Psychological and Substance Abuse Disorders

18


Psychological and Substance Abuse Disorders


Layne A. Prest



Objectives


At the completion of this chapter the reader should be able to do the following:


1. Recognize emotional and behavioral signs of common substance abuse and psychological problems, including mood, anxiety, eating, and attention deficit hyperactivity disorders


2. Intervene appropriately with the affected athlete through discussion, supportive confrontation, education, and referral


3. Be aware of and establish collaborative relationships with qualified physical and mental health professionals in the recognition and treatment process


4. Identify a variety of educational and supportive resources (printed, web based, and organizational materials) that are available to both professionals and patients affected by these disorders



Introduction


The twenty-first century is supposed to be the era of healthier people; and, of course, athletes are by definition among the healthiest. Therein lies the main dilemma when assessing and intervening in potential mental health concerns of athletes. Many people, perhaps athletes more than the average person, have been conditioned to minimize or even deny physical health problems, and they are even more inclined to do so with mental health issues. Being sick or disabled physically is one thing; being crazy or weak mentally or emotionally is quite another! Professionals working with athletes are increasingly likely to have been educated about mental health issues, however, or know of someone in their personal or professional circle who has struggled with emotional or behavioral problems in the past. It is hoped that more exposure will erase stereotypes and increase the likelihood of early detection and appropriate intervention. This chapter is designed to educate the athletic trainer about the signs, symptoms, and prognosis of the most common mental health disorders. It is not intended that the athletic trainer actually counsel the athlete, as this is beyond the scope of practice; but rather that the athletic trainer know the appropriate situations to refer the patient. Toward that end, this chapter outlines the mental health problems most commonly experienced by athletes, suggests red flags for earlier detection, and describes strategies for intervention.


The World Health Organization (WHO) identifies mental and behavioral health conditions as 4 of the 10 leading causes of disability worldwide and as affecting 25% of all people at some time in their lives.1 These four causes of disability are depression, anxiety disorders, suicide, and alcohol use. Other serious disorders include schizophrenia, bipolar disorder, dementia, obsessive-compulsive disorder, posttraumatic stress disorder, and panic disorder. Problems with attention and concentration, disordered eating, personality issues, and other forms of substance abuse also contribute greatly to the disease burden throughout the world.2 Some of these difficulties, chiefly depression, anxiety, and substance abuse problems, are ubiquitous in American society. The others, including attention deficit hyperactivity disorder (ADHD), personality disorders, and disordered eating, are not as common. All can impair athletic performance and overall life adjustment. These conditions also can be difficult to treat, especially if allowed to escalate out of control. Therefore athletic trainers working with physically active people must be able to identify these potentially serious problems as early as possible. Following a description of typical physical and emotional symptoms, diagnostic criteria, and potential red flags, suggestions are made for initial intervention, referral, and treatment recommendations. The diagnostic criteria are taken from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).3



Understanding the Role of Mental Health Professionals


At the outset, a full and comprehensive treatment plan needs to be developed in the context of the athlete’s relationship with a trusted licensed professional operating within the scope of professional practice. The athletic trainer, who may be among the first to detect a problem, can be instrumental in getting the athlete needed help. Athletic trainers need to be familiar with the various mental health professionals to whom they may refer a patient for professional services. A reasonable professional to start with is the patient’s primary care physician.


The U.S. federal government has designated five disciplines with competency to provide mental health services to the population: (1) psychiatry, (2) psychology, (3) marriage and family therapy, (4) social work, and (5) psychiatric nursing (Table 18-1). Other professionals who provide mental health services include professional counselors and clergy members. Licensure and certification for most of these professionals are becoming standardized within each discipline, and the boundaries are better delineated among disciplines. A fair amount of overlap remains, however, and providers in any of these categories can potentially help with any of the clinical problems this chapter addresses. Referrals may be guided somewhat by the discipline of the professional but more importantly by the person’s clinical specialty.



The training of psychiatrists and psychiatric nurse practitioners enables them to assess the patient from a medical point of view and to prescribe medicine to address the underlying physiological or chemical components of the problem. They may also provide supportive counseling, psychoeducation, or assistance in problem solving. If a major mental disorder is suspected and medical intervention is needed, a referral to one of these professionals would be appropriate.


The various types of psychologists—clinical, educational, and counseling—have different but overlapping training, experience, and areas of expertise. They can be trained at either the master’s or doctoral level. Typically psychologists are the professionals to contact if psychological or educational testing is needed. Psychologists also provide counseling services.


Marriage and family therapy, especially medical family therapists, views problems from the biopsychosocial point of view. Consequently their clinical approach considers various aspects of the person’s life. Marriage and family therapists work with typical mental health issues, such as depression, anxiety, eating disorders, and ADHD, but will often do so by including part or all of the family and in collaboration with a primary care provider.


