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CONTENTS VOLUME 24 • NUMBER 4 • OCTOBER 2005

Foreword xiiiMark D. Miller

Preface xvIan R. Tofler and Eric D. Morse

Interviewing Principles for the Psychiatrically Aware Sports Medicine Physician 745Ronald L. Kamm

This article describes how sports medicine physicians can best approachthe diagnosis of mental illness in athletes. Examples of psychiatric prob-lems common to athletes, their incidences in the population, and diag-nostic tips to ferret them out are given. Vignettes of well-known athleteswho have had these problems are included. Each highlights how a lackof diagnostic awareness and the stigma of having a “mental illness” pre-vented the athlete from getting treatment sooner.

Diagnosis and Psychiatric Treatment of Athletes 771Ira D. Glick and Jessica L. Horsfall

Although enormous amounts of time and money have been invested inenhancing performance for college and professional athletes, their psychi-atric needs have been minimally addressed. Given the virtual absence ofcontrolled scientific literature, in this article the authors detail the diagnos-tic issues and delineate treatment principles, including: (1) making an accu-rate diagnosis; (2) setting realistic goals; (3) delivering psycho-education;(4) inducing the patient to undergo treatment, including involving thefamily and significant others; and (5) delivering appropriate treatment(the most difficult task). The objective is to improve performance andquality of life by treating the problem or psychiatric illness. A specialconcern is minimizing countertransference feelings and avoiding under-treatment, because by definition the athlete needs to perform.

Developmental Overview of Child and Youth Sports for the Twenty-first Century 783Ian R. Tofler and Grant J. Butterbaugh

This article presents an overview of sporting participation for childrenand adolescents from psychological, physical, social, developmental,

The Interface Between SportPsychiatry and Sports Medicine

CLINICS IN SPORTS MEDICINE

and historical perspectives. The following areas are reviewed: (1) normaldevelopmental readiness and sporting participation; (2) benefits and risksof athletic participation for the child and adolescent; (3) self-concept andsporting participation; (4) adverse psychophysiological and somatoformeffects of sports; (5) interactional and systemic contributions to adversephysical and psychological effects; (6) a historical/social perspective ofsport in the United States; (7) the current and future role of psychiatristsin conjunction with sports medicine physicians; (8) the sports psychia-try interview of the child, family, and coach; and (9) summary andfuture challenges.

Achievement by Proxy Distortion in Sports: A DistortedMentoring of High-Achieving Youth. Historical Perspectives and Clinical Intervention with Children,Adolescents, and their Families 805Ian R. Tofler, Penelope Krener Knapp, and Michael Larden

This article describes potentially pathogenic behavior in youth sports. Itdelineates the four stages of achievement by proxy distortion (ABPD)behavior and attempts to raise awareness of that behavior and to facili-tate communication among sports medicine and psychiatry professionalsof the potential for exploitation and abuse of children and adolescentsby parents, mentors, coaches, and the systems that nurture and developthese children. Information is presented to distinguish motivationsbehind normal parenting from those that lead to risky sacrifice, objecti-fication of the child, and potential abuse. Distinct abuse stages of ABPDare described. The authors identify “red flags” that indicate distortedviews and potentially harmful behavior toward children.

Attention Deficit/Hyperactivity Disorder andPsychopharmacologic Treatments in the Athlete 829David O. Conant-Norville and Ian R. Tofler

It is conjectured that attention deficit/hyperactivity disorder (ADHD)symptoms adversely impacting academics, family functioning, socialrelationships, and vocational performance might also negatively affectathletic and sport performance and enjoyment; this warrants further sci-entific inquiry. Children, adolescents, and adults participate in orga-nized and impromptu sport activities, both team and individual. Withthe concern about an epidemic of obesity in the United States, barriersto participation in sport and exercise such as ADHD need to be betterunderstood. This article approaches ADHD in sports by providing abrief introduction to ADHD, first reviewing general clinical findings,then discussing recreational youth sports and psychopharmacologicaltreatment risks and benefits for the elite athlete.

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Aggression and Sport 845Robert W. Burton

Viewing aggression in its healthy form, in contrast to its extreme andinappropriate versions, and sport as a health-promoting exercise in psy-chological development and maturation may allow participants andspectators alike to retain an interest in aggression and sport and derivefurther enjoyment from them. In addition, it will benefit all involvedwith sport to have a broader understanding of human aggression.Physicians, mental health professionals, and other health care providerscan be influential in this process, and should be willing to get involvedand speak out when issues and problems arise.

Suicide in Athletes: A Review and Commentary 853Antonia L. Baum

Not only are athletes at risk for psychiatric illness, but they are at risk ofsuicide. In an effort to learn more about suicide in athletes and those con-nected to the sports arena, a review of the medical literature from 1960to 2000 was conducted through Medline, and a review of the periodicalliterature from 1980 to 2000 was conducted through Infotrac. Thesereviews revealed 71 cases of athletes who have either contemplated,attempted, or completed suicide. In this article, these cases are analyzedby sport, gender, and age. Through inference, an attempt to establishthe etiologic basis for these behaviors is undertaken. Intervention andprevention strategies are discussed, based on the available data.

