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Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports...

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Sports Psychiatry Portable Didactic Elective Curriculum Authors: Claudia L. Reardon, MD, University of Wisconsin School of Medicine and Public Health ([email protected]) Vuong Vu, MD, University of Wisconsin Hospital and Clinics ([email protected]) Allie Dyer, Medical College of Wisconsin ([email protected]) Robert M. Factor, MD, PhD, University of Wisconsin School of Medicine and Public Health ([email protected]) Ira Glick, MD, Stanford University ([email protected]) Pratik Mehta, MD, UCLA ([email protected]) Todd Stull, MD, University of Nebraska ([email protected]) on behalf of the International Society for Sports Psychiatry Curriculum Release Date: May 2018 Intended Learners: Psychiatry residents desiring an elective in sports psychiatry Psychiatry fellows (especially child and adolescent, addiction, or sleep) desiring an elective in sports psychiatry Primary care (family medicine, internal medicine, pediatrics) residents desiring an elective in sports psychiatry Sports medicine fellows desiring an elective in sports psychiatry Senior medical students intending a career in psychiatry, sports medicine, or primary care and desiring an elective in sports psychiatry Introduction: Sports psychiatry is the sub-specialty within psychiatry largely focusing on diagnosis and treatment of psychiatric illness in athletes. While utilization of psychological approaches to enhance performance may also be part of the work of the sports psychiatrist, it tends to be less so as compared to addressing actual mental illness in this population. The work of sports psychiatry may also involve the use of exercise as a therapeutic or preventative intervention for mental illness. The field is relatively new, such that most medical schools and residency/fellowship programs do not have curricular offerings dedicated to the topic. Moreover, with the population of sports psychiatrists relatively small, and with a relatively small research base, when health care providers do deliver psychiatric care to athletes, they may do so without a full understanding of the diagnostic and therapeutic issues
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Page 1: Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports psychiatry • Senior medical students intending a career in psychiatry, sports medicine,

SportsPsychiatryPortableDidacticElectiveCurriculumAuthors:ClaudiaL.Reardon,MD,UniversityofWisconsinSchoolofMedicineandPublicHealth([email protected])VuongVu,MD,UniversityofWisconsinHospitalandClinics([email protected])AllieDyer,MedicalCollegeofWisconsin([email protected])RobertM.Factor,MD,PhD,UniversityofWisconsinSchoolofMedicineandPublicHealth([email protected])IraGlick,MD,StanfordUniversity([email protected])PratikMehta,MD,UCLA([email protected])ToddStull,MD,UniversityofNebraska([email protected])onbehalfoftheInternationalSocietyforSportsPsychiatryCurriculumReleaseDate:May2018IntendedLearners:

• Psychiatryresidentsdesiringanelectiveinsportspsychiatry• Psychiatryfellows(especiallychildandadolescent,addiction,orsleep)

desiringanelectiveinsportspsychiatry• Primarycare(familymedicine,internalmedicine,pediatrics)residents

desiringanelectiveinsportspsychiatry• Sportsmedicinefellowsdesiringanelectiveinsportspsychiatry• Seniormedicalstudentsintendingacareerinpsychiatry,sportsmedicine,or

primarycareanddesiringanelectiveinsportspsychiatryIntroduction:Sportspsychiatryisthesub-specialtywithinpsychiatrylargelyfocusingondiagnosisandtreatmentofpsychiatricillnessinathletes.Whileutilizationofpsychologicalapproachestoenhanceperformancemayalsobepartoftheworkofthesportspsychiatrist,ittendstobelesssoascomparedtoaddressingactualmentalillnessinthispopulation.Theworkofsportspsychiatrymayalsoinvolvetheuseofexerciseasatherapeuticorpreventativeinterventionformentalillness.Thefieldisrelativelynew,suchthatmostmedicalschoolsandresidency/fellowshipprogramsdonothavecurricularofferingsdedicatedtothetopic.Moreover,withthepopulationofsportspsychiatristsrelativelysmall,andwitharelativelysmallresearchbase,whenhealthcareprovidersdodeliverpsychiatriccaretoathletes,theymaydosowithoutafullunderstandingofthediagnosticandtherapeuticissues

