuals may engage in behaviors, such as alcohol or drug use or an eating disorder, that are designed to help manage their depression. These other behaviors may serve to dis- tract themselves, you and oth- ers from their underlying depression. dent-athlete 9s risk of injury. Depression in many student-athletes occurs for non- sports related reasons. For such student- athletes, their depression 4 or more specif- ically their depressive symptoms 4 may increase the likelihood of injury primarily through distraction (decreased concentra- tion resulting in being less alert, responding more slowly, or making poor decisions or judgments). A depressed batter might be less able to avoid being hit by a fastball. A diver might more easily lose where she is in space before impacting the water. Additional risk to the student-athlete may increase because the body has been med- ically compromised from the depressive symptoms of eating and sleep disturbance. Suicidal Risks Research suggests that suicide is the second leading cause of death among col- lege students. Approximately three suicides occur daily among college students, and seven to 10 percent of college students either attempt or contemplate suicide in a given year. The increased possibility of sui- cide attempts and suicides makes depres- sion the most critical disorder discussed in this handbook. Although early identification and treatment are important for all mental disorders, they are more important for mood disorders because of the potential for self-harm. Coaches sometime want to assume that student-athletes are healthy simply because they are athletes. Coaches must remember that they are not just stu- dent-athletes. They are human beings with the same potential frailties as non-athletes. They are young people attempting to deal with all of the complexities of life, the demands of college life and the pressures that sometimes accompany athletic performance. 8 Depression can have many causes, and may have little to do with sport. When depression is related to sport, it is often in response to injury and/or is a result of covertraining syndrome. d Management Although general recommendations on how to approach and respond to a dis- tressed student-athlete are specified in Chapter 5, a depressed individual who exhibits suicidal risks requires specific rec- ommendations about what to do and not do. Recommendations Regarding Individuals at Risk for Suicide: " When dealing with a student-athlete who has expressed, indicated an intent or plan, or attempted suicide, do not try to determine the clethality d (seriousness) of the thought, gesture or attempt. Such thoughts, behaviors or threats are seri- ous and potentially dangerous. " Do not assume the person is engaging in suicidal thoughts or actions for cattention. d " Make an immediate referral. It is even better to call a mental health profession- al to treat the student-athlete. Most col- lege campuses have a counseling center staff that can offer guidance or referral. Many counseling centers will offer cwalk- in d or cemergency d services. For emer- gency situations after normal office hours, counseling center staff can rec- ommend other options, such as going to the nearest hospital emergency room. Reasons for Responding Quickly and Seriously " Your quick response lets a student-ath- lete know that you take his or her health, difficulties and life seriously. " It 9s better to err on the side of respond- ing too quickly rather than too late. " Depressed individuals engage in negative thinking. They often feel unworthy, or worse yet, worthless. The lack of a response on your part may be interpreted as confirma- tion for the student-athlete that he or she is 9 Suicide Intervention If a Student-athlete: " Expresses a suicidal thought " Indicates an intent or plan " Or makes a suicide attempt MAKE AN IMMEDIATE REFERRAL not worth the time or trouble, which could worsen the student-athlete 9s condition. " As a coach, you have power and influ- ence with your student-athletes. That power and influence can be positive or negative. You need to be more respon- sive and careful with a depressed stu- dent-athlete, who might interpret your response negatively. Sport Participation An important part of a mood disorder assessment and management plan is whether the student-athlete should continue sport participation. Depending on the cause, nature and severity of the mood disorder, it may or may not be beneficial to the student- athlete to continue with training and compe- tition. Withholding a student-athlete with a mood disorder from participation may increase depression because sports compe- tition can provide a sense of identity, a source of self-esteem or a sense of accom- plishment. For others, sport participation that is apt to be negatively affected by depres- sion may increase the student-athlete 9s symptoms. A healthcare team must make this treatment decision. 10 " Do not assume the person is engaging in suicidal thoughts or actions for cattention. d " Student-athletes engaging in suicidal thought need prompt attention and referral. SUMMARY 1. Signs and symptoms of depression often include low moods, feelings of hope- lessness, disturbance in sleeping and eat- ing, decreases in energy, activity, concen- tration and motivation, and suicidal thoughts. 2. There are several different types of depression, and the causes can vary. Depression can occur in response to an event (outside of the individual) or because of a biological vulnerability to depression (inside the individual). Depression in stu- dent-athletes can be related to aspects of sport participation (i.e., injury). 3. All thoughts, behaviors and threats of suicide should be taken seriously. 4. Decisions regarding whether a depressed student-athlete should continue training and competing should be made by the healthcare treatment team. 11 SUICIDE Prevention Be Prepared: Make a Plan A 2 a.m. telephone call about a suicidal student-athlete is not the best time to generate a plan. Coaching and sports medicine staffs should work together to have a suicide prevention plan in place. The following steps should be clearly described and available to your coaching and sports medicine staffs. " Have the names and phone numbers of referral sources available. Include daytime sources such as the student health center, campus counseling centers and other local services. After-hours options also need to be included. Universities in larger communities may have several psychiatric emergency options. In smaller communities, the best option may be the nearest hospital emergency room. Determine your options now before you need them. " Make sure a suicidal student- athlete is not left alone. This is especially true for a student- athlete who actually has attempted suicide (i.e., overdosing on pills, cutting wrists, etc.). The student-athlete should have someone with him or her until a psychiatric evaluation is completed. In the meantime, follow the recommendations listed above. 