A Psychiatric Perspective on Athletes With Eating Disorders

Transcription

1 EATING DISORDERS Journal of Clinical Sport Psychology, 2007, 1, Human Kinetics, Inc. A Psychiatric Perspective on Athletes With Eating Disorders Alan Currie University of Newcastle, UK Athletes with eating disorders risk compromising not only their performance but also their health and general well-being. These serious issues make recognizing and treating eating disorders extremely important. Unfortunately, the prevalence of eating disorders in certain sports is high, and identifying problems can be difficult. Accessing and engaging such athletes in effective treatment is also no easy task. By fostering understanding and cooperation between clinicians and others who work in the sport environment, athletes will have the best opportunity to access high quality treatment at the right time and have the greatest chance to repair both their health and sport performance. This paper takes a psychiatric perspective on eating disorders among athletes and discusses prevalence, diagnostic issues, and treatment options. Eating disorders are complex, multifactorial medical conditions. Whether or not they occur in a sporting context, they can seriously compromise the health of the sufferer and can be life threatening. Even if an athlete with an eating disorder is able to avoid seriously compromising his or her health, he or she can expect to have a shorter sporting career characterized by inconsistent performances and recurrent injuries as a result of the disorder. As such, for the sports world, the primary issues to address are those of prevention and early identification of problems. When clinical disorders are present, it is the task of the clinical world to offer high quality clinical treatments while taking into account the sporting context in which the disorder arose. Importantly, if an athlete is to return successfully to competitive sporting activity, then there is a need for the clinical and sporting worlds to collaborate in order to ensure that reentry occurs safely and with minimum risks to future health. Prevalence There are many studies examining the prevalence of eating disorders in sports (see Byrne & McLean, 2001, for a review), and numerous studies report a higher prevalence in sporting populations compared to control groups or normative data. Large studies of this kind include those of Sundgot-Borgen (1993) with elite female athletes (N = 552); Johnson, Powers, and Dick (1999) with male and female Alan Currie, M.D. is with the University of Newcastle upon Tyne, United Kingdom. 329

2 330 Currie collegiate athletes (N = 1,445); Byrne and Mclean (2002); and Sundgot-Borgen and Torstveit (2004) with elite male and female athletes (N = 263 and N = 1,620, respectively) and others. Still, other studies have shown less consistent findings, which may depend on the exact nature of the athletic population under study or the method used to determine prevalence. Considering Prevalence by Population Regarding the inconsistent prevalence data noted above, elite athletes, for example, might be at lower risk for developing an eating disorder (Johnson et al., 1999), and recreational exercise among non-lean sports may confer some protection from developing a disorder (Smolak, Murnen, & Ruble, 2000). Elite runners in circumstances where the overall population prevalence is low (such as Kenya) have also been shown to have a lower prevalence of eating disorders than their non-running peers (Hulley et al., 2007). The prevalence is also known to vary from sport to sport. Sports where the prevalence is highest seem to be those in which performance can be influenced by weight (endurance sports such as distance running or cross-country skiing), weight category sports where there is an acute pressure to make weight in order to compete (such as Judo or Olympic wrestling), and sports where aesthetic adjudication prevails and where certain body sizes and shapes are more likely to be rewarded (such as gymnastics; Byrne & McLean, 2002; Johnson et al., 1999; Sundgot-Borgen, 1993). Measuring Prevalence Rates may also be influenced by the means chosen to estimate prevalence. Using screening instruments alone may lead to inaccurate estimates of prevalence because athletes may under-report eating problems (Garner, Rosen, & Barry, 1998; Johnson et al., 1999) and minimize certain associated symptoms (Sundgot-Borgen, 1993). Likewise, many standard rating scales have not been validated in athletic populations (Sundgot-Borgen, 1994), although it is not certain that results would differ. Finally, non-response rates are also often high. In one large research project, three out of six gymnastics squads invited to participate in the study declined to do so (Byrne & Mclean, 2002). To overcome these difficulties, it is necessary to study eating disorder prevalence in a clearly defined group of athletes and to do so using questionnaires or screening instruments appropriately validated. A study by Sundgot-Borgen and Torstveit (2004) meets all of these criteria. This study is powerful because of the large numbers surveyed and is important because it surveyed both male and female athletes. It is illuminating to examine the results in more detail. Regarding the Sundgot-Borgen and Torstveit (2004) study, the overall rates of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (ED-NOS) are summarized in Table 1. Of note are the higher overall prevalence rates for athletes (male or female) compared to controls. For female athletes, the prevalence is increased approximately by a factor of 2 compared to controls. However, for males, the prevalence in athletes exceeds that in controls by a factor of 16. Another way of looking at this is to examine the male:female ratio of diagnosable eating disorders in each group. For athletes, this ratio is approximately 1:2.5 (i.e.,

