Sport and Mental Health: From Research to Everyday Practice 3031368630, 9783031368639

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Sport and Mental Health From Research to Everyday Practice David Baron Thomas Wenzel Andreas Ströhle Todd Stull Editors

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Sport and Mental Health

David Baron  •  Thomas Wenzel Andreas Ströhle  •  Todd Stull Editors

Sport and Mental Health From Research to Everyday Practice

Editors David Baron Center for Health and Sport Western University of Health Sciences Pomona, CA, USA

Thomas Wenzel Psychiatrie Meduniwien AKH Wien, Austria

Andreas Ströhle Klinik für Psychiatrie und Psychotherapie Charitè - Universitätsmedizin Berlin Berlin, Berlin, Germany

Todd Stull Department of Psychiatry & Neuroscience University of California, Riverside Riverside, CA, USA

ISBN 978-3-031-36863-9    ISBN 978-3-031-36864-6 (eBook) https://doi.org/10.1007/978-3-031-36864-6 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

As sports evolve worldwide, new and more recognized challenges are emerging to the longstanding issues. Mental health and substance use disorders are being increasingly acknowledged with less stigma. Mental illness is now at the forefront of the problems that athletes face. Physical health is linked to mental health, and health care professionals are now creating integrated treatment plans to provide complete health care. Delivering comprehensive health care requires collaboration among providers to offer individualized, integrated care. As the NCAA has noted from their research, mental health has moved to the forefront of the college athlete (Mind, Body and Sport: Understanding and Supporting Student-Athletes Mental Wellness). In addition, various other sports organizations have recognized the need to address mental health in athletes. The integrated effort to help athletes starts with the athlete being a part of the health care team. Coaches, family, medical staff, academic staff, physical therapists, audiologists, social workers, psychologists, and psychiatrists, along with many others, are members of the health care team. Numerous influences and information play a key role in supporting the athlete. The diagram noted below provides a picture of the integrated support team collaboration. This book is unique as it is dedicated to the concept of integrated interprofessional mental health care for athletes. Sports mental health is a field that is evolving to help meet the needs of athletes, coaches, teams, and family members. Mental health care for athletes is best delivered when adapted to the relevant context of the athletic setting. Athletes’ mental health can affect their mood, behavior, thinking, and performance.

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Sports and Mental Health: Research to Everyday Practice-Interprofessional Integrated Care fits with the spirit of the time to describe and discuss athletes’ mental health needs and treatment. This book is geared toward different disciplines working together to provide complete health care for athletes. The book is intended for a broad readership, unlike other existing books geared toward specific disciplines. For our readers, the book is designed to provide background information and go a little deeper into the mental health field. The chapters are written for athletes, coaches, and nonmental health providers. We want the readership to take away a practical understanding of the topics written about in each chapter. Authors are sports psychiatrists, sports psychologists, sports physical therapists, sports social workers, and sports medicine physicians, and most of the authors are former athletes. Mental health exists along a continuum from flourishing to illness. Mental illness can be mild to moderate to severe with associated functional impairments. Recognition and proper assessment along with treatment are vital components. In addition, education and training for athletes, coaches, and others within the integrated support team create a basic understanding of mental health in sports. This book contains chapters discussing evidence-based research, case examples, key points, and collaborating roles of different disciplines. A range of topics is discussed, including the most common mental health conditions experienced by athletes. The chapters are written from the athlete’s perspective, not a general review. Included in the book are chapters on youth sports, gender issues in athletes, transcultural and sociopolitical aspects of sports, mental health, concussion, sleep, substance use, depression, anxiety, psychopharmacology, doping, psychiatric emergencies in sport, psychotic disorders, personality disorders, eating disorders, attention deficit hyperactivity disorder, and post-traumatic stress disorder.

Foreword

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A final wish is that the readership will find the book valuable and relevant to the ongoing development of the field of mental health for athletes. Finally, we hope the reader will find the book a step toward the complete health care of athletes to enhance well-being. International Society for Sports Psychiatry Riverside, CA, USA

Todd Stull

Preface

The role of mental health and athletic performance has been an integral component of sports psychiatry and sports psychology for well over 5 years. Sports psychologists have made significant contributions in the extant literature on the role of behavioral techniques to enhance and improve athletic performance, while sports psychiatrists have focused more on athletes as a unique patient population, requiring special considerations when diagnosing and treating psychiatric symptoms and syndromes. Only recently, behavioral health care specialists from different disciplines have begun to work together collaboratively in the integrated care of athletes and in conducting scholarly research. The COVID pandemic has demonstrated the critical need for collaboration between all stakeholders, from a bio-psycho-social perspective, to achieve desired outcomes. Facts are necessary, and important, but attitudes and behaviors play a key role in determining outcomes. In the world of sport, outcome is measured by performance. However, performance is determined by a number of factors other than athletic training. In fact, mental health issues can play a significant role in the outcome of athletic training and athletic performance. Athletes and coaches are constantly seeking opportunities to gain a competitive advantage. Unfortunately, information available on the internet and social media is often difficult to interpret and of questionable scientific validity. In addition, the existing sports mental health literature rarely discusses the role of teammates, coaches, and different disciplines in assessing and treating behavioral health issues in athletes. This is the unique focus of this text. The intended readership includes athletes, teammates, coaches, sports federation officials, and health and mental health providers of athletes (from an interprofessional perspective). The overall goal is to review the current evidence-based research and what it means for everyday application for the athlete. The topics covered in each chapter represent the key issues in current sports mental health. Each chapter covers a different area of interest and follows a standard template. The use of medical jargon and psychiatric terms (often referred to as “psychobabble” by non-MH professional) is avoided to improve comprehension and readability for nonprofessionals. Each chapter begins with a brief Abstract describing content to follow, next are a list of Keywords and a discussion of current ix

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state-of-the-art, evidence-based research, and historical highlights, if available. This is followed by a relevant case presentation to highlight key clinical points and demonstration of the role and responsibility of each stakeholder (the athlete, teammates, coaches, trainers, sports medicine providers, non-sports medicine health and mental health providers, and others). Each chapter concludes with a discussion of future directions for research and clinical care, focusing on interprofessional integration, recommended additional readings for the interested reader, and relevant references. Each chapter is written by experts in the field with extensive experience in sports mental health. This novel approach to the field is the future of sports mental health, active application of an interprofessional integrated care model, based on state-of-the-art, evidence-based information, relevant for the athlete, coaches, sports administrators, and care providers. Despite ongoing prejudice toward mental health issues in athletes, improvement in acceptance of mental health challenges experienced by athletes at every level of competition continues (in large part due to high profile athletes speaking out). All stakeholders, working respectfully and collaboratively together, the overarching theme, and goal of this text will improve the quality of life for all athletes, currently and in the future. The editors and chapter authors of this book offer this as a challenge to all readers become a part of the solution by working together. A united, evidence-based approach will surely result in a gold medal outcome for athletes and hall of fame status for all who contribute to the effort. Enjoy the read! DAB Pomona, CA, USA Wien, Austria  Berlin, Germany  Riverside, CA, USA 

David Baron Thomas Wenzel Andreas Ströhle Todd Stull

Contents

Part I Factors Affecting Mental Health in Athletes A Proposed Novel Multidisciplinary Approach to the Care of the Young Athlete ����������������������������������������������������������������������������������������    3 H. Baron Steven, A. Baron Michael, and J. Baron Steven  Gender Differences in the Psychiatric Treatment of Athletes����������������������   23 Danielle Kamis and Roy Collins  Transcultural and Cultural Aspects of Sport Psychiatry ����������������������������   33 T. Wenzel, A. F. Chen, and T. Akkaya-Kalayci  Sport and Human Rights��������������������������������������������������������������������������������   49 Thomas Wenzel and Reem Alksiri  Sleep and Sleep Disorders in Elite Athletes ��������������������������������������������������   59 C. A. Mikutta, A. Wyssen, and T. J. Müller  Mental Health Emergencies in Athletes��������������������������������������������������������   69 Carla Edwards Doping in Sports����������������������������������������������������������������������������������������������   79 Todd Stull, Anna Sheen, and David Baron  After Sexual Abuse or other Extreme Life Events����������������������������������������  101 Thomas Wenzel, Anthony Fu Chen, and Reem Alksiri  Sports in the COVID-19 Era��������������������������������������������������������������������������  119 Carla Edwards Pharmacotherapy in Sport������������������������������������������������������������������������������  131 Vuong Vu and Claudia L. Reardon Concussion in Athletes������������������������������������������������������������������������������������  143 David Baron, Aaron Jeckell, and D. Andrew Baron

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Part II Clinical Mental Health Symptoms and Syndromes in Athletes  Helping the Athlete with Depression��������������������������������������������������������������  169 Alan Currie and Tim Rogers Anxiety in Athletes ������������������������������������������������������������������������������������������  195 Erik Levinsohn and Claire Twark Substance Use in Athletes��������������������������������������������������������������������������������  211 John W. Dougherty III, Amir Garakani, and Robyn P. Thom Psychosis in Sports������������������������������������������������������������������������������������������  229 Patrick A. Ho, Todd Stull, and Douglas L. Noordsy  Eating Disorders in Sport��������������������������������������������������������������������������������  247 Cindy Miller Aron, Sydney LeFay, and Rebeccah R. Rodriguez ADHD in Athletes��������������������������������������������������������������������������������������������  269 Ranjit Menon, Aaron Winkler, Julie H. Sutcliffe, and Adam Deacon Personality in Athletes ������������������������������������������������������������������������������������  293 Antonia Bendau, Jens Plag, and Andreas Ströhle

Part I

Factors Affecting Mental Health in Athletes

A Proposed Novel Multidisciplinary Approach to the Care of the Young Athlete H. Baron Steven, A. Baron Michael, and J. Baron Steven

1 Introduction Around the turn of the twentieth century, sports played an increasingly prominent role in the lives of adults as well as children. During this time, formal professional leagues were created, and children played sports casually in the streets and parks for fun. There were no parents, let alone coaches, and certainly no pressures beyond the desire to have fun and compete against peers. This trend was universal in nature, and similar scenarios could be observed across the globe. Whether it was a modified game of soccer, a culturally specific game such as “kick the can”, or a game of tag, it was just a group of kids being active together. Sadly, over the past hundred years, this has changed. There has been a dramatic increase in costs, time commitment, and stress on the young athlete. Youth sport participation shifted from casual and jovial to more intense and demanding. Despite this massive adjustment, youth sports generally do not offer the same equivalent level of total care that is provided to their older, and paid, counterparts.

1.1 Global Overview Globally, youth sport organizations have a long history of serving various roles within a community. For many of these organizations, their aspirations can include feeding the national teams, Olympic squads, and professional rosters. Their attempts H. Baron Steven (*) · A. Baron Michael Montgomery County Community College, Blue Bell, PA, USA e-mail: [email protected] J. Baron Steven Forward Progress Injury Care, Horsham, PA, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. Baron et al. (eds.), Sport and Mental Health, https://doi.org/10.1007/978-3-031-36864-6_1

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to effectuate these goals range from establishing national legislative change to advocacy. In the USA, youth sports are increasingly moving toward “pay-to-play” models and professionalization. Today, there are non-sport-specific agencies attempting to assert themselves at the national level (e.g., the Aspin Institute and the Foundation for Global Sports Development). The Foundation for Global Sports Development’s mission is to deliver, support, and promote fair play, education, and the numerous benefits of abuse-free sport for youth [1]. In other countries, such efforts are government backed and have produced significant outcomes. When comparing youth sport participation on a global scale, only a small subset of countries show a marked increase in activity level among children compared to their American counterparts. Between 2008 and 2018, the UK saw an average of around 88.76% of children participating in sports on a monthly basis [2]. Additionally, the European Union published that, as of 2017, 62% of those between the ages of 15 and 24 years old engage in weekly physical activity, most commonly in an outdoor setting [3]. In Germany, 70% of adolescents are members of sports clubs with favorable support to engage in physical activity [4]. Europe has historically housed its youth sports within clubs and associations that for the most part avoided professionalizing much longer than in the USA, a fact that still holds true to this day. Many competitions in Europe host both amateur and professional clubs while simultaneously embracing an international governance/ interaction over a national-only format often found within the USA [5]. Sport in Europe has generally been backed by the local community and only recently embraced a private or commercial influence due to the growing market [5]. This is in stark contrast to the system that emerged in the USA, where youth sports are heavily organized in schools. In Germany, most youth sports, both for leisure and competition, are organized in clubs [6]. This highlights the reality of most European nations, where sport is primarily (although not exclusively) operated beyond the schooling system. As youth sports continue to globalize, the presence and direct impact of these clubs have expanded beyond the community as they have taken on a more prominent role nationally.

1.2 General Youth Sports Research Generally speaking, research pertaining to the youth athlete has significantly lagged behind research for the adult participant. This only serves to exacerbate the problem within highly competitive youth sports, as their unique challenges and obstacles are either overlooked or interpreted from an adult perspective. A publication that addressed youth sports did not appear until the late 1970s, with a second prominent source not appearing for another few years with the first being “Joy and Sadness in Children’s Sports” in 1978 and later in 1982, “Children in Sport.” These groundbreaking sources were intended for coaches, players, parents, and league officials of young athletes. Unlike most of the literature in this area, which is published by researchers for other researchers, these anthologies were intended for those who were directly involved with youth sports. Not to be dismissive of the countless

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scientific articles published in all areas of sports science, these early sources rather provided a bridge between the research shared among the scientists and the literature produced specifically for the parents, players, coaches, and administrators. The problem with most of these sources lies in their myopic scope directed toward individual practitioners within youth sports. Further, the literature offers very little from a developmental perspective. There are even fewer resources tying these two areas together (e.g., research/position papers written for parents to educate them about coaches or articles/research provided for a broader audience devoted to nutrition for the youth athlete). There is no literature regarding a thorough, multidisciplinary approach to the care of the young athlete. This chapter presents a multidisciplinary framework for athletes between 9 and 16 years of age.

1.3 The Potential Value of Youth Sports Participation Despite the numerous issues associated with the professionalization of youth sports, they are still recognized for their possible benefits [7–10]. The literature clearly suggests that youth sports participation has the capacity to provide wonderful physical, social, and mental health benefits. For example, in a dissertation published by Guarin in 2018, it was found that there is a positive correlation between participation in a team sport and overall mental health [11]. However, research conducted by the Aspin Institute over a 10-year period showed decreased participation among US children aged 6 to 12 years old for various sports, with only about 56% of children playing in team-organized sports [12]. Again, the focus of this chapter is to facilitate a greater chance of a young athlete experiencing the numerous physical and mental benefits of participation in sport, especially in the more competitive populations, while also reducing the potential liabilities, through an inter-disciplinary approach. Sports are unique in that they provide a tremendous opportunity for children to learn life skills across various facets of both personal and social development. Participation in sport doubles as a space to learn sport-specific skills while also serving as a place to develop team and problem-solving skills. These acquired traits can also benefit the participant through a boost in confidence and mental well-being.

2 Youth Sports and Mental Health Despite the fact that research in the area of pediatric psychiatry and psychology tends to lag behind all other age groups, there is a small body of literature looking at common child/adolescent mental health issues and youth sports participation. For example, the ADHD Editorial Board published an article in which they recommend 11 specific sports as ideal for the child with attention-deficit/hyperactivity disorder (ADHD). Those sports are swimming, martial arts, tennis, gymnastics, wrestling, soccer, horseback riding, cross-country running, archery, and baseball [13]. But the

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literature also shows an increase in depression, anxiety, and substance abuse in youth and adolescent athletes. Perhaps the added pressure of playing in high-level environments is related; potential explanations include fear of failure or fear of disappointing others (e.g., teammates, parents, or coaches). Regardless, the pros of youth sports are not always experienced by all as the structure of competition professionalizes.

3 The Professionalization of Youth Sports In January 2019, Chelsea F.C. of the English Premier Soccer League (the highest professional division in England) paid Borussia Dortmund of the German Bundesliga (the highest professional division in Germany) $73 million for the rights to sign Christian Pulisic (a record transfer fee for an American player). Christian was raised in Hershey, PA, in the USA.  As a child, he played for his local soccer club, PA Classics Development Academy. At the age of 16, he and his father moved to Germany to begin his tenure with Dortmund. The young man who started in the small town of Hershey, PA, is now wealthy, playing at the highest level in the world and at the core of a historically massive business transaction. This is but one of many examples that could be presented to shed light on the growth and metamorphosis of youth sports around the world, a metamorphosis taking it from calisthenics/gymnastics to one of the most lucrative and fast-growing businesses in the world [14]. This business is growing so fast that it is expected to reach a global value of $77.6 billion by 2026, but the US youth sport market alone already rivals that of the National Football League (NFL) [15]. As such, the child/ adolescent shifts from a participant motivated by the desire for affiliation, mastery of a sport, or improved personal health to a participant in a global mega-business. Ultimately, as the professionalization is well understood and documented, it is now crucial to provide our youngest athletes the same access to multidisciplinary services to maximize individual growth and development as is the case in the professional ranks.

3.1 Developmental Considerations Although we have seen the systemic professionalization of youth sports, there is still the reality that these athletes are developing and growing children. As such, they are prone to orthopedic injuries including fractures, strains, and sprains, as well as being even more vulnerable to bullying and shaming. There are also the threats emanating from sources like parents and coaches attempting to live vicariously through the young athlete. Other potential barriers to a more positive experience include reduced access to quality protective equipment and fewer sports science practitioners with developmentally specific training.

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4 Overview of the Suggested Model This chapter suggests an adaptation of a developmental model first described a long time ago (Bronfenbrenner). Bronfenbrenner’s systems-based ecological approach highlights the various social settings, and their subsequent interactions, that impact an individual’s development [16]. In fact, a recent model has similarly echoed Bronfenbrenner’s work in devising a framework for the mental health of young athletes [17]. Our suggested model (see Fig. 1) expands upon this while implicating several other important aspects that influence the young athlete. Our model can serve as a universal guide for the proper care of young athletes as they progress through higher levels of sports by a defined interdisciplinary approach consisting of parents, players, coaches, primary care physicians, mental health practitioners, physical therapists/physiotherapists, teachers, and nutritionists. The model acknowledges that along with increased levels of competition, there are greater challenges

Fig. 1  The Systems of Influence Model for Youth Athletes

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physically, psychologically, socially, and emotionally as a player progresses. In order to mitigate the growing potential for harm, this evidence-based model was developed with an awareness of potential developmentally-driven clinical risks and hazards; a real-world application of this robust model is best exemplified through a case study that will be presented later.

5 Level I: Introduction to Youth Sports: The Player, Parent, Coach, and Peers There are many reasons children get involved with youth sports: • • • •

Parental motivation The desire to have fun The desire to hang out with friends Love of sports/games

In most cases, the child’s first athletic experience will be at the intramural or community level. For better or worse, if a child is good enough, they have the opportunity to advance to higher levels of competition. This system carries with it potentially contradictory directives. On the one hand, the child will be guided toward the more competitive, single sport programs, which carry with them the enticement of a potential college scholarship and/or professional contract. Such a path requires higher time commitments, more intense training and competition, as well as stress. At the same time, the sport science literature suggests the importance of children playing more than one sport. Rugg et al. (2018) examined the relationship between number of sports played in high school and injury risk in NBA players. They concluded that while most NBA players played a single sport in high school, those that were multi-sport athletes enjoyed longer careers, played in more games, and experienced fewer major injuries [18]. This leaves the child, parent, and coach with a difficult choice. Regardless, the child will be exposed to a potentially significant source of physical and psychological stress. At the entry level, the child is protected due to the very nature of the intramural and community programs. And as long as the parent and coach have a healthy perspective and motive, the child’s experiences should remain positive.

5.1 The Player The child’s entrance into the world of youth sports should be self-driven. Participation should be based solely on fun and appropriate age-based development. Within the literature, one of the prominent threats to the young athlete is his or her involvement being driven by the parent’s desire to live vicariously through the child. A second

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threat is the overzealous, untrained coach whose personal goals may not foster a positive environment for his or her players. With proper support, involvement should have few physical, psychological, social, or emotional risks. The child should be encouraged to be respectful and attentive to the coach. The child should also be guided and supported toward establishing healthy, age-appropriate social relationships with teammates. Opponents should be viewed as fellow competitors and afforded respect.

5.2 The Parent/Guardian As mentioned previously, the role of the parent is minimal at the intramural or community level. However, it is still important that the parent does not begin to live vicariously through his or her child’s participation. The parent also serves as the buffer between the child and the coach. That being the case, the child’s level of involvement leaves them less prone to any ill effects of the coach’s involvement. The parent should consider the reality that they are always a role model to their children [19]. As such, they need to consider the basis of their conversations to and from the field. Are they inappropriately judging the other players? Is the focus of their conversations either excessive or inappropriate levels of competition? Is the parent providing more condemnation than support? In each case, this innocent, starter level of sport participation may already provide potential psychological, social, and emotional harm. With regard to the parent–coach relationship, it is important that parents establish a positive line of communication with the coach. They also need to be mindful of the coach’s interactions. Though hard to believe, even at this level, there will still be overinvolved or ill-prepared coaches.

5.3 The Coach It is unlikely that the intramural or community coach will have any sports-specific training and even more unlikely that they will have any mental health training. This is especially true in specific sports where most countries have no official, organized youth sports coaching education programs. Youth sports coaches engage with a high volume of children, second only to the school setting. But, similar to teachers, sports coaches serve as educators and role models in their respective field. However, a major difference between teachers and many youth sports coaches is the availability of, and requirement for, training in their respective field and age of competition [20]. In those sports with sports-specific training (e.g., soccer), though there are specific education programs for coaches that are designed for players at the higher level (e.g., USYS Coach Education Program), few intramural or community programs can invest in coaching programs and preparation to that same extent. Often,

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these programs utilize parent volunteers to serve in a coaching capacity. As the level of competition is intended to be low, the absence of formal coaching education is not a major issue. But given the amount of contact and influence at this stage, it is still a reasonable question to ask the coach about his or her qualifications (e.g., coaching, playing experience, education, etc.). At its best, the role of sports coaches is not just to coach. Coaches are well placed to help their players reach their athletic potential and assist with mental health by providing a healthy, age-appropriate environment that supports self-esteem, problem-­solving skills, and a team culture that underlies proper social development. They also play a key role in facilitating physical activity in children and teenagers through their participation in youth sports. However, this promotion does not happen overnight. It takes guidance and an understanding of the power of sport. Coaches should be equipped to deliver on these expectations [21]. For those children with established conditions such as ADHD, the ADHD Board suggests that it is important that the coach be made aware of the diagnosis. As the coach is very unlikely to have a mental health background, they further recommend that the parent educate the coach as to relevant issues such as not paying attention or other distracting behaviors. Without such conversations, it is very likely that the coach will not understand that punishing such behaviors is ineffective and potentially humiliating.

5.4 Peers Various psychological theorists have studied the effect of peers on childhood development. These theorists have investigated the degree that peers shape behavior and moral and cognitive development, but few have looked at this dynamic relationship within a sport context. Jõesaar, Hein, and Hagger (2011) attempted to investigate the nature of peer-driven motivation in youth sport with regard to the satisfaction of psychological needs (autonomy, competence, and relatedness). It was found that satisfying these needs indirectly affected an athlete’s motivation and continuation within sports by way of peer support [22]. An additional study by Nicholls, Morley, and Perry (2016) highlighted the positive and negative benefits of peer influence in sports and the link between mental toughness and the satisfaction of psychological needs [23]. Other research points to those with a strong sense of self-identity through team membership as being more likely to be influenced by their peers in either a positive or negative way, depending on the group dynamic [24]. Due to the reciprocal influence from peers, those that are part of its construct should be aware of this dynamic and work within their respective scope to foster healthy relationships given its potential impacts.

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6 Level II: Greater Interaction among Level I Contributors As the athlete finds greater success, they are likely to progress to higher levels of competition. With greater success and subsequent competition, they are likely to experience equivalently higher demands on their time, energy, and emotions. Consequently, the primary role of the main participants (player, parents, and coach) becomes that much more important to the young athlete’s overall well-being. At this stage, it is very important for the child to learn what healthy competition is and what it looks like given the inherit change in level of play now.

6.1 The Player Often, we hear from parents who worry about young athletes who are hard on themselves, become easily frustrated, and take disappointment home with them after games or practices. You are likely familiar with these types of athletes; they are perfectionists or athletes who display perfectionistic behaviors [25]. As the young athlete progresses to higher levels of play, they are now in the position of feeling stress from the coach based on performance feedback and the potential fear of being cut from the team or losing play time. Is it possible for the child to misinterpret the coach’s feedback? YES! Clearly, such a situation increases the need for the parent to be more engaged and navigate the ebb and flow of emotions a player can experience throughout the season.

6.2 The Parent At this stage, the parent needs to be the child’s biggest ally and supporter. He or she is now the only outlet the child has with regard to the increased stress of playing at a higher level of competition. It is again crucial that the parent never permit himself or herself to live vicariously through the child’s participation. The parent needs to establish an increasingly open communication pattern with the child. Rides to and from practices and games need to emphasize the whole child, realistic expectations, and supportive discussions regarding the team and teammates. Overall, the key is to reduce all forms of stress that the athlete may be experiencing.

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6.3 The Coach At this level, the coach will likely have a greater impact as their evaluations are perceived to be more influential and important by the child. As this is now likely a more structured, success-based level of competition, it is more reasonable to expect the coach to have some level of formal training, as compared to the intramural or community level. In the USA, the coaching education system is intended to be developmentally driven, but this is not always the case. Coaching education also does not guarantee proper coaching or a healthy environment for the athlete. In Europe, the more organized club-based youth programs are much more likely to provide the young athlete at this level with a better trained coach. Again the parent is well within their right to ask the coach for their credentials. Note: Being an ex-­ player does not guarantee age-appropriate coaching, regardless of the level achieved, given the role of coach as educator and the importance of appropriately and efficiently navigating the various stresses placed on the player.

6.4 Peers As the level of competition increases, so too does the strength of effect mentioned previously. Where once teammates may be assigned based on geographic location, as the level of play increases, so too may the level of travel in order to find a team that fits the needs of the player. This increased travel may remove an individual from proximity-based peers, but, more importantly, allows him or her to find other new peers with the same shared goal of playing at a higher level. This common factor serves to further strengthen the impact these new peers can have on an athlete’s performance, development, and relationships as compared to the proximity-based peers who lack the same shared goal and are unable to and/or not motivated to compete at the same level as the athlete [26].

7 Level III: Interdisciplinary, Professional Sports Science Care The young athlete who finds himself or herself at this higher, more intense, success-­ driven level of competition will certainly be exposed to increased physical, psychological, social, and emotional stresses. As per the focus of the model being suggested, the authors are suggesting that the young athlete’s sports world should now include a broader interdisciplinary care team similar to the one provided for professional athletes. For each member of the “care team,” we will discuss professional preparation, the role that should be played, and the connections that are suggested to occur with the other practitioners.

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7.1 Teachers There is virtually no literature regarding the role of the teacher in the life of the young athlete. In fact, only recently have teachers in the USA been recognized for their role and impact related to children’s mental health. For example, research has investigated the role of the teacher in the diagnosis and treatment of ADHD. The teacher can observe the child early in the morning and later during the school day. But even in this more researched field, there is little to no literature regarding an interdisciplinary diagnostic and care team. Teachers should be aware of a student’s participation in sports and its potential effects in the classroom. This can be obtained through many different sources: parent-­teacher conferences, conversations with the student, emails, phone calls, or letters. Is the child becoming distracted by their participation? Are they being fatigued by their participation? Has the child just been cut from a team? Certainly, a teacher would need to know this to avoid drawing conclusions regarding their schoolwork. Importantly, this information can only be obtained through direct lines of communication between the teacher and/or the student/athlete and the parent. As Erikson stated, the child needs to find success in school during this life stage. This concept has been modified to point out that children simply need to find success in at least one area of their lives. If that is youth sports, the teacher may see a direct effect on the child’s schoolwork. The unknowing teacher might become confrontational regarding the child’s lack of effort and poor outcomes. As such, this could put even more pressure on the child to succeed in their sport. Conversely, the child who may have been cut from their team may need success within the classroom more than ever.