12 An important part of a mood disorder assessment and management plan is whether the student-athlete should continue sport participation. Everyone from time to time experiences symptoms of anxiety. For individuals with an anxiety disorder, however, these symp- toms tend to be bothersome daily and worsen when pressure or stress occur. According to the National Institute of Mental Health, anxiety disorders are the most common type of mental illness in the U.S. Approximately 40 million people over the age of 18 are affected each year. The cause of anxiety can vary with the disorder and the individual. Most anxiety disorders are probably due to genetic factors, per- sonality factors or life experiences. 13 Chapter 2 Anxiety Disorders Signs and Symptoms/Identification Anxiety symptoms can be general or specific to a particular stressful situation or set of circumstances. They may or may not have an apparent cause. Symptoms can include any of the following: " Excessive worry, fear or dread; " Sleep disturbances, especially difficulty falling asleep; " Changes in appetite, including either an increased need to eat when anxious or difficulty eating due to anxiety; " Feelings ranging from a general uneasi- ness to complete immobilization; " Pounding heart, sweating, shaking or trembling; " Impaired concentration; " A feeling of being out of control; " Fear that one is dying or going crazy; or " A disruption of everyday life. Types of Anxiety Disorders There are several types of anxiety disor- ders. The most common ones include: cGeneralized d anxiety disorder. This type of anxiety has sometimes been called cfree-floating d anxiety because it seems to occur without a particular precipitant. Individuals with a generalized anxiety dis- order often find it difficult to sit still, do nothing or relax. They also may be plagued with constant worries that interfere with concentration or daily functioning. Panic Attacks or Panic Disorder. This type of anxiety can occur without warning, often with a sense of impending doom. These feelings usually are accompanied by consequent or complicating physical symptoms (i.e., racing/pounding heart, shortness of breath, etc.). Obsessive Compulsive Disorders. Other anxiety symptoms manifest themselves as cobsessions d (recurring, redundant, rumi- 14 Case Illustration Allison 9s softball coach was concerned about her lack of con- centration. She had errors in the outfield and was making mental errors. She seemed distracted. In the dugout, at team meetings and traveling to away games, she had difficulty sitting still and was often 4 as her parents called it 4 cfidgeting. d When her coach asked if she was worried about something, Allison said she had always been a cworrier d and sometimes had difficulty falling asleep because her mind was cracing. d Allison also admitted that she specifically worried that she sometimes felt as though something cawful d was going to happen. When that feeling occurred, she worried that she might die from a heart attack because of her racing heart and shortness of breath. Allison admitted that she was worried that this cthing d would happen again, and she felt powerless to stop it. She said that she had mentioned it to her mother, who admitted that she had experi- enced the same problem. native or irrational thoughts), while others involve ccompulsions d (behaviors an indi- vidual feels compelled to perform). If the affected individual is unable to practice obsessive thinking or perform compulsive behaviors, anxiety can worsen. Obsessions and compulsions are initially practiced in an effort to reduce anxiety. However, they can take on a life of their own at some point and have to be practiced in order for the individual to avoid the increase in anxi- ety that will occur if they are not practiced. Phobias: A phobia involves an exagger- ated fear of a specific object or situation. One such phobia is a social phobia (some- times called social anxiety disorder). In this case, the individual has a significant fear of being judged negatively by others in a social or performance situation. Although many of the fears or anxieties associated with anxiety disorders are cirra- tional d (not logical, reasonable, or based on experience), others have developed as a result of an actual experience or trauma (i.e., sexual assault) and are sometimes called cpost-traumatic stress disorders. d Effects on Performance Not all anxiety is necessarily bad. In fact, a little anxious excitement can facilitate performance if managed properly. Some student-athletes without anxiety disorders may experience anxiety or nervousness when under pressure in an important com- petition. Often these student-athletes can overcome these problems with instruction in mental skills training that can help them focus, concentrate and perform. However, student-athletes with an anxiety disorder are less apt to be able to manage their anxiety properly and positively. Depending on the nature of the anxiety disorder, effects can vary. An anxiety disorder can 15 Effects on Performance " Student-athletes with an anxi- ety disorder are less able to manage their anxiety in sport and non-sport activities prop- erly and positively. " Anxiety disorders can nega- tively affect concentration, pri- marily through distraction by physical and psychological symptoms. " These student-athletes will often have difficulty focusing. In addition, they will attend to the negative rather than the positive. " Negative emotion can occur before, during and after competitions. negatively affect concentration, primarily through the student-athlete being distract- ed by his or her symptoms, which could include physical and psychological symp- toms. These difficulties can affect the stu- dent-athlete before, during and after com- petition. During competition, many