3 Psychiatric Perspective on Eating Disorders 331 Table 1 Prevalence of Eating Disorder Syndromes by Subtype Anorexia Nervosa Bulimia Nervosa ED-NOS (incl AA) Total Athletes n n % n % n % n % Male Female Controls Male Female Note. AA = Anorexia Athletica. Data from Sundgot-Borgen and Torstveit (2004) Table 2 Male Prevalence Rates of Eating Disorder Syndromes by Type of Sport Anorexia Nervosa Bulimia Nervosa ED-NOS (incl AA) Total Category n n % n % n % n % Antigravity Weight class Endurance All sports Aesthetic Note. AA = Anorexia Athletica. Data from Sundgot-Borgen and Torstveit (2004) two male athletes with an eating disorder for every five females athletes), while in the control population, this ratio is approximately 1:20. Male Athletes. Table 2 demonstrates the male athletes data in more detail and shows the prevalence rates for those sport categories where there are above average rates. For males, these are the antigravity sports (such as ski-jumping), weight class sports (such as wrestling), and endurance sports (such as distance running). In weight class sports, extreme weight loss measures are often engaged in from an early age (Sundgot-Borgen & Torstveit, 2004) and are likely to include purgative behaviors to lose weight in the few days prior to competition. These practices may be encouraged by individuals, such as teammates and coaches, and by sport culture activities such as weigh-ins (especially group weigh-ins; Steen & Brownell, 1990). It is noteworthy that in contrast to the female figures, no cases of eating disorders are described in the aesthetic sports category (see Table 3). According to Sundgot-Borgen and Torstveit (2004), this may be because male gymnasts tend to be older and better informed about nutritional practices than are female gymnasts. The hormonally driven, body composition changes of puberty may also have differential effects on male and female gymnasts. Fat deposition in females may have

4 332 Currie a detrimental effect on performance (in large part due to aesthetic judgments). In contrast, male gymnasts experience increased muscular development around this time that is likely to have a positive impact on performance. Female Athletes. Table 3 illustrates the prevalence data for female athletes in those sports where there is above average prevalence. Among the groups, aesthetic sports have the highest prevalence rates. It is unusual that in this group, the number of anorexia nervosa cases approaches that of bulimia nervosa cases. Bulimia nervosa cases predominate in other athletic and control groups. Diagnosis Since eating disorders can lead to extremely serious medical concerns, it is critical for such disorders to be appropriately diagnosed among athletes. Meta-analyses have demonstrated significantly higher standardized mortality rates (3.6 to 9.9; Nielsen et al., 1998) and crude mortality rates (5.9% or 0.56% per year; Sullivan, 1995). Among patients who survive, it has been reported that 20% remain chronically ill (Steinhausen, 2002). It is also important that practitioners understand the potential seriousness of the clinical syndromes that fall under the broad rubric ED-NOS and resist normalizing these conditions. Of course, diagnosing an eating disorder is not always a straightforward process. Psychologically healthy athletes may eat in unusual ways and these unusual eating patterns may never approach clinical significance. However, unusual eating practices that do not begin as disordered may merge into more clearly defined disordered eating practices. A description of types of eating practices/disorders among athletes is warranted. Athletic Eating The eating habits of a psychologically healthy athlete might include meticulous attention to diet and weight, such as weighing food before meals; avoiding certain food groups; carefully planning a daily, weekly, and monthly food diary; and regular measurements of weight and body composition. These strategies are typically engaged in to maintain or optimize performance by healthy eating practices or body Table 3 Female Prevalence Rates of Eating Disorder Syndromes by Type of Sport Anorexia Nervosa Bulimia Nervosa ED-NOS (incl AA) Total Category n n % n % n % n % Aesthetic Weight class Endurance All sports Note. AA = Anorexia Athletica. Data from Sundgot-Borgen and Torstveit (2004)