Social workers usually specialize in addressing macroissues, such as housing, income, or food deficiencies and insurance needs, or microissues, such as psychotherapy. Social work as a discipline also uses a holistic perspective of the client. A number of social workers also provide counseling services similar to other mental health providers.


Mental health professionals (MHPs) increasingly are being called on to demonstrate the effectiveness of their work with clients. As a result, more attention is being focused on the development of evidence-based protocols. Therapy typically begins with an intake session during which the professional gathers background information (e.g., family of origin details), a description of the problem and previous attempts to address it, and the client’s goals. A contract governing frequency and duration of sessions is negotiated, and parameters of confidentiality are discussed. MHPs will obtain a signed consent for release of information, allowing them to contact other professionals including the athletic trainer or family members working with the client.



Overview of Mental Health Issues in the Athlete


Everyone has symptoms of some type of mental health issue at some time in life when one or several stressors overwhelm the body’s ability to self-regulate or repair. The symptoms are usually, and arbitrarily, divided into the physical and mental categories. However, this artificial dichotomy does not match the affected person’s reality. In other words, 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 emotional or mental depression are the physical symptoms of sleep, energy, and appetite disturbance. This is because humans are made up of 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 attempt to correct the problem regardless of physiological, mental, or behavioral origin. In the mental health domain, signs of distress manifesting this state of disequilibrium are emotional, mental, behavioral, and physical.



Framework for Understanding Mental Health


In virtually all situations a variety of overlapping factors are at play and contribute to symptom development. The biopsychosocial–spiritual model (BPSS) is a framework for understanding the individual’s responses in a given situation and development of symptoms. Symptom etiology may be conceptualized in terms of a pie metaphor. Figure 18-1 shows how these various factors overlap and contribute to overall well-being. In a given individual, 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 individual’s overall adaptation and symptom development.


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FIGURE 18-1 The biopsychosocial–spiritual model is a framework for understanding an individual’s responses in a given situation and 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 their respective levels of physical conditioning and injury history but also by other physical and emotional conditions they may be experiencing, such as pain tolerance, attitude, perception of the problem, and its implications for their lives. The situation may also be impacted 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; and 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 treatment approaches that have been found to be effective for the problems discussed in this chapter are based on the same BPSS approach as in assessment and diagnosis. Different strategies are useful, depending on the biopsychosocial–spiritual components that are implicated in the assessment process. Treatment plans are often recommended by the practitioner on the basis of assessment and experience, and then negotiated with the individual or family members according to their preferences. The treatment may be offered on either an inpatient or, more commonly, outpatient basis.


Treatment may also involve the collaboration of a variety of treatment professionals. For example, eating disorder treatment often involves a physician, registered dietitian, and psychotherapist. This determination is made on the basis of the severity of symptoms, the difficulty the athlete has in making changes, the amount of support the athlete has, and other resources that impact 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 person 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, what it is, and 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 that case, functioning in one or more areas of life can be affected, sometimes severely. Restricting an athlete’s participation in a sport if necessary will depend on the athlete, coach, and athletic trainer’s assessment of the individual’s level of functioning. The treatment plan, even when it includes appropriate medication, should not affect the athlete’s ability to participate. Initially, while the medication dose is being adjusted, the athlete could experience problematic adverse effects, such as nausea, headache, sedation, balance, or stimulation, that could affect participation or performance. 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.4


The last general point to be made is that some people experiencing the problems described in this chapter may consider suicide or become homicidal. Most health care or other professionals are required by state law and/or their professional code of ethics to report to the authorities if someone with whom they are working is a danger to self or others. Athletic trainers, too, may encounter an individual 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 for such a report. An assessment of suicidality or homicidality includes a determination that the person has a specific plan, the means to carry it out, the intention to carry it out, and a measure of how lethal the plan is. Those who have a personal or family history of this type of ideation or action, or whose judgment is impaired, perhaps through the use of substance abuse, are more at risk to follow through.