7.2 Primary Care Physicians A preliminary search using “Primary Care Medicine and Youth Sports” will usually yield “No Results Found.” This reflects the reality that this is rarely seen as a relevant relationship. According to Breuner (2012), “Pediatricians are in an excellent position to monitor and support the child as they enter into the world of sports.” Breuner goes on to present a biopsychosocial approach to present specific information a pediatrician should consider for the preschooler and those in middle childhood, as well as adolescence, that would help parents shape the selection of a sport and the relevant biological and cognitive skills per stage of development [27]. The author also discusses the stressors that might lead to burnout by utilizing a case study of a 12-year-­ old boy [27]. The recommendations focus on sport selection and do not consider the level of competition. We will discuss a patient case similar to that described by Breuner but expand on the evolving relationships as a player progresses to more advanced levels of competition. Our patient, named Martin aged 12 years old,

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exhibits various physical, social, and psychological challenges that highlight the utility of our model. In 2016, the American Academy of Pediatrics released a report regarding burnout in youth sports [28]. The report mentions the roles of coaches and parents and offers guidelines for the participants, parents, and pediatricians regarding participation and the avoidance of overuse injuries. The report also presents information regarding the psychological problems associated with overtraining and sport specialization for youth athletes. As such, this chapter provides an early foray into the need for a multidisciplinary approach to the care and maintenance of today’s young athlete to mitigate or, ideally, resolve these various issues. Unfortunately, the reality is that while the pediatrician should be part of the multidisciplinary team, his or her role is yet to be fully understood. As most societies view the primary care physician as the hub of the child’s care, they are likely to be brought in for most physical issues that emerge. Per the case report mentioned, it is suggested that the pediatrician be aware of any psychological issues. But the reality is that they lack advanced training in this area, thus necessitating the sport psychologist and/or the sport psychiatrist. Regarding overuse, it would certainly benefit the young athlete to be provided access to a physical therapist (or physiotherapist) as well as a nutritionist given their specialized training. There are certainly numerous potential physical risks associated with youth sports participation. For example, young athletes may be especially susceptible to various overuse injuries due to generally having weaker bones compared to their ligaments and tendons, which can drastically increase the risk of bone and growth plate fractures [29–33]. As participation in youth sports continues to rise, a direct impact on injury rates, medical costs, family burden, and time away from sport is observed, similar to the rising burden of general healthcare costs. Accurate and comprehensive data on sporting injuries in the young athlete have been difficult to obtain because of inconsistent definitions of sports injury, under-reporting of injuries by parents and athletes, and lack of professional oversight in record keeping. In 2014, the National Center for Sports Safety reported that 3.5 million children under the age of 14 required medical care due to injuries from participating in sports; furthermore, the majority of sports-related injuries that ended up being treated at hospitals were for youth athletes (as opposed to adult athletes) [34]. The total healthcare cost of sports-related injuries in the USA is believed to be around 2 billion dollars [35]. Youth sports have recently mirrored the growth of its professional counterparts in the ever-expanding hierarchy of levels of play. Whether it is a professional academy or neighborhood group, one important focus should remain in the developing child: player safety. Players, family members, coaches, and healthcare providers all play an integral role in facilitating an environment that fosters appropriate growth and development, both on the field and off. Recent research has demonstrated the scope of physical therapists, or their European equivalent, physiotherapists, in managing the development of youth athletes as a part of the healthcare team. Sanders et al. argue in their 2013 study that, in addition to other healthcare providers, physical therapists can be responsible for organizing and administering a preparticipation

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physical examination [36]. While there are 11 specific objectives of the examination, its main goal is promoting health and safety. Through the preparticipation examination, physical therapists may formulate specific, individual training programs to optimize fitness and health and thus reduce the risk of injury at the beginning of the competitive season. Physical therapists are also an effective part of the healthcare team to reduce the risk of injuries during the season itself. O’Brien et al. (2017) conducted a cross-­ sectional survey regarding perceptions of injury risk at four professional youth soccer academies in Europe [37]. The survey asked soccer coaches, fitness coaches, and physical therapists associated with the respective academies about their thoughts on the FIFA 11+, a dynamic warm-up endorsed by the world soccer’s governing body, FIFA, as well as other factors related to injury prevention [37]. The study concludes that while injury prevention exercise is crucial, it must also be adapted to individual needs including progression and variety [37]. Physical therapists, per the International Classification of Functioning, Disability and Health framework, are in an optimal role to coordinate these efforts. Essentially, a training program must address sport-specific movements but also other physiological and musculoskeletal concerns to maximize athletic potential and minimize injury risk as children tend to focus on specific sports as they age. Furthermore, a separate study by Ekstrand et al. (2019) investigated the role of communication among medical staff of European soccer clubs in injury prevention [38]. Poor communication between the coaches and medical team (the latter including doctors and physiotherapists) was deemed a risk to increased injury rate and severity [38]. Interestingly, greater communication among the medical staff members also was believed to demonstrate reductions in injury risk [38]. Thus, it is crucial that healthcare providers work in concert with one another as well as with the player and his or her family to provide optimal care.

7.3 Sport Psychologist Sport psychologist generally focuses on three primary areas of specialization: Applied Sport Psychology, Clinical Sport Psychology, and Academic Sport Psychology. Of the three, very few graduate programs provide the necessary training, clinical supervision, and clinical hours to earn licensure. For better or worse, with the professionalization of youth sports comes the greater demand for higher and higher levels of performance. Thus, the trained sport psychologist is essential to meet this requirement. As carved out, the sport psychologist specializes in the knowledge and skills to assist the young athlete regarding performance enhancement. Some of the more common techniques are imagery, goal setting, enhancement of concentration, and positive self-talk. Though many certified sport psychology program curriculums include some small amount of counseling course work, that is not the focus of the training and subsequently there is no mental health certification or licensure attained. This is where the sport psychiatrist joins the team. In conjunction with all of the other members of the young

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athlete’s “team,” the sport psychologist can identify any need for mental health assessment and/or intervention. NOTE: To date, there is virtually no specialized training/certification within sport psychology for the young athlete.

7.4 Sport Psychiatry The subspeciality of sport psychiatry owes much of its foundation to Daniel Beger, who published a paper examining the nuances in development among young athletes and the sports-specific contexts that shape this process [39]. The International Society for Sports Psychiatry functions in order to “facilitate scientific communication about, and understanding of, disorders of the brain and behavior associated with sport, and to advance their prevention and treatment” [40]. Clearly, youth sports participation does not safeguard a child from mental health problems. Quite to the contrary, youth sports participation, and all of its stressors, is likely to exacerbate or serve as a catalyst to mental health problems. The sport psychiatrist needs to be a part of the team to ultimately safeguard and protect the child from significant mental health duress beyond performance-related setbacks.

8 Level IV: External Forces The impact from this level may appear to be indirect and perhaps insignificant, but there is no doubt that governing bodies and agencies functioning at the community/ state/national level have an influence on an athlete and his or her experiences within youth sports. One such example from Wharam et al. (2020) discusses how club-­ level organizational procedures (e.g., formal work plans, a policy manual, and a formal evaluation process for competitions, training, and athletes’ progress) can directly impact the level of performance by the club’s athletes [41]. Furthermore, these results seem to show a correlation between performance outcomes and the degree of organization by the club; perhaps this suggests that intramural/community clubs, by design and structure, cannot achieve the same level of player achievement as higher-level clubs.

9 Case We first met Martin as he walked out onto the field for the first day of soccer tryouts for our team. Even though our first glimpse was from more than 75 yards away, we could immediately see variations in his gait pattern that limited his efficiency of movement. As he walked toward the field, he was dressed in a complete goalie kit,

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including wearing a pair of goalie gloves. While the other boys began mulling around together, including introducing themselves and starting to pass to each other, Martin hovered on the outside of the field. When we called the boys in to formally introduce ourselves as the coaches of the team, we noticed that instead of standing among the other players, Martin gravitated toward us. As we started to run drills, we noticed that in addition to issues with his gait, there were other psychomotor variations. These included altered kinematics completing power-based movements as well as multidirectional movement patterns. As a part of the progression of the tryout, we instructed the players to begin to communicate with one another verbally. Martin was one of the first to acquiesce although he did so with a mocking, almost condescending tone toward the coaching staff. Throughout the tryout, we also noticed Martin’s dad slowly made his way to the sidelines where he began to interact with the other parents, though always keeping a close eye on his son. At the conclusion of the tryout, we called the players in to speak to them. Martin once again gravitated toward the coaching staff. As the team philosophy has a “no cut” policy, his actual performance was a moot point. Furthermore, as the team was devoid of goalies, he was going to be an important part of the team. After we spoke with the players, Martin and his father approached us for a follow-up discussion. During our interaction, it was clear that Martin and his father were very dedicated and passionate about his performance and desire to improve. As such, Martin began to train with the team’s goalie coach between practices. As time went on, we saw consistent examples of potential psychosocial issues exhibited by Martin. Over time Martin’s father became comfortable enough to share with us that Martin did in fact have formal diagnoses of cognitive and psychomotor issues. Fortunately, the team has a multidisciplinary leadership group composed of teachers, coaches, sport psychologists, and a physical therapist. As such, we were able to work with the family to conduct numerous assessments leading to consultation with a sport psychiatrist and initiate multiple interventions. At present, Martin is the starting goalie and has been admitted to a very academic private school. Martin’s introduction to the world of youth sports is not unlike that of many other participants. He enjoys specific sports, listens attentively to his coaches, and tries to implement the instructions as best he can. But at the same time he is certainly not a finished product as he can be molded both mentally and physically through interactions with various people as he progresses in athletics.

9.1 Application of the Model to Martin As presented, we meet Martin as he is taking his first steps into the third ring of the model. He has advanced past his first experience at the intramural/community level. He has also graduated from the second ring as he was trying out for a team whose roster will compete outside of the local community.

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Martin’s participation in youth athletics is clearly not being driven by his father. As presented, there is no evidence of the traditional issues of the ego-involved parent trying to live vicariously through their child. The father seems to be willing to support his son’s desire to grow in his sport. This bodes well for Martin’s safety as he progresses to the higher levels. His dad also seems very willing to engage any professional who might be able to help his son. If Martin’s father was driven purely by his ego involvement, it is ethical to suggest that services be provided first to the parent in order to initiate an open conversation as to the child’s actual level of interest. It appears that Martin’s first coaches did nothing to dissuade him from further participation. Though they may not have done much to further his skill development, more importantly, they fostered his passions and did no harm to his well-­ being. NOTE: Martin’s first coaches had no formal coaching education. Based on the non-sport-specific issues impacting Martin’s performance, it would be reasonable to bring a sport psychologist into his “team.” Their role would be to work adjunctively with the coach to provide appropriate psychological skills training. For example, Martin might benefit from goal setting and imagery. Recognizing the scope of the sport psychologist training, they would want to collaborate with the sport psychiatrist regarding potential cognitive issues and any pharmacological needs. As Martin grows, it would be beneficial for updates from his teacher regarding any behavioral, social, and cognitive changes being seen in that environment. Regarding Martin, the input from the teacher was invaluable to not only his diagnosis but also his ongoing mental health. The teacher was exemplary with regard to the suggested model. Yet a nutritionist and sport psychiatrist would also be useful in order to assist with whatever might be diagnosable. Once this larger care team would be in place, Martin’s well-being is all but guaranteed. Martin’s primary care physician is of the utmost importance regarding the developmental issues of a physical nature. As he is highly committed, it is suggested that Martin’s parents keep his primary physician in contact with an appropriately qualified physical therapist as well as with the other members of his team. The primary care physician and physical therapist work collaboratively with a nutritionist to ensure his physical well-being, while the sport psychologist provides further resources to maximize performance. The sport psychiatrist works with the sport psychologist to help navigate his psychological issues.

10 Future Directions 10.1 Youth Sports Programs Perhaps it is no longer possible to “put the genie back in the bottle.” As the professionalization of youth sports is now engrained within a global, multibillion-dollar industry, the child has sadly become a commodity. We owe the young athletes of the world more. We owe them the kinds of safeguards that are built into our educational

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systems. The school provides medical coverage, psychological services, a nationally governed curriculum, as well as open communication between all members of the program. These formally structured, governed, and enforced systems provide evidence that an equivalent, multidisciplinary approach to the care of the young athlete as they advance through the system can be accomplished. As presented, there are organizations working behind the scenes seeking such improvements. Yet even with these advocacy groups, they might need to recognize that some of their goals directed at the “re-amateurization” of all youth sports might not be feasible as youth sports have become an integral piece of the larger, multibillion-­dollar sports machine. Further, it would behoove these groups to advocate for broader care systems.

10.2 Coach Training Unlike the majority of Europe, the USA needs to establish formal, enforceable guidelines to ensure that better qualified coaches serve the entry levels of participation. For example, it is frequently the case in Germany that some of the club’s most highly qualified coaches work with the youngest players. In the USA, these same levels are frequently coached by parents with no formal coaching education. Such coaches are merely a parent of one of the players on the team. The training itself also needs to morph in order to match the reality that young athletes are participating in a professionalized model. As such, education programs need to emphasize the proper implementation of psychologically, socially, physically, and emotionally developmentally sound education. These programs need to also guide future coaches on the importance of their role with regard to helping parents utilize all areas of sports science in a multidisciplinary approach to the care of their children as they proceed through the youth sports system.

10.3 Sports Science Practitioners Pediatric medicine was not a part of the original models of physician preparation. In the early days of psychiatry and psychology, pediatric psychiatry/pediatric psychology was not an identified or formal specialization. Even at present, the idea of specialized training in youth sport psychology, youth sport physical therapy/ physiotherapy, or youth sports nutrition is rare at best. Clearly, the need has been established based on the participation numbers. There is an infrastructure in place based on the massive money already embedded in youth sports. Sadly, it is part of the global history of healthcare that childhood tends to be the last stage of the life span to receive attention. If we can develop specialized training programs for other populations, we can clearly establish equivalent rational programs for the millions and millions of children participating in youth sports around the world.

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10.4 Final Discussion Prior to becoming a generation’s role model, the highly profiled multi-millionaire-­ dollar professional athlete was once a child playing that sport for fun. Sadly, for every one of those children who makes it to the top level of play (where they receive constant, all-encompassing care), there are hundreds who are burned out by the system. We have forever recognized childhood as a separate stage of the life span – a stage that is today recognized by its need for care, supervision, and developmentally appropriate, progressive movement toward adulthood. That being the case, youth sports far too frequently fail to meet these goals. No child’s well-being should be negatively impacted during their time in youth sports. We have the science. We have an infrastructure. This chapter provides a novel model to introduce those who are already invested in the many areas suggested to a more appropriate, team-based approach to the care of the young athlete.

References 1. Foundation for Global Sports Development: Mission & Values. http://globalsportsdevelopment.org. 2020. Accessed 15 Aug 2020. 2. Lange D. Share of children (aged 5–15) participating in any sport in the last 4 weeks in England from 2009 to 2018. In: Statista. 2019. https://www.statista.com/statistics/421116/childrens-­ sports-­involvment-­england-­uk/#statisticContainer. Accessed 26 Mar 2020. 3. European Commission: New Eurobarometer on sport and physical activity. https://ec.europa. eu/. 2018. Accessed 25 Mar 2020. 4. Demetriou Y, Hebestreit A, Reimers AK, Schlund A, Niessner C, Schmidt S, Finger JD, Mutz M, Völker K, Vogt L, Woll A, Bucksch J. Results from Germany’s 2018 report card on physical activity for children and youth. J Phys Act Health. 2018;15(2):363–5. https://doi.org/10.1123/ jpah.2018-­0538. 5. Van Bottenberg M.  Why are European and American sports worlds so different? Path-­ dependence in the European and American sports history. In: Tomlinson A, Young C, Richard H, editors. Transformation of modern Europe: states, media and markets 1950–2010. London/ New York: Routledge; 2011. p. 205–25. 6. German Olympic Sports Confederation. About Us. https://www.dosb.de/en/. 2020. Accessed 25 Aug 2020. 7. Holt NL, editor. Positive youth development through sport. New York, NY: Routledge; 2008. 8. Zarrett N, Lerner RM, Carrano J, Fay K, Peltz JS, Li Y. Variations in adolescent engagement in sports and its influence on positive youth development. In: Holt NL, editor. Positive youth development through sport. New York, NY: Routledge; 2008. p. 9–23. 9. Young CC.  The importance of putting the fun Back into youth sports. ACSMs Health Fit J. 2012;16(6):39–40. 10. Merkel DL. Youth sport: positive and negative impact on young athletes. Open Access J Sports Med. 2013;31(4):151–60. 11. Guarin J.  The effect of team sports on mental health in adolescents (61) [Master’s thesis/ SUNY Brockport]. https://digitalcommons.brockport.edu/pes_synthesis/61. 2018. Accessed 11 Apr 2020. 12. The Aspen Institute: sports participation and physical activity rates: participation. https://www. aspenprojectplay.org/. 2020. Accessed 10 Sep 2020.

A Proposed Novel Multidisciplinary Approach to the Care of the Young Athlete

21

13. ADHD Editorial Board. ADDitude Magazine: karate or kickball? Fencing or football? The best sports for kids with ADHD. https://www.additudemag.com/. 2017. Accessed 24 Mar 2020. 14. Hyman M. The Most expensive game in town. The rising cost of youth sports and the toll on Today’s families. Boston, MA: Beacon Press; 2012. 15. WinterGreen Research. Youth sports: market shares, strategies and forecasts, worldwide, 2019–2026. 2019. In: Financial Buzz. Youth sports: market shares, strategies and forecasts, worldwide, 2019–2026. https://www.financialbuzz.com/. 2019. Accessed 17 Mar 2020. 16. Bronfenbrenner U. The ecology of human development: experiments by nature and design. Cambridge, MA: Harvard University Press; 1979. 17. Purcell R, Gwyther K, Rice SM. Mental health in elite athletes: increased awareness requires an early intervention framework to respond to athlete needs. Sports Med-Open. 2019;5(1):46. https://doi.org/10.1186/s40798-­019-­0220-­1. 18. Rugg C, Kadoor A, Feeley BT, Pandya NK. The effects of playing multiple high school sports on National Basketball Association players’ propensity for injury and athletic performance. Am J Sports Med. 2018;46(2):402–8. https://doi.org/10.1177/0363546517738736. 19. PennState Extension: Parents making youth sports a positive experience: role models. https:// extension.psu.edu/. 2017. Accessed 14 Mar 2020. 20. Cohen A, Wegis H, Dutto D, Bovbjerg V. The role of organized youth sports in reducing trends in childhood obesity. Sport J. 2019; 21. Ellerton H. Human kinetics: what is the role of sport coaches and how can they influence athletes? https://humankinetics.me/. 2018. Accessed 25 June 2020. 22. Jõesaar H, Hein V, Hagger MS.  Peer influence on young athletes’ need satisfaction, intrinsic motivation and persistence in sport: a 12-month perspective study. Psychol Sport Exerc. 2011;12(5):500–8. https://doi.org/10.1016/j.psychsport.2011.04.005. 23. Nicholls AR, Morley D, Perry JL. Mentally tough athletes are more aware of unsupportive coaching behaviours: perceptions of coach behavior, motivational climate, and mental toughness in sport. Int J Sports Sci Coach. 2016;11(2):1–10. https://doi.org/10.1177/1747954116636714. 24. Graupensperger SA, Benson AJ, Evans MB. Everyone else is doing it: the association between social identity and susceptibility to peer influence in NCAA athletes. J Sport Exerc Psychol. 2018;40(3):117–27. https://doi.org/10.1123/jsep.2017-­0339. 25. Taylor J. Psychology today: sports parents, we have a problem. https://www.psychologytoday. com/. 2018. Accessed 8 June 2020. 26. Tagliaferro LA, Rienzo BA, Miller MD, Pigg RM Jr, Dodd VJ. High school youth and suicide risk: exploring protection afforded through physical activity and sport participation. J Sch Health. 2008;78(10):545–53. https://doi.org/10.1111/j.1746-­1561.2008.00342.x. 27. Breuner C. Avoidance of burnout in the young athlete. Pediatr Ann. 2012;41(8):335–9. https:// doi.org/10.3928/00904481-­20120727-­14. 28. Brenner JS, Council on Sports Medicine and Fitness. Sports specialization and intensive training in young athletes. Pediatr. 2016;138(3):154–7. 29. Hedstrom R, Gould D.  Research in youth sports; critical issues status. Unpublished manuscript,. Institute for the Study of Youth Sports, Michigan State University; 2004. 30. Merkel DL, Molony JT. Recognition and management of traumatic sports injuries in the skeletally immature athlete. Int J Sports Phys Ther. 2012;7(6):691–704. 31. Micheli LJ, Purcell L, editors. The adolescent athlete. New York, NY: Springer; 2007. 32. Chang DS, Mandelbaum BR, Weiss JM. Special considerations in the pediatric and adolescent athlete. In: Fontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical sports medicine: medical management and rehabilitation. Philadelphia, PA: Saunders Elsevier; 2007. 33. Kasser J, Moroz PJ. Fractures in the growing knee in the child and adolescent. In: Micheli L, Kocher MS, editors. The pediatric and adolescent knee. Philadelphia, PA: Saunders Elsevier; 2006. 34. National Center for Sports Safety Sports Injury Facts. http://www.sportssafety.org/sports-­ injury-­facts/. In: Merkel, D. L.Youth sport: positive and negative impact on young athletes. Open Access J Sports Med. 2012;31(4):151–60.

22

H. Baron Steven et al.

35. Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Med. 2003;33(1):75–81. https://doi.org/10.2165/00007256-­200333010-­00006. 36. Sanders B, Blackburn TA, Boucher B. Preparticipation screening–the sports physical therapy perspective. Int J Sports Phys Ther. 2013;8(2):180–93. 37. O’Brien J, Young W, Finch CF.  The delivery of injury prevention exercise programmes in professional youth soccer: comparison to the FIFA 11+. J Sci Med Sport. 2017;20(1):26–31. https://doi.org/10.1016/j.jsams.2016.05.007. 38. Ekstrand J, Lundqvist D, Davison M, D’Hooghe M, Pensgaard AM. Communication quality between the medical team and the head coach/manager is associated with injury burden and player availability in elite football clubs. Br J Sports Med. 2019;53:304–8. 39. Begel D. An overview of sport psychiatry. Am J Psychiatry. 1992;149(5):606–14. https://doi. org/10.1176/ajp.149.5.606. 40. Reardon CL, Factor RM.  Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med. 2010;40(11):961–80. https://doi. org/10.2165/11536580-­000000000-­00000. 41. Wharam D, Geringer S, King R, Kerr M. Local sport club structures and their effect on athletic performance: the relationship between formalization and athletic performance in swimming. Sports J. 2020;41(2)

Gender Differences in the Psychiatric Treatment of Athletes Danielle Kamis and Roy Collins

1 Current Research of Gender Differences in the Psychopathology of Athletes 1.1 Mood Disorders Previous research has found that the incidence of mild depression in the overall athletic population is 23.7% and moderate to severe depression was 6.3%. When separating by sex, female athletes were found to have a higher incidence of mild depression at 28.1%, with the level of moderate to severe depression being 7.5% [1]. The most recent survey data (2015) makes clear that female athletes are at greater risk to depression than their male counterparts. The higher rate of depression among women extends to nonathletes as well [2]. Additionally, the incidence of depression varies sport by sport with some examples highlighted below.

Track and field Soccer Lacrosse

Incidence of depression (male) 25% 13% 12%

Incidence of depression (female) 38% 31% 17%

It is interesting to note the high level of depression in both sexes for track and field, though the incidence of depression within each specific sport for females continues to be greater than their male counterparts. In addition, when analyzing incidence of depression by sport, the data suggest that sports that put a premium on

D. Kamis (*) · R. Collins Stanford University School of Medicine, Palo Alto, CA, USA e-mail: [email protected], [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. Baron et al. (eds.), Sport and Mental Health, https://doi.org/10.1007/978-3-031-36864-6_2

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individual performance and low body weight tend to also have a higher incidence of depression [2]. For male athletes, mood disorders tend to present as externalized symptoms of aggression, rather than internalized apathy or sadness, as is more often seen by their female counterparts. Outward display of actions received as disruptive or disrespectful should alert invested parties of the possibility of an underlying mood disorder [3]. In regard to treating mood disorders such as depression, men may not respond as well to antidepressant medications as women. Studies show these differences are less applicable to young athletes under 50 years of age; however, when offering help to young male athletes, it is important to consider how hormonal differences between sexes may play a role. Therefore, when treating a male athlete suffering from depression, one might expect several different medications to be initiated and trialed before an ideal medication regimen is found [4]. An additional complication to treating male athletes may be the common consensus that females, in general, are more adherent to their prescribed medications than males [5].

1.2 Anxiety Disorders Generalized anxiety disorder (GAD), characterized by persistent worry in a multitude of areas of life, is the most prevalent disorder found in male and female athletes, especially in aesthetic sports such as gymnastics, figure skating, etc. Specifically, 38.9% of women in aesthetic sports were had a lifetime prevalence of generalized anxiety disorder, a sharp contrast to the rate of 10.3% for women in other sports. Men were found to have a lifetime GAD prevalence rate of 16.8% in aesthetic sports and 6.8% in all other sports [6]. This 3:2 ratio of the prevalence of GAD in women to men resembles the ratio that is usually reported in large population studies. In comparing females to males, their generalized anxiety presentations are similar. However, extreme presentations of anxiety appear differently for males. Social anxiety presents in the male athlete as someone who is afraid to conversate, socialize, or hold meaningful relationships outside of his own family with anyone who is not directly associated with his sport. Social anxiety, like mood disorders, is also more likely to present in an externalized fashion. Antisocial personality disorder, pathological gambling, and substance abuse all represent externalized anxiety. Thought to be on the extreme end of the anxiety spectrum, males in general are also more likely than their female counterparts to be diagnosed with obsessive-­ compulsive disorder (OCD) and represent roughly 70% of all children diagnosed [7]. In 2017, an estimated 5.7% of NCAA athletes surveyed met full criteria for OCD, meaning the statistical likelihood is high for OCD, or at least OCD symptoms, to present in male athletes. Most athletes of both gender identities practice “rituals” in order to control as many variables as they can in competitive fields where results are uncertain. The presenting symptoms in male athletes, however, are

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going to show as motor tics, contain intrusive sexual and religious obsessions, and will also appear as compulsive behaviors for items in their view to be symmetrical and ordered.

1.3 The Female Athletic Triad The female athlete triad is a medical condition observed in physically active females involving three key components including low energy availability with or without an eating disorder, menstrual disturbance or amenorrhea, and bone loss or osteoporosis. In the healthy athlete, an optimal balance between energy availability, bone health, and menstrual function exists, and as a consequence, an energy deficiency is the main cause of the female athlete triad. An energy deficiency is defined as an imbalance between the amount of energy consumed and the amount of energy expended during exercise. Often, this can involve a conscious restriction of food intake, problems with body image, and a high drive for thinness. Sometimes, these conditions can lead to disordered eating or more serious eating problems, like anorexia or bulimia. Low energy availability is associated with hypothalamic dysfunction and subsequently will negatively affect menstrual function and bone health. In fact, the most serious menstrual problem associated with the triad is amenorrhea, defined as no menstrual period for 3 months or more. However, athletes who have irregular menstrual cycles are also susceptible to the effects of the triad. Additionally, women with the triad are at higher risk for low bone mass leading to osteoporosis in its severe form. When there is insufficient energy to fuel the athletes to maintain normal bodily processes, the reproductive system is shut down to conserve energy, and as a consequence, the body stops producing estrogen. Without estrogen, the body cannot build bone mass, resulting in a loss of bone mineral density. This type of bone loss can cause an increased risk of fractures, including stress fractures. While the prevalence of all three components tends to be rather low and shows a high level of variation (0–16%), the presence of one or two concurrent components approaches 50–60% [8]. As mentioned previously, the main problem is the athlete’s negative energy balance, whether it is purposefully caused or not. This energy deficiency then may alter the activity of the hypothalamic pituitary axes and the hormones involved in menstrual function and bone metabolism. It has also been found that athletes who engage in sports where low body weight and lean physique are desired (e.g., dancers, gymnasts, and runners) are at the greatest risk of female athletic triad. Of importance to note is that the consequences of these critical conditions mentioned above may not be reversible, so prevention and early intervention are critical.

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1.4 Eating Disorders Eating disorders among athletes have been relatively well studied. The two most common eating disorders in elite athletes are anorexia nervosa and bulimia nervosa. Anorexia is characterized by a refusal to maintain a minimum healthy weight, whereas bulimia nervosa involves repeated episodes of binge eating followed by self-induced forced regurgitation. The incidence of eating disorders is strongly gender dependent, and women are significantly more likely than men to have had anorexia or bulimia in their lifetime. In fact, some studies put female incidence of eating disorders as high as 60% for highly competitive female athletes [9]. The most common sports in which female athletes develop eating disorders are found in what are considered “leanness sports” such as long-distance running, gymnastics, figure skating, and cheerleading. Respectively in leanness sports, male athletes have approximately 1/3 less chance of developing eating disorders compared with females.

