The Emerging Field of Sports Psychiatry: A New Niche for Psychiatric Practice

“Plastics,” Mr McGuire famously said to Dustin Hoffman’s character Benjamin in The Graduate. What did he mean? Was he suggesting that to be successful Benjamin should find a niche? Or have we only now mastered the concept of a niche, subdividing fields into narrow areas of alleged expertise. Did he mean plastic surgery? I wondered. If so, was he going to be a breast guy? A hand guy? A face guy? Or had Mr McGuire meant actual plastic, and if so, in what niche? PCBs? Saran wrap? Wheels? Bottles? Toys? Packaging?

A niche is a way for us to package, or market, ourselves. The thinking is that it may help us attract patients. The theory is that a niche signifies expertise, which ultimately would benefit a patient. What is a niche, how is it done, and is there a purpose? According to Merriam Webster, niche is a “place, employment, status, or activity for which a person or thing is best fitted.”

Developing a professional niche takes passion, perseverance, and a body of knowledge that is unique. In psychiatry, a heightened knowledge of and sensitivity to a particular area has the potential to benefit our patients. Although in theory we can all bring that tabula rasa and empathic connection to our patients, we do gain instant credibility if our experiences resonate with those of our patients.

There are a number of well-established niches in psychiatry, from forensics to addictions to LGBT. What are the origins of a niche, particularly in psychiatry? You may find your niche if you have been imprinted by a charismatic mentor, such as an eccentric but charming professor of neuropsychiatry, who ignites an enthusiasm for study in an area of research or practice. Or perhaps by an uncle with bipolar disorder, who will afford you a unique sensitivity to and an insider’s expertise on mood disorders. Could the budding forensic psychiatrist be sublimating his desire to go to law school?

Sports psychiatry

Sports psychiatry is a niche that took root 22 years ago, when 4 psychiatrists came together and started a group for those who shared this interest. The group has since grown into an international organization called the International Society for Sports Psychiatry (ISSP) (www.TheISSP.org) with over 100 members from Europe to South America to Japan and Australia. The ISSP has become an allied group of the American Psychiatric Association (APA). Every year at the APA annual meeting, members of the board meet. There are scientific sessions, the ISSP presents a symposium on a timely topic in sports psychiatry, and featured athletes present their histories.

Sports psychiatry distinguishes itself from the well-established field of sports psychology. While our interventions often do affect sports performance positively-and performance problems may in fact be the presenting complaint-our primary goal is not performance enhancement per se, but rather a focus on psychopathology. Some illnesses may have been present before the person became an athlete or the potential may have been there. Perhaps there is a genetic predisposition to, for example, bipolar disorder. Similarly, it is not uncommon to make a diagnosis of new-onset schizophrenia in a young high school or college athlete, given the demographics of the illness.

[[{"type":"media","view_mode":"media_crop","fid":"17813","attributes":{"alt":"","class":"media-image media-image-right","height":"242","id":"media_crop_1952452201861","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1123","media_crop_rotate":"0","media_crop_scale_h":"435","media_crop_scale_w":"500","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image","width":"280"}}]]Involvement in sports may exacerbate some existing illnesses; for example, an anxiety disorder might be exacerbated by the unique pressures of athletic competition. Other psychopathologies may be engendered through the sport itself: an eating disorder in a gymnast or anabolic steroid abuse in a body builder.

There are unique considerations when choosing pharmacological interventions. It is vital to attend to adverse events that may impair athletic performance, such as a tremor induced by lithium, or weight gain secondary to an antipsychotic. In addition, sports psychiatrists must be mindful of prescription medications and must keep in mind the banned substances list for each sporting body. A common example: drugs perceived as having performance-enhancing properties, such as psychostimulants for ADHD. The rules vary from one governing body in sports to another, but a therapeutic use exemption may be available for an athlete after a careful review of his or her history.

What qualities might a sports psychiatrist have? Most of us who are drawn to the field have been athletes, and we are no strangers to the discipline, single-mindedness, and competitive spirit required to succeed on the field. This resonates with our patients.

Personal reflections

Life experience can create a niche. I grew up in a family with a weekly tradition of Sunday brunch, but only after all 7 of us-accompanied by a growing crowd as we added boyfriends, girlfriends, and eventually spouses-went to the gym. Working out was the family religion. We tumbled as toddlers (an activity that came to be known as gymnastics), swam competitively as elementary school kids during our years in Texas, were cross-country ski racers during our adolescence in upstate New York, and (I then) played field hockey in high school and college. Ultimately, there were marathons and triathlons in medical school. I had initially aspired to become an orthopedic surgeon-a logical way to marry sports and medicine.

As my interests in medicine changed, the desire to work in sports medicine persisted. As a resident in psychiatry, when tasked with presenting grand rounds, I sought to spin a tale, constructing a talk on my notion of sports psychiatry, complete with slides of beautiful bodies in motion. When I finished my presentation, my supervisor, a well-respected professor and researcher declared: “I cannot recall the last time a varsity athlete came in to see me.”

Determined not to be dissuaded, I reconfigured the talk for the athletic director and coaches at the university affiliated with my residency program. I like to think I earned my audience by making myself available to the athletic department as a part of my rotation at the campus’s student health service. Recognizing the stigma associated with all problems psychiatric in the world of sports, I offered to see patients on their turf . . . literally. Twice a week, I would park myself in a small office adjacent to the training room, where there was always an odeur de sweat.

The patients came, a trickle at first. There were the curbside consultations from this coach or that trainer, about an athlete, himself or herself, a relative. I sensed I had opened Pandora’s box. Thus began my education in sports psychiatry. The old adage see one, do one, teach one seemed to apply, but in reverse. I had to create theory, present it, and see what came through the door. My patients taught me the field.