Role of Stress in Psychological and Substance Abuse Disorders


A related topic for the health care professional to consider is the role of stress in the life of an athlete. Determining how much stress an athlete is experiencing, and how well he/she is coping, is an important part of assessing their level of functioning overall. First of all, what is it? Stress is alternatively thought of as bad, normal, healthy in moderation, and/or an inescapable fact of life. In fact, all of these are true. Stress is the word we use for the impact of our physical, emotional, psychological, and social experiences in life. Athletes, like all human beings, experience stress just by living life. And by virtue of the self- and other-imposed demands as a part of their training, athletes have another level of stress with which to contend. But stress is a two-sided coin. We need the stimulation, challenge, and motivation that come from being stressed. Because we are stressed we strive to meet the basic survival needs for ourselves and our loved ones. Being stressed is what helps us push toward a goal and rise to the occasion in competitions. But too much stress can be debilitating. Ineffective stress management contributes to the variety of psychological and substance abuse disorders described in more detail below. Being overloaded with demands can lead to an athlete decompensating, becoming less effective, and ultimately failing in their pursuits. As a result, the prevailing thinking about stress for the last several decades has focused on both sides of the coin. Research and clinical experiences suggest that we should strive for a balance between rest and activity, pushing for improvement and adjusting to limitations, a goal-directed orientation and being in the experience. Athletic trainers are advised to help the athletes with whom they work to pause and reflect on the amount of stress they are under and whether or not the effects are helpful and motivational or undermining and disabling.


There are a variety of tools for measuring stress—some adapted for specific populations. One that has been used in studying athletes in a variety of sports is the COPE inventory (full and brief versions; the latter is included below). By having an athlete complete this inventory, the athletic trainer can get a clearer sense about the athlete’s coping strategies and the degree to which s/he is coping successfully and constructively.



Anxiety Disorders


Anxiety is one of the most common human experiences. For example, most people have experienced a momentary sensation of “butterflies” in the stomach. In fact, the ability to respond with anxiety is considered normal and even desirable; and anxiety is what helps us “get our game face on” (Figure 18-2). However, given the right set of factors—physiology, central nervous system sensitivity, perceptual filters, belief system, coping, and support system—people may respond to one or more acute or chronic stressors by developing anxiety serious enough to be considered a disorder. This is a case of too much of a good or necessary thing. The individual is wracked with very serious and debilitating apprehension, excessive and ongoing worry, overwhelming fears, or compulsive behaviors. Some 40 million Americans (18.1% of the population) experience one of the more debilitating forms of anxiety and have been diagnosed with an anxiety disorder.5


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FIGURE 18-2 Athletes often become anxious during competitive events and may be able to use that anxiety to good advantage.

Red flags for problems with anxiety include outbursts of irritability or anger, substance abuse, changes in athletic performance, or other behaviors that are uncharacteristic for the athlete. Anxiety symptoms include both somatic–behavioral and emotional–cognitive disturbances.6 The presence of some or all of these symptoms may signal an anxiety problem or even an anxiety disorder (Box 18-1). People can be screened for anxiety disorders using a variety of standardized measures, such as the Hamilton Anxiety Scale (HAMA).



BOX 18-1   SIGNS AND SYMPTOMS OF ANXIETY





Generalized Anxiety Disorder


Generalized anxiety disorder (GAD) is a condition in which the individual is worried or nervous about many or most things in life. The person may complain on a regular basis of one or more of the anxiety symptoms listed previously. Box 18-2 summarizes criteria for diagnosing generalized anxiety. It has been estimated that 6.8 million people, or 2.7% of the American population, have this disorder. Women are twice as likely as men to report generalized anxiety.5 Consistent with the BPSS model described previously, the causes of GAD and other anxiety problems are varied. Fortunately, a number of effective treatment approaches and self-help measures are available.7



BOX 18-2   CRITERIA FOR DIAGNOSING GENERALIZED ANXIETY DISORDER





Panic Attacks


Among the 6 million people (2.7% of the population) who experience panic attacks, some say that these episodes seem to come out of nowhere when in fact they are probably in response to an accumulation of stressors. At other times the attacks may be stimulated by an identifiable, acutely stressful event.5 Symptoms that seem cardiovascular in nature are particularly striking during these episodes, for example, chest pain or shortness of breath. The attacks can be so overwhelming and produce such fear and intense anxiety that the affected person may begin avoiding stressful situations and other stimuli perceived as being triggers.8 As a result, the panic attacks may become panic disorder that can be accompanied by agoraphobia or avoiding going out into open spaces or public places. Panic disorder can be so severe and distressing that someone affected might consider suicide as the only way out; in fact, up to 20% of those affected consider this step. Women experience panic attacks at twice the rate of men.



Posttraumatic Stress Reactions


Similar to the intense responses involved in panic attacks are varying degrees of posttraumatic stress reactions (e.g., acute stress disorder [ASD], posttraumatic stress disorder [PTSD]) experienced by approximately 7.7 million Americans.5 These reactions are in response to exposure to life-threatening events or other situations outside the normal range of human experience (e.g., war, serious physical or sexual assault, motor vehicle accident). ASD and PTSD result because the survivors have witnessed and/or experienced events that include serious injury, life-threatening trauma, or death. Examples of situations that have caused some of those involved to develop PTSD are the 9/11 attacks, the Iraqi and Afghani wars, and campus-based assaults and killings such as took place at Virginia Tech. People can be so overwhelmed by the event or series of events that they will go to great lengths to avoid similar situations, as well as the thoughts or feelings associated with the original experience, because their responses involved intense fear, helplessness, or horror.