1.5 Substance Use In an increasingly competitive world, athletes are constantly looking for an edge in order to rise against their competition, leading to the abuse of anabolic steroids. The stakes are also continuously rising, as professional salaries have never been higher, and as a result, more pressure is applied to athletes to excel at younger ages than ever before. Performance-enhancing drugs, such as anabolic steroids and like metabolites, are ubiquitous across multiple different sports and levels of play. Men use anabolic-androgenic steroids (AAS) significantly more than women, although women have been using AAS in increasing fashion. Concurrent with active AAS use are consequential psychiatric symptoms, such as psychosis, anxiety, depression, hostility, and paranoia. These symptoms can be dose dependent, meaning that they occur at higher rates associated with higher AAS usage, and are more prevalent in individuals while they are using, as opposed to times when they are not actively using [10]. AAS use is no longer limited to professional and college athletes, bodybuilders, or weightlifters but also currently extending to the general population, including younger populations. The modern AAS user may be competing in high school sports or simply have a fitness accounts on social media. The psychiatric profile of an AAS user in today’s time is associated with concurrent diagnoses of narcissism, body dysmorphia, and eating disorders. AAS users are also more likely than non-­ AAS users to carry traits of antisocial personality disorder, a personality disorder associated with a complete disregard for morality, socially accepted norms, and the feelings of others [10]. Anabolic steroid use is also linked to eventual dependence on the substance. In one way, the actual amount of the steroid taken rises with each “cycle” or

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programmed use, as the human body develops tolerance each time. Other notable paradigms of dependence present as AAS users may develop refractory mood symptoms, such as depression, once the steroid has been discontinued. Chronic AAS users may find mood stability associated with steroid use, and therefore, discontinuation further complicated with both physical and mental side effects. Very gradual decreasing or tapering of the steroid is recommended for chronic users who have secondary psychiatric side effects associated with steroids. Anabolic steroid use in athletes can also be associated with or potentially be used as a metric to predict use of illicit substances, as users are more prone to consume multiple substances at once and generally engage in risk-seeking behaviors. Compared to nonusers, users of steroids and other performance-enhancing drugs have higher rates of concurrent use of heavy alcohol, tobacco, marijuana, amphetamines, narcotics, and impermissible dietary supplements. Younger age groups are particularly vulnerable to polysubstance use [11]. Additionally, trends in substance use by male and female college-level players show many similarities. Data reported for the years 2005, 2009, and 2013 show a consistently high rate of alcohol use over the past 12 months by collegiate players. Although similar percentages of male and female student-athletes report using alcohol, men have an overall high rate of substance use than women [12]. Cannabis is particularly popular among youth and college athletes, as legal changes have made the substance more accessible. Official tracking of marijuana use in young athletes is limited due to the evolving legality of use; thus, collected data is only reliable in “of age” user 21 years old or older. However, surveys distributed across gymnasiums and on social media suggest nearly 30% of athletes from ages 21 to 39 use cannabis, and those who returned the surveys were made up of two-thirds male respondents [13]. Altogether, women’s college sports show substantially less drug and alcohol use than men’s sports. However, the patterns and trends in use of specific substances can be very similar. Among women, ice hockey shows the most overall substance use, exhibiting the highest levels of past-year alcohol use in women’s programs. Women’s basketball and track rank near last for total substance use – only gymnasts reported less overall usage. Surprisingly, women’s soccer, tennis, and basketball players all show a greater prevalence of past-year alcohol use than participants in men’s programs. At the same time, marijuana was used less frequently by women than men across all sports, with women’s ice hockey players exhibiting the greatest level of use (25.3%). Cigarette smoking was most common among lacrosse players (16.7%) followed by softball players, and ice hockey was once again the top sport for smokeless tobacco use (11.8%).

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2 Clinical Cases [6] A. Kelly Catlin was over the top gifted. At seven, she was an accomplished violin player; within 2 years of taking up bike racing, she was invited to the national team workout facility; there – though she was not especially large person, she put out more power on an erg than anyone before her. She and her team were in the hunt for gold in the Olympics – some had them favored. She had a perfect score in the SATs. She was enrolled in a graduate program at Stanford, Computational Mathematics, fulfilling a lifelong obsession with numbers. She was positioning herself to have a high-level job in Silicon Valley after her racing days were over. Unfortunately, due to poor interdisciplinary support, Kelly lost her life to suicide. Her father, a pathologist, blamed her suicide on a combination of factors, including a success-at-all-cost personality, overtraining stress, and athletic injuries. The breaking point was a concussion she sustained during a training ride. Regarding her suicide, there were many warnings. She had previously had a failed suicide attempted by enclosing herself in a car filled with helium. In this devastating clinical case, there was a failure of support for this highly trained and talented athlete, which likely led to the loss of her life. A key point to highlight in this case is the absence of a multidisciplinary support team. If an interdisciplinary team of a sports psychiatrist, sport medicine physician, therapist, coach, trainers, etc. were all aware and in communication of these series of unfortunate events in Kelly’s life, there is a strong change that this suicide may have been prevented with the appropriate targeted support provided. B. Kevin Love is a world-class basketball player who won the National Basketball Association (NBA) Finals as a member of the Cleveland Cavaliers. Love’s personal life became the topic of news in 2018 when he, as well as fellow NBA player DeMar DeRozan, publicly spoke about his mental health struggles with depression and anxiety. In an article in which he chronicles his first experience with a diagnosed panic attack, Love describes his initial aversion to mental health evaluation in relation to his male identity: Growing up, you figure out really quickly how a boy is supposed to act. You learn what it takes to “be a man.” It’s like a playbook: Be strong. Don’t talk about your feelings. Get through it on your own [14].

He further described mental health and associated treatment as a “weakness” that would both impair his athletic success and ostracize him from his teammates. The association of the male gender and an aversion to seeking mental health services are not one that is new. Studies have shown diagnostic aversion moderated the positive association between traditional male ideology (TMI) and externalizing symptoms, such that men who are strongly aligned with TMI demonstrated higher levels of diagnostic aversion. In other words, those who most identify with traditional male ideologies are far more likely than others to ignore and suppress emotions necessary for appropriate psychiatric diagnostic evaluation and treatment [15].

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As a result, traditional male ideology is then linked to a higher prevalence of maladaptive coping behaviors, such as substance use and violent outbursts. For male athletes who are more likely than their female-identifying counterparts to have been raised such that their values are closely aligned with traditional male ideologies, special considerations should be incorporated into their care. Male athletes may be less open about experienced symptoms associated with vulnerability, such as guilt, feelings of worthlessness, and sadness. Instead, male athletes are more likely to express externalized symptoms such as headache, chest pain, fatigue, insomnia, or difficulty with concentration. The true incidence of mental health disorders among male athletes is likely near that of female athletes; however, their expressed symptoms are subtle and are confounded with what one may reasonably associate with high-level competition (e.g., fatigue with long practice hours, headache with contact sports). Therefore, an interdisciplinary team, where multiple observers can interact with athletes across multiple points in the day and in different settings such that the totality of the observations provides an invaluable insight into each athlete, and their subtle symptoms are more likely to be captured.

3 The Interdisciplinary Team: Duties Supporting Male and Female Athletes [7] The interdisciplinary team consists of the medical staff including a sports psychiatrist, coaches and training staffs of the athletic department, therapist, social workers, and teammates. The coaching staff and the trainers, while they are not counselors, are an important first line of support and should have a sound background for specific items to screen for given the age, sport, and gender of the athlete. Coaches, trainers, and other support staff cumulatively are able to observe and interact with athletes across multiple hours of their days and also across multiple settings and environments. With this cumulative benefit comes the responsibility of interdisciplinary communication and discussion around mental health warning signs. If appropriate, teammates, trainers, or their coach may suggest that the athlete speaks with a counselor. Counselors must be able to recognize when a member of the medical staff, such as the sports psychiatrist, should be brought in for additional counseling and tests. Clear communication within the athletic department, as well as the medical and psychological staff, is key. All team members, especially those on the mental health team such as therapists and sports psychiatrists, should be aware of the gender differences in psychopathology of their athletes for more thorough, streamlined, and comprehensive evaluation. It is also important to consider the sexual orientation of the athlete, in case interactions with previous health providers have in any way informed that the athlete may respond to suggestions about seeking mental health care.

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The presenting symptoms of a mental health disorder may or may not differ according to identified gender. However, supporting the mental health of athletes requires a close appreciation for subtle characteristics for which intervention is appropriate. The recommendation for monitoring both precipitating symptoms and outcomes may be best anchored around external measures such as sleep quality, appetite, energy level, concentration, and also possibly overall performance. Social factors, such as the longstanding stigma surrounding mental health diagnoses and treatment, should always be considered when trying to best help a struggling athlete. One must also be aware that in comparison to more physical health knowledge, the general public has a lower mental health literacy. For college athletes in particular, busy schedules are often a limiting factor and can impede an athlete from seeking treatment in which he or she has little initial interest. Hypermasculinity is associated with reduced internalizing of diagnostic mental health symptoms and is thus a barrier to be addressed in male athletes. Non-white athletes statistically have less access to mental health care and, as a result, are also less likely to both self-identify the need for mental health treatment and may also have reservations about seeking treatment due to cultural backgrounds. Mental health evaluation and treatment often involve expensive outpatient appointments, and therefore, baseline economic status should be considered when discussing an athlete’s past mental health history. The role of substance use plays a key factor in an athlete’s mental health. Historically, athletes and nonathletes alike have used substances as self-guided mental health treatment devices. Illicit substance use almost always worsens or exacerbates underlying mental health issues, so monitoring of the alcohol, marijuana, and tobacco intake for both male and female athletes will undoubtedly shed light on underlying or worsening issues.

4 Key Points Elite female athletes are more likely to receive a psychiatric diagnosis than men and appear more susceptible to difficulties encountered in their environment than their male counterparts. Variations in frequency, as well as in type of psychiatric diagnoses, occur according to the type of sport practiced. We see the development of specific disorders facilitated by a combination of a few key components: the demands and pressures associated with the practice of a particular sports, socio-environmental risk factors, and an individual’s particular personality and genetic predisposition. Illicit substance use is more frequently associated with males; however, substance abuse is prevalent and affects the performances of both male and female athletes. Whether the substance is performance enhancing or recreational, illicit substances almost always worsen or exacerbate underlying mental health issues; thus, the role of substance use by an athlete is an important consideration.

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5 Summary and Future Direction While a large body of literature exists on the gender differences in psychopathology for the general population, such large-scale psychological data on male and female elite athletes is scarce. A discrepancy exists between the incidences of psychiatric illness in the general population compared to elite athletes. Other studies report exercise as a protective factor, implying that psychopathology would be less frequent in the athletic population. Still others believe the stress of sports and athletics leads to higher levels of psychopathology. Further studies must be completed in order to determine which of these effects is dominant. In addition, further resources and evaluation should be directed toward athlete habits, particularly concerning medication adherence. Interventions aimed toward athletes are only as effective as can be reasonably incorporated into the arduous schedule of an athlete.

References 1. Wolanin A, Hong E, Marks D, et al. Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. Br J Sports Med. 2016;50:167–71. 2. Castaldelli-Maia JM, Gallinaro JGDME, Falcão RS, et al. Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment. Br J Sports Med. 2019;53:707–21. 3. Gressier F, Calati R, Serretti A. 5-HTTLPR and gender differences in affective disorders: a systematic review. J Affect Disord. 2016;190:193–207. https://doi.org/10.1016/j.jad.2015.09.027. 4. Quitkin F, Stewart J, McGrath P, Taylor BP, Tisminetzky MS, Petkova E, Chen Y, Ma G, Klein DF. Are there differences between women’s and men’s antidepressant responses? Am J Psychiatry. 2002;159:1848–54. 5. Degli Esposti L, Piccinni C, Sangiorgi D, Fagiolini A, Buda S. Patterns of antidepressant use in Italy: therapy duration, adherence and switching. Clin Drug Investing. 2015;35(11):735–42. https://doi.org/10.1007/s40261-­015-­0332-­4. 6. Schaal K, Tafflet M, Nassif H, Thibault V, Pichard C, Alcotte M, Toussaint JF, et  al. Psychological balance in high level athletes: gender-based differences and sport-specific patterns. PLoS One. 2011;6(5):e19007. https://doi.org/10.1371/journal.pone.0019007. 7. Altemus M, Sarvaiya N, Neill Epperson C. Sex differences in anxiety and depression clinical perspectives. Front Neuroendocrinol. 2014;35(3):320–30. https://doi.org/10.1016/j. yfrne.2014.05.004. 8. Committee on Adolescent Health Care. The female athlete triad. Obstet Gynecol. 2017;129(6):e160–7. 9. Hausenblas H, Downs S.  D comparison of body image between athletes and non athletes review. J Appl Sport Psychol. 2001;13:323. 10. Sirois F.  Steroid psychosis: a review. Gen Hosp Psychiatry. 2003;25(1):27–33. https://doi. org/10.1016/s0163-­8343(02)00241-­4. 11. Buckman JF, Farris SG, Yusko DA. A national study of substance use behaviors among NCAA male athletes who use banned performance enhancing substances. Drug Alcohol Depend. 2013;131(1–2):50–5. https://doi.org/10.1016/j.drugalcdep.2013.04.023. 12. Linzer M, Spitzer R, Kroenke K, et al. Gender, quality of life, and mental disorders in primary care: results from the PRIME-MD 1000 study. Am J Med. 1996;101(5):526–33. https://doi. org/10.1016/s0002-­9343(96)00275-­6.

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13. Zeiger JS, Silvers WS, Fleegler EM, Zeiger RS.  Cannabis use in active athletes: behaviors related to subjective effects. PLoS One. 2019;14(6):e0218998. Published 2019 Jun 28. https:// doi.org/10.1371/journal.pone.0218998. 14. Love K. Everyone is going through something. The Player’s Tribune. 2018., www.theplayerstribune.com/en-­us/articles/kevin-­love-­everyone-­is-­going-­through-­something. 15. Jampel JD, Gazarian D, Addis ME, et  al. Traditional masculinity ideology and diagnostic aversion predict symptom expression in a community sample of distressed men. Sex Roles. 2020;82:704–15. https://doi.org/10.1007/s11199-­019-­01083-­3.

Further Reading Bennett K.  Treating athletes with eating disorders: bridging the gap between sport and clinical worlds. Routledge; 2022. Committee on Adolescent Health Care. The female athlete triad. Obstet Gynecol. 2017;129(6):e160–7. Hedenborg S, Pfister G. Gender, media, sport. Routledge; 2017. Woods R, Butler BN. Social issues in sport. Human Kinetics Publishers; 2020. Krane V, editor. Sex, gender, and sexuality in sport: queer inquiries. Routledge; 2018 Dec 7. Billings AC, Hardin M. Gender, sports, and cultural barometers: the state of play in the year 2022. Commun Sport. 2022 Aug;10(4):591–3.

Transcultural and Cultural Aspects of Sport Psychiatry T. Wenzel, A. F. Chen, and T. Akkaya-Kalayci

1 Introduction Globalisation, increased mobility, international sporting events with multinational audiences, and multi-ethnic teams in sports create an emerging situation characterised by new challenges. Mental health is a crucial aspect of transcultural care in all medical specialties, as well as in sport medicine, due to many factors that will be explored in this chapter. Racism and other political factors may also be seen in this context. Transcultural factors and sociocultural backgrounds are generally important for multi-ethnic teams [1], especially in pluralistic larger countries, such as the USA, France, and the UK. Their impact may also be introduced to the healthcare professional—to patient relationship through the background of the physician. For example, a physician with an urban background may have difficulty understanding or recognising problems of patients from traditional rural communities or minority groups such as the Amish in the USA. Other physicians may feel at odds with religious groups in other countries as they may be influenced by a lack of awareness of their own cultural belief systems, religious or subconscious racist or “colonial” bias [2]. They or their patients might be themselves recent migrants over the past few generations with ambivalence as to cultural patterns and beliefs. These different aspects can be important information to know as they may affect the interaction, T. Wenzel (*) · A. F. Chen World Psychiatric Association Scientific Section for Sport and Exercise Psychiatry, and OEGBA, Vienna, Austria T. Akkaya-Kalayci Outpatient Clinic of Transcultural Psychiatry and Migration Induced Disorders in Childhood and Adolescence, Department of Child and Adolescent Psychiatry, Postgraduate University Program Transcultural Medicine and Diversity Care, Medical University of Vienna, Vienna, Austria © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. Baron et al. (eds.), Sport and Mental Health, https://doi.org/10.1007/978-3-031-36864-6_3

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trust-building, help-seeking, parallel or alternative use of traditional healing models by the patient, role of the family in coping with or contributing to a problem, form and expression of mental health problems, compliance, diagnostics, or treatment success and athlete performance [3–6]. Similar considerations would also apply if the sport psychiatrist migrates into other countries or gives support in international sports events [7]. Awareness of a culture’s traditional healing models such as herbs or animal products like musk in traditional Chinese medicine (TCM) [8] and resulting possible doping considerations have also so far not been sufficiently explored and will be discussed further below. In this chapter, we want to draw attention to the following—not necessarily comprehensive—list of potentially relevant factors in these settings. It should be considered that in many countries, the distinction between psychiatric and neurological or other primarily physical disorders is by no means clear in the expectations of the patients and also in the general population [9]. An athlete with undifferentiated neurological but potentially also psychiatric symptoms, for example, headaches, might first contact a doctor of any of the two specialties. In some cases, the athlete would rather contact a neurologist or family physician than a sport psychiatrist [10] due to fear of cultural or other stigma. In the work with team members and athletes from other cultures or ethnic groups, it is important to keep in mind that generalisations and simplifications can be misleading and detrimental to understanding the individual client. A person-centred approach is always important [11]. We should not classify clients as “a Muslim”, “an African American”, or as “a Syrian” or “an Afghan”. Identity and health behaviour are complex issues. Behaviour, values, and health belief models can be influenced by any of the numerous diverse psychosocial backgrounds present globally also in traditional local cultures. An individual’s social background includes education, urban versus rural upbringing, national identity, migration history, and membership in different religious groups. For an athlete, it may also be defined by their specific sport’s “sub-­culture”, which may differ between different sports, or even individual versus team sports. For some clients, religion is less relevant in everyday life, but for others, it can be very important, and it is essential that the psychiatrist understands this. Examples for situations where this matters include Ramadan practices [12–15] in most forms of Islam, or nutritional precepts in Judaism, as religious precepts can influence patient compliance with medication, activity, or nutrition. More rarely, athletes might be members of smaller religious groups with their own rules and concepts, such as Yezidi or Ismaili. It can be important to know the special rules and exceptions for religious fasting, which may be made for very sick patients, travellers, children, and the elderly in this context. Certain ethnic backgrounds may encourage the use of traditional medicines that also can be relevant for support and sport-related challenges such as doping control as outlined below in more detail. Training in transcultural medicine may complement medical school curricula in helping address these complex issues and has therefore been promoted by many authors [16–18]. It should also be part of sport medicine and sport psychiatry.

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2 Stigma, Health Belief Systems, Idioms of Distress, and Public Health In many countries, ethnic minority groups have special barriers to accessing good healthcare, often due to economical and sociological factors [19–21], but also because of language [22, 23]. It can be assumed that patients with more severe mental health or neurological problems might then be particularly susceptible to this problem, especially during the present pandemic, which leads to a compounded barrier to seeking help [24]. Traditional health belief models can influence disclosure, help-seeking, and even the specific presentation of symptoms (in the DSM 5, referred to as “cultural formulation”) [25, 26]. Culture-specific symptoms can present in dramatic forms, for example, in non-epileptic seizures and syncope, which are traditionally classified as conversion or somatoform symptoms [27–29]. They might be cultural expressions (idioms) of distress, as discussed later in this chapter [27]. Treatment in traditional medicine models usually reflects such beliefs and might lead to unexpected problems including treatment compliance, side effects, drug interaction, or with anti-doping regimes. If a patient has symptoms that are often stigmatised in their sport or cultural background, they might only selectively report physical symptoms that are less stigmatised, such as headaches or lack of energy and not depressed mood, sexual dysfunction, or suicidal ideation. Patients with “psychological” symptoms, even if they have a neurological problem such as a stroke, brain trauma, or a tumour, might avoid medical treatment due to the already-­ mentioned fear of stigma or even because of fear of long-term hospitalisation against their will in a psychiatric hospital, which is still a common practice in some countries with developing mental healthcare systems or through political abuse of psychiatric facilities. While such problems might be less common in active and high-performance athletes, they should still not be completely ignored. Stigma against mental health must, as noted before, be further expected to not only impact primary help-seeking but also to create problems in the understanding of treatment needs and options and consequently in compliance [30]. The fear of stigma must also be treated as a potentially serious reason for anxiety, especially in group-oriented or collectivist (“Universalistic”) cultures and even professional “subcultures” of athletes as described before. Mental health-related stigma of the person, potentially also in the family, may disrupt this crucial element of social support [31], further isolating the athlete within their ethnic or sport community. Therefore, this must be addressed with the team and family in direct contact.

3 Interpreters, Language, and Cultural Formulations If working with athletes who speak a different language from the psychiatrist, choosing the correctly trained professional interpreter during direct patient contact or over video- or telephone-based systems [32–34] can positively influence the

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setting, resulting in improved quality of care, compliance, and outcome. Conversely, “ad hoc” interpreters, especially children and other family members, should only be used in emergencies [35–37]. In many migrant communities, trust in the interpreter with different ethnic or religious background might also be limited, especially when persecution has been experienced by the patient in their home country. Health belief models and the aforementioned “cultural formulation” [38] as described in the DSM 5 [39] include the experience, interpretation, and (causal) attribution [40] of somatic or somatoform symptoms to psychological, physical, or metaphysical causes [41–43] and might, if not recognised, lead to problems in the doctor-patient relationship, including a mutual lack of understanding, lower satisfaction in patient and healthcare professionals, and a subpar diagnosis and treatment for the migrant. Symptoms describing heaviness, feeling cold, feeling “without appetite”, a “restless” or “sinking” heart [44], or “generalised pain” [45] might, as already described in the context of selective reporting to avoid stigma, reflect a general cultural formulation of depression symptoms. This is different from the concept of “somatisation”, or in neurology, “conversion”, which is the presence of multiple symptoms not adequately explained by physical findings, requiring specific psychodynamic models [46, 47]. The development of concepts and diagnostic categories during the history of medicine that relate to conversion and “hysteria” models illustrates well that medicine, especially psychiatry and neurology, has culture-specific cultural formulations that change over time with their evolving culture [48–51]. UNHCR has collaborated with leading transcultural psychiatrists to provide a handbook of such cultural formulations and the “idioms of distress” for what may be the current most relevant refugee group, the Syrian refugees,1 but unfortunately no such manuals are available for most other cultural groups. In the USA, Latin American groups have been best explored by research so far [52–56]. The already-­ mentioned American Psychiatric Association’s DSM 5 recommends the well-­ established “Cultural Formulation Interview” (CFI) [57, 58] available in patient and non-patient (informant) versions, with additional modules and materials supplied by APA and other organisations2 to train healthcare professionals in this important aspect of public and mental health [59, 60]. It is freely available from their website3 and is a good alternative to the (unrealistic) search for a “complete” handbook of cultural formulations and culture-bound syndromes for the wide global range of cultures. Special challenges in this context are culture-bound syndromes (CBS) [61–63] and the already-described (cultural) “idioms of distress”. Culture-bound syndromes are  Available from https://www.unhcr.org/protection/health/55f6b90f9/culture-context-mental-­ health-psychosocial-wellbeing-syrians-review-mental.html 2  Center for Substance Abuse Treatment (US). Improving Cultural Competence. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. Appendix E, Cultural Formulation in Diagnosis and Cultural Concepts of Distress. Available from https://www.ncbi. nlm.nih.gov/books/NBK248426/ 3  www.psychiatry.org 1

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infrequently seen in everyday transcultural psychiatry in most countries and are highly specific; one could even say somewhat “exotic” [64]. An example is “vento caido” (fallen wind) in the Amazon region [65]. More common problems are culture-­specific idioms of distress [66–72], the characteristic behaviours, symptoms, and emotions that a member of a culture presents, often as a medical problem, to signal distress and seek help, which are then usually recognised by mother members of the same culture. Examples are the already-mentioned symptoms like “functional” (non-epileptic) seizures, fainting, or headaches [73]. This phenomenon can also be seen in the European cultural and medical history of “hysteria” [74], when the historical health belief model in society and even in academic medicine was that a “moving uterus” would create a wide range of symptoms [75]. From today’s perspective in transcultural psychiatry, this example is seen as the severe stress of the patient, usually a woman exposed to social conflict or trauma [75] without sufficient social support, as a background of this historical syndrome, but which is not commonly seen today. Its absence today indicates that idioms of distress are very common in a culture at a given time but can change with the social environment [76]. They are in our understanding a learned, culture-specific behaviour not under the conscious control of the patient and might be seen in athletes, who often suffer under significant stress loads.

4 Case Example 1 We had recently published a case of a young Afghan refugee, referred after a soccer game, presenting with seizures, who was then evaluated with an positron emission tomography (PET) scan during a seizure and consequently demonstrated the presence of posttraumatic stress disorder without any brain injury or morphological changes arising after a stressful situation, concluding with a diagnosis of culturespecific idiom of distress, as we have observed the same phenomenon in other Afghan (Pashtun) patients with prior war exposure [77]. Treatment was unsuccessful until a specialist in transcultural therapy was included in the team, who identified also ongoing distress resulting from an insecure legal status and asylum application that negatively impacted treatment. Many patients from traditional cultures, particularly from Asian countries and ethnic groups, utilise alternative traditional medicine and healers, sometimes complementary to mainstream treatment, and this is only revealed when the client trusts the majority culture psychiatrist. Regarding this, the World Health Organization (WHO) has stated that “Traditional, complementary and alternative medicine (“traditional medicine”) can be used as an input to “modern” pharmaceutical research, but also as source of effective treatments in its own right”.4 Traditional healing can include the use of herbal medicines that may result in side effects, changes in drug metabolism of other substances, interaction with medications, interplay with doping

 https://www.who.int/intellectualproperty/topics/traditional/en/, accessed 31.8.2020

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concerns, or delay of other treatment including efficient psychological and other strategies to support and complement “modern” host country medicine. This may lead to significant complications and in rare cases even lethal complications [78– 81]. Chan, for example, has drawn attention to the problems with anti-doping rules in regard to the common Traditional Chinese Medicine (TCM) anti-cold preparation Sho-seiryu-to (Ephedrae Herba) even after a single use [82]. Fernando et  al. observed that in a group of 209 elite athletes in Sri Lanka, 60.8% of the sample practiced self-­medication and 9.4% consumed herbal/traditional medicines, while a third of the group used both western and traditional medication, mainly for common problems such as musculoskeletal pain. He et al. followed up on the complexity of the reported use of musk, seen as doping in the 2011 FIFA Women’s World Cup, and possible findings after different laboratory analytical methods [8, 83]. Sinomenium acutum stem use in TCM can be a further challenge in doping control, as explored by Huang et al. [84] and by Ogano et al. in the case of higenamine [85]. Falace et al. have consequently recommended target group-specific anti-doping campaigns supported by all team members and professions [86], and we think that consideration of cultural background might be important to make such campaigns more efficient.

5 Treatment and Transcultural Psychotherapy Any treatment in a transcultural setting requires consideration of the factors listed above and a willingness for open curiosity and dialogue, ideally with formal training in transcultural psychiatry if possible. Treatment with psychoactive pharmaceuticals should consider differences in metabolism, health belief models, possible concurrent use of traditional medicines, and religious practices, in addition to sufficient explanation of the planned treatment, especially to address the patient’s culture-­specific health belief models. Again, effective transcultural psychotherapy requires special training of the therapist (as outlined in [2]) and might use established diagnostic and therapy models adapted to culture, such as those promoted by Hinton [87]. A good general strategy is usually to respect the suffering of the patient and additionally focus on measures of social support and conflict resolution, in collaboration with a transcultural psychiatrist, psychotherapist, or psychologist as well as members of the family or community. This must be done with care because it is often family, partner, or team conflicts that could be factors identifying distress and would need to be first identified as such. Stress factors in athletes might be related to the sport or their performance, or to their private lives. Depression and posttraumatic stress spectrum disorders reflecting earlier traumatic experiences are common in some groups, as discussed in a separate chapter of this book and as demonstrated in our case examples. They will interact [88] but also influence the outcome of other treatments such as physiotherapy and rehabilitation measures. Chronic and often therapy-resistant pain is a well-known problem especially in survivors of sexual violence [89–93] and might be shaped by cultural formulations. Athletes might

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experience danger to their lives and safety from prior political or gender-related persecution, resulting in psychological trauma. This must be considered especially in LGBTQ+ athletes. Danger in some countries might be extreme, exemplified by, for example, the fate of athlete Navid Afkari, executed in Iran, in spite of international protests. They might force the athlete into exile as a refugee, if they survive. Any such team member obviously should receive special support. More recent examples could be listed, as the problem appears to be on the rise, which underlines the need for a comprehensive effort to protect athletes in a time of autocratic regimes on the rise.

6 Case 2 A female top athlete with LGBTQ+ background had experienced numerous acts of discrimination, threat of execution, and different forms of violence in her home country, where gay and lesbian orientation was stigmatised and even punished by law. She presented with an upsurge of symptoms of posttraumatic stress disorder and anxiety after being on a team with an athlete from her home country. She had no trust in members of her ethnic community and confided her history, after first considering withdrawal from the team, to the sport psychiatrist. Individual psychotherapy by a psychotherapist experienced in the culture of the athlete led to improvement of symptoms and increased self-confidence and also resulted in a coming out with her sexual orientation to her team members, as well as sharing some of her earlier experiences. This was successful and further helped her towards recovery. Her coming out was followed by demonstrated support from the trainer, improved success in competitions, and better team integration.