of these student-athletes will have difficulty focus- ing; or they will focus on the negative rather than the positive. Before competi- tion, they are inclined to worry that they will not perform well, perhaps setting up their worst fears. After a competition, espe- cially one in which they perceive that their performance was inadequate, they worry that they are cnot good enough d and that significant others (i.e., coaches, team- mates, family, friends, etc.) will be disap- pointed in them. Stress Symptoms of stress are similar to anxi- ety disorder characteristics. Symptoms of anxiety disorders often worsen under stress. Stress refers to the tension, pres- sure and anxiety that are common to our society. We all feel stress to some degree. Some feel it more than others and are affected more. Its symptoms can be both physiological and psychological. Stress can affect sleep, eating and relationships, and academic and athletic performance. A student-athlete may be experiencing stress because of the transition of being away from home, living in a dorm, or from aca- demic performance in terms of cmaking grades d and becoming or staying celigible. d They may feel stress related to their own expectations and from those of significant others regarding their sport performance. Their stress also may be related to family problems or issues related to significant people in their lives, either at home or 16 A student-athlete may be experiencing stress because of the transition of being away from home, living in a dorm, or from academic performance in terms of cmaking grades d and becoming or staying celigible. d school or both. Many college campus counseling centers offer cstress manage- ment d assistance. Your student-athletes may benefit from such programs. Sport Participation Should a student-athlete with an anxiety disorder train and compete? From a physi- cal/medical health standpoint, there is no obvious reason why a student-athlete should not continue sport competition, unless it in some way renders the student- athlete more at risk for injury. From a psy- chological/emotional health standpoint, pro and con arguments could be made to per- mit the student-athlete to train and com- pete. It might be helpful for a student-ath- lete to have sport as a healthy distraction from his or her symptoms. Not having sport participation might create more cspare d time in which to worry and obsess. Additionally, the physical nature of sport might provide the student-athlete with a physical means to release some of the troublesome anxiety. Less anxiety in turn might create less of a need for sympto- matic behavior used to manage the anxi- ety. On the other hand, sport participation might be perceived as another stressor or worry and increase the need for symptoms. The decisions regarding training and com- petition should be made by the healthcare professional(s) treating the student-athlete, in consultation with sport personnel and the student-athlete. The decision should be solely based on what is in the student-ath- lete 9s best interest. Special Management Issues Student-athletes with an anxiety disorder are likely to welcome an offer of assis- tance. Individuals with such disorders are often tired or even exhausted by their 17 The decisions regarding training and competition should be made by the healthcare professional(s) treating the student-athlete, in consultation with sport personnel and the student- athlete . The decision should be solely based on what is in the student-athlete 9s best interest. symptoms and are looking for some relief. The discomfort of an anxiety disorder can be quite motivating in this regard. Although they may respond positively to your attempts to help, they might worry about what you might think of them. Such is the nature of these disorders. Given their doubts, worry and obsessiveness (repeti- tive thinking that is usually unwelcome), they will probably need considerable sup- port and reassurance. SUMMARY 1. Signs and symptoms of anxiety disor- ders often include fear, worry, changes in sleep and eating, shaking/trembling, and a feeling of being out of control. 2. Causes of anxiety disorders can include genetic and personality factors, and life experiences. 3. An individual may have more than one anxiety disorder and other disorders such as depression. 4. Anxiety disorders can decrease sport performance because they negatively affect concentration and focus. 18 An individual may have more than one anxiety disorder as well as other disorders such as depression. Eating disorders are somewhat of a mis- nomer. They are not only disorders of eat- ing. They are mental disorders that mani- fest themselves in a variety of eating and weight-related symptoms. Focus should not only be on eating disorders such as anorexia nervosa, bulimia nervosa or an eating disorder not otherwise specified; it also should include cdisordered eating. d Prevalence, Risk Factors and Causes Eating disorders are common among col- lege-age females. They are much less com- mon among males, but it should be remem- bered that 10 to 25 percent of individuals with eating disorders are male. Eating disorders result from a combination of factors that include genetics, personality, socio-cultural pressures regarding thinness, social learning and family issues. Although sport participation for most individuals is a healthy experience, aspects of the sport environment can increase the individual 9s risk for an eating disorder. Eating disorders often begin or worsen during transition periods, such as when an individual leaves home to attend college. Because eating disorders usually are trig- gered by dietary restraint (dieting) for weight loss, they tend to be more prevalent in sports that emphasize a thin body size or a low weight, such as cross country, diving, gymnastics, lightweight rowing and wrestling. However, eating disorders for many student-athletes are not directly related to their sport. They likely would have the disorder even if they were not stu- dent-athletes. For these student-athletes, athletics may simply be another stressor that increases the need for the disorder. Purposes and Functions Eating disorders can serve a variety of pur- poses or functions for the individual. Most eat- 19 Chapter 3 Eating Disorders and Disordered Eating Good Nutrition Promotes Health, Enhances Performance ing disorders begin as an attempt to lose