Fairly often people will replay or reexperience the traumatic event in the form of recurrent or intrusive and distressing recollections, images, thoughts, perceptions, recurrent dreams, illusions, or hallucinations. They often experience great physiological reactivity and therefore engage in persistent avoidance of stimuli and numbing of general responsiveness. This involves avoiding associated thoughts, feelings, conversations, activities, places, and people. At times this process of compartmentalization can be so severe as to lead to an inability to recall important aspects of the event, marked anhedonia, detachment or estrangement, restricted range of affect, and a sense of a foreshortened future. Without intervention to help survivors deal with the enormity of what they have experienced, PTSD can develop and cause many physical, emotional, and social difficulties for years to come.



Obsessive–Compulsive Disorder


Approximately 19 million individuals, or 8.7% of the U.S. population, display characteristics of anxiety in a more circumscribed manner by developing phobias to specific triggers or fears about specific issues. These include abnormal anxiety regarding being in social situations, public speaking, fear of flying, or preoccupations with germs or disease.5 These manifestations of anxiety can be less incapacitating if the person is successfully able to avoid the stimuli without compromising life and activities, but otherwise they can be quite disruptive. Some aspects of anxiety can be useful. For example, attention to detail and the ability to be thorough in a task can be very valuable attributes in environments such as athletic competition, where excellent performance is a premium. However, taken or driven to the extreme, these characteristics can be debilitating. Obsessive–compulsive disorder (OCD) is a condition that affects approximately 2.2 million people in the United States and is equally common among men and women. The basis for OCD consists of persistent thoughts, impulses, or images about exaggerated or imaginary circumstances. The thoughts the person has are experienced as intrusive or inappropriate to the situation. Compulsive or repetitive behaviors are paired with the obsessions, with the goal of eliminating, reducing, or ignoring the resultant anxiety. As with the obsessions, the person frequently recognizes that the compulsive behaviors are, to some degree, excessive or unreasonable, especially if they impede the person’s performance, routine, or social activities. The most common obsessive thoughts are those concerning contamination, doubts, loss of order, horrible trauma, and sexuality. Table 18-2 summarizes common compulsive behaviors, and Box 18-3 lists diagnostic criteria for OCD.



BOX 18-3   DIAGNOSTIC CRITERIA FOR OBSESSIVE–COMPULSIVE DISORDER






Treatment of Anxiety Disorders


Treatment plans for anxiety disorders are often recommended by the practitioner on the basis of assessment and experience, and then negotiated with the individual or family members according to their preferences. The treatment plan for addressing anxiety can include one or all of a group of evidence-based interventions.


When there is a strong family history of anxiety problems, there is likely a biological or physiological predisposition that can be ameliorated through psychopharmacological measures. One class of psychotropic medications often used includes those that act on the serotonin system. These include selective serotonin reuptake inhibitors such as fluoxetine (Prozac), paroxetine (Paxil), and escitalopram (Lexapro). When anxiety coexists with depression, medications that affect dopamine or norepinephrine, as well as serotonin, can be useful. These include venlafaxine (Effexor), and mirtazapine (Remeron). Benzodiazepines have been used for many years to treat anxiety and consequently are fairly well known. These medications include diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax).


The antianxiety drugs are prescribed according to their rate of onset, effects, and adverse effect profiles. Medication can be used from the outset or added after treatment begins. It is usually recommended that the person stay on the medication for 9 to 12 months or until symptoms are fully resolved. The medication dosage may need to be adjusted, or a different type or class of medication altogether may be needed. In the case of first or second episodes of anxiety, medication can be discontinued after the person has developed healthy, alternative coping strategies. If the anxiety recurs, then the individual may need to take the medication for the duration.


Other important steps to take to reduce anxiety on a physical level are to get regular exercise and regulating sleep. Exercise, particularly at aerobic levels, has been shown to significantly reduce levels of anxiety. This may be a moot point for those who are already physically active, but at times people will discontinue exercise if they are sufficiently distressed. For the injured athlete, the importance of maintaining aerobic conditioning during rehabilitation is equally important for mental as well as physical well-being. Most people should be encouraged to slowly reestablish healthy patterns of physical activity. Similarly, good sleep hygiene addresses the basic human need for restful sleep, which in turn supports well-being and stable functioning.



KEY POINTS


GOOD SLEEP HYGIENE



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Working With Special Populations The Medical Examination Therapeutic Drug Categories Neurological System Dermatological Conditions Common Procedures in the Athletic Training Clinic

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Sep 3, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Psychological and Substance Abuse Disorders

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