7 Politics in Sport This important aspect is shortly summarised in this chapter but explored in more detail in another chapter of this book. Even in modern democracies, racism leading to discrimination, mobbing, or even violence can have a destructive impact on members of different ethnic, gender orientation, or religious groups. It is unfortunate that a country’s political situation must also be considered in the mental health and well-being of athletes. The ideal of a peaceful and fair sports environment independent from conflict and bridging differences is frequently shattered by events such as the Munich Olympic massacre [94], or the barely hidden racism in the NS games in 1933 [95, 96], even to public demonstration of racism in present soccer

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games and the courageous stance of some athletes against it.5 The impact has so far not been explored by research in most cases that were reported by the media. In the everyday life of the athlete, especially in countries such as the People’s Republic of China, or former East Germany [97], athletes are embedded in a political system that puts severe pressure on them to behave in a politically appropriate manner, as well as by extreme performance expectations, imposed already on very young athletes. Currently, a spotlight is being shown on the use of forced doping and its consequences such as androgenisation in female athletes [98], which has been controlled and ordered by governments. Often, it was tolerated or supported by trainers and sport medicine professionals, without the knowledge of the young athletes, and this has become an issue of public discussion after the fall of the East German republic [98–101]. It is also now discussed in the case of other countries with totalitarian governments [102]. Group pressures demanding success, suppressing individual opinions and needs, and prohibiting the reporting of abuse or doping can also be especially strong in “universalist” (group-oriented) societies like China. After being publicly exposed for the use of doping [103], athletes in any country must be expected to suffer not only medically [104] but also socially and economically, resulting in severe mental health consequences [105], but this has so far not been covered by significant research. Doping might destroy not only the career but also the feeling of identity, self-confidence, and metal health of the athlete, resulting in loss of embedding in the sub-culture of their sport and team. This will be a special challenge for the sport psychiatrist or sport psychologist.

8 Physical Factors Finally, it should be considered that apparently atypical or “unexplained” symptoms in athletes from other countries might be part of an illness that is rare or not present in the host country such as familial Mediterranean fever (FMF) [106, 107], poisoning (see, for example, lead poisoning in some environments [108–112]), parasitosis, or infectious disorders. These might be missed or misinterpreted as “psychosomatic” or as cultural formulation based in transcultural settings. Physical factors of relevance in transcultural (sport) psychiatry are also the differences in biosystems, like, for example, cytochromes, that influence drug metabolism and drug interactions [113–116] and must be considered for all prescriptions, doping considerations, and probably also in drug safety testing, such as how ethnic differences in alcohol metabolism [117, 118] might influence symptoms and treatment [119].

  See, for example, https://abcnews.go.com/Sports/wireStory/soccer-players-lay-marker-fight-­­ racism-74620829, accessed 29.12.2020 5

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9 What Can the Athletes, Team Members, and Caregivers Do? Table 1 gives some examples for the possible roles of the athlete and the different groups supporting athletes, including family members and other health professionals such as physiotherapists and psychologists, in building a culture-sensitive, racism-free sporting environment. In our opinion, these issues should be included in all team assisting programs [120, 121] and in sports curricula for trainers, athletes, and healthcare professionals. Table 1  What can team members do? Sport psychiatrist, psychologist, or healthcare expert Train in transcultural psychiatry and medicine

Trainers and coaches Understand the background culture of the athlete in identifying challenges and resources Explore and Help to promote understand the equal rights and cultural background culture sensitivity of the athlete and fight racism in teams Consider cultural and biological factors including traditional medicine use Include culture experts

The athlete Reflect critically on their own cultural background as a challenge and a resource Be careful with the use of traditional medicine

Take a strong position for equality and fight against racism, both in the team and in public Try to understand and respect the religion and culture of other team members

Politicians, public figures, umbrella organisations, and sport functionaries Support anti-stigma strategies regarding mental health in athletes and the idea of fair play, antiracism, and equal rights in sports Support strategies to promote transcultural medicine also in sports

Fight racism and political abuse of sports, protect human rights

Support research, training, and awareness-raising programs in the above fields

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10 Short Summary and Checklist: What to Take Home • Cultural backgrounds of athletes and their other team members—including social, ethnic, biological, and religious factors, as well as a history of discrimination and persecution—should be considered by all parties involved in the sport. This background can influence the development of problems and conflicts, shape illness behaviour and cultural formulations of illness, but can also provide positive coping strategies and influence a positive identity. • Physical factors such as the use of traditional medicines and genetic aspects of drug metabolism should also find consideration in treatment and sport-related challenges such as doping control. • Transcultural understanding and respect are the background of the historical and present ethics of sport. Sport psychiatrists and other mental health professionals working with athletes should acquire skills and participate in trainings in transcultural psychiatry and take a strong position against racism, political abuse, xenophobia, and ethnic or religious discrimination in sports.

11 Conclusions Ethnicity and cultural factors in mental health are an important consideration in sport psychiatry, and there is a need for special training in this field as multi-ethnic teams, global travel and transfer of athletes, and globalisation of sporting events become more common at least in high-performance sports. These include physical, psychological, social, and sometimes legal aspects and therefore require an interdisciplinary approach coordinated between experts in different fields of medicine to create a comprehensive and effective treatment plan. Research is needed to understand the specific aspects of transcultural psychiatry and how to develop healthy, fair sports that take care of the athlete. A joint effort is required to fight discrimination and racism in sports, and this should be supported by all team members, athletes, and the sporting community at large. Acknowledgements  We are grateful for advise by Professor Vassilis Klissouras, former Dean, University of Athens, Department of Sport Medicine. No conflict of interest None. Recommended Reading  See [122, 123].

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References 1. Wei X, Chen J, Chen P, Newell JN, Li H, Sun C, et  al. Barriers to TB care for rural-to-­ urban migrant TB patients in Shanghai: a qualitative study. Tropical Med Int Health. 2009;14(7):754–60. 2. Wenzel T, Drozdek B, Fu Chen A, Kletecka-Pulker M. The significance of intercultural psychotherapy in further education and professional training. In: Schouler-Ocak M, Kastrup MC, editors. Intercultural psychotherapy. New York: Springer; 2020. p. 59–80. 3. Luitel NP, Jordans MJD, Kohrt BA, Rathod SD, Komproe IH.  Treatment gap and barriers for mental health care: a cross-sectional community survey in Nepal. PLoS One. 2017;12(8):e0183223. 4. Subba P, Luitel NP, Kohrt BA, Jordans MJD. Improving detection of mental health problems in community settings in Nepal: development and pilot testing of the community informant detection tool. Confl Heal. 2017;11:28. 5. Baarnhielm S, Sundvall M. Clinical challenges in cultural psychiatry–searching for meaning, searching for methods(dagger). Nord J Psychiatry. 2018;72(sup1):S9–S12. 6. Tobin CL, Di Napoli P, Beck CT. Refugee and immigrant Women's experience of postpartum depression: a meta-synthesis. J Transcult Nurs. 2018;29(1):84–100. 7. Etienne MO, Messmer PR, Danis SJ, Blot G.  Outcomes of an immersion Proiect in The Dominican Republic Bateyes. J Natl Black Nurses Assoc. 2016;27(1):31–7. 8. He Y, Wang J, Liu X, Xu Y, He Z.  Influences of musk administration on the doping test. Steroids. 2013;78(11):1047–52. 9. Gelfand T.  Neurologist or psychiatrist? The public and private domains of Jean-Martin Charcot. J Hist Behav Sci. 2000;36(3):215–29. 10. Dain N. Reflections on antipsychiatry and stigma in the history of American psychiatry. Hosp Community Psychiatry. 1994;45(10):1010–4. 11. Balint M, Ball DH, Hare ML. Training medical students in patient-centered medicine. Compr Psychiatry. 1969;10(4):249–58. 12. Aslam M, Wilson JV.  Medicines, health and the fast of Ramadan. J R Soc Health. 1992;112(3):135–6. 13. Hussain SA. Medication during Ramadan. Lancet. 1989;1(8650):1331. 14. Aslam M, Healy MA. Compliance and drug therapy in fasting Moslem patients. J Clin Hosp Pharm. 1986;11(5):321–5. 15. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health. 1986;100(1):49–53. 16. Braybrooke ME.  Understanding other cultures: the need for training. Edtna Erca J. 1998;24(1):19–21. 17. Palmer CJ.  Engendering cultural sensitivity in nursing students. Aust N Z J Ment Health Nurs. 1997;6(2):66–72. 18. Millon-Underwood S. Educating for sensitivity to cultural diversity. Nurse Educ. 1992;17(3):7. 19. Santalahti M, Sumit K, Perkio M.  Barriers to accessing health care services: a qualitative study of migrant construction workers in a southwestern Indian city. BMC Health Serv Res. 2020;20(1):619. 20. Cabieses B, Oyarte M. Health access to immigrants: identifying gaps for social protection in health. Rev Saude Publica. 2020;54:20. 21. Castaneda H. Illegality as risk factor: a survey of unauthorized migrant patients in a Berlin clinic. Soc Sci Med. 2009;68(8):1552–60. 22. Jaeger FN, Pellaud N, Laville B, Klauser P.  The migration-related language barrier and professional interpreter use in primary health care in Switzerland. BMC Health Serv Res. 2019;19(1):429. 23. Zheng Y, Lamoureux EL, Chiang PC, Anuar AR, Ding J, Wang JJ, et al. Language barrier and its relationship to diabetes and diabetic retinopathy. BMC Public Health. 2012;12:781.

44

T. Wenzel et al.

24. Tan GTH, Shahwan S, Goh CMJ, Ong WJ, Samari E, Abdin E, et al. Causal beliefs of mental illness and its impact on help-seeking attitudes: a cross-sectional study among university students in Singapore. BMJ Open. 2020;10(7):e035818. 25. Aggarwal NK, Glass A, Tirado A, Boiler M, Nicasio A, Alegria M, et al. The development of the DSM-5 cultural formulation interview-Fidelity instrument (CFI-FI): a pilot study. J Health Care Poor Underserved. 2014;25(3):1397–417. 26. Novins DK, Bechtold DW, Sack WH, Thompson J, Carter DR, Manson SM. The DSM-IV outline for cultural formulation: a critical demonstration with American Indian children. J Am Acad Child Adolesc Psychiatry. 1997;36(9):1244–51. 27. Minhas FA, Nizami AT.  Somatoform disorders: perspectives from Pakistan. Int Rev Psychiatry. 2006;18(1):55–60. 28. Escobar JI, Burnam MA, Karno M, Forsythe A, Golding JM. Somatization in the community. Arch Gen Psychiatry. 1987;44(8):713–8. 29. Mezzich JE. Cultural formulation and comprehensive diagnosis. Clinical and research perspectives. Psychiatr Clin North Am. 1995;18(3):649–57. 30. Sun KS, Lam TP, Lam KF, Lo TL.  Barriers and facilitators for psychiatrists in managing mental health patients in Hong Kong-impact of Chinese culture and health system. Asia Pac. Psychiatry. 2018;10(1) 31. Heim E, Wegmann I, Maercker A. Cultural values and the prevalence of mental disorders in 25 countries: a secondary data analysis. Soc Sci Med. 2017;189:96–104. 32. Joseph C, Garruba M, Melder A. Patient satisfaction of telephone or video interpreter services compared with in-person services: a systematic review. Aust Health Rev. 2018;42(2):168–77. 33. Kushalnagar P, Paludneviciene R, Kushalnagar R.  Video remote interpreting Technology in Health Care: cross-sectional study of deaf Patients' experiences. JMIR Rehabil Assist Technol. 2019;6(1):e13233. 34. Hwang K, De Silva A, Simpson JA, LoGiudice D, Engel L, Gilbert AS, et  al. Video-­ interpreting for cognitive assessments: an intervention study and micro-costing analysis. J Telemed Telecare. 2020;28:1357633X20914445. 35. Kletecka M, Parrag S, Drozdek B, Wenzel T. Language barriers and the role of interpreters: a challenge in the work with migrants and refugees. In: Wenzel T, Drožđek B, editors. An uncertain safety–integrative health care for the 21st century refugees. New York: Springer; 2019. p. 345–61. 36. Gray B, Hilder J, Donaldson H. Why do we not use trained interpreters for all patients with limited English proficiency? Is there a place for using family members? Aust J Prim Health. 2011;17(3):240–9. 37. Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256–62. 38. Lewis-Fernandez R, Aggarwal NK, Baarnhielm S, Rohlof H, Kirmayer LJ, Weiss MG, et al. Culture and psychiatric evaluation: operationalizing cultural formulation for DSM-5. Psychiatry. 2014;77(2):130–54. 39. Aggarwal NK, Nicasio AV, DeSilva R, Boiler M, Lewis-Fernandez R.  Barriers to implementing the DSM-5 cultural formulation interview: a qualitative study. Cult Med Psychiatry. 2013;37(3):505–33. 40. Schmidt A, Schneiders M, Dopfner M, Lehmkuhl G. Disorder attribution in psychiatric problems of adolescents. A pilot study of inventory validation of disorder attribution of psychiatric problems in adolescents. Z Kinder Jugendpsychiatr Psychother. 2003;31(2):111–21. 41. Borra R. Working with the cultural formulation in therapy. Eur Psychiatry. 2008;23(Suppl 1):43–8. 42. Lewis-Fernandez R. The cultural formulation. Transcult Psychiatry. 2009;46(3):379–82. 43. Lewis-Fernandez R, Diaz N. The cultural formulation: a method for assessing cultural factors affecting the clinical encounter. Psychiatry Q. 2002;73(4):271–95. 44. Krause IB.  Sinking heart: a Punjabi communication of distress. Soc Sci Med. 1989;29(4):563–75.

Transcultural and Cultural Aspects of Sport Psychiatry

45

45. Baarnhielm S. The meaning of pain: a cultural formulation of a Syrian woman in Sweden. Transcult Psychiatry. 2012;49(1):105–20. 46. Garcia RD.  Interpretation for patients with conversion disorders. Rev Psicoanal. 1957;14(1–2):47–52. discussion−4 47. Biran S.  The mechanism of the neurotic conversion process. Acta Psychother Psychosom Orthopaedagog. 1955;3(3):219–25. 48. Chertok L. Hysteria, hypnosis, psychopathology. History and prospective. Ann Med Psychol (Paris). 1974;2(5):695–709. 49. Cramer B.  Changes in the investment of the body: conversion symptoms during puberty. Psychiatr Enfant. 1977;20(1):11–127. 50. Dawes LG. The psychoanalysis of a case of grand hysteria of Charcot in a girl of fifteen. Nerv Child. 1953;10(2):272–305. 51. Kirmayer LJ, Young A. Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosom Med. 1998;60(4):420–30. 52. Caplan S, Alvidrez J, Paris M, Escobar JI, Dixon JK, Desai MM, et  al. Subjective versus objective: an exploratory analysis of latino primary care patients with self-perceived depression who do not fulfill primary care evaluation of mental disorders patient health questionnaire criteria for depression. Prim Care Companion J Clin Psychiatry. 2010;12(5) 53. Earl TR, Fortuna LR, Gao S, Williams DR, Neighbors H, Takeuchi D, et  al. An exploration of how psychotic-like symptoms are experienced, endorsed, and understood from the National Latino and Asian American study and National Survey of American life. Ethn Health. 2015;20(3):273–92. 54. Ginzburg SL, Lemon SC, Rosal M. Neighborhood characteristics and ataque de nervios: the role of neighborhood violence. Transcult Psychiatry. 2020;1363461520935674:438. 55. Lewis-Fernandez R, Gorritz M, Raggio GA, Pelaez C, Chen H, Guarnaccia PJ. Association of trauma-related disorders and dissociation with four idioms of distress among Latino psychiatric outpatients. Cult Med Psychiatry. 2010;34(2):219–43. 56. Stein MJ. Blood, sweat, and/or tears: comparing Nervios symptom descriptions in Honduras. Cult Med Psychiatry. 2019;43(2):256–76. 57. Aggarwal NK, Jarvis GE, Gomez-Carrillo A, Kirmayer LJ, Lewis-Fernandez R. The cultural formulation interview since DSM-5: prospects for training, research, and clinical practice. Transcult Psychiatry. 2020;57(4):496–514. 58. Shariati B, Keshavarz-Akhlaghi AA, Mohammadzadeh A, Seddigh R. The content validity of the cultural formulation interview (CFI). Psychiatry J. 2018;2018:3082823. 59. Lewis-Fernandez R, Aggarwal NK, Kirmayer LJ.  The cultural formulation interview: Progress to date and future directions. Transcult Psychiatry. 2020;57(4):487–96. 60. Owiti JA, Ajaz A, Ascoli M, de Jongh B, Palinski A, Bhui KS. Cultural consultation as a model for training multidisciplinary mental healthcare professionals in cultural competence skills: preliminary results. J Psychiatr Ment Health Nurs. 2014;21(9):814–26. 61. Levine RE, Gaw AC. Culture-bound syndromes. Psychiatr Clin North Am. 1995;18(3):523–36. 62. Prince R, Tcheng-Laroche F. Culture-bound syndromes and international disease classifications. Cult Med Psychiatry. 1987;11(1):3–52. 63. Littlewood R.  The migration of culture-bound syndromes. Int J Soc Psychiatry. 1985;31(2):156–9. 64. Ventriglio A, Ayonrinde O, Bhugra D.  Relevance of culture-bound syndromes in the 21st century. Psychiatry Clin Neurosci. 2016;70(1):3–6. 65. Pagani E, Santos JFL, Rodrigues E. Culture-bound syndromes of a Brazilian Amazon riverine population: tentative correspondence between traditional and conventional medicine terms and possible ethnopharmacological implications. J Ethnopharmacol. 2017;203:80–9. 66. Fabian K, Fannoh J, Washington GG, Geninyan WB, Nyachienga B, Cyrus G, et  al. “My heart die in me”: idioms of distress and the development of a screening tool for mental suffering in Southeast Liberia. Cult Med Psychiatry. 2018;42(3):684–703.

46

T. Wenzel et al.

67. Dura-Vila G, Hodes M.  Cross-cultural study of idioms of distress among Spanish nationals and Hispanic American migrants: susto, nervios and ataque de nervios. Soc Psychiatry Psychiatr Epidemiol. 2012;47(10):1627–37. 68. Nichter M. Idioms of distress revisited. Cult Med Psychiatry. 2010;34(2):401–16. 69. Olfson M, Lewis-Fernandez R, Weissman MM, Feder A, Gameroff MJ, Pilowsky D, et  al. Psychotic symptoms in an urban general medicine practice. Am J Psychiatry. 2002;159(8):1412–9. 70. Otake Y, Tamming T.  Sociality and temporality in  local experiences of distress and healing: ethnographic research in northern Rwanda. Transcult Psychiatry. 2020;58:1363461520949670. 71. Palinkas LA, Petterson JS, Russell JC, Downs MA. Ethnic differences in symptoms of post-­ traumatic stress after the Exxon Valdez oil spill. Prehosp Disaster Med. 2004;19(1):102–12. 72. Parsons CD, Wakeley P. Idioms of distress: somatic responses to distress in everyday life. Cult Med Psychiatry. 1991;15(1):111–32. 73. Desai G, Chaturvedi SK. Idioms of distress. J Neurosci Rural Pract. 2017;8(Suppl 1):S94–S7. 74. Catonne JP. Hippocratic concept of hysteria. Ann Med Psychol (Paris). 1992;150(10):705–19. 75. Auxéméry. From hystero-epilepsy to psychogenic nonepileptic seizures: Continuity or discontinuity? Annales Médico-psychologiques. 2012;170(9):609–14. 76. Gibson K, Haslam N, Kaplan I.  Distressing encounters in the context of climate change: idioms of distress, determinants, and responses to distress in Tuvalu. Transcult Psychiatry. 2019;56(4):667–96. 77. Mirzaei SPB, Wenzel T. Localizing a metabolic focus during a functional seizure with fluorodeoxyglucose positron emission tomography-computed tomography. World. J Nucl Med. 2020;61:18N. 78. Meel BL.  HIV/AIDS and traditional healers: a blessing in disguise. Med Sci Law. 2010;50(3):154–5. 79. Jha V, Chugh KS. Nephropathy associated with animal, plant, and chemical toxins in the tropics. Semin Nephrol. 2003;23(1):49–65. 80. Luyckx VA, Ballantine R, Claeys M, Cuyckens F, Van den Heuvel H, Cimanga RK, et al. Herbal remedy-associated acute renal failure secondary to cape aloes. Am J Kidney Dis. 2002;39(3):E13. 81. Musa AA, Ogun SA, Agboola AO, Shonubi AM, Banjo AA, Akindipe JA. Surgical complications from local herbal practitioners: report of five cases. East Afr Med J. 2007;84(5):240–5. 82. Chan KH, Hsu MC, Chen FA, Hsu KF. Elimination of ephedrines in urine following administration of a Sho-seiryu-to preparation. J Anal Toxicol. 2009;33(3):162–6. 83. He Y, Wang J, Wang M, Zhang J. Discrimination of wild and domestic deer musk using isotope ratio mass spectrometry. J Mass Spectrom. 2018;53(11):1078–85. 84. Lv Y, Zhao P, Pang K, Ma Y, Huang H, Zhou T, et al. Antidiabetic Effect of a Flavonoid-­ Rich Extract from Sophora alopecuroides L. in HFD- and STZ- Induced Diabetic Mice through PKC/GLUT4 Pathway and Regulating PPARalpha and PPARgamma expression. J Ethnopharmacol. 2020:268 113654. 85. Okano M, Sato M, Kageyama S.  Determination of higenamine and coclaurine levels in human urine after the administration of a throat lozenge containing Nandina domestica fruit. Drug Test Anal. 2017;9(11–12):1788–93. 86. Fallace P, Aiese P, Bianco E, Bolognini I, Costa MP, Esposito R, et al. Peer education strategies for promoting prevention of doping in different populations. Ann Ig. 2019;31(6):556–75. 87. Hinton DE, Jalal B.  Transdiagnostic multiplex CBT for Muslim cultural groups: treating emotional disorders. Cambridge; New York, NY: Cambridge University Press; 2020. 88. Wenzel T, Griengl H, Stompe T, Mirzaei S, Kieffer W. Psychological disorders in survivors of torture: exhaustion, impairment and depression. Psychopathology. 2000;33(6):292–6. 89. Carinci AJ, Mehta P, Christo PJ. Chronic pain in torture victims. Curr Pain Headache Rep. 2010;14(2):73–9.

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90. Liedl A, Knaevelsrud C. Chronic pain and PTSD: the perpetual avoidance model and its treatment implications. Torture. 2008;18(2):69–76. 91. Perera P. Physical methods of torture and their sequelae: a Sri Lankan perspective. J Forensic Legal Med. 2007;14(3):146–50. 92. Norredam M, Crosby S, Munarriz R, Piwowarczyk L, Grodin M. Urologic complications of sexual trauma among male survivors of torture. Urology. 2005;65(1):28–32. 93. Thomsen AB, Eriksen J, Smidt-Nielsen K. Chronic pain in torture survivors. Forensic Sci Int. 2000;108(3):155–63. 94. Sonneborn L. Murder at the 1972 Olympics in Munich. 1st ed. New York: Rosen Pub. Group; 2003. p. 64. 95. Krüger A, Murray WJ. The Nazi Olympics: sport, politics, and appeasement in the 1930s. Urbana: University of Illinois Press; 2003. 96. Barry JP.  The Berlin Olympics, 1936: black American athletes counter Nazi propaganda. New York: F. Watts; 1975. p. 85. 97. Shackleton C. Steroid analysis and doping control 1960-1980: scientific developments and personal anecdotes. Steroids. 2009;74(3):288–95. 98. Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government. Clin Chem. 1997;43(7):1262–79. 99. Tuffs A. Doped east German athletes to receive compensation. BMJ. 2002;324(7353):1544. 100. Gerrard D. Drug misuse in sport: a historical perspective. N Z Med J. 2015;128(1426):16–8. 101. Doping in East Germany. Drugs as a geopolitical tool. Prescrire Int. 2016;25(175):251. 102. Sobolevsky T, Krotov G, Dikunets M, Nikitina M, Mochalova E, Rodchenkov G.  Anti-­ doping analyses at the Sochi Olympic and Paralympic games 2014. Drug Test Anal. 2014;6(11–12):1087–101. 103. Vlad RA, Hancu G, Popescu GC, Lungu IA. Doping in sports, a never-ending story? Adv Pharm Bull. 2018;8(4):529–34. 104. Pope HG Jr, Katz DL. Psychiatric and medical effects of anabolic-androgenic steroid use. A controlled study of 160 athletes. Arch Gen Psychiatry. 1994;51(5):375–82. 105. Bird SR, Goebel C, Burke LM, Greaves RF. Doping in sport and exercise: anabolic, ergogenic, health and clinical issues. Ann Clin Biochem. 2016;53(Pt 2):196–221. 106. Frenkel J, Bemelman FJ, Potter van Loon BJ, Simon A. Familial Mediterranean fever: not to be missed. Ned Tijdschr Geneeskd. 2013;157(18):A5784. 107. Ebrahimi-Fakhari D, Schonland SO, Hegenbart U, Lohse P, Beimler J, Wahlster L, et  al. Familial Mediterranean fever in Germany: clinical presentation and amyloidosis risk. Scand J Rheumatol. 2013;42(1):52–8. 108. Mathew J, Mathew T, Kannan R, Satheesh S, Sundararaman T, Sethuraman KR. Unexpected presentations–four cases of lead poisoning. J Assoc Physicians India. 2002;50:1172–5. 109. Dunbabin DW, Tallis GA, Popplewell PY, Lee RA. Lead poisoning from Indian herbal medicine (Ayurveda). Med J Aust. 1992;157(11–12):835–6. 110. Abdullah MA.  Lead poisoning among children in Saudi Arabia. J Trop Med Hyg. 1984;87(2):67–70. 111. Beritic T. Lead neuropathy. Crit Rev Toxicol. 1984;12(2):149–213. 112. Linden MA, Manton WI, Stewart RM, Thal ER, Feit H. Lead poisoning from retained bullets. Pathogenesis, diagnosis, and management. Ann Surg. 1982;195(3):305–13. 113. Relling MV. Polymorphic drug metabolism. Clin Pharm. 1989;8(12):852–63. 114. Kalow W. Ethnic differences in reactions to drugs and xenobiotics. Caffeine and other drugs. Prog Clin Biol Res. 1986;214:331–41. 115. Omenn GS. Ethnic differences in reactions to drugs and xenobiotics. Susceptibility to occupational and environmental exposures to chemicals. Prog Clin Biol Res. 1986;214:527–45. 116. Kalow W. Ethnic differences in drug metabolism. Clin Pharmacokinet. 1982;7(5):373–400. 117. McCarthy DM, Pedersen SL, Lobos EA, Todd RD, Wall TL.  ADH1B*3 and response to alcohol in African-Americans. Alcohol Clin Exp Res. 2010;34(7):1274–81.

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118. Segal B. ADH and ALDH polymorphisms among Alaska natives entering treatment for alcoholism. Alaska Med. 1999;41(1):9–12, 23. 119. Ehlers CL, Liang T, Gizer IR. ADH and ALDH polymorphisms and alcohol dependence in Mexican and native Americans. Am J Drug Alcohol Abuse. 2012;38(5):389–94. 120. McDuff DR, Morse ED, White RK. Professional and collegiate team assistance programs: services and utilization patterns. Clin Sports Med. 2005;24(4):943–58. x-xi 121. Jacobsson J, Ekberg J, Timpka T, Haggren Rasberg L, Sjoberg M, Mirkovic D, et  al. Developing web-based health guidance for coaches and parents in child athletics (track and field). Scand J Med Sci Sports. 2020;30(7):1248–55. 122. Cox JL. Transcultural psychiatry. London; Dover, N.H: Croom Helm; 1986. p. 337. 123. Winkelman M.  Culture and health: applying medical anthropology, vol. xxv. 1st ed. San Francisco: Jossey-Bass; 2009. p. 480.