weight. The disorder can generalize to many other aspects of a person 9s life and may become the primary means of coping with life. Usually the longer a person has the disorder, the more purposes and functions it serves. Disordered Eating All eating disorders are included in disor- dered eating, but not all disordered eating meets diagnostic criteria for an eating disor- der. Disordered eating consists of the spec- trum of unhealthy eating from dietary restraint to clinical eating disorders. Dietary restraint or cdieting d is included as disor- dered eating because dieting is the primary precursor or trigger for the development of an eating disorder. Although some disor- dered eating does not meet the criteria for an eating disorder, it can create significant problems for a student-athlete, most notably complications related to what has been termed the Female Athlete Triad 4 disor- dered eating, amenorrhea (loss of menstrua- tion) and loss of bone mass (osteopenia/osteoporosis). In this case, dis- ordered eating usually begins the triad by causing insufficient energy to fuel the stu- dent-athlete 9s exercise and training and to maintain normal bodily processes related to health, growth and development. When this occurs, the reproductive system is shut down to conserve energy. As a conse- quence, the body stops producing estrogen. Without estrogen, the body cannot build bone mass, resulting in a loss of bone miner- al density. Extensive information about these problems is contained in the cNCAA Coaches Handbook: Managing the Female Athlete Triad. d Types of Eating Disorders/Identification " Anorexia nervosa, often referred to as 20 Although sport participation for most individuals is a healthy experience, aspects of the sport environment can increase the individual 9s risk for an eating disorder. Female Athlete Triad Disordered Eating Amenorrhea Osteoporosis simply canorexia, d can be described as a self-starvation syndrome. Most anorexic individuals also engage in excessive exercise, which increases their risk and can be difficult to determine or identify in student-athletes. " Bulimia nervosa, usually referred to as cbulimia, d can be described as a binge/purge syndrome in which individu- als ingest food and then cpurge d it, usu- ally through self-induced vomiting, laxa- tive/diuretic abuse or excessive exercise. " Eating disorder not otherwise specified (EDNOS) includes eating problems with some of the diagnostic criteria of anorexia or bulimia but not all. " Binge eating disorder (eating large quanti- ties of food without purging) is included in EDNOS. " Disordered eating includes the full spec- trum of unhealthy eating from simple dieting to clinical eating disorders. Effects on Performance Of all the disorders discussed in this handbook, performance is probably most affected by eating disorders and disordered eating. In general, healthier student-athletes perform better, and health is greatly affected by nutrition. Because of inadequate nutrition, student-athletes with eating difficulties tend to be malnourished, dehydrated, depressed, anxious and obsessed (with eating, food and weight). In addition to their negative effects on a student-athlete 9s physiology, these problems decrease concentration and the capacity to play with emotion. Regarding the physical effects of disor- dered eating, research suggests that intense dieting can negatively affect VO 2 max and running speed for some student-athletes. Because most individuals with eating prob- lems are restricting their caloric intake, they 21 Case Illustration Mary's athletic trainer mentioned to her coach that she often gave excuses about why she could not eat while on road trips. She would say that she could not eat before a competition because she would feel ill or too heavy to run well. Mary's teammates noticed that when she did eat, she often went to the restroom shortly afterward. Mary was not overweight, but she often referred to herself as being cfat. d Her performance had decreased during the past year. She maintained that in order to perform well, she needed to be cleaner. d Mary's last medical evalu- ation indicated that her menstrual cycle was irregular and that she had lost eight pounds in the past year. Her medical history included two stress fractures. are likely to ingest inadequate amounts of carbohydrate in part because they often view carbohydrates as being cfattening. d Restricting carbohydrates 4 the best energy source 4 leads to glycogen depletion soon- er. Without adequate carbohydrate ingestion, the body tends to convert protein into a less efficient form of energy. The risk of muscle- related injury and weakness increases with inadequate protein. For a variety of reasons (i.e., restriction of carbohydrates, induced vomiting, excessive exercise, etc.), student- athletes with disordered eating are apt to be dehydrated, which negatively affects athletic performance. Sport Participation One of the most difficult decisions that arises with a student-athlete with a mental health problem is whether he or she should be training and competing while sympto- matic. This decision may be most difficult with a student-athlete with an eating disorder because the disorder affects the student-ath- lete emotionally and also can significantly compromise the student-athlete 9s physical health. On the surface, the simple solution would appear to be to prohibit sport partici- pation until recovery from the disorder. Why even consider allowing a student-athlete with an eating disorder to train and compete? There are actually several rationales for allowing a student-athlete with an eating disorder to train and compete. Reasons for allowing student-athletes to train and com- pete include: " It allows the student-athlete to remain part of a team and maintain a sense of attachment. " It can make it easier to monitor the stu- dent-athlete 9s eating and condition. " It allows the student-athlete to participate in the primary or only activity through which 22 Effects on Performance " Generally, healthier student- athletes perform better longer, in large part due to good nutrition. " Eating disorders affect the student-athlete both physically and psychologically. " Physical effects can include decreased VO 2max and running speed, low energy, weakness, dehydration, and increased risk of energy. " Psychological effects can include decreased concentration due to