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Eur Arch Psychiatry Clin Neurosci (2011) 261 (Suppl 2):S182S185 DOI 10.



Sport psychiatry and psychotherapy. Mental strains and disorders in professional sports. Challenge and answer to societal changes
Valentin Z. Markser

Received: 4 July 2011 / Accepted: 3 August 2011 / Published online: 27 August 2011 Springer-Verlag 2011

Abstract Professional athletes are subject to massive somatic, social, and mental stress. Despite great public interest for athletic achievements, the emotional strains thereof are very poorly investigated and discussed. The main reason for this is the widespread assumption that only emotionally very strong athletes are able to compete at the highly professional level and therefore mental disorders do not exist in professional sports. But available research data about the prevalence of mental disorders in this area suggest that this hypothesis must be revised. With respect to depression and the overtraining syndrome, attempts have been made to demonstrate the difculties with etiology, diagnostics, and treatment for sports psychiatry and psychotherapy. Scientically, sport psychiatry and psychotherapy can be dened as a discipline, whose focus is the investigation, treatment, and prevention of the extreme and sports-specic emotional strains and disorders. In addition to sport psychology, which focuses mainly on performance enhancement, mental stress, and disorders can hereby be recognized, disorders be treated and the athletic performance sustained. With the foundation of the Task Force for Sports Psychiatry and Psychotherapy at the German Association for Psychiatry and Psychotherapy, scientic research, further education, prevention, and treatment for mental disorders in professional sports will be improved. Keywords Selection hypothesis Prevalence Sport psychiatry Sport psychotherapy Overtraining syndrome Sport-specic diagnosis and treatment Qualication

Selection hypothesis There is a widely held view, shared by athletes, their coaches and trainers, and the general public, that only mentally strong athletes can be successful. This means that there is no place for mental disorders in high-performance sport. They are considered as failures in the system. As a result, athletes with mental illness are seen as individual cases to be hastily diagnosed away from public view and treated by external specialists. As a consequence, there are relatively few academic papers and little serious research in this area. What is more, there is still no effective early warning system and there is a lack of therapists specically trained to treat the athletes.

Prevalence studies After evaluating publications on the quantity of mental disorders in professional support, it can be concluded that mental disorders are as common in professional sports as they are within the general population. Furthermore, there are sport-specic variations and some disorders are more common in certain types of sports than in others. Psychotic disorders, such as schizophrenia and mania, are very rare among high-performance athletes, usually manifesting after taking anabolic steroids [1]. Anxiety disorders, on the other hand, are common among both male and female athletes and have been well documented in the literature of sport psychology [2]. Eating disorders have probably been subject of the most research. 15% of women in the eld of aesthetic sports suffer from anorexia or bulemia [3]. Furthermore, 20.1% of female and 7.7% of male professional athletes from Norway, as well as 60% of female gymnasts with normal

V. Z. Markser (&) Clever Str. 32 a, 50668 Koln, Germany e-mail: valentin.z.markser@netcologne.de


Eur Arch Psychiatry Clin Neurosci (2011) 261 (Suppl 2):S182S185


weight have been diagnosed with an eating disorder [4, 5]. All in all, it can be said that athletes in endurance sport disciplines or in sports in which individual weight is of great importance, have a signicantly higher risk for suffering from eating disorders [6]. The tendency toward alcohol addiction and eating disorders is diagnosed considerably more often in athletes than in non-athletes [7]. 15% of US college students were found to have a gaming addiction [8]. Twenty-three percent of athletes who take anabolic steroids reports symptoms of bipolar disorder and 12% report psychotic disorders [9]. The issue of doping is particularly interesting in this context, as public discourse is rather one-sided in this regard. Doping is generally seen from a legal or moral standpoint. But sport psychiatrists are interested in understanding why the athletes have difculties to accept their own limits and why they often risk their health and even their lives. In a repeated survey into the frequency of doping among German professional athletes undertaken in 2009, Pitsch, Maats, and Emrich estimated that 35% of them had consciously taken illegal performance-enhancing substances at least once during their sporting career [10]. The professionalization and commercialization of sport have led also to an increase in the number of head injuries. Amateur athletes who have suffered concussion 3 or more times in their sporting career are 7.7 times more likely to experience memory impairment [11]. A survey of 2,552 football players who suffered concussion at least 3 times revealed a signicantly higher risk of depression [12]. Depression is the most common mental disorder in the eld of sport [13]. Depression diagnoses are approximately as common in professional sports as in the general public [14, 15]. Intensive training can contribute to depression or be used to positively affect symptoms of depression. The protective effect of regular physical activity has been well researched. On the other hand, there is evidence to suggest that depression can be seen as mental answer to physical stress. 60% of long-distance runners and 50% of basketball players experience exhaustion depression at least once during their sporting career [16]. Overtraining syndrome is, besides anorexia athletica, probably a prototypical sport psychiatric illness with physical components, social impacts, and mental stress. The syndrome is dened as a state of performance loss and a chronic feeling of exhaustion coupled with excessive and continuous training. The athletes capacity to recuperate is extremely reduced. The underlying mechanism is still not well understood despite scientic research over the past century.