5 Psychiatric Perspective on Eating Disorders 333 weight management. The emphasis is usually on ensuring an adequate intake of calories, fluids, and nutrients rather than a restriction of necessary dietary elements. In many cases, these practices are state dependent and will normalize during the off-season and upon retirement (Currie & Morse, 2005). Disordered Eating The unusual eating patterns of the elite athlete may merge and overlap with more obviously pathogenic weight control measures. These pathogenic measures lie on a continuum from mild to very serious, and where one falls on the continuum depends not only on the degree to which these practices are adopted, but also on the nature of the practice employed. Toward the milder end of the continuum lies the use of heavy exercise as a weight control measure. This is often a difficult practice to notice in an athlete, as training loads are normally very high. An elite athlete training for several hours each day will generally have built up to this level over many years in a progressive manner, in careful consultation with a coach and others, and with a clear goal in mind. The absence of this gradual progression, progression without a clear goal, and secretive training should alert the practitioner to the possibility that the athlete is using excessive exercise to control weight instead of enhance performance. Inevitably, however, there is a degree of subjectivity in this assessment. Athletes may also pursue extreme or fad diets. While not to reflexively be considered disordered eating, unusual diets that compromise the intake of vital nutrients or calories may be considered a form of disordered eating. The presence or absence of a clear performance enhancement goal may also be a useful pointer. Some authors have used the term orthorexia to describe the more severely restricted diet of this type (Bratman, 2001). More clearly defined pathological weight control measures include severe dietary restriction and the use of laxatives, enemas, diet pills, stimulants, diuretics, and self-induced vomiting to reduce or maintain weight. Such weight control measures are common characteristics of the three primary eating disorders classified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision; DSM-IV-TR, 2000). The disorders include anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (ED-NOS). Anorexia Nervosa. The diagnosis of anorexia nervosa (DSM-IV-TR; APA, 2000) is based on four core features: (a) refusal to maintain a minimally normal weight for age and height (defined as 85% or less of expected weight); (b) intense fear of becoming overweight despite being underweight; (c) body image distortion and denial of low weight; and (d) amenorrhea, which is defined as the absence of three consecutive menstrual cycles. The identification of underweight individuals who may have anorexia nervosa is complicated in sport populations for several reasons. First, in lean sports, a pathologically thin performer is less likely to be conspicuous. Second, the denial and secrecy that are hallmarks of an eating disorder might be more prominent in athletes who fear losing what is dearest to them, which for many athletes is their sport life. They may also fear being excluded from competition or set apart from their team-mates (Thomson & Trattner Sherman, 1993).