malnutrition, anxiety, depression and obsessive thinking. he or she receives self-esteem. " It allows the student-athlete to maintain the important identity of cstudent-athlete. d " It may facilitate the eating changes that will be necessary. " Sport participation can be used to moti- vate the student-athlete in treatment by withdrawing or reinstating participation based on the student-athlete 9s treatment compliance and progress. " It is a way to determine if the student-ath- lete really cwants d to participate in sport. Despite these rationales for training and competition, there are conditions under which the student-athlete should not be allowed to train and compete. These con- ditions and others under which training and competing might be permitted are identi- fied in the cNCAA Coaches Handbook: Managing the Female Athlete Triad. d The health and safety of the student-athlete are always the primary consideration, and the recommendations listed in the female triad handbook are proposed on that basis. Management of Eating Disorders and Disordered Eating Because this topic is covered in consid- erable detail in the cNCAA Coaches Handbook: Managing the Female Athlete Triad, d refer to the handbook for specific recommendations on how best to manage these student-athletes (see www.ncaa.org/health-safety). Remember that individuals with eating disorders are inclined to deny having a problem. Typically, they are concerned that their dis- order will displease significant others (i.e., coaches). For this reason, they may resist your advice and assistance. Being student- athletes, they have another reason to resist 4 they fear admitting the problem may 23 The health and safety of the student-athlete are always the primary consideration. result in being withdrawn from their sport. Usually it is better to approach them with general concerns for their health rather than directly confronting them with evi- dence of eating symptoms. For more infor- mation about this special issue and more general management concerns and ques- tions, refer to the coaches handbook. SUMMARY 1. Eating disorders usually are triggered by dietary restraint. 2. Eating disorders can serve several purposes and functions for the individual, and they usually increase with the duration of the disorder. 3. Eating disorders can negatively affect health and sport performance from a phys- ical and psychological standpoint. 4. Decisions regarding sport participa- tion of the student-athlete with an eating disorder should be made by the healthcare treatment team and can be a way to motivate the student-athlete in treatment. 24 Usually it is better to approach them with general concerns for their health rather than directly confronting them with evidence of eating symptoms. In this handbook, the term csubstance d refers to a variety of drugs or chemicals, including those that are legal, illegal, pre- scribed, over-the-counter (OTC) and per- formance-enhancing. Primary focus is on substances that appear to be used fre- quently by college-age individuals, and those that for various reasons may be stu- dent-athletes 9 substance of choice. Although substance use often is associat- ed with terms like cabuse, d cdependence d or caddiction d to indicate the severity of use, that part of the identification process is well beyond the scope of this handbook. The focus of this handbook is to help coaches identify a student-athlete with a possible problem, refer the student-athlete to the appropriate professional who can assess the extent of the problem and arrange necessary treatment. Much of the information in this chapter was drawn from the six NCAA studies investigating sub- stance use by student-athletes. Based on the self-reporting of drug use, these data are probably conservative. Actual use is apt to be higher than reported use. Substances Alcohol Current Usage. Although alcohol con- sumption decreased among student-ath- letes from 1989 to 2005, more than three- fourths of the student-athletes surveyed in a 2005 NCAA study reported using alcohol during the previous 12 months. More dis- turbing was the increase in the number of student-athletes who reported drinking 6 or more or 10 or more drinks in a sitting. Effects on Performance. Alcohol is a central nervous system (CNS) depressant. It can decrease concentration, coordination, reaction time, strength, power and endurance. Alcohol also can inhibit the 25 Chapter 4 Substance- Related Disorders body 9s absorption of nutrients. For these reasons, alcohol will negatively affect per- formance. The extent of the effect depends on the amount and type of alcohol ingested, the weight and health of the individual, and the timing of the alcohol consumption. For cheavy drinkers, d the effect can last for days. See cFor the Athlete: Alcohol and Athletic Performance d for additional effects on per- formance (www.ncaa.org/health-safety). Findings in a recent NCAA survey suggested that many student-athletes do not see alco- hol consumption as a problem. Almost 60 percent of student-athletes reported that they did not believe that alcohol affected their athletic performance. However, almost 30 percent admitted that they had performed poorly in practice or a competition because of drinking or drug use. Reasons for Use. Most individuals con- sume alcohol recreationally to cfeel good d or chave a good time. d Some, however, use it as a means to calm themselves to avoid or manage anxiety. Some will even suggest that alcohol acts as an cergogenic d that allows them to perform better by helping them to crelax. d Some may use alcohol to help them sleep. Others will use alcohol in response to being depressed; however, because it is a CNS depressant, alcohol only serves to further (biochemically) depress them. Signs and Symptoms. The signs and symptoms of alcohol (ab)use can vary with the type and amount of alcohol consumed and the individual 9s personality. In general, student-athletes with this problem might be expected to be more irresponsible regarding commitments or responsibilities to school, sport, and relationships. They might be more likely to drink in situations that could be dangerous to themselves or others. They might show a propensity for 26 2005 NCAA Study Social Drug Use 4 Historic Trends 90 80 70 60 50 40 30 20 10 0 1989 1993 1997 2001 2005 alcohol marijuana spit tobaco cigarettes Percent 2005 NCAA Study Among Drinkers,Those Having 