Pursuing sports psychiatry has been exciting and eye opening. I knew logically that there would be psychopathology amongst athletes. I just never knew how much.

During my last year of residency training, I worked with a university baseball pitcher whose chief complaint was that he had lost his mojo on the mound. As his story unwound, he was able to work through a striking mirroring of his relationship with his father and with his coach. Without any specific attention to his pitching arm, he got his game back. On the last day of treatment, he presented me with an object that still sits on my office desk: his play-off game ball, inscribed by him with a tribute and his signature. Invaluable.

The sports doctor is in: lessons on the field

Twenty-five years ago, when I completed my residency training, I found myself in a foreign country, not merely geopolitically (Canada), but metaphorically. I stumbled into the referral center for all eating disorders in British Columbia: Vancouver. The inpatient unit at St Paul’s Hospital, a part of the University of British Columbia, could keep patients for what seemed an eternity-months-thanks to socialized medicine. Although I had not yet had a lot of experience in the area of eating disorders, I welcomed the opportunity to work on this unit, because I had already begun to encounter athletes with eating disorders and thought it would be a good idea to learn more.

There was a patient on the unit with anorexia nervosa who came from a lineage of Olympic runners. She was also a runner, and when her psychiatrist informed her she could not exercise, it was as if her oxygen supply had been cut off and she was in danger of asphyxiation. Although I was new to the discipline, I stood my ground in rounds the next day on the importance to this young woman’s identity of her ability to train. Naturally, she needed to compensate calorically but, I pointed out, preventing her from running was tantamount to negating her existence. For this young woman, running was as natural as breathing. To my amazement, the attending showed a willingness to bend, and the patient-who had to earn her stripes by being a good soldier and complying with her nutritional regimen-had a good outcome.

Years later, working in psychiatry at a large, urban outpatient medical center, I joined forces with the school’s sports team’s orthopedic surgeon once a week. Our evaluative clinic took place in the non-threatening atmosphere of the university’s training room. The athletes lined up to have their knees or elbows examined, and we would routinely discuss their fluoxetine or bupropion. Those who desired more time, attention, and privacy could see me in my clinic. For some of the athletes, such as an anorectic gymnast who struggled to maintain a safe body weight, seeing me was a condition of continuing their athletic participation.

After a fellowship in consultation-liaison psychiatry, it occurred to me that this was a useful model for integrating psychiatric treatment into the lives of athletes, bypassing their usual knee-jerk rejection of mental illness-athletes are made of Teflon; they do not have frailties.

A few months ago, I received a phone call from the mother of a young lacrosse player who attends a local prep school. She had had the third in a series of concussions and a worrisome eye injury. Several weeks into intensive psychotherapy with this athlete, who had developed a post-concussive depression and become suicidal, she revealed that she had fabricated the extent of the eye injury using makeup, coupled with an uncanny ability to maintain her eyelid at half-mast. This was, as it turned out, the only gracious way she felt she could extricate herself from a sport that had become competitive in a destructive way.

Success on the field had always been the way to gain approval from her athletic father and her perfectionist mother. It had been ingrained in her that one must achieve a cer-tain level in athletics to have a worthy college resume. Once cleared by a neurologist to return to play, this young athlete delighted in sustain-ing a second anterior cruciate ligament tear, which benched her for the season.

I have a few props in my office-a couple of bike tires, my helmet, some running shoes, a cap and goggles, old racing bibs. Tentative athlete-patients scan the room and visibly relax. They are on familiar turf. Sometimes we go outdoors and walk the nearby hills, or we have running sessions. The patients are more comfortable with their eyes trained on the horizon, lulled by their labored breathing. Being a member of the club may confer confidence. This can be the power of the niche for the patient.

New opportunities

New areas of intersection between the psyche and sports appear on my radar screen on a regular basis. These issues-aggression, traumatic brain injury, gender identity, substance abuse, overexercise, ethics, performance enhancement, retirement-to name a few, lead us to the need for data collection to enhance our understanding of the field (ie, the niche).

I am often asked by young, eager residents: “How do I get into sports psychiatry?” While there is one opportunity for a fellowship in the field, under the auspices of the ISSP’s current president, Thomas Newmark, MD, at Cooper University Medical Center in Camden, NJ, my general response is this: passion and sweat equity. The field does not come to you; you have to make it happen.

And to those of you in the latter stages of your career, fear not lest you think you are too late to establish a niche. You may already have one. And if not, you, too, can make the opportunities happen!

Further Reading

• Baum AL. Eating disorders in athletes. In: Baron DA, Reardon CL, Baron SH, eds. Clinical Sports Psychiatry: An International Perspective. Oxford, UK: Wiley-Blackwell; 2013:44-52.

• Baum AL. Sports psychiatry: an outpatient consultation-liaison model. Psychosomatics. 1998;39:395-396.

• Baum AL. Young females in the athletic arena. Child Adolesc Psychiatr Clin N Am. 1998;7:745-755, viii.

• Baum AL. Concussive injury, suicidal ideation in a 16-year-old female athlete. Psychiatr Ann. 2012;42:361-363.

• Baum AL. Suicide in athletes: a review and commentary. Clin Sports Med. 2005;24:853-869, ix.

• Baum AL. Suicide in athletes. In: Baron DA, Reardon CL, Baron SH, eds. Clinical Sports Psychiatry: An International Perspective. Oxford, UK: Wiley-Blackwell; 2013:79-88.

Disclosures:

Dr Baum is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and is in private practice in Chevy Chase, Md.