6 334 Currie Bulimia Nervosa. Bulimia nervosa is characterized by regular food binges, often of very large quantities, consumed quickly, and with loss of control over the behavior. The binge is quickly followed by a compensatory purge, which is commonly self-induced vomiting. To make the diagnosis according to DSM-IV- TR criteria, these episodes should occur, on average, twice or more per week for three consecutive months (DSM-IV-TR; APA, 2000). The presence of bulimia is not always easy to notice, as bulimic behaviors are not only secretive, but the sufferer can be of normal weight and physical appearance (Thomson & Trattner Sherman, 1993). Eating Disorder not Otherwise Specified. An eating disorder not otherwise specified (ED-NOS) is usually a similar clinical syndrome to either anorexia or bulimia nervosa, but with one or more symptoms at the sub-threshold level (DSM- IV-TR, 2000). For example, bingeing and purging may only have been present for two months (instead of three for bulimia nervosa), bodyweight may not yet have dropped below the 85% threshold, or menstruation may not have stopped entirely for three consecutive months (required for anorexia nervosa). However, a diagnosis of ED-NOS is not necessarily less serious. An athlete bingeing and purging for two months while still maintaining a high training load could clearly become very ill. In fact, many of the medical complications of eating disorders (Sharp & Freeman, 1993) are the result of the particular pathological weight control measure that is employed rather than its frequency. Anorexia Athletica Because eating disorders among athletes are not uncommon and they pose serious health and well-being risks, it is critical to accurately identify these clinical concerns. As such, the anorexia athletica category was proposed in part to assist in identification of athletes with serious eating disorder symptoms (Sundgot-Borgen, 1993). The core features of anorexia athletica (Pugliese, 1983; Sundgot-Borgen, 1993) share much in common with anorexia nervosa. There will be an intense fear of gaining weight, even though the athlete is lean or underweight. Energy intake may be reduced, often alongside excessive or compulsive exercise. The reduction in weight is not explained by any other condition and body image is distorted. Menstrual irregularity or delayed puberty may be present. Finally, some individuals use purgative weight control measures extensively and may accurately be seen as actual or subclinical bulimia nervosa (ED-NOS). In other cases, the features are those of a subclinical anorexia nervosa syndrome (ED-NOS). In Sundgot-Borgen s study (1993), oligomenorrhea (menstrual cycle lasting more than 35 days) was more common than both primary and secondary amenorrhea combined. In these circumstances, an ED-NOS is the most accurate categorization. The issue of an athlete s absolute weight, however, is worthy of closer inspection. Anorexia nervosa is diagnosed if the sufferer meets all criteria including being 85% or less of expected weight for height. What is the expected weight of a muscular athlete? A muscular athlete may appear artificially heavy despite his or her leanness, and even a weight of 95% of expected weight for height with reference to population norms might actually represent a significant weight reduction. In cases like this, a diagnosis of anorexia nervosa might more accurately reflect the true clinical picture.

7 Psychiatric Perspective on Eating Disorders 335 Other authors have drawn a distinction between pathological anorexia nervosa and eating disorders associated with sport performance (Birch, 2005). To do so may contribute to a climate that fails to recognize the serious and pathological nature of anorexia athletica. The same climate may normalize the disordered behaviors and frame them as associated with a sporting subculture rather than a psychiatric disorder. Female Athlete Triad The Female Athlete Triad is the combination of menstrual disturbance, osteoporosis, and disordered eating that falls short of the full diagnostic criteria of anorexia nervosa or bulimia nervosa (Nattiv et al., 1994; Otis et al., 1997). Stress such as a high training load may alter hypothalamic and pituitary function with a secondary reduction in oestrogen production. Inadequate energy intake may lead to the suppression of sex and other hormones as an adaptive energy conservation measure. As a consequence of these hormonal changes, bone density may decrease as hypooestrogenism accelerates bone reabsorption. Athletes may experience secondary amenorrhea or fail to begin menstruating (primary amenorrhea) and these athletes may also have low rates of bone formation (Louckis, 2005). Reduced bone density can be partly (but not completely) offset by the increases in bone density that will be provided by the mechanical stress of exercise. Hormonal changes can affect the entire skeleton, while mechanical stress only confers a degree of protection where this stress is loaded (Carbon, 1992). Each of the three corners of the Triad should be considered as pathological states (subphysiological hormone levels, suboptimal bone density, and inadequate nutrition). The Triad should be considered an ED-NOS, and thus, the tendency to normalize its presence as the inevitable consequence of high-level sport should be avoided. Its medical status as an unhealthy state, and its high prevalence in sports and among those who exercise is a powerful argument for viewing the Triad as a discrete subtype of ED-NOS. Treatment Engaging eating disorder sufferers in effective treatment programs is often difficult and denial and resistance are common. For athletes, this is often compounded by the fear that they may no longer be able to participate in their sport (Thomson & Trattner Sherman, 1993). When treatment is required, a high degree of expertise is necessary and treatment may last for extended periods of time. The key competencies of an athlete s therapist include having expertise in treating eating disorders combined with an understanding of the sport context (Johnson, 1994). Sports organizations and the members of an athlete s support team (coaches, strength and conditioning advisors, nutritionists, etc.) should restrict themselves to ensuring that appropriate preventative measures are in place rather than providing interventions. Preventative practices in coaching and nutrition have been shown to considerably reduce the incidence of eating disorders in sport (Sundgot-Borgen & Klungland, 1998). Preventative practices include educating coaches and trainers on proper nutrition and early warning signs (Sundgot-Borgen, 1994), avoiding high-risk weight management strategies such