6 or More Drinks per Sitting 70 60 50 40 30 20 10 0 1997 2001 2005 Male Female Percent 2005 NCAA Study Among Drinkers,Those Having 10 or More Drinks per Sitting 30 25 20 15 10 5 0 1997 2001 2005 55.5 20.7 56.5 22.6 61.9 26.9 Male Female Percent 20.5 2.3 20.7 2.4 27.8 3.4 getting into trouble when drinking (i.e., fighting, legal problems, etc.). These exam- ples are observable signs, but it should be remembered that drinking alone often is a sign of an alcohol problem. Thus, a stu- dent-athlete who abuses alcohol may do his or her drinking alone and avoid drawing attention to observable signs. Stimulant-Type Substances- Amphetamines, Cocaine, Ephedrine, and Medications for Attention Deficit and Hyperactivity Disorder (ADHD). In contrast to a CNS depressant like alcohol, substances in this class are CNS stimulants. Whereas CNS depressants slow the nervous system, CNS stimulants speed up the nervous system. Users sometime refer to these drugs as cspeed. d Current Usage. The percentage of stu- dent-athletes reporting using ampheta- mines, cocaine and ephedrine is small (four percent or less). However, ampheta- mine and cocaine use by student-athletes has been increasing in recent years. Ephedrine use has not increased. This type of drug use often begins before col- lege. The abuse of medications for ADHD is a relatively new phenomenon, but one that is increasing in prevalence 4 especially in the college population. These medications, when used by individuals who need them for treatment of their hyperactivity symp- toms (i.e., distractibility) have a paradoxical effect. Although ADHD medications are stimulants, they decrease the individual 9s distractibility and facilitate concentration and focus. Some individuals are illegally or illicitly obtaining the medications for their own use or for sale. These medications usually are amphetamines such as Adderall and Dexedrine. 27 Case Illustration Jim was told by his coach to see his academic counselor when he had been placed on academic pro- bation. He explained to the coun- selor that he had been missing classes, especially morning classes, because he often didn't feel well in the morning. Jim reported that he seldom felt like getting up to go to class because he often woke up with physical symptoms that includ- ed nausea and headaches. His counselor asked if he had been examined medically regarding these symptoms. Jim indicated that he had, but that the doctors could not find anything wrong with him. When his counselor asked about his drink- ing, Jim angrily said that he was not an calcoholic d and that he knew an alcoholic when he saw one because his father was an alcoholic. The counselor asked about an inci- dent that had occurred the previous year when he had been arrested for fighting outside of a bar. Jim denied that he had had too much to drink at that time and said that the other guy started the fight. When asked by his counselor if he had had any other arrests, Jim reported that he had been arrested as a high school junior for underage drinking, but he dismissed the incident by saying that he wasn 9t drunk and was just in the wrong place at the wrong time. Effects on Performance. Because the drug makes a student-athlete feel more ener- getic and alert, it is assumed that it will posi- tively affect performance. The drug can make many individuals nervous or jittery, which would negatively affect any skill requiring fine motor coordination and concentration. Performance also can be negatively affected because this type of drug increases heart rate and blood pressure. In addition to these potential problems, drugs like ephedrine can increase body heat production and body temperature. Because these drugs can lead the student-athlete to feel overly energetic, they may lead to overexertion, which could result in injury or even death in extreme cases. It is ironic that many student-athletes may be taking these drugs as an cergogenic d aid to help them perform better, when in fact these drugs may have more of an cergolytic d (negative performance) effect. Reasons for Use. This type of drug usu- ally is used for cenergy d or to raise mood. It also may be used for weight control/loss. Amphetamines also may be used to improve performance. Signs and Symptoms. Common signs and symptoms include shakiness, rapid speech or movements, difficulty sitting still, difficulty concentrating, lack of appetite, sleep disturbance, and irritability. Marijuana: Current Use. Marijuana is the most widely used illegal drug by the general population. Marijuana appears to be a drug of choice for college students, and it appears to be a popular drug used by stu- dent-athletes. Although marijuana use by student-athletes has declined in recent years, a 2005 NCAA study found almost 20 percent of student-athletes reported having used the drug in the past year. 28 The abuse of medications for ADHD is a relatively new phenomenon, but one that is increasing in prevalence 4 especially in the college population. Effects on Performance. The effects of marijuana on sport performance are much like those of alcohol. It can slow reaction time, impair both motor and eye-hand coordination, and affect time perception. Research related to the duration of the effect of this drug is inconclusive, but some researchers believe it can last an entire day or longer. Reasons for Use. Student-athletes reported that they used marijuana for recreational and social purposes in order to cfeel good. d Signs and Symptoms. Signs and symp- toms vary depending on the frequency of use. There may be no signs associated with infrequent use. Possible signs could include red eyes, paraphernalia related to marijuana use (i.e., papers, pipes, etc.), and scales for weighing the drug. Physical symptoms could include lethargy and increased appetite, especially immediately after smoking the drug. Anabolic Steroids: Current Usage. Steroid use by student- athletes has been decreasing. Now, less than two percent report using steroids. The majority of users are male. Of those who use steroids, more than half say they use them to enhance performance and that their use began before college. Effects on Performance. Steroid use typically is associated with an increase in athletic performance. Steroids can increase muscle mass, and as a result may increase strength, power, speed and endurance. Reasons for Use. The primary reason reported for steroid use is performance enhancement from an increase in size and strength, and to recover more quickly from an injury. 