Sport and Human Rights Thomas Wenzel and Reem Alksiri

1 Introduction In this chapter, we do not want to cover the history and all relevant areas of sport and human rights we believe to be a crucial but at least partly neglected area of research and teaching in sport sciences. The combined impact of financial interests, political or national interests and ambition has in our opinion created significant risks and possibly the impression that even fundamental human rights can be neglected in the field of sports due to these paramount interests. Some of the relevant aspects such as sexual abuse also have been covered in other chapters of this book, so we will not take them up in this chapter again, which should not be understood as neglect of these important issues. In the context of this chapter, we do not want to take up the related subject of ethics in sport, covered by a number of recent books, while confirming with our argument the need of a stringent set of ethical guidelines and of efficient, fair and fast control mechanisms to provide for their implementation. Human rights violations such as persecution and sexual violence are unfortunately globally the probably most common but also severe adverse factors in public mental health, besides and often in addition to poverty. They have been documented to lead or contribute to a large range of mental health problems such as depression or posttraumatic stress disorder that, in turn, adversely affect all areas of life, including also athletic performance, and, even more importantly, the health and well-being of athletes, spectators and all those involved in sports. The special environment, especially of international and performance sports, also can be seen as conducive to

T. Wenzel (*) · R. Alksiri World Psychiatric Association Scientific Section on Sport and Exercise Psychiatry, Geneva, Switzerland International Organisation of persecuted women, Vienna, Austria © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. Baron et al. (eds.), Sport and Mental Health, https://doi.org/10.1007/978-3-031-36864-6_4

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special challenges in this area, mainly due to the three key factors already mentioned, i.e. economic, political and ambition-related influences. Human rights are usually not a key area covered in sport education or in the training in sport sciences and sport medicine, but we want at this point to draw attention to some key areas, without giving a handbook on all relevant issues. They should be covered in detail and adapted to the respective field and situation by an Table 1  Relevant areas and examples in the sports field Examples for relevant situations Instrumentalization of sports by The Munich Olympic games in 1936 (by the NS ideology) and politics 1972 (by political terror groups) Political reorientation of sports organizations (e.g. “Nationalsozialistischer Reichsbund für Leibesübungen” replacing the former German Olympic board) Athletes as victims of Persecution of women athletes and sport spectators in persecution and severe human Afghanistan and other countriesa, athletes taken “hostage” in rights violations, in the context political conflicts of sports Athletes as victims of Cruel punishment against UN standards (execution) of Iranian persecution and severe human athlete Navid Afkari after a trial seen as unfair and, reportedly, rights violations in general tortureb Human rights of the young Doping reportedly forced on young athletes in the former East athlete Germany (DDR) and other countries without free and informed consent [1, 2] Racism in sports Multifaceted major problem, including inter alia: Spectators and fans verbally attacking athletes from different ethnic groups or migration background in soccer (“monkey” calls) “everyday” racist behaviour in multiethnic teams Sexual violence, discrimination Possible Peng Shuai case in China, IOC criticized for and abuse insufficient investigation long-term abuse of young female athletes by team doctors in the United States without sufficient early intervention and investigation inclusion of disabled persons [3] Right to privacy and other Possible violation by urinary sample collection especially in human rights—Also for female minor athletes athletes? Protection of vulnerable groups LGBT athletes persecuted by family or governments Equality Unequal access to health resources in different groups Kabul Girls Soccer Club, Martha Brady, “Creating Safe Spaces and Building Social Assets for Young Women in the Developing World: A New Role for Sports”, Women’s Studies Quarterly, Vol. 33, Nos. 1/2 (2005), pp. 35–49 b https://www.theguardian.com/world/2020/sep/12/iranian-champion-wrestler-navid-afkari-executed-despite-globaloutcry, accessed 20.7.2023 a

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interdisciplinary team both in curricula and in monitoring and sanctioning probable violations (Table 1).

2 Human Rights: Standards of Relevance Human rights have in themselves a long history that can probably be traced back as far as the Iranian emperor Cyrus the Great1 and have been elaborated to cover a wide range of critical situations, including such issues as sexual identity, right to equal access to health, protection of privacy and others. In the following decades, the importance of the “droits des hommes” outlined in the French revolution and taken up among others by the United States Declaration of Independence and Constitution has inspired further initiatives, such as the development of the humanitarian law in the Geneva Conventions. It should be considered that human rights definitions are enshrined in different types of documents, which are binding to state and other parties to a different degree, might require in some cases ratification and signatures by countries and are implemented to different monitoring and sanctioning authorities by the United Nations (UN), international organizations and national laws and institutions. Still, fundamental “key” human rights that are the background to all further statements, conventions and treatises are usually generally accepted and, following the concept of “natural law”, considered binding under all circumstances and by all parties without contractual signatures. We want to refer to the milestone, the UN Universal Declaration of Human Rights, in this context and quote the key articles that should also guide any discussion on human rights in sports, sports and sport sciences in general2.

2.1 Article 1 All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood.

 As preserved in the famous “Cylinder“record, see John Curtis, The Cyrus Cylinder and Ancient Persia, A New Beginning For the Middle East, British Museum Press, London, 2013. 2  https://www.un.org/en/about-us/universal-declaration-of-human-rightshttps://www.un.org/en/ about-us/universal-declaration-of-human-rights, accessed 2.07.2021 1

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2.2 Article 2 Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty.

2.3 Article 3 Everyone has the right to life, liberty and security of person. The basic concepts of the UNHR have been confirmed and elaborated by a number of further specific and regional standards, including, for example, the EU, with corresponding implementation strategies such as the UN committees and special rapporteurs, the European Court for Human Rights, the EU Anti-torture Committee or the Inter-American Court. They might be seen as frequently still insufficient, for example, in the influence of powerful political “players” in the composition and actions of the UN Security Council or the limitations given by the International Criminal Court (ICC) “Rome” Statute. If National Mechanisms Are Not Sufficient and in Addition to or in Place of Implementation Mechanisms to Ensure Sport Principles and Human Rights in the National or Global Professional Umbrella Organizations in Sports and Health Care, International Courts or Mechanisms like Universal Jurisdiction Might Be Considered. Also, Athletes Might in Conflict Situations Be Taken “Hostage” with Allegations or Unfair Trials Suspected, Potentially Reflecting Political “Poker” Games. It should be noted in this context that in present understanding, human rights can be separated in “derogable” human rights, i.e. those that can be suspended under very specific circumstances (but only if no other means are available, with good and public reasoning and in limited time frames, e.g. see the pandemic’s restrictions), and “non-derogable” ones, such as the prohibition against torture, that cannot be suspended under any circumstances or with any excuse, such as national emergencies. Suspension of any human rights in sport can in this context hardly be by any of the necessary justifications listed above. A critical point is the actual implementation to make human rights a reliable everyday practice. This includes both prevention and sanctioning/redress mechanisms. Raising of awareness of the importance and concrete application to different situations in all groups must be supported by embedding in local and national legislation and in professional ethical standards, as in sports and health sciences, but also in all teaching and curricula. Strategies to provide monitoring and sanctioning for

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violations must be developed, as noted before, including, for example, the International Criminal Court (ICC), in spite of their sometimes limited reach, as, for example, in the limitations given by the Rome Statute. Medical ethics and the concept of fair behaviour in sports must also be monitored, and adequate sanctioning mechanisms for transgressions must be developed and implemented rigorously. While human rights are directly related to professional and especially medical ethics and the protection of human rights is a cornerstone of healthcare ethics, both fields can be seen as complex. In this chapter, we want to focus primarily, though not exclusively, on human rights in the context of sports. The origin of both sport and medical ethics are usually seen in the context of oaths originating in ancient Greece, the Olympic Oath, adapted by the modern Olympic Games at the 1920 Olympic Games in Antwerp (but not by all sport events), and the Hippocratic oath, adopted in adapted versions by medical schools that could be seen as confirming again the importance of related principles for athletes and health professionals. It could, for example, be argued that the paragraph in the original Hippocratic oath stating that “Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so.” might well speak against doping at least in spirit, if doping is seen as a form of poisoning as it carries significant risks without benefit but rather adverse to health, and in the Olympic Oath “commit ourselves to sport without doping”. The Olympic Oath is taken for all involved professionals and is phrased: We promise to take part in these Olympic Games, respecting and abiding by the rules and in the spirit of fair play, inclusion and equality. Together we stand in solidarity and commit ourselves to sport without doping, without cheating, without any form of discrimination. We do this for the honour of our teams, in respect for the Fundamental Principles of Olympism, and to make the world a better place through sport.3

Besides prohibition of certain practices, the oath underlines an active role of the spirit of fair sports in the improvement of all societies, as does the Universal Declaration of Human Rights and related standards. Inclusion, equality and prohibition of discrimination are clearly also concepts in the above more general human rights standards. This was historically confirmed by Avery Brundage in 1936, stating (according to the US Holocaust memorial4) in the context of the already mentioned NS games that. The very foundation of the modern Olympic revival will be undermined if individual countries are allowed to restrict participation by reason of class, creed, or race.

Unfortunately, he later accepted the avoidance of a boycott or sanctions, based on “cursory” inspection, and according to the US Holocaust Memorial Holocaust Encyclopedia, even Brundage alleged the existence of a “Jewish-Communist conspiracy” to keep the United States out of the Games, opposing supporters of  As cited in the Olympic Games website https://olympics.com/ioc/faq/games-ceremonies-and-­ protocol/what-is-the-olympic-oath (Accessed 11.7.2021) 4  https://encyclopedia.ushmm.org/content/en/article/the-movement-to-boycott-the-berlin-olympics-of-1936 3

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boycotts such as Judge Jeremiah Mahoney, president of the Amateur Athletic Union.5 This discussion appears to be ongoing today with nearly the same argument. The positive impact of sport ethics to improve the world [4] and consequently, as can be assumed, psychological health and well-being has been demonstrated by a number of positive examples and especially in the development of a sense of self-­ worth, confidence and identify in persecuted and disadvantaged groups such as small countries, ethnic minorities and gender. The subject has been taken up, for example, in recent books by Barbara Kays and other authors [5, 6], to which we want to refer instead of a more comprehensive discussion of this aspect. The potentially positive role of “sports diplomacy” as discussed recently by Esherick [7] can also be seen in this context.

3 Case Example A 40-year-old successful athlete, female member of the LGBT community, was repeatedly threatened by persecution and possible execution in a near-east country, attacked on the street by unnamed security forces and discriminated, with persecutors insulting her for her sexual orientation. She developed periods of depression and symptoms of PTSD and consequently fled the country to go into exile. Asylum was first refused but then granted on appeal in Europe. In contact with a sports psychiatrist, medication was given to improve sleep disturbance and nightmares, and psychotherapy sessions were prescribed. The disillusion with the resulting concept of fair sports and reduced feeling of self-worth were major subjects covered in these sessions. International and national coordinated efforts and maybe further actions in courts including international courts and Universal jurisdiction will be necessary to improve this situation in the face of massive economic and political factors supporting many forms of abuse. This is again under discussion in regard to the recent soccer world cup in Qatar, where strong indicators of the abuse of human rights were reported already in the discussion of granting the location,6 and the discussion is ongoing at the time of writing this chapter [8], as also in the case of the treatment of religious and ethnic minorities in China. The discussion of possible remedies and interventions is complex and should well consider the impact of the neglect of addressing and preventing abuses. This negative impact not only extends to the credibility of sports, and on democratic and human rights principles and societies at large, but also on the individual athletes affected either by persecution and abuses or conflicts caused by their indirect involvement in abuses as representation figures for autocratic and

 As footnote 6, both accessed 5.12.2022  https://www.equidem.org/assets/downloads/Equidem_Qatar_World_Cup_Stadiums_Report_ Final.pdf 5 6

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dictatorial regimes. In this context, newspaper reports have even drawn attention to the dangers for journalists and spectators arising in this context. At a minimum, this is a task for international sport umbrella organizations, such as the IOC or FIFA. Measures might include boycotts and a refusal by athletes and country organizations, but this measures must be considered with care depending on the case, as they can also be in turn politicized, necessary as they might be, and long-term strategies must be considered. Setting also positive examples, IOC has also established a special refugee competition unit, Refugee Olympic Team (ROT), used, for example, by the Syrian swimmer Yusra Mardini.7 In a recent editorial in the respected “Lancet”, the authors of the article summarize: “Human rights abuses against LGBTQ+ people and migrant workers are global health issues, not just Qatari ones. The legacy of the 2022 World Cup for health can still be shaped. Not least, the World Cup is an opportunity to contemplate social responsibility, and for sporting organizations, global health institutions, medical journals, and any associations planning global events to reflect on the countries they partner with and question the implications for health. It is not just about what takes place on the pitch” [9].

The editor also drew attention to the fact that promises for benefits, such as positive benefits for health, have usually not been fulfilled in such situations.

4 Possible Interventions As noted, all those individuals and organizations involved in sports, from athletes, caregivers, sports psychiatrists, stakeholders, umbrella organizations, law makers to courts, are challenged to fight the recent increase in human rights violations in sports and should use all legitimate tools at their disposal. Boycotts have, as noted, been repeatedly discussed or implemented in sport history, not for the first time in the above example of the NS Olympic Games, and most recently in regard to the Chinese Olympics in regard to severe human rights abuses as noted by the UN high commissioner on human rights in East Turkestan and against ethnic and religious minorities. The pros and cons must be carefully weighted in each case, and different sports organizations have taken different positions. The personal courage in setting signals, as the initial refusal of the Iranian team soccer players to sing the national anthem in the compromised games in Qatar8 in order to support protests against severe human rights violations in their country,

 ”The inspirational Olympic journey of refugee swimmer Yusra Mardini”. Olympic.org. Olympic Games (Retrieved 20 April 2016) 8  https://www.theguardian.com/football/2022/nov/25/iran-players-sing-national-anthem-worldcup-end-silent-protest-qatar 7

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gives a good example, and the protection and support for this courageous teams and individuals should be ensured by all parties active in the sports field.

5 Giving Asylum Granting asylum in third countries might be one of the useful tools, but as an important “last hope” intervention, as protection of human rights and human rights defenders should be effective at an earlier stage in the process.

6 Role of the Multidisciplinary Team The role of the multidisciplinary team is of special importance of this subject. Critical situations and actual instances of human rights violations must be recognized and addressed by all professionals and team members and lead to integrate well-considered action of that team. Lawyers might help to identify and classify violations in the context of ethics and national and international laws and provide references to relevant standards, as well as support victims and witnesses legally. Coaches and trainers should be aware of risks and participate actively in prevention,

Table 2  Roles of the different professions to support human rights Athletes

Coaches, trainers

Family members and other caregivers Psychiatrists and other healthcare professionals Sport officials and managers

Law makers and politicians

Stand firm on human rights, both locally and in international competitions, refuse to participate in compromised settings, report abuses and support victims, be solidaric Support human rights in all above aspects, include human rights education in trainings, help victims, report abuses and support and advise athletes in conflicts of consciousness, help to develop strategies to counter compromising situations such as competition in dictatorships and abuse of sports for political gains of autocratic regimes Support athletes and take a firm position against human rights abuses

Educate on the adverse impact of violence and different forms of human rights violations, support victims and document and report abuses Support a team/corporate identity demonstrating respect for human rights, appoint a human rights “guardian” (lawyer?) for the team/organizations, take a firm stance against compromising situations, take measures to stop corruptions that are conducive to abuses, protect whistleblowers Support human rights standards and their defenders especially in sport, independent from “national” or financial interests

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identification of cases and early intervention and teach human rights in sports in any curriculum and make sure they are understood and followed by all involved parties. And, speaking with a motto of a recent major World Psychiatric Association conference, “there is no mental health without human rights”, also, but especially in sports and in the care of athletes (Table 2).

7 Summary and What to “Take Home” Human rights cannot be suspended but should receive special consideration in sports, independent from financial and nationalistic interests, and are a prerequisite also to health and especially mental health. Sports should be a safe area, from the grassroots sports to international competitions, and all active in sports should educate athletes, protect victims and support human rights to keep the Olympic spirit and fairness in sports and society alive. New Centres  https://www.sporthumanrights.org/

References 1. Doping in East Germany. Drugs as a geopolitical tool. Prescrire Int. 2016;25(175):251. 2. Tuffs A. Doped east German athletes to receive compensation. BMJ. 2002;324(7353):1544. 3. Al-Harahsheh ST, Swart K, Neves J, Shaban S. Inclusion of persons with disability in sport: part 1–rights and challenges in Qatar. Br J Sports Med. 2022;56(22):1257–8. 4. Collison-Randall H, Darnell SC, Giulianotti R, Howe PD. Routledge handbook of sport for development and peace. Abingdon, Oxon: New York, NY: Routledge; 2019. 5. Keys BJ. The ideals of global sport: from peace to human rights, vol. vi. 1st. ed. Philadelphia: PENN, University of Pennsylvania Press; 2019. p. 237. 6. Collison H, Darnell SC, Giulianotti R, Howe PD. Routledge handbook of sport for development and peace. Abingdon, Oxon: New York, NY: Routledge; 2019. 7. Esherick C. Case studies in sport diplomacy. 1st. Morgantown, WV: FiT Publishing., a division of the International Center for Performance Excellence; 2017. x, 219 8. O'Rourke A, Theodoraki E.  The FIFA world cup Qatar 2022 sustainability strategy: human rights governance in the tripartite network. Front Sports Act Living. 2022;4:809984. 9. Editorial. Will the Qatar world cup be good for health? Lancet. 2022;440(10365):1741.

Further Reading Keys BJ.  The ideals of global sport: from peace to human rights, vol. vi. 1st ed. Philadelphia: PENN, University of Pennsylvania Press; 2019. p. 237. Collison-Randall H, Darnell SC, Giulianotti R, Howe PD. Routledge handbook of sport for development and peace. Abingdon, Oxon: New York, NY: Routledge; 2019. Giulianotti R, McArdle D. Sport, civil liberties and human rights, vol. viii. London; New York: Routledge; 2006. p. 224.

Sleep and Sleep Disorders in Elite Athletes C. A. Mikutta, A. Wyssen, and T. J. Müller

1 Overview 1.1 Introduction The importance of sleep is underlined by the observation that humans and other mammals spend about one third of their lives asleep. Numerous studies have centred on potential functions of sleep for the brain, such as synaptic downscaling [1], metabolic clearance [2] and overall mental health [3]. Other, but fewer studies point to potential relevance of sleep for peripheral organs, such as cardiovascular regulation [4, 5]. In general, sleep is considered to have the main functions (3 Rs): (A) rest [6], (B) reparation [7] and (C) reorganisation [8]. Recent increase of research concerning sleep in athletes shows an increasing interest in this field [9]. Yet despite this obvious evidence of the importance of sleep for athletic performance, a recent review found that there is a high prevalence of poor sleep quality and lack of total sleep time in elite athletes [10]. C. A. Mikutta (*) Translational Research Center, University Hospital of Psychiatry, University of Bern, Bern, Switzerland Private Clinic Meiringen, Schattenhalb, Switzerland Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK A. Wyssen Translational Research Center, University Hospital of Psychiatry, University of Bern, Bern, Switzerland T. J. Müller Translational Research Center, University Hospital of Psychiatry, University of Bern, Bern, Switzerland Private Clinic Meiringen, Schattenhalb, Switzerland © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. Baron et al. (eds.), Sport and Mental Health, https://doi.org/10.1007/978-3-031-36864-6_5

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1.2 Causes of Altered Sleep Quality in Elite Athletes A sleep amount of less than 7 h is defined as insufficient [6]. Through a vast majority of sports disciplines, athletes get frequently less than these recommended 7 h of sleep [11]. Mean sleep time in Olympic athletes was reported between 6.5 and 6.8 h [11]. Also 50% of collegiate athletes report a sleep time less than 7 h. Besides sleep time, quality of sleep is often impaired with a lower sleep efficiency and a prolonged sleep latency. In a recent survey, 42% of collegiate athletes reported poor sleep quality. Further, about 50% of the same athletes showed daytime sleepiness [12]. In a similar study from Europe, one of four professional hockey players reported a lowered sleep quality [13]. Quantity and quality of sleep may be altered due to increased psychological stress, increased muscle pain/tension and increased core temperature following competition and training [14]. This is especially true during high-intensity training periods and the night before competition [15]. Further, major negative influences on sleep quality are large increases in training load and exposure to hypoxia [16, 17]. Circadian dysregulation (misalignment between the individual’s sleep–wake pattern and the desired pattern) is common in elite athletes. Please note that morning (7–10  a.m.) and evening exercise (after 7  p.m.) might cause a phase shift in the melatonin response equivalent to light exposure and therefore alter sleep quality essentially [18]. In this regard, traveling through time zones is another crucial factor that alters melatonin patterns and might cause a jet lag [19]. Especially crossing time zones from west to east seems to have negative effects on sleep quality and therefore on performance. Yet another important factor might be the increased use of smartphones (the blue light of the screen causes melatonin secretion) and the use of (and obligation to use) social media [20]. Also non-organic insomnia as defined by the cardinal symptoms of difficulty initiating or maintaining sleep (despite adequate opportunity to sleep) and/or non-­ restorative (unrefreshing) sleep, together with impaired daytime functioning, is common in elite athletes. Recent evidence suggests that over 60% of Olympic athletes reported symptoms of insomnia [21]. Further, it should be considered that insomnia is an independent risk factor for developing a depression [22]. Sleep in heights (>2500 m) is disturbed in nearly everybody. Although the sleep architecture (rapid eye movement sleep, deep sleep) is nearly the same as at sea levels, the main factor deteriorating sleep is respiratory arousals. Without proper acclimatisation, a rapid accent and overnight stay in greater heights (>2500 metres) might bear the danger of developing acute mountain sickness [23]. Main symptoms are headache, fatigue, dizziness and anorexia and sleeping problems. A further complication is the high-altitude pulmonary oedema (HAPE), most often occurring in the second night in higher altitudes. Main symptoms are decreased exercise performance, increased recovery time, dry cough and dyspnoea especially during the night. Please note that HAPE often develops during the night and disables the patients’ moving capabilities in the morning. As a serious complication, a high-altitude cerebral oedema (HACE) [24] might occur as well.

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The main therapy of all three syndromes is an immediate descent [25]. For further details, please refer to Auerbach’s Wilderness Medicine [26]. Further, organic sleep disorders like sleep apnoea (periodic reduction of breathing during sleep) might also occur in athletes with given risk factors like obesity (e.g. some positions in American football and rugby, wrestling, sumo wrestling) [27]. If not properly diagnosed, sleep apnoea causes severe impairments of athletic performance.

1.3 Psychiatric Diagnoses Causing Altered Sleep Quality Disturbances in sleep are common in nearly all psychiatric disorders [28]. There is no clear epidemiological data for the most common psychiatric diagnoses in elite athletes [10]. However, there is no evidence indicating that those diagnoses are less common in elite athletes than in the average population. Therefore, it is essential to rule out psychiatric disorders if severe sleep problems occur. Especially disorders with high prevalence, e.g. depressive disorder, should be regularly checked for using both an interview with a sports psychiatrist and proper instruments like the Baron Depression Screener for Athletes (BDSA). Also anxiety disorders might cause impaired sleep, especially problems with initiating sleep. Another important psychiatric diagnosis concerning sleep problems is substance addiction. Most of the common drugs, including alcohol, alter sleep architecture and therefore might cause sleep problems. Evidence points out that alcohol consumption is as well a problem in elite athletes [29]. Please note that also substances that are frequently used for doping may cause severe sleeping problems (e.g. steroids, diuretics) [30].

1.4 Consequences of Sleep Deprivation in Elite Athletes Poor sleep quality and sleep deprivation may lead to altered hormonal (growth hormone, cortisol) and glucose metabolism [31]; increased pro-inflammatory cytokines, thereby impairing immune system functioning [32]; altered cardiovascular and autonomous regulation (imitating overtraining symptoms) [33]; disturbed cognitive functions including impaired decision making [34]; and, as a consequence, poor athletic performance. Furthermore, poor sleep is associated with an increased risk of injuries [35].

1.5 Diagnostic Instruments for Monitoring Sleep A routine somatic history, psychiatric history, sleep history, blood test and a thorough body check-up should always be included.

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An additional way to monitor sleep is through diaries and questionnaires. In general, the Pittsburgh Sleep Quality Index (PSQI) [36] is a widely used instrument. Further, there are two instruments specifically designed to monitor athletes: (A) the Athlete Sleep Screening Questionnaire (ASSQ) [37] including the total sleep time, insomnia, sleep quality, chronotype, sleep-disordered breathing and travel disturbances, trying to indicate sleep disorders, and B) the Athlete Sleep Behavior Questionnaire (ASBQ) [38], which is designed to identify maladaptive sleep behaviour. An uncomplicated method to measure sleep is actigraphy, which is based on a wristwatch-like device monitoring movement. This device can be used to measure inter alia total sleep time, number of wake periods, sleep latency and bed and wake time. Actigraphy is a well-assessed and practical method to assess sleep. Actigraphy is especially preferable if alteration of the circadian rhythm is suspected. If a circadian rhythm problem is suspected, specific questionnaires like the Munich Chronotype Questionnaire [39] and specific tests like the dim light melatonin onset should be administered. The gold standard to asses sleep is the polysomnography (PSG). Electrodes are used to monitor brain activity (electroencephalogram), eye movements and muscle and cardiac activity. PSG is the main method to diagnose and evaluate treatment of sleep disorders. PSG should be used if there is a clear suspicion of a sleep disorder. PSG should be routinely administered if a somatic cause of the insomnia is suspected. Figure 1 depicts the diagnostic algorithm for impaired sleep.

Fig. 1  Algorithm of diagnostic steps in athletes with sleep problems (Adapted from Riemann et al. (DGPPN S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen [DGPPN S3 Guideline Non-­ restorative sleep/sleep disorders]) [40])

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2 Sleep Hygiene Teaching sleep hygiene helps athletes to practice behaviours that facilitate sleep. Sleep hygiene has proven to be a powerful tool to improve sleep quality within individual and team athletes. Intensive sleep hygiene teaching should be done by trained (sports) psychologists or sports psychiatrists. However, basic sleep hygiene should also be implemented by coaches/trainers. As a valid source for coaches/ trainers, we recommend Why We Sleep by Matthew Walker [41]. Table  1 summarises Matthew Walker’s top 12 tips for sleep hygiene.

2.1 Psychotherapy Following current European and American practice guidelines for adult patients, cognitive behavioural therapy for insomnia (CBT-I) is the first-line treatment [40]. CBT-I is a treatment package including psychoeducation, restriction of time in bed, relaxation and cognitive restructuring. During psychoeducation, information about sleep is provided and common misunderstandings regarding sleep-related behaviour are discussed. The rationale of bedtime restriction is to increase sleep pressure and facilitate sleep onset and sleep maintenance. Progressive muscle relaxation is typically used for physical relaxation, and imagination exercises facilitate mental relaxation. During cognitive therapy, dysfunctional thoughts and attitudes related to sleep are identified and disputed. Table 1  Sleep hygiene tips

1 2 3 4 5 6 7 8 9 10 11 12

Stick to a sleep schedule Exercise is great, but not too late in the day Avoid caffeine and nicotine Avoid alcoholic drinks before bed Avoid large meals and beverages late at night If possible, avoid medicines that delay or disrupt your sleep Do not take naps after 3 p.m. Relax before bed Take a hot bath before bed Dark bedroom, gadget-free bedroom, cool bedroom Have the right sunlight exposure Do not lie in bed awake

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3 Pharmacological Interventions In general, pharmacological inventions for treating sleep problems should always be the second choice. There are three main aims in prescribing sleep-related medication in elite athletes: (A) reduction of arousal, (B) chronobiological issues (e.g. jet lag) and (C) treating habitual bad sleep (insomnia). There is a lack of specific studies with elite athletes focussing on ‘hangover symptoms’ or alterations in athletic performance (endurance, precision, cognitive functions). However, the commonly used drugs are found to be safe for the general population, and with the exception of imidazopyridines and benzodiazepines, users are allowed to participate in car traffic. For (A), mostly benzodiazepines are used. Please note that benzodiazepines have an addiction potential. Further, depending on the half-life time, they might cause a hangover in the morning. Although these medications help falling asleep, they may alter sleep patterns by reducing slow-wave sleep and REM sleep, thereby reducing sleep quality. Imidazopyridines (zolpidem and zopiclone) may be effective alternatives for insomnia disorder. They have less of an impact on next-day physical performance than benzodiazepines [42]. Please note that benzodiazepines as well as imidazopyridines are on the doping list of most precision sports, e.g. golf, and are forbidden in car sports. For (B), there is good evidence using synthetic melatonin [43]. Please note that melatonin supplements in the United States are not FDA regulated. Therefore, they may have variable potency, may have side effects and may contain contaminants, resulting in a positive drug test. In Europe, drug administration-regulated melatonin is available (e.g. Circadin®). For (C), there are several options including benzodiazepines (only short term), sedative antidepressants (SAD) (e.g. trazodone, mirtazapine, trimipramine) or sedative antipsychotics (SAP) (e.g. quetiapine). There is no data for elite athletes for any of these options [44, 45]. Further, all options have severe caveats in elite athletes. As outlined above, benzodiazepines are problematic for long-term use. The SADs trazodone and trimipramine might alter the electric pathway of the heart (QTc time prolongation). The SAD mirtazapine may cause weight gain. SAP quetiapine might alter metabolic functions including blood fat levels and blood sugar and cause weight gain. There is anecdotal evidence that sports psychiatrists tend to use melatonin for treating insomnia as well since it is the best studied agent in elite athletes [43]. In the special case of sleeping problems in high altitude, the main and best treatment is an immediate decent. Since sleeping problems in high altitudes are often caused by high-altitude disease, a causal treatment is the administration of oxygen [23]. Further medical treatment consists of acetazolamide and non-steroidal antiphlogistics. HAPE and HACE are life-threatening conditions with a high mortality rate. In case of HAPE (besides decent and oxygen), Ca antagonists are an evidence-­ based treatment. In case of HACE (besides decent and oxygen), the administration of corticosteroids (oral or i.m.) is a life-saving treatment [46].