8 336 Currie as rapid or unsupervised weight loss, and ensuring the availability of appropriate nutritional advice and support. Practitioners Working With Elite Athletes Many elite athletes have access to a range of practitioners who support their highlevel performance endeavors. Often, these practitioners work as a team, and the support team may include coaches, strength and conditioning advisors, nutritionists, sport psychologists, sports medicine specialists, physiotherapists, and others. It is important that each member has a basic awareness of eating disorders, their effects, and what to look for in order to recognize when an athlete has a problem. Each support team member should be aware of competency and training limitations, however, and should avoid the temptation to intervene with an athlete unless they have specific skills in this area (UK Sport, 2007). Assessment Health care systems vary from country to country and accessing eating disorder specialty services can involve traveling long distances or enduring lengthy waits. Sports organizations should be encouraged to develop clear policies and procedures for accessing the necessary medical, psychological, and psychiatric support for an athlete with an eating disorder. Once services have been initiated, the first priority is for a detailed assessment of physical, psychological, and social functioning. This should include a thorough risk assessment that is not restricted to the physical risks of starvation or disordered eating, but also includes an assessment of psychiatric risk. Psychiatric risk includes suicide and possible comorbid conditions such as depression, substance misuse, and obsessive-compulsive disorder. Once this has been conducted, treatment can be implemented. Treatment guidelines are available at the American Psychiatric Association website ( and the website of the National Institute for Clinical Excellence in the United Kingdom ( A comprehensive discussion of the empirically supported treatments for eating disorders can be found elsewhere in this issue (Moore, 2007). Anorexia Nervosa With anorexia nervosa, the initial aims of treatment will be to reduce risk, encourage weight gain and healthy eating, and facilitate both psychological and physical recovery. In-patient treatment will be necessary if risk levels are very high and/or refeeding is required. Out-patient treatment programs, however, require highly competent staff specializing in psychological treatment approaches such as Cognitive Analytical Therapy (CAT), Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy (IPT), and focal dynamic therapy. Specific family interventions are also often helpful. Ideally, the treatment approach would be determined in collaboration with the athlete during and after assessments have been conducted. In reality, availability of treatment will often determine which approach is taken. Treatment is usually required for 6 months or longer in severe cases.