29 Marijuana is the most widely used illegal drug by the general population. Signs and Symptoms. Signs and symp- toms can include a variety of changes in the student-athlete. Some changes may occur in the size and musculature of the body. There may be personality changes, often with a variety of psychiatric symp- toms, including increased anger and aggression, or what has sometimes been referred to as croid rage. d Physical/medical signs can range from acne to reproductive system dysfunction to liver and cardiovas- cular system problems. Sport Participation Usually, the primary issue regarding whether a student-athlete with a mental health problem should be training or com- peting concerns the physical and psycho- logical risk to the student-athlete. A deci- sion to allow the student-athlete to contin- ue with sport participation is usually made if the healthcare team agrees that training and competition do not increase the risk to the student-athlete. However, the issues for a student-athlete with a substance-related disorder will likely be different. Due to the use of substances that are illegal, sub- stances on the NCAA banned substance list or substances that are prohibited by the coach or athletics department 9s sub- stance abuse policy, the question of whether the student-athlete should partici- pate in his or her sport may be a moot point because of legal issues or an imposed suspension related to the sub- stance abuse. Most athletics departments will have substance-abuse policies that will provide guidance regarding recommended procedures. Even if the NCAA or the insti- tution 9s policy does not prohibit the stu- dent-athlete from practice and competition, it may be in the best interest of the stu- dent-athlete for you to require substance- 30 Of those who use steroids, more than half say they use them to enhance performance and that their use began before college. abuse treatment as a condition of partici- pation. That is, sport participation can be used as a way to motivate the student-ath- lete in treatment. Approaching a Student-Athlete Approaching a student-athlete with a suspected substance-abuse problem is somewhat different from approaching a student-athlete regarding symptoms of depression or anxiety. Student-athletes with depression and/or anxiety may be more receptive because they feel bad and may be motivated for assistance, hoping to feel better. Student-athletes with sub- stance-related difficulties may be less receptive to assistance for the following reasons. " They may not actually feel bad because they may be using the substance in order not to feel bad or at least not be aware of feeling bad. " They may be cdependent d on their sub- stance, whereas the depressed or anx- ious student-athlete is not apt to be dependent on their symptoms. " Denial of the problem is common with substance abuse. " The substance abuser may fear punish- ment (i.e., suspension) for his of her use because the substance being used may be illegal, on the NCAA banned sub- stance list, or prohibited by the coach or athletics department. " Although there may still be a stigma attached to problems like depression or anxiety, there is apt to be a more nega- tive attitude associated with substance abuse. As a result, a student-athlete with substance use may more actively resist admitting to the problem. 31 Sport participation can be used as a way to motivate the student-athlete in treatment. Given these issues, approaching student- athletes with a substance-use problem could prove to be difficult. They will likely deny the problem and resist your efforts to assist them. It is probably best not to argue with them or try to convince them. Simply tell them that you are concerned and that the only way to know for sure if there is a problem is for them to be evaluated by a professional with experience and expertise in this area. Make the referral and follow- up to make sure the referral was accepted and completed. SUMMARY 1. Substance abuse by student-athletes includes drugs that can be classified as legal, illegal, prescription, over-the-counter and performance-enhancing. 2. Substance abuse by student-athletes usually begins before coming to college. 3. Many of the drugs classified as CNS stimulants may be viewed by student-ath- letes as performance-enhancing. 4. Student-athletes who have sub- stance-related disorders may be more diffi- cult to assist because of the denial that is often characteristic of such disorders and because the drug use often carries sanc- tions or punishments that may have legal or eligibility consequences. 32 Denial of the problem is common with substance abuse. This chapter will primarily focus on responding to the student-athlete with a suspected mental health problem. Because approaching the individual is necessary for effective management and is critical in obtaining the student-athlete 9s compliance, this first step is perhaps the most impor- tant part of the process. An important disclaimer in this chapter involves the limits of responsibilities of the person responding to the student-athlete. Your job is not to evaluate, counsel or treat. Rather, it is to assist the individual in getting to the right treatment professional. Talking with the Student-Athlete Who should talk with the student-ath- lete? The person approaching the student- athlete should be a person of some author- ity. More important, however, is that this initial step should be taken by someone who has a good relationship with the stu- dent-athlete or who is comfortable in dis- cussing important and sensitive issues. This might be a coach, an athletic trainer, a team physician or some other individual involved in the student-athlete 9s life. How should the student-athlete be approached? The layperson 9s biggest fear in responding to an individual with an emo- tional problem is often the fear of saying the wrong thing and worsening the situa- tion. Probably the most serious mistake that anyone can make in (mis)managing a student-athlete with a mental health problem is to respond as if the problem is trivial or is a sign of weakness. For someone who has never been clinically depressed, it may be difficult to imagine that people could be so depressed that they literally cannot get out of bed. In such a case, you might be tempted