There were a large number of studies about the effects of endurance training on the release of endorphins (endogenous opioide peptides) and on the concentration of neurotransmitters. A large number of authors postulate that tryptophan and serotonin concentrations probably play a decisive role in the etiology of the overtraining syndrome [17].

Sport psychiatry and psychotherapy. Object and methodology Due to the sports-specic characteristics of many mental disorders, with diagnostic and therapeutic difculties, a special qualication is needed to meet the challenges in this eld. The author Daniel Begel dened sport psychiatry as the implementation of psychiatric knowledge and treatment methods in the world of sport [18]. It is a medical discipline whose topic is the research, treatment, and prevention of massive and sport-specic mental stress and disorders. It employs a full range of psychiatric, neurological, psychotherapeutic, psychosomatic, and psychopharmaceutical procedures. Sport psychiatry does not only deal with the treatment for mental disorders but also aims to promote mental health and thereby to optimize performance. An important factor with a great impact on the athletes is their social role; it involves contradictory and rapidly changing expectations. Not all athletes are prepared for this kind of pressure, especially if they are young. Their image as heroes, role models, or as national gureheads, can change overnight into roles of failure, losers, traitors, or even criminals. It has to be taken into account that there are a lot of sports disciplines in which the peak of the athletes career takes place during adolescence and puberty. Therefore, athletes often have to start an intensive and systematic training program at a time when their psychological development is unable to keep up. With the extreme concentration on physical function, training methods based on the continuous measuring and psychological motivation techniques hold difculties for athletes to judge effectively when they reach their limits. The result is often a refusal to accept limitations and a tendency to shift the problem onto the physical level. Sport-specic inuences therefore make the diagnosis of the functional problems and psychosomatic symptoms more difcult. The difculty of diagnosing eating disorders and the need for sport-specic diagnostic criteria has already been discussed in relation to anorexia athletica. Because of the muscle growth, the athletes maintain 85% of their weight without problems.



Eur Arch Psychiatry Clin Neurosci (2011) 261 (Suppl 2):S182S185

The overtraining syndrome has been another diagnostic problem in professional sport for many years. The neuroendocrinological and neurobiological changes lead to the release of endorphins and stress hormones that can result in an alteration of the synaptic cleft. This can in turn inuence the athletes moods and make it difcult for them to recognize in time onset of complete exhaustion. Treatment is another factor that is signicantly inuenced by the sport-specic situation. There is rarely time for appropriate psychotherapeutic treatment. Athletes tend to avoid doctors consultations and hospital beds. As a result, treatment is insufcient, interrupted, or not even attempted. In many cases, medication cannot be given due to doping regulations and the possible side effects on the daily training program. Due to the need of close collaboration, the relationship between sport psychiatry and sport psychology is of special importance and deserves an intensive preoccupation and examination. In the area of optimizing performance and treating mental disorders, sport psychology and sport psychiatry support and respect each other. Issues such as prevention and mental health can be dealt with more effectively together. It is my hope that, despite some initial hesitation, these two disciplines will prot from each another and bring real benet to athletes in general.

Conclusion Mental disorders do exist in high-performance sport as much as in the general public. The selection hypothesis does not prove to be right. Mental stress is an integral part of high-performance sport. So far, mental disorders have been seen as weaknesses in a generally well-functioning system. In fact, the massive levels of physical, social, and mental stress are part of the high-performance sport system and stress is very close to disorder. Recognition of mental stress and disorders will not lead to nancial disadvantage for sporting associations. Untreated mental, psychosomatic, and functional disorders lead to much greater problems, both in terms of economic disadvantage and performance, and can result in the premature retirement from sport. Because of the ever-growing emotional and social strain in professional sport, a complete and contemporary medical care in professional sports cannot disclaim the continual advisory collaboration of sport psychiatrists and psychotherapists. In the same way as conventional sport doctors look after the physical health of athletes, sport psychiatrists and psychotherapists attempt to maintain mental health and protect athletes from the effects of over-exertion. We need more certied qualication in sport psychiatry and psychotherapy. Because of the specic circumstances found in high-performance sport, general psychiatric studies are not enough to deal adequately with the diagnostic and therapeutic challenges in this eld. At the same time, the characteristics of mental disorders in professional sports blur the transition between health and illness, challenging the eld to develop psychotherapeutic, psychodynamic, and preventive competences.
Conict of interest interest. The author declares that he has no conict of

DGPPN. The German association for psychiatry and psychotherapy. Task force for sport psychiatry and psychotherapy Mental stress and disorders in high-performance sport rst became a topic of national interest in Germany in the last two decades, especially after publishing depressions and suicides in professional sport. Within the German Association for Psychiatry and Psychotherapy, we discussed the lack of treatment options for athletes and consequentially founded a task force. One of the most important goals is to promote an understanding of mental stress and disorders within the training of sports medicine doctors, sport psychologists, and coaches. At the same time, there could be a duty to offer specic options in response to specic conditions. General psychiatric studies are not enough to adequately deal with the diagnostic and therapeutic challenges we face in this eld. With the organization of the rst training course, a new period in a qualication in sport psychiatry and psychotherapy begins.

This supplement was not sponsored by outside commercial interests. It was funded by the German Association for Psychiatry and Psychotherapy (DGPPN).

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