9 Psychiatric Perspective on Eating Disorders 337 Medication may also be required as part of the treatment program. Selective Serotonin Re-uptake Inhibitors (SSRIs) and atypical antipsychotics (e.g., Risperidone, Quetiapine, Olanzapine) are known to be helpful (Powers, 2004). SSRIs may be partially helpful in treating eating disorders in athletes when there is a large obsessional component (Currie & Morse, 2005). However, caution should be exercised when prescribing because (a) cardiovascular side effects can be especially troublesome if cardiovascular function is compromised by the eating disorder, and (b) some co-morbid depressive or obsessional symptoms may improve simply with improved nutrition and weight gain. Throughout treatment there is also a need for regular physical monitoring and close liaison with physicians when medical risk is high. All risks (medical and psychiatric) should be carefully monitored and regularly assessed during treatment. Bulimia Nervosa Milder cases of bulimia nervosa may respond to self-help or guided self-help procedures. This is perhaps the only instance in the treatment of eating disorders when referral to a specialist may not be necessary. In cases of moderate to high severity, specialized psychological treatments are necessary. CBT specifically tailored to bulimia nervosa and IPT are both effective treatments, although the latter typically takes longer. Antidepressant drugs can reduce the frequency of binge eating or purging and are often effective within a few weeks. SSRIs are recommended as first choice drugs because of acceptability, tolerability, and symptom reduction. High doses are recommended (e.g., Fluoxetine = 60 mg). During the assessment process and throughout treatment, fluid and electrolyte imbalance should be regularly monitored. If imbalances are mild, treatment can focus on correcting the behavior. In other cases, oral supplementation is recommended. For atypical or subclinical conditions (ED-NOS), it is appropriate to tailor treatment to whichever disorder it most closely resembles. Regardless, a variety of psychological and pharmacological treatments are available for the spectrum of eating disorders. Most require psychological and/or psychiatric expertise that necessitates referral to a specialty clinic. Returning to Sport Once an athlete is in treatment and is beginning to recover, the issues of how and when to return to training are likely to arise. This is the time where close liaison between the sport and clinical worlds is most important. If the seriousness of an athlete s condition warrants cessation of all training, then the therapist will need to consider the consequences of removing an athlete from his or her support network. Issues to consider include the possibility of incorporating training modifications into the treatment contract and involving the coach in this endeavor. It is important for clinicians to appreciate the nature of the coach-athlete relationship, as the coach is likely to be a key influence in the life and behavior of the athlete. A gradual return to training may form part of an important reward system that fosters progress in therapy and close consultation between the coach, athlete,

10 338 Currie and therapist will be necessary in this regard. Of course, this may be appropriate for athletes who are progressing in treatment and ready to change, rather than for athletes likely to use training and competition as a distraction or excuse for avoiding therapy (Thomson & Trattner Sherman, 1993). When considering a return to training or competition, a number of issues will need to be addressed (Littlefield & Zuercher, 2003) and all involve some degree of communication and cooperation between the sport and clinical worlds. First, is the athlete medically stable to resume exercise? This covers areas such as cardiovascular status, anemia, bone density, and the risk of injury. Second, is the athlete s nutrition appropriate to the demands of resuming training/exercise? Third, to what degree is the athlete refraining from disordered eating behaviors and what does this say about the athlete s stage of recovery? A graded return to exercise alongside a graded reduction in behaviors is usually recommended. Finally, to what extent will returning to sport exacerbate stress? If recommencing training or competition is likely to increase personal difficulties, family problems, or academic pressures, then there is a higher risk of the eating disorder resurfacing. Conclusion In many respects, the true prevalence of eating disorders in sport is not the primary issue to be addressed. The primary issue is to identify athletes struggling with such disorders and provide effective treatment for these potentially fatal conditions. While delivering this treatment is primarily the role of clinicians, other sport professionals can be of support. Acknowledging the higher prevalence in some sports does allow an examination of how the sporting environment may be contributing to this excess, however. From this, we may develop a clearer understanding of how this environment can be modified to reduce health risks without compromising sport performance. References American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text revision). Washington, DC: Author. Birch, K. (2005). Female athlete triad. BMJ, 330, Bratman, S. (2001). Health food junkies. Orthorexia: Overcoming the obsession with healthful eating. New York: Broadway Books. Byrne, S., & McLean, N. (2001). Eating disorders in athletes: A review of the literature. Journal of Science and Medicine in Sport, 4, Byrne, S., & McLean, N. (2002). Elite athletes: Effects of the pressure to be thin. Journal of Science and Medicine in Sport, 5, Carbon, R.J. (1992). Exercise, amenorrhea and the skeleton. British Medica Bulletin, 48, Currie, A., & Morse, E.D. (2005). Eating disorders in athletes: Managing the risks. Clinics in Sports Medicine, 24, Garner, D.M, Rosen, L.W., & Barry, D. (1998). Eating disorders among athletes: Research and recommendations. Child and Adolescent Psychiatric Clinics of North America, 7, Hulley, A., Hill, A., Njenja, F., & Currie, A. (2007). Eating disorders in elite female distance runners: Effects of nationality and running environment. Psychology of Sport and Exercise, 8,

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