to accuse a student-athlete of simply being clazy d or 33 Chapter 5 Management and Treatment Issues What to Do cirresponsible d and recommend that he or she cget the lead out of your butt. d Similarly, for someone who has never experienced a panic attack, it may be hard to believe that people could be so anxious that they become immobilized or fear that they are going to die. You might be inclined to see them as being cweak d and recom- mend that they just ctoughen up. d A cnor- mal d eater, who eats whatever he or she wants, may think it is silly that a student- athlete is cafraid d to eat and might demand that she cstop being ridiculous d and cjust eat. d Someone who views substance abuse simply as a cchoice d by a student- athlete who is being cstupid d may think that treatment rather than punishment is only ccoddling d the student-athlete. Even if you cannot understand the seri- ousness or difficulty of the student-ath- lete 9s problem, you must accept that it is a serious problem for that individual. Depressive disorders, anxiety disorders, eating disorders and substance-related disorders are mental health problems in need of treatment. They are illnesses 4 not choices; that is why they are called disorders. Individuals with mental health problems are not weak. Their difficulties are not insignificant, and their recovery is not simple or easy. If their problems were simple or insignificant, and getting over them were easy, they would have already found a solution and implemented it. They need assistance. As their coach, you may be the first step in the process. Admitting their difficulties will not be easy for them. With the disorders we discuss in this handbook, the student-athlete is likely to already feel bad about his or her circum- stances. A critical, judgmental or detached response on your part will likely serve to worsen those feelings. A positive, con- 34 Your job is to assist the individual in getting to the right treatment professional. cerned and involved response on your part is a good first step. How to respond when the student-ath- lete approaches you. When an individual approaches you, he or she is indicating a need to talk with you. The best way to respond is to listen. Stop what you are doing, look at the student-athlete and lis- ten. This posture communicates that you are ready and willing to listen. Listening is the most important part of communicating. It is hard to listen when you are talking. If you are listening, you will likely know when to talk and what to say. Generally, wait to speak until the student-athlete stops talk- ing or appears to be waiting for you to respond. It is all right to ask questions for clarification, but be careful not to judge or be critical. Accept what you are given. It is okay to repeat back what you have heard to be sure you heard it correctly. Indicate that you are glad the person has chosen to speak with you. Ask if there is anything else that needs to be said. If not, or after he or she finishes what needs to be said, respond by saying that you want to help get the necessary assistance. You then make the referral. Making a referral. Unfortunately, many referrals are not accepted or used by the student-athlete. There are aspects of mak- ing a referral that increase the likelihood of it being successful. Know or at least have some knowledge regarding the referral per- son or agency. Share that knowledge with the student-athlete. Also, referrals are more often accepted when the referral is made to a specific person. Either you make the call or have the student-athlete make the call at the time to make the necessary arrangements. If you feel the individual needs assistance at the time, take him or her to the referral person or facility. 35 How to respond when the student-athlete approaches you. " The student-athlete 9s approach indicates a need to talk with you. " Stop what you are doing, look at the person, and listen . " Listening is the most important part of communica- tion. " It is hard to talk and listen at the same time. " If you listen well, you will know when to speak and what to say. " Accept what you are given. Ask questions for clarification without judging . " When it appears the person has finished talking, ask if there is anything else he/she needs to say. " Indicate that you are glad he/she came to you and that you want to help. " Make the necessary referral and encourage/support its acceptance. How to respond when the student-ath- lete is in need and has not approached you. Obviously, it is easier and better if the student-athlete with a mental health prob- lem comes to you. However, it is probably more likely that you will need to initiate the contact, in part because the individual may not feel there is a problem, or because of being embarrassed or uneasy about approaching someone in authority regard- ing his or her difficulties. It is best to approach the individual privately to decrease the likelihood of embarrassment and to avoid any other activity that might distract you or the student-athlete. Sensitivity is a key in facilitating the discus- sion. Begin by saying that you are con- cerned about the individual 9s welfare and would like to help. Ask how he or she is feeling, and how school, practice and games are going. Hopefully, this approach will allow the student-athlete the opening to talk with you about his or her difficulties. If so, follow the same recommendations dis- cussed above regarding when the individual comes to you. If not, then you should tell the student-athlete that you need to make sure he or she is okay. Relate to the person that in order to determine this, you need to have him or her talk with a healthcare pro- fessional and that you would like to help arrange the appointment. If the student-ath- lete resists, you should say that you simply want to arrange an evaluation to determine if there is a problem. Tell the student-athlete that you hope that the evaluation deter- mines that he or she does not have a prob- lem, and if that is the case, then we can all breathe a sigh of relief and go on with our lives. The student-athlete should be told that if the professional 9s evaluation indi- cates that a problem exists, then the pro- fessional will discuss treatment options. 36 It is best to approach the individual privately to decrease the likelihood of embarrassmen

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