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4  Clinical Case: The Importance of Sleep Hygiene An elite climber approaches his sport physician that he feels continuously sleepy during the day since 1 month. Blood test, MR scan and somato-neurological status were in order. The athlete was sent to the sports psychiatrist. In the first step, sleep diaries and the PSQI were administered. Total PSQI score was at 15 (range 1–31). In the interview, it became clear that the young athlete got a new sponsor contract and in parallel was in the process of increasing the training load within his training cycle. Since he still works part-time in an outdoor/climbing store, he had to shift the more intense trainings into the evening. Further, he had to operate several social media formats due to his new sponsor contract. He took care of these liabilities before going to bed using his tabloid. In the first step, sleep hygiene was taught to the athlete. Then he was encouraged to take care of his social media liabilities during the day or in the morning. Further, in close interaction with the trainer, the training schedule was adjusted so that the more intense workouts could take place in the afternoon, whereas stretching and technique training was shifted to the evening. After 2 weeks, the PSQI score went down to 3 and sleepiness during the day vanished almost entirely.

5 Role of Different Disciplines in Providing Integrated Care to the Athlete Stakeholders Sports physician Sports psychiatrist Sports psychologist Trainer/coach

Role Diagnoses/treats somatic causes of sleep problems Diagnoses/treats psychiatric disorders accompanied with sleep problems, sleep monitoring, teaches sleep hygiene Psychotherapy, teaches sleep hygiene, sleep monitoring

Organizes training/competition plan according to sleep hygiene requirements, teaches sleep hygiene League officials Organizes timetable taking into care time shifts, regular resting days and resulting sleep hygiene needs (team) managers Organise media/public appointments, taking sleep hygiene into account Organise hotel with proper bed/noise reduction during night

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6 Text Box • Sleep is an important factor for well-being, mental health and athletic performance. • Elite athletes may need up to 9 h of sleep/night. • Sleep hygiene and psychotherapy may solve the greater part of sleep problems in athletes. • Somatic and psychiatric causes of sleep problems should always be considered. • Above 2500 meters, there is a risk to develop acute mountain sickness with severe impairment of sleep and possible life-threatening symptoms without proper acclimatisation.

7 Summary Sleep with its 3R (rest, reparation and reorganisation) functions is a crucial factor for well-being, mental health and athletic performance. The elite athlete population is facing specific difficulties in maintaining a proper sleep hygiene resulting in a high prevalence of sleep-related problems. These might severely impact athletic performance and increase the risk of injury. A joint effort of different disciplines is needed in order to (A) create an environment (training and competition schedule, media appointments, etc.) where a comprehensive sleep hygiene is possible, (B) keep the entry threshold for psychotherapy deliberately low for informal participation and (C) make a sound psychiatric and somatic diagnostic approach available if a somatic aetiology and/or a psychiatric comorbidity is suspected.

References 1. Tononi G, Cirelli C. Sleep and the price of plasticity: from synaptic and cellular homeostasis to memory consolidation and integration. Neuron. 2014;81(1):12–34. 2. Ding F, O'Donnell J, Xu Q, Kang N, Goldman N, Nedergaard M. Changes in the composition of brain interstitial ions control the sleep-wake cycle. Science. 2016;352(6285):550–5. 3. Baglioni C, Nanovska S, Regen W, Spiegelhalder K, Feige B, Nissen C, et al. Sleep and mental disorders: a meta-analysis of polysomnographic research. Psychol Bull. 2016;142(9):969–90. 4. Penzel T, Kantelhardt JW, Bartsch RP, Riedl M, Kraemer JF, Wessel N, et al. Modulations of heart rate, ECG, and cardio-respiratory coupling observed in polysomnography. Front Physiol. 2016;7:460. 5. Kuo TB, Chen CY, Hsu YC, Yang CC.  EEG beta power and heart rate variability describe the association between cortical and autonomic arousals across sleep. Auton Neurosci. 2016;194:32–7. 6. Consensus Conference P, Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, et al. Joint Consensus statement of the American Academy of sleep medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. J Clin Sleep Med. 2015;11(8):931–52.

Sleep and Sleep Disorders in Elite Athletes

67

7. Xie L, Kang H, Xu Q, Chen MJ, Liao Y, Thiyagarajan M, et al. Sleep drives metabolite clearance from the adult brain. Science. 2013;342(6156):373–7. 8. Mikutta C, Feige B, Maier JG, Hertenstein E, Holz J, Riemann D, et  al. Phase-amplitude coupling of sleep slow oscillatory and spindle activity correlates with overnight memory consolidation. J Sleep Res. 2019;28:e12835. 9. Lastella M, Memon AR, Vincent GE. Global research output on sleep research in athletes from 1966 to 2019: a bibliometric analysis. Clocks Sleep. 2020;2(2):99–119. 10. Reardon CL, Hainline B, Aron CM, Baron D, Baum AL, Bindra A, et  al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). Br J Sports Med. 2019;53(11):667–99. 11. Lastella M, Roach GD, Halson SL, Sargent C. Sleep/wake behaviours of elite athletes from individual and team sports. Eur J Sport Sci. 2015;15(2):94–100. 12. Mah CD, Kezirian EJ, Marcello BM, Dement WC. Poor sleep quality and insufficient sleep of a collegiate student-athlete population. Sleep Health. 2018;4(3):251–7. 13. Tuomilehto H, Vuorinen VP, Penttila E, Kivimaki M, Vuorenmaa M, Venojarvi M, et al. Sleep of professional athletes: underexploited potential to improve health and performance. J Sports Sci. 2017;35(7):704–10. 14. Roberts SSH, Teo WP, Warmington SA. Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis. Br J Sports Med. 2019;53(8):513–22. 15. Lastella M, Lovell GP, Sargent C. Athletes' precompetitive sleep behaviour and its relationship with subsequent precompetitive mood and performance. Eur J Sport Sci. 2014;14(Suppl 1):S123–30. 16. Bartsch P, Dehnert C, Friedmann-Bette B, Tadibi V. Intermittent hypoxia at rest for improvement of athletic performance. Scand J Med Sci Sports. 2008;18(Suppl 1):50–6. 17. Copenhaver EA, Diamond AB. The value of sleep on athletic performance, injury, and recovery in the young athlete. Pediatr Ann. 2017;46(3):e106–e11. 18. Youngstedt SD, Elliott JA, Kripke DF. Human circadian phase-response curves for exercise. J Physiol. 2019;597(8):2253–68. 19. Smith RS, Efron B, Mah CD, Malhotra A. The impact of circadian misalignment on athletic performance in professional football players. Sleep. 2013;36(12):1999–2001. 20. Dunican IC, Martin DT, Halson SL, Reale RJ, Dawson BT, Caldwell JA, et al. The effects of the removal of electronic devices for 48 hours on sleep in elite judo athletes. J Strength Cond Res. 2017;31(10):2832–9. 21. Juliff LE, Halson SL, Peiffer JJ. Understanding sleep disturbance in athletes prior to important competitions. J Sci Med Sport. 2015;18(1):13–8. 22. Riemann D.  Epidemiology of sleep disorders, sleep deprivation, dreaming and spindles in sleep. J Sleep Res. 2019;28(1):e12822. 23. Basnyat B, Murdoch DR. High-altitude illness. Lancet. 2003;361(9373):1967–74. 24. Wu T, Ding S, Liu J, Jia J, Dai R, Liang B, et al. Ataxia: an early indicator in high altitude cerebral edema. High Alt Med Biol. 2006;7(4):275–80. 25. Yih ML, Lin FC, Chao HS, Tsai HC, Chang SC.  Effects of rapid ascent on the heart rate variability of individuals with and without acute mountain sickness. Eur J Appl Physiol. 2017;117(4):757–66. 26. Auerbach PS, Cushing TA, Harris NS.  Auerbach’s wilderness medicine. Philadelphia: Elsevier; 2017. 27. George CF, Kab V. Sleep-disordered breathing in the National Football League is not a trivial matter. Sleep. 2011;34(3):245. 28. Riemann D, Krone LB, Wulff K, Nissen C.  Sleep, insomnia, and depression. Neuropsychopharmacology. 2020;45(1):74–89. 29. Dunn M, Thomas JO, Swift W, Burns L. Elite athletes' estimates of the prevalence of illicit drug use: evidence for the false consensus effect. Drug Alcohol Rev. 2012;31(1):27–32. 30. Momaya A, Fawal M, Estes R. Performance-enhancing substances in sports: a review of the literature. Sports Med. 2015;45(4):517–31.

68

C. A. Mikutta et al.

31. Morselli L, Leproult R, Balbo M, Spiegel K. Role of sleep duration in the regulation of glucose metabolism and appetite. Best Pract Res Clin Endocrinol Metab. 2010;24(5):687–702. 32. Haack M, Sanchez E, Mullington JM.  Elevated inflammatory markers in response to prolonged sleep restriction are associated with increased pain experience in healthy volunteers. Sleep. 2007;30(9):1145–52. 33. Jarrin DC, Ivers H, Lamy M, Chen IY, Harvey AG, Morin CM.  Cardiovascular autonomic dysfunction in insomnia patients with objective short sleep duration. J Sleep Res. 2018;27(3):e12663. 34. Taheri M, Arabameri E. The effect of sleep deprivation on choice reaction time and anaerobic power of college student athletes. Asian J Sports Med. 2012;3(1):15–20. 35. Milewski MD, Skaggs DL, Bishop GA, Pace JL, Ibrahim DA, Wren TA, et al. Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J Pediatr Orthop. 2014;34(2):129–33. 36. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ.  The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. 37. Samuels C, James L, Lawson D, Meeuwisse W. The athlete sleep screening questionnaire: a new tool for assessing and managing sleep in elite athletes. Br J Sports Med. 2016;50(7):418–22. 38. Driller MW, Mah CD, Halson SL. Development of the athlete sleep behavior questionnaire: a tool for identifying maladaptive sleep practices in elite athletes. Sleep Sci. 2018;11(1):37–44. 39. Zavada A, Gordijn MC, Beersma DG, Daan S, Roenneberg T.  Comparison of the Munich Chronotype questionnaire with the Horne-Ostberg's Morningness-Eveningness score. Chronobiol Int. 2005;22(2):267–78. 40. Riemann D, Baum E, Cohrs S, Crönlein T, Hajak G, Hertenstein E, Klose P, Langhorst J, Mayer G, Nissen C, Pollmächer T, Rabstein S, Sitter H, Weeß H-G, Wetter T, Spiegelhalder K. Leitlinie S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen. Somnologie. 2017;21(2):44. 41. Walker M. Why we sleep: the new science of sleep and dreams. New York: Penguin; 2017. 42. Ito SU, Kanbayashi T, Takemura T, Kondo H, Inomata S, Szilagyi G, et  al. Acute effects of zolpidem on daytime alertness, psychomotor and physical performance. Neurosci Res. 2007;59(3):309–13. 43. Atkinson G, Drust B, Reilly T, Waterhouse J. The relevance of melatonin to sports medicine and science. Sports Med. 2003;33(11):809–31. 44. Reardon CL, Factor RM. Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med. 2010;40(11):961–80. 45. Reardon CL.  The sports psychiatrist and psychiatric medication. Int Rev Psychiatry. 2016;28(6):606–13. 46. Wilson MH, Newman S, Imray CH. The cerebral effects of ascent to high altitudes. Lancet Neurol. 2009;8(2):175–91.

Mental Health Emergencies in Athletes Carla Edwards

Key Points • Athletes are not immune to mental health crises and emergencies, and sports can sometimes become triggering events for crises. • Although most members of the Integrated Support Team (IST) do not have a significant amount of mental health training, they can still play very valuable roles in managing an athlete in distress. • Managing a mental health crisis in a sport environment may proceed more smoothly if protocols are developed in advance, such as a Mental Health Emergency Action Plan. • Dealing with a mental health emergency is intense for all involved, and it is important to recognize the impact on members of the IST who have been involved with either witnessing or managing a crisis. • Creating a safe environment for staff to be able to debrief and discuss their reaction to the event is very important.

1 Introduction Management of mental health emergencies in the general population has evolved over many centuries, and concerted efforts have been made by modern societies to refine ethical, evidence-based multidimensional approaches. In contrast, recognition and management of psychiatric emergencies in athletes are a relatively new landscape. C. Edwards (*) McMaster University Department of Psychiatry and Behavioural Neuroscience, Hamilton, ON, Canada e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. Baron et al. (eds.), Sport and Mental Health, https://doi.org/10.1007/978-3-031-36864-6_6

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Let us consider the athletic life experience of a high-performance, elite, or professional athlete. Many who have reached those levels of competition have spent countless hours over many years learning and improving their craft, advancing through age levels with different coaches, new teammates, travel, and increasing levels of competition as their career unfolded. Their pathways cross many significant periods of health and personal development. The athlete’s experience in the sport world during the “formative years” can greatly influence development of their sense of self, self-confidence, self-esteem, identity, ability to work with others, and how to “manage the essence of sport” (including winning graciously, losing gracefully, and maintaining their composure). Young athletes often find a role model to identify with and aspire to achieve similar success. When the athlete can proceed along their developmental trajectory without exposure to extreme adversity (such as abuse, poverty, discrimination, family conflict, or significant injury), their pathway can be relatively seamless and smooth. Many factors challenge this pathway, however, as internal and external factors can create significant disturbances in an athlete’s psychological well-being. Athletes are under perpetual pressure and stress related to sport and its elements. Uncertainty, controversy, and conflict are not uncommon. Despite this, psychiatric emergencies and crises are relatively rare but still occur.

2 Definitions For the purpose of this chapter, it is important to define key concepts: Resilience  The ability to mentally and emotionally navigate and adapt through difficult situations without significant disruption in function. Stress  The way the brain and body react to demanding and challenging situations. Any life circumstance can create stress (including work, family, finances, athletic or work performance), and it can be short-lived or more chronic. Individuals may respond to stress very differently, which can affect the duration and impact of disturbance [1]. Adversity  Hardship, obstacle, challenge, or misfortune that affects our lives. Examples include physical, emotional, financial, mental, social, and relationship based. Distress  Extreme worry, sadness, or pain; physical or mental anguish or suffering. Crisis  The mental state that arises when a person’s capacity to make decisions, manage their behavior, and maintain their safety is overwhelmed. It is considered a transient mental state that is activated by stressors or situational circumstances and can be associated with suicidal thoughts, self-harm behavior, and functional impair-

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ment. Crises can evolve into psychiatric emergencies; thus, it is important to have a system of resources in place to assess crises when they occur [2, 3]. Emergency  An acute disturbance of thought, mood, behavior, or social relationship that is determined to require immediate intervention [2]. The mental state of an individual who is experiencing a mental health emergency has the potential to rapidly deteriorate into a catastrophic outcome. In many situations, sport training environments do not have appropriate resources in place to manage this level of severity, and thus, it may be necessary to enlist more intensive resources in the community (or develop the system internally). Mental Health Action Plan (MHAP)  A document that can be developed in collaboration with the athlete that identifies the major challenges (can be description of symptoms and/or diagnoses) and creates a “road map” to identify: • • • • • •

Triggers Helpful interventions Unhelpful interventions Key people to involve in assistance Key people to not involve in assistance Incorporate with emergency action plan for crises (typically organizational/program based) • Can include “roles and goals” of each person included on the MHAP (including those who support the athlete) Mental Health Emergency Action Plan (MHEAP)  A document that should be widely available and outline the following [4]: • Situations, symptoms, or behaviors considered mental health emergencies. • Procedures for managing. –– Suicidal or homicidal ideation. –– Sexual assault. –– Highly agitated or threatening behavior, including acute psychosis, hallucinations, delusions, paranoia, and acute delirium. –– Acute intoxication or drug overdose. • Situations to contact emergency medical services immediately. • Situations to contact trained on-call counselor or campus crisis center, if available. • Contact information for on-call counselors trained to provide crisis intervention, if available. • Expectations of all personnel (athletic therapists (ATs)/physiotherapists (PTs)/ student therapists, coaches, team physicians, athletics department representatives) during a crisis intervention. • Policy for contacting the athlete’s family members or emergency contact person.

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• Appropriate follow-up steps and referrals to be made by all once the emergency situation has been resolved. • Debrief procedures to review each emergency situation once it has been resolved. Athletes are incredibly resilient individuals. This is attributable to their ability to manage intense competitive challenges, battle through injuries, and demonstrate the ability to achieve success when faced with adversity. Adversity in sport can include defeat, demotion, failure, injury, discrimination, and abuse. Elements of adversity for athletes are sometimes displayed in the public forum, while others can occur in their private lives and silently influence their well-being. When the athlete’s ability to manage challenge and adversity is overpowered, mental health crises and emergencies can occur.

3 Case Illustration A 20-year-old elite athlete developed significant depressive symptoms (low mood, poor concentration, poor motivation, low energy, insomnia, and suicidal thoughts) during the year prior to an international Major Games event. He continued to train and compete and was selected to the National Team. During that time, he was seen by the team physician and prescribed an antidepressant and a sedative. He was also supported by a psychologist and received regular support from the team’s Integrated Support Team (IST) which included an athletic therapist (AT), physiotherapist (PT), physiologist, strength and conditioning coach (S&C), biomechanist, mental performance consultant (MPC), and coaching staff. Several months before the Games, he took an intentional overdose of the sedative medication (with suicidal intent) and was managed conservatively in the community. With support, he was able to return to training and travelled with the team to the International Major Games. He performed beyond expectations at the Games and earned a bronze medal. In the month following the Games, he returned to college, experienced a significant relapse in his mood and was hospitalized following a suicide attempt. He required a prolonged hospitalization due to multiple additional suicide attempts and self-harm behavior (cutting). Several different medication trials were necessary to arrive at an effective regimen, and he was given a diagnosis of bipolar disorder. Electroconvulsive therapy (ECT) was also necessary to treat the severe mood disorder. His coach and physiotherapist visited him on the inpatient unit several times, and this experience had a profound effect on them as they were unprepared for what they saw (including the mental and physical state of the athlete and the environment that they were in). Over the year following the Major Games event, he required three extensive psychiatric hospitalizations due to mood disturbance and persistent suicidal thoughts, intentions, and attempts. His outpatient support team was bolstered with the addition of a sports psychiatrist to bridge the worlds of mental health and sport. This relationship brought an additional layer of support as the psychiatrist was part of the Integrated Support Team and worked together with the “team”

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(including the athlete) to incorporate sport into his mental health management plan and conversely incorporate mental health considerations into his sport plan. With the athlete’s consent, meetings were held biweekly with the sports psychiatrist, psychologist, coach, team physician, and team manager to discuss the athlete’s overall stability, ongoing concerns, tolerance of training regimen, and suitability to travel and compete. During the quadrennial that followed the International Major Games, the athlete continued to receive all of the supports already described and continued to fluctuate into and out of significant mood episodes. Hospitalization was not needed, but medication management and outpatient ECT were required. He provided consent for the IST to meet on a regular basis so that elements of safety could be discussed, appropriate levels of training could be matched to capabilities, and the IST could understand how best to support him. In the last year of the quadrennial leading to the next International Major Games, the IST introduced the use of a “Role and Goals” document to clearly identify each individual’s role in supporting the athlete (including the athlete) and concrete goals of the management plan. In addition, an MHAP was developed with input from the athlete to help the IST understand his main symptomatic challenges (i.e., low mood and anxiety), common triggers (i.e., poor performance, poor sleep, stress), helpful interventions (i.e., giving him space, allowing him to leave practice early if necessary), and things that are not helpful (i.e., too many people approaching him at once and asking if he was okay; forcing him to finish practice if his mental health was deteriorating). Linkage to the Center’s Emergency Action Plan (EAP) was also created. The Sport Organization monitored the management plan peripherally and ensured the needed supports were provided. Assessment of safety was communicated prior to travel and major competitions. Regular communication occurred between the team physician, sports psychiatrist, sports psychologist, and mental performance consultant to review the work being done, ensure consistency in approach and messaging, and clearly delineate roles.

4 Dissecting the Case This case illustrates the story of an athlete who suffered with a significant mood disorder and descended into crisis on numerous occasions. His crises became emergencies as he required acute psychiatric intervention and intensive management. The IST members continued to support him while he was hospitalized but ultimately were traumatized by their experience since they had never experienced an athlete in that condition or environment before. Years later they still talk about their experience with the same emotion they experienced at the time. Bringing a sports psychiatrist onto the team merged the medical, psychiatric, and sports dimensions and gave the IST an invaluable resource to support the care of their athletes and enhance their mental health literacy. In addition to direct care for the athlete, the sports psychiatrist was a resource for the IST and sport organization and provided

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support, recommendations, and protocol development regarding the management of mental illness in their athletes. Members of the IST (i.e., AT, PT, S&C) are often privy to information about the athlete before anyone else based on the frequency, modality of treatment, and development of rapport through the sessions. They play a valuable role in communicating areas of concern, inquiring how they should handle different situations, and having roles in the management plan. Some individuals will have active roles, while others will not. Confidentiality must be preserved and protected throughout this process, and consent should be obtained as necessary. Consent to release information related to mental health should be obtained separately from that obtained for physical health. Common risk factors for crises and emergencies in the athlete population are listed below: 1. Mental illness: Diagnoses such as major depressive disorder, bipolar disorder, anxiety, posttraumatic stress disorder, psychosis, personality disorders. 2. Substance intoxication or withdrawal: Substance-induced states that alter judgment or inhibitions could increase the risk of mental health emergencies in individuals who are struggling. 3. Suicide: Athletes are at risk for suicide, and risk factors that appear to have an influence on athlete suicide include injury, psychosocial stressors, pressure to win, substance abuse, retirement, mental illness, and anabolic steroid use [5]. 4. Maltreatment: Abuse, harassment, neglect, and other forms of maltreatment of athletes can have significant multidimensional impacts on the athlete, including physical, emotional, cognitive, behavioral, mental health, relational, and economic [6]. 5. Failure-based depression, post-games “crash”: Failure (real or perceived) in a high-stakes setting can be catastrophic for athletes and may lead to increased risk for mental health crises and suicide [5]. 6. Career transitions: Athletes who dedicate a considerable portion of their youth and adult lives training for and competing in professional or elite sports often struggle to “regular life” when they step away from their competitive roles. Loss of “identity,” community, sense of importance, and regimented routine can be catastrophic for many athletes, particularly if they do not have education or other life experience to use as foundation for their next exploits. 7. Career-threatening injuries: Injuries can be devastating for athletes, depending on the timing and nature of the injury and potential impact on the competitive season or career. 8. Traumatic brain injury: Brain injuries are commonly associated with the development of various mental illnesses including anxiety and depression, as well as suicidality, and neuropsychiatric sequelae (which can include violence, impulsivity, emotional lability, and “challenging behavior [5]”). 9. Androgenic-anabolic steroids: Can lead to aggression, hostility, rage, violence, mood disturbance, and psychosis [5]. 10. Eating disorders: Interruption of the training and competition routine of an athlete with an eating disorder (i.e., due to injury, illness, or demotion) can lead

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to increased disordered eating, subsequent medical sequelae, and increased psychological distress. Stigma, fear of sport-related repercussions, and not wanting to appear “weak” often delay or prevent the athlete from seeking help. The IST can play a significant role in creating a safe culture to disclose and manage the mental health of the athletes.

5 Signs of Mental Distress It is important to develop an approach to understanding the signs of mental distress so an appropriate intervention can be chosen. Common signs of mental distress are listed below: 1. Emotional dysregulation: reactivity, volatility, anger, tearful, irritability 2. Change in sleep pattern: too much or too little 3. Increased alcohol, drug, or prescription use 4. Social isolation or withdrawal 5. Significant decrease in energy and interest 6. Hopelessness 7. Agitation 8. Signs of self harm: self-inflicted cuts, burns, unexplained bruising 9. Significant change in appetite: increase or decrease 10. Presence of suicidal thoughts, intentions, or plans; or thoughts of hurting someone else 11. Significantly decreased ability to cope with regular routines or solve problems 12. Distraction and lack of ability to engage with people or activities

6 Managing a Mental Health Crisis with the IST Although most members of the IST do not have a significant amount of mental health training, they can still play very valuable roles in managing an athlete in distress. Managing a mental health crisis in a sport environment may proceed more smoothly if protocols are developed in advance and roles in the management plan are identified. It would be extremely beneficial for the team, center, or organization to ensure that all IST members have training in Psychological First Aid at a minimum, and some form of suicide prevention training would be optimal. Staff with formal mental health training should become involved as the “point person” to engage directly with the athlete in crisis. This should be done in a safe, private environment if possible, and other staff should be nearby to assist as necessary (i.e., to assist in de-escalation), call for additional emergency services if necessary, and bring items as needed (i.e., water). They may also be able to step in and aid the first

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point person if they need a break or additional help. Directing traffic is an important job that should be assumed by another staff in order to reduce the attention on the athlete in distress, remove others from danger (if appropriate), and reduce the environmental stress and congestion. The team physician, psychiatrist, psychologist, or mental performance consultant should be involved by this point and should be notified if they have not already been. A decision will have to be made about the next disposition of the athlete—if calm, rational, future oriented, and well supported by people in their lives, they may be able to go home (with someone) with a plan for a team discussion as soon as possible to discuss next steps and return to sport. If the athlete’s mental state remains significantly disturbed or there are safety concerns and few supports, then calling 911 and crisis services or bringing them to a hospital may be required. Key roles in managing a mental health emergency are listed below: 1. Point person: Main person interacting with the athlete. This person could be anyone in the vicinity of the athlete, and they should be comfortable engaging with someone in distress. Finding a private and safe place to talk would be helpful. 2. Traffic director: A person who directs bystanders or teammates away from the distressed athlete. His or her duties may include protecting the athlete from media or cameras. 3. Support for the other athletes: They will be wondering what is happening and worrying about their teammate—this person can provide a place for them to express their worries and also provide reassurance. 4. Coordinator: This person contacts emergency services if necessary or can reach out to friends or family members of the athlete in distress as appropriate. They would also reach out to the mental health supports for the athlete to inform them of the incident. 5. Backup: This person can step into any of the roles as needed. Dealing with a mental health emergency is extremely intense for all involved, and it is important to recognize the impact on members of the IST who have been involved with either witnessing or managing a crisis. Creating a safe environment for staff to be able to debrief and discuss their reaction to the event is very important. Timing is also extremely important, as leaving the debrief for too long (i.e., beyond several days) may lead to elements of trauma, anxiety, and mood changes in the staff. They will also need to be prepared for the return of the athlete to the training environment when appropriate.

7 Take-Home Points 1. Athletes can experience crises and mental health emergencies like the general population, and both sport and non-sport-related elements can lead to these significant disturbances in mental health.

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2. The Integrated Support Team has important roles in communicating observations and concerns to the mental health and medical staff and can also play significant roles in managing a mental health crisis. 3. Policies and protocols can be helpful in establishing a crisis response plan in advance, with identified roles and pathways to follow. 4. Documents that outline “roles and goals,” a mental health action plan, emergency action plan, and crisis response plan can facilitate management of an athlete at risk and mitigate the severity of crises that may develop.

8 Summary Athletes can experience mental health emergencies, and these may, at times, occur in the training environment or while at competition. More often than not, neither the athletes nor their Integrated Support Team (including coaches) have formal mental health training and are not equipped to manage mental health emergencies. With the establishment of educational programs, policies, and protocols, staff can better manage the athlete at risk and potentially mitigate the severity of the crisis that may develop. Having a sports psychiatrist on the Integrated Support Team provides the organization with a source for education, athlete mental health management, strategy development, enhancement of the mental health literacy of the organization (including the athletes), and a specialized perspective of the biopsychosocial, medical, and sport dimensions to apply when an athlete (or staff) struggles with their mental health.

9 Future Directions More research is needed to understand the true incidence of mental health emergencies in athletes. As stated earlier, numerous factors commonly inhibit athletes from seeking help during mental health crisis, and this may lead to underreporting and under-recognition of cases. Formal mental health training such as Psychological First Aid and/or suicide prevention courses should be mandated for all staff of high-­ performance centers and made available to sport organizations and athlete supports at all levels. Sport organizations can begin to develop mental health plans for any athletes who struggle with resilience, coping, or mental illness; and an emergency action plan should be available for everyone to access and implement. “Roles and goals” documents can be initiated at any time and are useful when multiple professionals are supporting an athlete. Organizations should look for opportunities to either collaborate with or add a sports psychiatrist to round out their Integrated Support Team.