Eating Disorders in Athletes: Managing the Risks 871Alan Currie and Eric D. Morse

Athletes risk injuries and make personal sacrifices in their education,careers, and personal relationships in pursuit of excellence. Well-preparedathletes and their support teams take steps to minimize these risks. Sincethe 1980s, it has been apparent that development of an eating disorderis a risk associated with considerable morbidity and significant mortality,and with shorter careers characterized by inconsistency and recurrentinjury. How likely is it that an athlete will develop an eating disorder?Who is at risk? Can eating disorders be prevented? How can eating dis-orders be identified? What are the consequences of developing an eatingdisorder? What can be done to help an athlete who has an eating dis-order? This article attempts to answer these questions.

Substance Use in Athletics: A Sports Psychiatry Perspective 885David R. McDuff and David Baron

Athletes use substances to produce pleasure, relieve pain and stress,improve socialization, recover from injury, and enhance performance.

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Therefore, they use some substances in substantially higher rates thannonathletes. Despite these higher rates of use, rates of addiction may in factbe lower in athletes. This article reviews the prevalence and patterns ofuse, health and performance effects, and preventive and treatment inter-ventions for alcohol, tobacco, stimulants, and steroids. Each substance isconsidered from the differing perspectives of abuse/addiction and per-formance enhancement models. Similarities and differences between col-lege and professional athletes are discussed. Finally, suggestions for futureresearch are made.

Invisible Players: A Family Systems Model 899Jon Hellstedt

This article attempts to demonstrate that the family is a key player inthe athlete’s development and performance, sometimes invisible, butoften all too visible. The practice of clinical sport psychology is enrichedby a family-based orientation to the assessment and treatment of athletes.Creating a workable family system is a challenge for parents. They havemany difficult decisions to make, and are often without support anddirection in making those choices. Sport psychiatrists and psychologistscan be helpful to parents as well as athletes by using family-based assess-ments and treatment interventions that provide education, challenge, andsupport as they negotiate the tasks and transitions in the family life cycle.

Systemic Issues Involved in Working with Professional Sports Teams 929Joshua W. Calhoun, Kennise M. Herring, and Teresa L. Iadevito

Sport psychiatrists face a number of systemic and intra-psychic issueswhen treating professional athletes. Although only a modicum of litera-ture exists to aid sport psychiatrists, there are several steps they may taketo become an integral part of an athletic organization and to be success-ful in the treatment of the athletes themselves. The ability to delineatetheir role within the sports club is crucial to mental health professionals’organizational success. Equally important, it is incumbent upon sportpsychiatrists to recognize and transcend intra-psychic issues that occurbetween athlete and physician.

Professional and Collegiate Team Assistance Programs:Services and Utilization Patterns 943David R. McDuff, Eric D. Morse, and Robert K. White

Elite professional and collegiate athletes underuse stress control, mentalhealth, and substance abuse treatment services. Behavioral health ser-vices use can be increased by establishing on-site, sports-specific services.Like Employee Assistance Programs of industry and government, TeamAssistance Programs (TAPs) address critical issues such as substance

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abuse prevention, tobacco cessation, stress recognition, mental illnessmanagement, injury rehabilitation, performance enhancement, and cul-tural support. Strong links with the team’s medical and conditioningstaff can ensure a steady stream of TAP referrals and build trust withplayers and team staff. This article describes nine years of operation fortwo professional TAPs and three years for one college TAP. Use patternsand linkage strategies with team physicians, trainers, strength staff, chi-ropractors, and nutritionists are discussed.

The Sport Psychiatrist and Golf 959Terrence P. Clark, Ian R. Tofler, and Michael T. Lardon

The sport psychiatrist is well-positioned to consult to competitive golfers.The interrupted pace of play in golf provides ample time for the golfer’sthoughts to go awry. The sport psychiatrist can work with competitivegolfers in refining their strategies for dealing with these myriad distrac-tions and stressors. The authors review pre-performance routine andmethods for optimizing focus, and discuss the science behind being “inthe zone.” The authors also discuss how acute performance failure, or“choking,” is best understood as being three separate disorders. Thesport psychiatrist’s unique role in competitive, professional golf is dis-cussed by employing the concept of a sports mental health continuumand its relation to psychiatric disorders.

The Use of Relaxation, Hypnosis, and Imagery in Sport Psychiatry 973Thomas S. Newmark and David F. Bogacki

Hypnosis is a procedure during which a mental health professional sug-gests that a patient experience changes in sensations, perceptions, thoughts,or behavior. The purpose of this article is to briefly describe the use ofvarious methods of relaxation, hypnosis, and imagery techniques avail-able to enhance athletic performance. The characteristics that these tech-niques have in common include relaxation, suggestibility, concentration,imaginative ability, reality testing, brain function, autonomic control, andplacebo effect. Case studies are provided for illustration.

Erratum 979

Cumulative Index 2005 981

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