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References 1. 5 Things You Should Know About Stress from the National Institutes of Mental Health: NIH Publication No. 19-MH-8109 [Internet]; [undated; cited August 11, 2020]. Available from: https://www.nimh.nih.gov/health/publications/stress/19-­mh-­8109-­5-­things-­stress_142898.pdf. 2. Allen MH, Forster P, Zealberg J, and Currier G. APA taskforce on psychiatric emergency services report and recommendations regarding psychiatric emergency and crisis services [internet]; [posted August 2002; cited August 11, 2020]. Available from: http://www.psychiatry.org/ File%20Library/Psychiatrists/Directories/Library-­and-­Archive/task-­force-­reports/tfr2002_ EmergencyCrisis.pdf. 3. Zeller S, Kircher E. Psychiatric times: understanding crisis services: what they are and when to access them [Internet]; [posted August 6, 2020; cited August 11, 2020]. Available from: https://www. psychiatrictimes.com/view/understanding-­crisis-­services-­what-­they-­are-­when-­access-­them 4. U SPORTS Sports Medicine and Research Science Committee: U SPORTS Mental Health Best Practices [Internet]; [posted (undated) 2020; Retrieved August 15, 2020] Available from: https://usports.ca/uploads/hq/Medical/USports_mentalHealthDoc_2020_EN_digital.pdf 5. Edwards CD, Berlin J. The psychiatric emergency care of VIPs and athletes in crisis. In: Glick RL, Zeller S, Berlin J, editors. Emergency psychiatry principles and practice. Philadelphia, PA: Wolters Kluwer; 2021. p. 459–69. 6. Mountjoy M, Brackenridge C, Arrington M, Blauwet C, et al. International Olympic Committee consensus statement: harassment and abuse (non-accidental violence) in sport. Br J Sports Med. 2016;50:1019–29.

Further Reading Blakelock DJ, Chen MA, Prescott T. Psychological distress in elite adolescent soccer players following deselection. J Clin Sport Psychol. 2016;10:59–77. Currie A, McDuff D, Johnston A, et al. Management of mental health emergencies in elite athletes: a narrative review British Journal of sports medicine 2019;53:772-778.Newman BM, Ravindranath D. managing a psychiatric emergency. Psychiatr Times. 2010;27:1–5. Galambos SA, et al. Psychological predictors of injury among elite athletes * commentary. Br J Sports Med. 2005;39:351–4. Patel MX, Sethi FN, Barnes TR, et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation. J Psychopharmacol. 2018;32:601–40.

Doping in Sports Todd Stull, Anna Sheen, and David Baron

1 History of Doping in Sports Doping is the use of a banned substance to improve athletic performance and is not restricted to elite athletes. Performance-enhancing substances can be illicit drugs and prescription drugs or found in a variety of compounds or supplements. As the influences of urbanization and industrialization took place, the pharmaceutical industry expanded, and over time some athletes began to use new potent drugs to enhance performance and accelerate recovery. The use of supplements to enhance performance dates to the ancient Olympic games. This included the use of grape skins, brandy/wine, hallucinogenic mushrooms, and various plants to enhance performance, manage pain, and accelerate recovery. During the early years of doping, it was already considered unethical [1]. In 1904, Olympic track and field athlete Thomas Hicks consumed a mixture of brandy and strychnine to increase his stamina. Amphetamines were introduced in the 1920s, along with heroin, cocaine, and caffeine, and became popular among athletes [2]. In the 1950s, attempts to control substance use in sports emerged but lacked sophistication with testing procedures. In the 1940s and 1950s, amphetamine was widely used in society to enhance mental awareness and to delay fatigue in combat. Anti-doping lagged behind the increasingly complex doping strategies. In 1954, anabolic steroids were introduced. The Soviet Olympic team began

T. Stull (*) · A. Sheen Department of Psychiatry and Neuroscience, University of California Riverside, School of Medicine, Riverside, CA, USA e-mail: [email protected] D. Baron Office of the President, Western University of Health Sciences, Pomona, CA, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. Baron et al. (eds.), Sport and Mental Health, https://doi.org/10.1007/978-3-031-36864-6_7

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experimenting with testosterone to increase power and strength. In 1958, Dianabol was synthesized and used by the American weightlifters at the 1962 World Championships. The first designer androgen identified in an athlete’s urine was norbolethone, originally synthesized in 1960 but never marketed. This was followed by the discovery of the government-sponsored use of steroids in East Germany by athletes, most notably in women. In the 1960s, several new classes of drugs were developed and included corticosteroids, beta blockers, tranquilizers, and oral contraceptives [1]. In 1963, France introduced anti-doping legislation. In 1966, the International Federations for football and cycling introduced doping tests into their respective World Championships. in 1967, the International Olympic Committee (IOC) introduced the first prohibited list followed by IOC testing in 1968 at the winter games. In 1976, anabolic steroids were prohibited, and in the 1980s, Therapeutic Use Exemptions were introduced. In the 1980s, blood doping was the first doping method to be added to the IOC Prohibited List. In 1989, Recombinant EPO was introduced and resulted in the sudden death of European cyclists [1]. Olympic sprinter Ben Johnson’s infamous steroid scandal drew attention to the world of sports as steroid use had extended beyond pure strength events. Blood testing of athletes was implemented at the 1994 Winter Olympics Games and included an “upper limit for eligibility to participate.” The World Anti-Doping Agency (WADA) was established in 1999 followed by the First World Anti-Doping Code. Gene doping was prohibited in 2003, and Athlete Biological Passport (ABP) was introduced in 2008 [3, 4]. Between 2000 and 2010, the use of stimulant-containing over-the-counter (OTC) medicines increased and created serious issues that resulted in the tighter regulation and limits of levels for some OTC medicines [5]. An underground process was also taking place to produce designer drugs that were difficult to detect such as tetrahydrogestrinone (THG). Various labs in ten countries who were manufacturing large quantities of steroids resulted in more than 100 arrests. The Global Drug Reference Online (Global DRO) was developed to provide athletes and support personnel with details on the prohibited status of medication [1]. The Lance Armstrong doping scandal was yet another and arguably the most high profile example of the ongoing dark side of sports. As a result, the WADA Code continues to be updated on a regular basis in order to promote fair ethical competition. It defines doping as when a substance/drug or method has the potential to enhance sport performance, represents a potential or actual health risk to the athlete, and violates the spirit of sport. The WADA Code targets testing based on improved anti-doping intelligence. Furthermore, athletes and athlete support personnel can be held culpable for doping violations [6, 7]. Despite the many risks involved including medical complications and sanctions to being banned from competition, athletes continue to seek out strategies that may be illegal to enhance performance. Growing public recognition of doping in sports has resulted in more attention to research in the area. Public skepticism contributes to the “cheating” perception, which WADA has made a priority to address. The actual prevalence of doping remains unknown. To address cheating and prevalence,

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WADA has developed high standard accredited labs in addition to expanding the testing procedures including the ABP [7]. There are different types of anti-doping rules violations including [8] • • • • • • • •

Presence of prohibited substance or its metabolites in an athlete’s sample. Use or attempted use of a prohibited substance or method. Refusing or failing without justification to submit sample. Whereabouts violation. Tampering or attempted tampering with any part of doping control. Possession of prohibited substances or methods. Trafficking or attempted trafficking in any prohibited substance or method. Administration or attempted administration of any prohibited method or substance or assisting, encouraging, aiding, abetting, and covering up.

Performance-enhancing substances (PESs) and methods may be grouped into categories [8]: • • • • • • •

Mass builders – enhancing strength, power, and explosiveness. Endurance builders – improving the oxygen-carrying capacity. Recovery enhancers – augmenting recovery and return to play/competition. Inflammation and pain modulators. Attention/alertness enhancers. Blood manipulators. Gene/cell modifiers.

Table 1 reflects WADA classification of prohibited substances and methods in and out of competition and prohibited substances in competition. The table reflects the ergogenic (positive) and ergolytic (negative) effects of each class/category [6].

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Table 1  World anti-doping code prohibited list Substances Prohibited at All Time (In-and Out-of-Competition) Effectiveness in performance enhancement 1 (+) to 4 (++++) Performance Category effects Anabolic-androgenic steroids (AAS) and other anabolic agents (++++) Anabolic-androgenic steroids (AAS) = androgens Increases Stanozolol Muscle mass Nandrolone Strength Trenbolone Endurance Testosterone Fat loss Other anabolic agents Muscle recovery Clenbuterol in food Aggression Selective androgen receptor modulators (SARMs), Motivation ostarine and RAD 140 Hemoglobin

Side effects

Men:  Diminished spermatogenesis  Diminished fertility  Decreased testicular size  Gynecomastia  Baldness  Impotence  Prostate enlargement Women:  Clitoral enlargement   Facial and body hair growth Both:  Liver dysfunction  Acne  Aggressiveness   Mood changes:   Mania   Depression  Hypertension   Muscle strain   Tendon rupture  Growth impairment Peptide hormones, growth factors, related substances, and mimetics (+++ to ++++) Erythropoietin (EPO) Increases: Heart attack Hypoxia-inducible factor (HIF), e.g., cobalt Muscle mass Cardiomyopathy Peptide hormones and their releasing factors Strength Stroke [gonadotropin (CG) and luteinizing hormone (LH)] Endurance Pulmonary Corticotropins Fat loss embolism Growth hormone (GH) and hGH growth hormone-­ Protein synthesis Deep venous releasing hormone (GHRH) Muscle repair thrombosis Growth factors and growth factor modulators Muscle/tissue Soft/connective recovery tissue injuries Gastrointestinal side effects Acromegaly Joint issues including arthritis

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Table 1 (continued) Substances Prohibited at All Time (In-and Out-of-Competition) Effectiveness in performance enhancement 1 (+) to 4 (++++) Performance Category effects Beta-2 agonists (++) Increase aerobic All selective and non-selective beta-2 agonists capacity and   (except: Inhaled salbutamol: Maximum 1600 exercise micrograms over 24 h in divided doses, not to exceed endurance 800 micrograms over 12 h starting from any dose; Muscle growth inhaled formoterol: Maximum delivered dose of 54 Fat loss micrograms over 24 h; inhaled salmeterol: Maximum 200 micrograms/24 h)

Hormone and metabolic modulators (++?) Aromatase inhibitors Selective estrogen receptor modulators (tamoxifen) Other anti-estrogenic (clomiphene) Agents preventing activin receptor IIB activation Metabolic modulators Insulins and insulin mimetics  Meldonium Diuretics and masking agents (0 - +) Plasma expanders Acetazolamide Furosemide Spironolactone Hydrochlorothiazide Triamterene

Side effects Arrhythmias and tachycardia Hypokalemia Increased glucose Muscle tremor Anxiety Dizziness Headache Insomnia Mood changes

Increases: Muscle size and growth Strength Reduces side effects Androgens

Gastrointestinal Reduced sex drive Flushing Sweating Mood changes

Weight loss Prevents detection of banned substances

Cardiovascular issues Kidney problems Electrolyte disturbances Low blood pressure Headaches Muscle cramps

Manipulation of blood and blood components (+++) Administration of blood or red blood cell products Increases endurance Delays fatigue of any origin into the circulatory system Enhances recovery Artificially enhancing the uptake, transport, or delivery of oxygen (excluding supplemental oxygen by inhalation) Any form of intravascular manipulation of the blood or blood components by physical or chemical means

Myocardial infarction Stroke Polycythemia Hypertension Thromboembolic events (continued)

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84 Table 1 (continued) Chemical and physical manipulation Tampering, or attempting to tamper samples collected during doping control including sample substitution and/or adulteration Intravenous infusions and/or injections of more than a total of 100 mL per 12-h period except for those legitimately received in the course of hospital treatments, surgical procedures, or clinical diagnostic investigations Gene and cell doping (unknown) The use of nucleic acids or nucleic acid analogues that may alter genome sequences and/or alter gene expression by any mechanism (gene editing, gene silencing, and gene transfer or the use of normal or genetically modified cells)

Stimulants (++++) All stimulants, including all optical isomers, e.g., d- and l- of amphetamine (Adderall, Vyvanse, methamphetamine) Methylphenidate (Ritalin) Cocaine Ephedrine (prohibited when the concentration of either in urine is greater than 10 micrograms per milliliter) Bupropion, caffeine, nicotine, phenylephrine, phenylpropanolamine, pipradrol, and synephrine; these substances are included in the 2020 Monitoring Program Narcotics (+++ to ++++) Buprenorphine Diamorphine (heroin) Fentanyl Hydromorphone Methadone Morphine Oxycodone Oxymorphone

Increases muscle mass Alters metabolic properties of the muscle Improves the performance of the cardiovascular system

Introduces a pathogen Disseminated intravascular coagulation Alters immune function Heart attack and stroke

Improves reaction time Improves performance Enhances alertness/ arousal Increases endurance Decreases fatigue

Shakiness/tremor Anxiety Insomnia/sleep changes Mood changes Weight loss Headaches Cardiovascular-­ heart attack Arrhythmia Paranoia Psychosis Stroke

Short-term use – Analgesia resulting in decreased pain, “play through pain/injury”

Nausea/vomiting Sweating Drowsiness Confusion Slowed reaction time Mood changes Decreased libido

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Table 1 (continued) Cannabinoids (0 to +) All natural and synthetic cannabinoids are prohibited Except: Cannabidiol

Glucocorticoids (++ to +++) Glucocorticoids All glucocorticoids are prohibited when administered by oral, intravenous, intramuscular, and rectal routes Betamethasone Budesonide Cortisone Dexamethasone Fluticasone Hydrocortisone Methylprednisolone Prednisolone Prednisone Triamcinolone Beta-blockers (++ to +++) Beta-blockers Beta-blockers are prohibited in competition only, in the following sports, and prohibited out of competition where indicated* Archery* Automobile Billiards Golf Shooting* Skiing/snowboarding sports

Reasons for use Relaxation Stress Improves performance

Impaired   Coordination and reaction time Thinking and problem-solving  Sleep   Learning and memory Anxiety Mood changes Appetite changes Increased heart rate

Short-term effects: Improve performance Decrease inflammation Decrease pain Metabolic changes to produce more energy

With long-term use: Bone loss Muscle wasting Skin thinning Glaucoma Cataracts Insulin resistance Mood changes Sleep changes Impaired immune function

Decrease tremor/ shakiness Decrease anxiety Manage the “yips”

Arrhythmias Hypotension/ lightheaded Dizziness Mood changes Fatigue Cold extremities Hypoglycemia Sleep changes

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2 Current State of Doping Adverse analytical findings (AAFs) are a report from a World Anti-Doping Agency (WADA)-approved laboratory that identifies the presence of a prohibited substance, its metabolites or markers, or evidence of the use of a prohibited method. There are approximately 30 WADA labs in the world. AAFs from 2003 to 2015 showed that the top substances identified in order of number of findings were anabolic agents, stimulants, diuretic and masking agents, glucocorticoids, cannabinoids, beta-2 agonist, peptide hormone, growth factors, and related substance and hormone antagonists and metabolic modulators. The number of adverse analytical findings (AAFs) was 1.43% in 2017 and 1.42% in 2018 [9]. The prevalence of performance-enhancing substances (PES) use varies depending on the substance detection method and sport. Data from WADA laboratories reported the most common adverse analytical findings (AAF) in all sports between 2013 and 2017 were anabolic agents [10]. Androgens make up half of all adverse analytical findings in drug testing from WADA labs. Despite the WADA lab results indicating that most positive results are androgens, anabolic agents including SARMS continue to increase. Selective androgen receptor modulators (SARMs) such as ostarine, RAD 140, and LGD-4033 are becoming increasingly popular. A perceived advantage of using SARMs is the avoidance of androgenic effects and targeting of specific tissues and improvement of mass and performance with reduced undesired side effects [11]. Hormone and metabolic modulators, including GW1516, are increasing as well in the last 2 years. The National Collegiate Athletic Association (NCAA) reports the use of anabolic steroids in 2009, 2013, and 2017 at 0.4% when averaging the data for all men’s and women’s sports [9]. Androgens are a class of hormones based on two endogenous steroids: testosterone and its potent metabolite dihydrotestosterone (DHT). Androgen is a term synonymous with anabolic steroids, androgenic anabolic steroids, and selective androgen receptor modulators (SARMS). Direct doping involves administration of endogenous or synthetic androgens. Indirect doping refers to administration of non-­ androgenic drugs that increase endogenous testosterone to gain a performance advantage. This includes the use of hCG and LH and anti-estrogens including estrogen receptor antagonists or inhibitors. Natural androgen precursors like dehydroepiandrosterone (DHEA) or androstenedione are converted to testosterone or DHT or epitestosterone and are used to mask the testosterone/epitestosterone ratio [12]. Cannabis and related products are the most widely used illicit substance among athletes. The rates of cannabis and synthetic cannabinoids use in athletes have risen over the last 10 years to between 20% and 25% of male and female athletes across all countries in a range of sports. Additionally, the levels of tetrahydrocannabinol (THC) in marijuana products are significantly higher now compared to 10 to 15 years ago and can range from 30% to 90% concentration. The most common self-reported reasons for opioids and cannabis use in sports are socialization, relaxation, stress and anxiety reduction, appetite stimulation, mood and anger management, insomnia, and pain control [13].

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The 2017 NCAA National Study on Substance Use Habits of College Student-­ Athletes showed that 11% of student-athletes reported using narcotic pain medication with a prescription, down from 18% in 2013. Three percent of student-athletes reported using narcotic pain medication without a prescription in the past year, and 2% of student-athletes reported misusing narcotic pain medication [14]. Stimulants are used to increase alertness, endurance, strength, power, and attentiveness. Caffeine is the most used stimulant in sports. Nicotine is the second most widely used stimulant, and usage rates depend on the sport, sex, and culture. Across all genders, the NCAA found that in the past year, use rates were 17% for cigars, spit tobacco at 13%, hookah at 11%, combustible cigarettes at 10%, and E-cigarettes at 8%. Prescribed stimulants such as amphetamine formations or methylphenidate were the third most used stimulants in sports [15]. Athletes also use dietary supplements to enhance performance. Unlabeled doping substances (i.e., amphetamines and anabolic steroids) were often found in vitamin and creatine supplements in voluntary testing of Olympic athletes in 2002. Erythropoietin, growth hormone, insulin-like growth factor, and growth-hormone-­ releasing protein have been found in supplements as well. The Food and Drug Administration (FDA) does not approve or regulate dietary supplements or validate claims of performance-enhancing substances (PES) [16, 17]. Reasons for quitting or limiting PES include the following [14]: • • • • •

Fear of getting caught. Being banned or sanctioned. Loss of status. Loss of funding. Health-related effects.

Table 1 describes the performance effects on physiology, behavior, emotions, and health and side effects of a given substance or method. Table 2 describes the signs and symptoms of use and withdrawal [1, 11, 13, 18–22].

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Table 2  Recognition of use—signs and symptoms of use and withdrawal Substance Anabolic-­ androgenic steroids

Cannabis

Signs/symptoms of use Acne, rapid weight gain, irritability, mood changes, rage, joint pain, insomnia, injection site irritation In females: Deepening of voice, facial hair, clitoromegaly In males: Gynecomastia and baldness Increased appetite, drowsiness, slowed responses, bloodshot eye, smell on cannabis, memory issues, paranoia, cough

Opioids

Constricted pupils, sedation, cognitive slowing, constipation, drowsiness, slurred speech, impaired memory

Stimulants

Tachycardia/bradycardia, pupillary dilation, high or low blood pressure, perspiration or chills, nausea or vomiting, weight loss, psychomotor agitation or retardation, muscle weakness, chest pain, arrhythmias, confusion, seizure, dyskinesia, dystonia Acne, bruising, sleep changes, mood changes, weight gain, pink stretch marks, elevated blood sugars, high blood pressure, fluid retention, increased infections, thin skin Often difficult to tell Effects from polycythemia, often change in performance that may be unusual Nerve, muscle, or joint pain, edema, elevated blood sugar, carpal tunnel syndrome, numbness and tingling of the skin, high cholesterol levels

Glucocorticoids

Erythropoietin (EPO) Growth hormone/IGF-1

Signs/symptoms of withdrawal Headaches, sleep changes, mood changes, fatigue

Sleep problems, craving, irritability, anger, anxiety, restless, depressed mood, reduced appetite and weight changes, shakiness, sweatiness, fever, chills, headache Watery eyes, rhinorrhea, diarrhea, muscle cramps, goose flesh, sweating, nausea, vomiting, dysphoric mood, yawning, fever, insomnia Fatigue, unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation/ agitation

Fatigue, physical weakness, muscle aches, joint pain, appetite and weight loss, nausea and vomiting, diarrhea, abdominal pain Difficult to tell

Fatigue, irritability, increased fat content

3 Doping Control/Testing The testing of athletes involves urine and/or blood collection. Athletes can be tested 365 days per year without advance notice, both in competition and out of competition. Doping control is the efforts of organized sports federations or leagues to identify athletes who dope and to educate all athletes, coaches, and athlete support personnel on the health risks associated with doping. Once notified, they are informed by a doping control officer and accompanied by a chaperone. In addition, they are required to inform United States Anti-Doping Agency (USADA) (or

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equivalent in county of origin) of their daily regular schedule and must report changes. In the process where a sample of urine or blood is obtained, a chain of custody process is followed. It is a protocol to ensure the sample is not tampered with before being received and evaluated in the testing lab [1, 8]. The World Anti-Doping Agency (WADA) regularly updates and publishes versions of the World Anti-Doping Code (“the Code”) and International Standards. The latest came into force on January 1, 2021. The Code is the fundamental and universal document upon which the World Anti-Doping Program in sport is based. It is divided into several articles and parts. The Athlete Biological Passport (ABP) is used to monitor blood and urine over a longitudinal course in athletes. Repeated samples are taken over time. The hematological ABP module includes several targets to monitor over time that follow the athlete and include hematocrit, hemoglobin concentration, red blood cell (RBC) count, and reticulocyte percent and count, to name a few. It is helpful to identify EPO use or blood transfusions. EPO is used to increase blood oxygen-carrying capacity to increase performance especially in endurance sports and helps with training and in competition. EPO can be detected in blood or urine and tested using the hematological ABP. The steroidal ABP targets androgen use and may require isotope ratio mass spectrometry (IRMS) testing to evaluate the testosterone/epitestosterone (T/E) ratio. The T/E ratio can be influenced by alcohol, 5-alpha reductase inhibitors, aromatase inhibitors, anti-estrogens, diuretics, and ketoconazole. An athlete who has been drinking alcohol the day before a test may have a doubled T/E ratio [3, 22].

4 Culture of Doping in Sport Culture is often defined as the arts, customs, lifestyles, background, and habits that characterize a particular society or nation and includes the beliefs, values, behavior, and material objects that constitute people’s way of life. Although athletic competition (sport) is not a society or nation, it clearly has its own unique culture. A key component of the belief system of sport is the commitment to fair competition, health and safety of the athlete, and integrity of sports. Sports doping is broadly defined as the use of banned drugs to improve athletic performance. This includes banned drugs to increase muscular size and strength, decrease recovery time from injury or intense workouts, increase oxygen capacity, or mask other banned substances from detection. Sports doping is as old as competitive sport, dating back to ancient Greece, and is in direct violation of the core tenets of sport culture. It is cheating and, when detected, has always resulted in sanctions to the offending athlete or team. Organized anti-doping programs (testing for banned substances) date back to the late 1960s and are now an integral component of most athletic competitions. The development of the World Anti-Doping Agency (WADA) has demonstrated the commitment by organized sports to attempt to ensure fair competition, protect the safety of athletes, and maintain the integrity of sports. Over

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the years, doping control programs have struggled to keep pace with athletes’ intent on gaining an unfair competitive advantage. Unfortunately, certain sports have historically had more of a challenge dealing with a subculture of doping. Cycling and powerlifting have suffered a long history of doping, just to stay competitive. The use of anabolic steroids to improve strength and power in weightlifting dates back to the 1940s, and the locker room belief that “if you ain’t cheatin, you ain’t tryin” has been attributed to cycling. This culture complicated efforts to reverse the doping practice in these sports [1]. Athletes who dope to achieve an unfair advantage represent a very small minority of competitors. In fact, many athletes themselves are the strongest advocates of a clean sport and should be credited for continuing to advance anti-doping programs across all sports. However, all athletes need to be educated about the growing list of banned substances and take responsibility for everything they put in their bodies. WADA has dedicated significant resources to educate athletes, coaches, and trainers on advances in anti-doping strategies. An effective anti-doping program requires the interprofessional collaboration of all stakeholders, including athletes, healthcare providers, sports federations and leagues, doping control officers, and the sports media. A consistent, coordinated message focused on the key elements of athlete safety, fair competition, and sport integrity is essential. Athletes must be assured that doping is not a venerable part of any sport subculture and is simply not tolerated in any form.

5 Case Study Player V is 32, married with two young children, and a contracted professional football (soccer) player in the UK.  Some of his career was played at a top-tier “Premier League” club in England, but he is now playing as a midfielder in the “Championship” tier below. He is currently receiving support to face a Football Association disciplinary tribunal, following the discovery of metabolites of cocaine in a urine sample that was provided to a doping control officer in the hours before a Championship league match against his club’s local rivals. V is the eldest of several brothers. He was born into a devout Catholic family in a South American country in which football (soccer) was passionately supported and revered in his community. His family had few resources as he grew up. Both of his parents sometimes worked more than one job and, at other times, worked in none at all. He and his brothers were close. V’s father played football for his local side, and while his mother worked and fulfilled a role as homemaker, she had during late adolescence and early adulthood been a successful competitive swimmer. V’s grandparents are deceased. One—to whom he was close as a child—died recently. There is no family history of mental disorder, the latter which was generally frowned upon within his family. V suspects that his father had periods when he struggled to control his alcohol use.

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V had an interesting route into professional sport. He and his brothers attended many years of education in South America. Due to the family’s financial circumstances, they found themselves working during adolescence. Applying themselves fully to learning was difficult. V describes healthy attachment toward both parents; however, he recalls a clear sense of longing for financial security and prosperity as a young boy. There was no account of proxy achievement in sport; his parents were encouraging of his developing football skills but not for the purposes of competing and sport for its own reasons. Success at professional sport was, instead, seen by all the family as a possible route out of financial insecurity. V was the only one of his brothers for whom his level of sporting ability and potential suggested that this outcome seemed a possibility. Later into adolescence he displayed sufficient dedication and commitment that he was offered the opportunity to travel to North America, where he found the opportunity to play NCAA soccer. Here, he was scouted and offered professional contracts first in mainland Europe before, latterly, in England. Persistent issues with his right anterior cruciate ligament (ACL), including one that required complex arthroscopic surgery, saw him unable to persist with his sporting career at the highest level but did not necessitate retiring prematurely. Given his upbringing and his own fatherhood, V views the twilight of his career as an important opportunity to make sufficient income to allow him to provide for his young children in the way his parents could not for him. V feels that his earnings and employability away from football are significantly more uncertain. V married some years ago. His wife has her own career in marketing. Her opportunities to progress in income and through promotion were limited after they started a family together. However, she is now returning to work in a more time-consuming way, including needing to spend time away from home and their children. V’s wife is also South American. For this reason, they often perceive there is little support for them as parents of young children in England. This is a stressor that can make it harder for them to remain close. This aside, V and his wife have for some years enjoyed a relationship that was stable, faithful, and a source of support for both. V describes no history of childhood or adolescent mental ill health or disorder. In the US college system and later, he reports never having needed to access counselling, therapy, or clinical psychology support of any formal kind. He has always felt an interest in the mental and psychological side of sport, but his access to trained practitioners has been limited (or focused on team, rather than individual interventions). V feels that there was a culture in his family where changes in people’s mental well-being were not openly discussed. V spoke about his experiences of drug use. As an adolescent in South America, he and his peers were exposed to a variety of available drugs and alcohol. For the most part, his aspirations to become a professional athlete tempered any early drug use. However, V noticed, even as a young person, the way in which occasional cocaine use offered an intensely pleasurable rush that served as an immediate escape from whatever he happened to be feeling. Throughout his time playing NCAA soccer, V used no drugs at all. A period of many years of sobriety from drugs ended after his first significant injury; V struggled with worry about whether he would return to top-level football as he steadily completed his rehabilitation. V’s wife

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eventually discovered cocaine in his possessions, and she confronted him about the potential effects of drug use upon their children. V’s parents remain unaware that he has ever used cocaine. V was released by the Premier League club to which he was contracted at the time. To his knowledge, this was without them being aware of his cocaine use; instead, it was in the context of injury and absence from the team. V has no experience of any community drug treatment or harm minimization program. In his current team, V is one of a small number of players to whom the use of cocaine is known to each other. They will sometimes use together while other players celebrate match wins in a different way. Now contracted to a smaller club, V has once again found himself without a guarantee of regular selection for around 2 months. During that time, aware of his age, V has noticed that deselection has been associated once more with worries about future income and being able to provide for his young children. V found that the use of cocaine became more tempting. For some weeks, cocaine has insidiously become something that he has been using more often and hiding from others: his wife, his teammates, his agent. V describes a persistent desire to use cocaine, driven by the absence of any sense of worry while taking it. He began to struggle to stop using it in the last month, despite an awareness that it was likely to be damaging his ability to train and play and recover as effectively as he wanted to, in order to return to first team selection. V was subject to a random doping control in the hours before a Championship league match against his club’s local rivals. The metabolites of cocaine were discovered in a urine sample provided to a doping control officer. V had believed he would not be playing and, when called up late due to an injury, had felt he had to take his opportunity to play despite having used the drug earlier that day. The case of V is not unusual in relation to how drug use can present in elite football. However, the sanction for situations of this kind has been altered significantly in the above. V’s legal representatives have taken time and care to set out for the relevant authorities not only the intentions behind his drug use but also his beliefs about its effects upon his footballing performance. Previously, a finding of intentionality around an anti-doping rule violation (ADRV) involving a specified substance or method might have resulted in a period of ineligibility of up to 4 years. Notwithstanding any other provision in Article 10.2 of the code, where the anti-doping rule violation involves a substance of abuse, if an athlete can establish that any ingestion or use occurred out of competition and was unrelated to sport performance, then the period of ineligibility shall be dramatically reduced to 3 months. Further, if V were open to the completion of a substance of abuse treatment program approved by the relevant Anti-Doping Organization with Results Management responsibility, his period of ineligibility may be reduced to 1 month. Even where the ingestion, use, or possession occurred in competition, if the athlete can establish that the context was unrelated to sport performance, then this shall still not be considered intentional for purposes of Article 10.2.1. It shall not provide a basis for a finding of “Aggravating Circumstances” under Article 10.4.

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6 Treatment Issues Clinicians who provide physical and mental health care to athletes play an important role in sports anti-doping programs. Every provider caring for athletes who prescribes or recommends medications or supplements must be familiar with the list of banned substances and how to attain therapeutic use exemptions (TUE) in a timely manner. Many sports require trained clinicians who are certified to conduct a TUE evaluation before granting the athlete permission to use a banned substance. This is particularly prevalent in the use of stimulants to treat attention-deficit/hyperactivity disorder (ADHD) [6]. Just getting a prescription from a doctor does not automatically grant permission to use the medications. Although the athlete is ultimately responsible for everything they put in their bodies, they rely on the provider to be knowledgeable of banned substances, and not put their careers in jeopardy. Olympic athletes have lost medals over taking medications they were taking for legitimate medical conditions that were banned, and they did not get an approved TUE prior to testing. The health and well-being of athletes are always of prime importance to providers, but the rules of doping must be followed. This requires the prescribing physician to stay up to date with all doping guidelines and closely monitor WADA guidelines. The clinician must also take responsibility to confirm all members of the medical/training staff, coaches, and players are aware of doping guidelines, including the potential for over-the-counter supplements being on the banned list. Many ingredients found in OTC supplements may be banned, without the athlete being aware of the potential risk of use.

7 Interprofessional Integration of Care Model for Collaboration

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8 Responsibilities of Stakeholders 8.1 Athlete Ultimately, the athlete is responsible for everything they put into their body. Ignorance of the inclusion of a substance being banned is not acceptable. The athlete must be extremely cautious when taking any medication, especially unregulated supplements. The athlete should have the team physician clear all medications and supplements. Certain banned substances may be allowed after obtaining a therapeutic use exemption (TUE) from the doctor. The athlete should wait for approval of the TUE before starting or continuing any banned substance. Athletes are strongly encouraged to not rely on their personal provider for clearance, as many are not familiar with doping guidelines. The World Anti-Doping Agency (WADA) is an excellent source of information on all banned substances. Even a drug that is not a performance enhancer may be banned because of its potential to mask other banned substances. When in doubt, check it out!

8.2 Teammates Athletes will frequently discuss what they are taking, and why, with their teammates. Teammates should remind their colleagues of the dangers of taking supplements with unknown ingredients or any medications not cleared by the team doctor. Certain sports have had a history of doping as part of the culture of the sport, and teammates can help provide support to call out and discourage such practice. If a teammate has concern over the behavior of a fellow teammate, they might consider discussing the situation with a trusted trainer to assist in addressing a doping issue. This may not be easy, but it could save the career of a teammate.

8.3 Coaches Coaches can set the tone of the importance of strict adherence to all doping rules. The coach should inform all athletes of the risk of taking anything not approved or cleared for consumption. Coaches can make sure all athletes are fully aware of resources available to the athlete to discuss personal issues regarding medications and supplements. The coach should make a clear statement that doping violations not only impact the athlete but reflect negatively on the team and the entire sport. Simultaneously, coaches should take care to be a trusted and non-judgmental figure in order to foster an environment that athletes feel safe coming to them for help.

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8.4 Trainers and Athlete Care Providers The athlete will rely on trainers and all members of the health-care team to provide accurate, up-to-date information regarding banned substances. It is the responsibility of care providers to direct the athlete to appropriate resources when they have any questions regarding doping issues. Never assume that just because a medication or supplement is not considered a performance enhancer, it might still be listed as a banned substance. Recent reports of athletes eating food which may have resulted in a failed drug test are not an accepted excuse. Health professionals need to take on the responsibility of ensuring the athlete is well informed about all doping issues and create a culture of always ask and never assume. In addition, the health risks associated with drugs of abuse, like steroids and stimulants, must be made clear to the athlete. Mental health providers in particular fill a vital role in discouraging doping from the root motivation—if a provider suspects or knows an athlete is considering or is currently doping, the appropriate resources and mental support must be provided.

8.5 Governing Bodies All leagues and governing bodies should mandate effective and user-friendly education to all athletes, coaches, and healthcare providers on doping issues. This should include confidential access to hotlines for questions on doping and all banned substances. While there may be a need for punitive measures, the importance of support and open discussion should be equally, if not more, important. The league can set the tone for maintaining drug-free competition for all. The overarching goals of doping control—health of the athlete, fair competition, and the integrity of sports— need to be directly addressed by leadership of sports federations.

9 The Future-Evolving Issues in Doping in Sport Gene doping is the manipulation of the human genome. Gene therapy may provide treatment for diseases that result from mutations. The ability to manipulate the expression of functional genes and protein, along with the ability to influence protein synthesis, is appealing to the performance world. Gene doping is defined as the “transfer of cells or genetic elements or the use of pharmacologic or biologic agents that alter gene expression.” Gene doping can influence strength, explosiveness, endurance, and recovery. Today, there is an emerging science of genetic elements associated with athletic traits. The potential to target specific genes that affect performance or tissue repair is a growing area of interest. Gene doping may influence muscle fiber type that is associated with strength, power, and explosiveness. IGF-1

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and myostatin are genes that appear to influence strength. The ACE gene appears to have associations with cardiac and respiratory function and improve endurance in athletes. EPO and PPAR are specific genes that may affect endurance. An athlete predisposed to an injury may be identified early, and gene doping may prevent or minimize an injury by accelerating recovery. This area of science is still developing along with its application [23]. Another Athlete Biological Passport (ABP) in development includes an endocrine ABP that targets growth factors such as IGF-1 and growth hormone [24]. It may prove beneficial in the emerging practice of micro-dosing, the use of small doses of androgens that can avoid detection [19]. MicroRNAs (miRNAs) are small non-coding RNAs that regulate various biological processes. Since circulating miRNAs are highly stable in several body fluids, they hold potential as a new class of biomarkers for the detection of doping and may become a part of the Athlete Biological Passport. To detect gene doping and the consequences of alteration of genetic material, transcriptomics and proteomics may lead the way—RNA sequencing in the detection of anabolic steroid use and discovering the molecular mechanism of muscle memory is being explored [25]. Short- or long-term exposure to anabolic-androgenic steroids (AAS) might have a sustained effect on muscle morphological changes that sustain increased muscle mass and size leading to improved performance even after use has stopped [26]. Gene markers to detect the use of AAS and change in the morphology are being studied along with molecular signals using RNA sequencing [25]. Trends in drug testing also focus on methodology-dependent techniques such as cation exchange and analysis by Liquid Chromatograpy (LC)-Mass Spectrometry (MS)/MS, hydrolysis Gas Chromatograpy (GC)-MS/MS, solid-phase extraction (SPE) analysis, and LC-High Resolution Mass Spectrometry (HRMS). In the detection process, new strategies are being used and include the following [27]: Class Anabolic, growth factors, hormone and metabolic modulators, some opioids, cannabinoids Stimulants and diuretics Growth hormone and gonadotropin-releasing peptides (blood) Endogenous steroids Testosterone/Estrogen (T/E) ratio and some exogenous steroids EPO

Method of detection Fraction of urine by SPE and LC-MS/MS LC-HRMS SPE and LC-HRMS Hydrolysis, SPE, and GC-MS/ MS Sarcosyl-page

10 Summary Doping has been an unwelcome part of sport dating back to the ancient Greeks. The desire to win at any cost for some athletes has not changed over the millennia and will continue, especially as the financial reward for winning continues to grow significantly.

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Despite advances in doping control techniques and significant Investment in doping control programs in organized sport, seeking an unfair competitive advantage through the use of banned substances continues to make headlines and tarnish the reputation of athletes testing positive for banned substances. Doping, the use of a banned substance to improve performance or mask the use of another banned substance, is as old as sport itself. The goal of all doping control programs is to (1) protect the health of the athlete, (2) promote fair competition, and (3) maintain the integrity of sports. Over the past four decades, doping has become much more sophisticated and increasingly dangerous to the athlete’s immediate and long-term physical and mental health. In addition to performance enhancement, some athletes dope in order to return from injury quicker or extend their career. Certain sports have had a culture of doping over the years (“if you ain’t cheatin, you ain’t tryin”), but this has dramatically improved over the past decade. As laboratory detection techniques have advanced over the years, so to has doping (cheating) techniques. Doping has expanded from anabolic steroids used to increase strength and muscle mass to the use of masking agents to prevent detection of other banned substances and increase endurance through increased EPO and other agents to decrease recovery time from intense workouts and injury. Gene doping, the external manipulation of the human genome to improve athletic performance, has been banned by the World Anti-Doping Agency, despite documented cases in humans. The technique has been demonstrated in laboratory animals. Effective anti-doping programs start with educating all stakeholders, clear guidelines, and user-friendly resources available to athletes in a confidential setting. Everyone involved in sport needs to become a part of the solution to doping, not a contributor to the problem. As rewards for athletic success have risen dramatically over the years, the temptation to cheat has been enhanced. Fair and consistent penalties for those caught cheating and a growing emphasis on healthy competition can help change a culture where doping is considered a part of sports. The overwhelming majority of athletes have historically taken a strong stance supporting doping control programs and seek fair competition and athlete safety. Effective doping control needs to begin early in youth sports and continue through all levels of competition (Olympic and professional). The improvement of athletic performance needs to be driven by advanced training techniques, mental health, and improved equipment and technology, not advances coming out of a pharmaceutical lab. All stakeholders in organized sport need to collaborate to be a part of the solution in eliminating banned performance enhancement. Too much is at stake for all concerned. Unfortunately, this ongoing cat and mouse game between cheaters and those agencies working to keep sport clean will continue to be an unwanted reality of sporting competition.

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References 1. Andren Sandberg A.  Encyclopedia of anti-doping. In: An era of evidence based medicine. Stockholm: Karolinska Institute University Hospital; 2015. 2. Baron D, Martin D, Magd SA. Doping in sports and its spread to at-risk populations: an international review. World Psychiatry. 2007;6:118–23. 3. ISTI, ISL athlete biological passport operating guidelines. 2019. https://www.wada-­ama.org/ sites/default/files/resources/files/guidelines_abp_v71.pdf. Accessed 17 Aug 2021. 4. Torres C. Passport control to prevent athlete doping. Nat Med. 2010;16:142. 5. McDuff DR, Baron D. Substance use in athletics: a sports psychiatry perspective. Clin Sports Med. 2005;24:885–97. 6. Prohibited list–world anti-doping agency. https://www.wada-­ama.org/sites/default/files/ wada_2020_english_prohibited_list_0.pdf. Accessed 17 Aug 2021. 7. Heuberger JA, Cohen AF.  Review of wada prohibited substances: limited evidence for performance-­enhancing effects. Sports Med. 2018;49:525–39. 8. Anti-Doping rule Violations (ADRVs) Report. In: World Anti-Doping Agency. 2020. https://www.wada-­ama.org/en/resources/general-­anti-­doping-­information/anti-­doping-­rule-­ violations-­adrvs-­report. Accessed 17 Aug 2021. 9. Anti-Doping testing Figures REPORT.  In: World Anti-Doping Agency. 2021. https://www. wada-­ama.org/en/resources/laboratories/anti-­doping-­testing-­figures-­report. Accessed 17 Aug 2021. 10. de Hon O, Kuipers H, van Bottenburg M. Prevalence of doping use in elite sports: a review of numbers and methods. Sports Med. 2014;45:57–69. 11. Amalia M.  Selective androgen receptor modulators (SARMS) in the context of doping. Farmacia. 2018;66:758–62. 12. Mazzeo F. Anabolic steroid use in sports and in physical activity: overview and analysis. Sport Mont. 2018;16:113–8. 13. National Institute on Drug Abuse. Marijuana DrugFacts. In: National Institute on Drug Abuse. 2021. https://www.drugabuse.gov/publications/drugfacts/marijuana. Accessed 17 Aug 2021. 14. Green GA, Petr TA, Uryasz FD.  NCAA study of substance use and abuse habits of college student-athletes. Clin J Sport Med. 2018;11(1):51–6. https://pubmed.ncbi.nlm.nih. gov/11176146/. Accessed 17 Aug 2021 15. McDuff D, Stull T, Castaldelli-Maia JM, Hitchcock ME, Hainline B, Reardon CL. Recreational and ergogenic substance use and substance use disorders in elite athletes: a narrative review. Br J Sports Med. 2019;53:754–60. 16. Martínez-Sanz J, Sospedra I, Ortiz C, Baladía E, Gil-Izquierdo A, Ortiz-Moncada R. Intended or unintended doping? A review of the presence of doping substances in dietary supplements used in sports. Nutrients. 2017;9:1093. 17. Garthe I, Maughan RJ.  Athletes and supplements: prevalence and perspectives. Int J Sport Nutr Exerc Metab. 2018;28:126–38. 18. van Amsterdam J, Hartgens F.  Acute and chronic adverse reaction of anabolic–androgenic steroids. Adverse Drug React Bull. 2014;288:1111–4. 19. Piacentino D, Kotzalidis G, Casale A, Aromatario M, Pomara C, Girardi P, Sani G. Anabolic-­ androgenic steroid use and psychopathology in athletes. A systematic review. Curr Neuropharmacol. 2015;13:101–21. 20. Vorona E, Nieschlag E. Adverse effects of doping with anabolic androgenic steroids in competitive athletics, recreational sports and bodybuilding. Minerva Endocrinol. 2018;43:476. https://doi.org/10.23736/s0391-­1977.18.02810-­9. 21. McCartney D, Benson MJ, Desbrow B, Irwin C, Suraev A, McGregor IS.  Cannabidiol and sports performance: a narrative review of relevant evidence and recommendations for future research. Sports Med–Open. 2020;6:27. https://doi.org/10.1186/s40798-­020-­00251-­0. 22. Elliott S. Erythropoiesis-stimulating agents and other methods to enhance oxygen transport. Br J Pharmacol. 2008;154:529–41.

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23. van der Gronde T, de Hon O, Haisma HJ, Pieters T. Gene doping: an overview and current implications for athletes. Br J Sports Med. 2013;47:670–8. 24. Nicholls AR, Holt RIG. Growth hormone and insulin-like growth Factor-1. Front Horm Res; 2016. p. 101–14. 25. Leuenberger N, Robinson N, Saugy M. Circulating mirnas: a new generation of anti-doping biomarkers. Anal Bioanal Chem. 2013;405:9617–23. 26. Pokrywka P, Cholbinski P, Kaliszewski P, Kowalczyk K, Konczak D, Zembron D, Lacny A. Metabolic modulators of the exercise response: doping control analysis of an agonist of the peroxisome proliferator-activated receptor δ (GW501516) and 5-aminoimidazole-4-­ carboxamide ribonucleotide (AICAR). J Physiol Pharmacol. 2014;65:469–76. 27. Thevis M, Kuuranne T, Geyer H, Schänzer W.  Annual banned-substance review: analytical approaches in human sports drug testing. Drug Test Anal. 2017;9:6–29.

Further Reading McDuff D, Stull T, Castaldelli-Maia JM, Hitchcock ME, Hainline B, Reardon CL. Recreational and ergogenic substance use and substance use disorders in elite athletes: a narrative review. Br J Sports Med. 2019 Jun;53(12):754–60. Sport Psychiatry. Special issue: psychiatric issues of “doping” in Sports Vol 1:4 November 2022. Stull T, Morse E, McDuff D.  Substance use and its impact on athlete health and performance. Psychiatr Clin N Am. 2021;44(3):405–17.

After Sexual Abuse or other Extreme Life Events Thomas Wenzel, Anthony Fu Chen, and Reem Alksiri

1 Introduction and Brief History of Research and Clinical Care Extreme life events such as war or rape can and do lead to reactive long-term psychological “trauma” (a term taken from surgery) in a majority of those affected, even those with good resilience. This idea has by no means always been an accepted paradigm in medicine. The extreme suffering of many concentration camp victims observed after World War II resulted in the creation of diagnostic categories (concentration camp or “survivor” syndrome), but it was not until a lengthy discussion later, in the preparation of the Diagnostic and Statistical Manual revision (DSM III), when a distinct diagnosis of posttraumatic stress disorder (PTSD) was finally introduced [1]. In this case, it was used to describe the symptoms of Vietnam War veterans. Only in recent years, a by-now very large body of research has demonstrated that a number of clinical disorders including, but not limited to, posttraumatic stress disorder are not only frequent but sometimes even to be expected after seemingly less severe life events [2, 3]. This paradigm shift has been slow and hesitantly accepted by the field. This slow progress might reflect a strong preexisting bias against accepting that it is normal, and not a sign of weakness or lack of resilience, for many people to respond to adverse life events in this way. As of October 2020, nearly 6000 publications focusing on PTSD can be identified in MEDLINE alone. In sports medicine and sports psychiatry, the bias against this idea has been probably even stronger, probably due to the expectation that athletes should be more resilient due to their prowess in sports and competition. Because of this bias, only few research papers have been published on PTSD as a characteristic sequela of traumatic events in athletes, in spite of the recent claim by Lynch et al. [4] that “1 T. Wenzel (*) · A. F. Chen · R. Alksiri World Psychiatric Association Scientific Section for Sport and Exercise Psychiatry, and OEGBA, Vienna, Austria © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 D. Baron et al. (eds.), Sport and Mental Health, https://doi.org/10.1007/978-3-031-36864-6_8

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out of eight athletes suffers from PTSD.” Similarly, Aron et al. concluded in a narrative review published in the British Journal of Sport Psychology that “Athletes may exhibit greater rates of PTSD (up to 13–25% in some athlete populations) and other trauma-related disorders relative to the general population” [5]. Research has followed PTSD in association with brain trauma (see also the separate chapter in this book). Brassil et al. [6] used a pre- and post-test group design to compare a post-concussion group (n  =  62) to a matched control group of healthy athletes. Results indicated a higher rate of PTSD symptoms in the concussed group. The relative lack of systematic research corresponds with the more general bias against accepting the existence of mental health problems in athletes [7] and was addressed by recent International olympic Committee (IOC) statements [8, 9]. Many suicides of prominent athletes, including that of the German national goalkeeper [10], have drawn attention to the fact that it may be an invalid assumption that athletes have superior resilience. Athletes suffer from life events, both related and unrelated to their sport, just like any other population [5, 11–15]. In the world of sports, sportsrelated injuries [16–18] and sexual abuse in the sporting world [19] have received substantial attention, for example, in psychologist John Heil’s groundbreaking book on the psychology of sports injuries [20] and a 1991 publication by Gregory [21]. Newcomer et al. evaluated 283 athletes during the preseason including 43 without and 240 with history of injury using the Impact of Events Scale to elicit typical PTSD symptoms. Those with a recent injury history reported a higher frequency of intrusive thoughts and avoidance behavior [22] typical for PTSD. Suicides have also been identified as possible sequelae of traumatic events like sports injuries [23], especially if combined with brain trauma [24] or other stressors such as retirement [25]. A recent review by the National Collegiate Athletic Association (NCAA) reports an overall suicide rate of 0.93/100,000 per year in the already high-risk youth population. Another retrospective Internet query-based study on professional US football players identified 26 players who completed suicide [15]. Recent publications reflecting the creation of the special research group Enigma [26] have taken up this earlier research [27–30] and follow up on sports injuries, especially “blunt” and “mild” traumatic brain injury (TBI), as a contributing factor to psychological problems in athletes (see again the separate chapter by Baron et al. in this book). Brain trauma during accidents and sports injuries has been observed as an important factor that can cause many symptoms in athletes (see the separate chapter in this book). While PTSD and TBI may be similar in their relation to the presence of “trauma,” their presentation and treatment differ. Many TBI patients may experience psychologically traumatic events at the same time as the physical trauma, thus developing PTSD or trauma spectrum disorders [31–34], but the neurobiological mechanisms [35, 36] and treatment strategies are different, and symptom profiles only partly overlap. In both disorders, concentration and memory problems, irritability, or disturbed sleep are common, but other symptoms such as intrusive memories (flashbacks) or event-specific nightmares correlate only with PTSD. Also, most patients explored in general PTSD research did not experience TBI [37], and not all TBI patients develop PTSD.  It should be noted that a dual diagnosis is frequently associated with a worse outcome, including higher suicide

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rates [38, 39]. Differing prevalence of PTSD in large populations depends on exposure to adverse psychological and social events, not on prior TBI [37, 40, 41]. Therefore, PTSD and TBI need to be examined separately. It should be considered that in these few publications, there is often a focus on the performance of professional competitive athletes [42], who are in a very special environment that might shape risk factors, response, and treatment needs. In some countries, political, ethnic, or racist persecution and even war or civil war must be considered as primary sources of posttraumatic stress-related disorders independent from sports-related events. Lethal danger must unfortunately also be considered, as in the case of the Iranian wrestler who was sentenced to death despite international protests including that of World Players Association, after what was perceived internationally to be an inadequate trial with a confession likely coerced by torture.1 In another example, no major published study has, to our knowledge, followed up with the athletes exposed to terrorist attacks during the Munich Olympic Games, or the athletes exposed to abuse, repression, and forced doping in totalitarian regimes such as the former Eastern German Republic with the probable exception of doctoral and PhD thesis papers [43]. As noted in the chapter by Wenzel et al. in this book, human rights are also important to protect athletes and all civil society members from common factors resulting in traumatic stress (Fig. 1). Fig. 1  Potential exposure to traumatic events to be considered in athletes Accidents, death, or illness of family members

Domesc violence (present or past)

Psychological wellbeing, social and ocucpaonal funconing,

Sexual Abuse (family, school, sports)

performance

Mobbing, stalking, discriminaon in school, work or team

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 h t t p s : / / w w w. t h e g u a r d i a n . c o m / w o r l d / 2 0 2 0 / s e p / 1 2 / iranian-champion-wrestler-navid-afkari-executed-despite-global-outcry 1

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However, it has also been demonstrated that some sports activities in turn can be helpful in clients suffering from posttraumatic stress disorder if applied as part of an intervention package [44, 45]. Due to the data available from other (non-athlete) groups, a number of important conclusions can still be drawn for the care of athletes exposed to potentially traumatic events: 1. Extreme life events, including sexual abuse, can lead to or can be associated with a number of clinical symptoms and disorders, not limited to posttraumatic stress disorder, depending on age, event experienced and other factors. The term “trauma spectrum disorders” has therefore been introduced into the discussion [46, 47]. In children and younger adults, for example, eating disorders such as anorexia nervosa, which is also already part of the “athlete’s triad” [48–50], as well as somatization and somatoform disorders [51, 52] (where symptoms “cannot be sufficiently explained by physical findings”), have been linked to past sexual abuse or family violence [53, 54], but in adults, this context is rarely reported. Sundgot-Borgen et al. in a recent study have confirmed that eating disorders can be related to abuse in athletes [55]. Somatization after earlier abuse could play a role in delayed recovery from injuries in athletes [56] but can also reflect cultural factors that also must be considered in the treatment setting (see also the chapter on transcultural sport psychiatry in this book). Nearly all patients who are survivors of extreme violence like torture who suffer from posttraumatic stress disorder also suffer from mood and other comorbid disorders, especially depression [57, 58], and complications might include drug and substance use disorders [59– 61], especially if adequate treatment for problems like posttraumatic sleep disorders or nightmares is replaced by misguided self-help strategies like alcohol use to avoid mental health-related stigma. Specific impairment in many areas of life, including family interaction, job performance, and sexual functioning, has also been observed [62–64] and might be considered independently from or as part of a full clinical diagnosis of PTSD or other disorders. In summary, research has demonstrated that the singular focus on posttraumatic stress disorder, which was especially present in earlier research, is not sufficient and must be replaced by a multilevel approach considering comorbidity and other factors and symptoms. Due to the well-documented range of symptoms in posttraumatic stress disorder and other disorders observed after extreme life events, including lack of drive, decreased activity level, loss of self-confidence, impaired memory and concentration, dissociation, irritability, and impaired sleep, it should be expected that athletes who suffer from these extreme life events, regardless if it is sports related or external, will also suffer with regard to their performance, team integration, or other metrics of sport. Early recognition and treatment by an expert are therefore of crucial importance to protect the health of the athlete, possible indirect victims such as family members, and their sports career. Posttraumatic stress disorder is defined as An anxiety disorder precipitated by an experience of intense fear or horror while exposed to a traumatic (especially life-threatening) event. The disorder is characterized by intrusive

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recurring thoughts or images of the traumatic event; avoidance of anything associated with the event; a state of hyper arousal and diminished emotional responsiveness. These symptoms are present for at least one month and the disorder is usually long-term.2 … develops in reaction to physical injury or severe mental or emotional distress, such as military combat, violent assault, natural disaster, or other life-threatening events. Having cancer may also lead to post-traumatic stress disorder. Symptoms interfere with day-to-day living and include reliving the event in nightmares or flashbacks; avoiding people, places, and things connected to the event; feeling alone and losing interest in daily activities; and having trouble concentrating and sleeping.

The discussion on posttraumatic stress disorder as the most common sequela of stressful/traumatic events is further complicated by the frequent changes in definition between the different versions of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) and the World Health Organization’s International Classification of Diseases (ICD) [65–67]. They provide different diagnostic categories and symptom lists to be considered. In the most recent version of the DSM, the DSM 5, potentially associated symptoms of posttraumatic stress disorder such as dissociation and lack of trust, which are especially characteristic of PTSD after sexual abuse, have been integrated into the diagnosis [68], while the recent ICD revision (ICD-11) uses a slightly different definition and different categories, adding, for example, “complex” PTSD, characteristic also for sexual abuse and violence, as a separate category [69]. For children and young adults, attachment disorder has been officially integrated into the system, as this is a typical sequela especially of sexual violence experienced at an early age [70]. Other common but nonspecific sequelae include, as noted above, somatoform and eating disorders.

1.1 Sexual Abuse While many other traumatic experiences are commonly examined in psychological trauma research, an especially important problem is, again, sexual abuse, and this has become a major focus of not only research [19, 71] but also public discussion. It is important to consider that with sports, especially high-performance competitive sports, such as at the competitive college level [72, 73], there are high-risk situations that could lead to the sexual abuse of minors (as outlined in Table 1). This appears to be a global problem. For example, Ohlert et al. reported interpersonal violence experiences including sexual abuse in more than 24% of respondents in a sample of elite athletes from the Netherlands, Belgium, and Germany [74]. In a study by Fasting et al. comparing 660 Norwegian elite female athletes with an age-matched control sample of non-athletes, the athletes “experienced significantly more harassment from male authority figures than did the controls” [55, 75]. Navarro et  al. reported stronger agreement with rape myths, which potentially lower the barrier

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Table 1  Risk for sexual abuse, harassment, and trauma in sports Risk Trainers and coaches as trusted “alternative” caregivers, resulting in possible “transference” factors (in psychoanalytical terms), taking in practice or imagination the role of parents

Comment During sexual development, parents can become the focus of developing sexuality and therefore be at risk for committing abuse; this risk is extended to the trainer or coach as a replacement parent Frequent physical proximity and situations of Might be even more critical when limited undressing or restricted/revealing clothing facilities and slow inclusion of female athletes in “male disciplines” prevent sufficient separation of sexes Revealing the existence of abuse could Ambition or dependency on scholarships and jeopardize the career that athletes, sport-active financial benefits in parents or young athletes children or parents might see as being of central might lead to the decision not to report abuse importance in their lives of the athlete or other team members Team pressures and national or political National prestige considerations might interests might further limit reporting influence the athletes, families, other team members, or trainers, especially in autocratic regimes where severe sanctions might follow if abuse is disclosed Other risk factors for non-disclosure and limited help-seeking include threats of diverse sanctions threatened by the perpetrator in retaliation, or the feeling of obligation by the victim to keep silent

for sexual assault, in college athletes than in non-athletes [76]. Timpka reported on a larger sample of 197 Swedish athletes and observed that 11% reported lifetime sexual abuse, with a higher proportion of women reporting it (16.2%) than men (4.3%) (p = 0.005). Abuse exposure was associated with an increased likelihood of a non-sports injury (OR 8.78, CI 2.76 to 27.93; p