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uniquetothispopulation.Thus,thiscurriculumaimstoenhancetheknowledgebaseofphysiciansandphysicians-to-beinthescienceofsportspsychiatry,andtoincreasetheskillwithwhichthesecliniciansprovidepsychiatrichealthcaretoathletepopulations.ResourcesRequired:Faculty:Ideally,anon-sitepsychiatristwithexpertiseinsportspsychiatrywouldsupervisethiselectiveexperience.However,itisacknowledgedthatthefieldofsportspsychiatryisrelativelysmall,suchthatmedicalschoolsandresidencyprogramsmaynothaveafacultymember/attendingwhoidentifiesasanexpertinsportspsychiatry.Inthatcase,alocalfacultymemberwithaninterestinthefield,eveniflittleexperienceinit,couldsupervisethecurriculum.Afinaloptionisthatafacultymember/attendingfromaninstitutiondifferentthanthatatwhichthetraineetakingthecurriculumisenrolledcouldremotelysupervisethedidacticportionofthecurriculum.Inthelattercase,therewouldbenodirectclinicalaspecttotherotation.Inanycase,ideallytherewouldberegular(e.g.,weekly)meetingsbetweenthelearnerandsupervisorfordiscussionofreadingsandwritingassignments.Patientpopulation:Aclinicalpopulationofathlete-patientscouldprovideaclinicalcomponenttothiselective.Careofsuchpatientswouldbesupervisedbyanon-sitefacultymember/attending.However,thiselectivecanalsobecompletedassimplyadidactic/readingelective,inwhichthelearnercompletesthe“Readingsandassignments”and“Finalproject”describedbelow.Ifthelatter,afacultymentor/attendingshouldstillbeavailabletoreviewassignmentswiththelearnerandtoprovideaccountabilityinthatmanner.Materials:Theliteraturearticleslistedinthe“Readingsandassignments”sectionbelowareavailableonPubMed.Thetwoassignedbookchapterarticlesareavailableinthetext“ClinicalSportsPsychiatry:AnInternationalPerspective”(Wiley,2013).Ifthelearnerdoesnothaveaccesstothistext,eitherthroughtheirinstitution’slibrarylendingsystemortheirownortheirmentors’bookcollections,thenthesetopicsmaybeskippedorcompletedinmodifiedform,astherearenoequivalentjournalarticlesintheliterature.Ofnote,anyproceedsfromtheWiley,2013textgototheInternationalSocietyforSportsPsychiatryandnottoindividualeditorsorauthors.Layoutoftheelective:Theelectivecentersaroundadidactic/readingcomponent(see“Readingsandassignments”below).Theratewithwhichthelearnergoesthroughthereadings/assignmentswilldependonthetimeallottedfor,anddurationof,theelective,aswellaswhetherornotthelearnerhasclinicalrequirementsthatalsomustbecompletedduringthetimeoftheelective.Forexample,ifthelearnerissolelycompletingadidactic/readingelectiveduring½dayperweekofprotectedtime,theymightcomplete2topic“blocks”perweek(readingandaccompaniedassignment),andspendtheremainderofthetimeduringthat½dayeachweekworkingontheirfinalprojectandmeetingwiththesupervisor.Ifthelearneris

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completingasportspsychiatryclinicalexperiencealongwiththedidactic/readingcomponent,theymightcompletejust1“block”perweek,andspendtheremainderofthetimeduringtheelectiveeachweekseeingpatients,workingontheirfinalproject,andmeetingwiththeirsupervisor.Dependingonthedurationoftheelective,thelearnerandfacultysupervisormightselectanappropriatenumberoftopics(thosefelttobeofgreatestindividualinterestorofhighestrelevance)tobecoveredduringthattime,omittingtheothers.Detailedtimekeepingbyearlylearnersdemonstratedthateachtopic(includingtimeforreadingthefullarticle(s)andansweringthequestionsthoroughly)takesbetween30minutesand2.5hoursforthelearnertocomplete(mostinthe1-2hourrange).GoalsandObjectivesofthecurriculum:Goals:Bytheendofthisrotation,learnerswill:

1. Understandtheepidemiologyof,riskfactorsfor,anduniquemanifestationsofavarietyofpsychiatricdisordersandpsychosocialstressorsinathletes.

2. Understandhowtreatmentsforpsychiatricdisordersinathletesmaybesimilartoanddifferentfromtreatmentsforpsychiatricdisordersinthegeneralpopulation.

3. Appreciatethatthereareindividualleveltreatmentsaswellassystemwideinterventionstoaddressmentalillnessinathletes.

4. Developfamiliaritywiththemedicalliteratureonavarietyoftopicsrelatedtosportspsychiatry.

Objectives: Specificobjectivesarecoveredbythereadingassignmentquestions.Bythe endofthisrotation,learnerswillbeabletoanswerallofthequestionsposed inthereadingassignments.Finalproject:Learnerscompletingthiselectivearetoproduceascholarlyproductrelevanttothefieldofsportspsychiatry.Thetopicandformatoftheproductissubjecttoapprovalbythesupervisingfacultymember/attending.Optionsincludeamanuscript(e.g.,astandardresearchstudy,reviewpaper,opinionpieceinajournal,AmericanJournalofPsychiatryResidents’Journalarticle,etc.),posterpresentation(local,regional,national,orinternational),apresentation,talk,orworkshop(local,regional,national,orinternational),educationalsession(e.g.,aone-hourdidacticsessionforotherlearnersintheiracademicprogram,oraGrandRounds),oreducationalcolumn(e.g.,intheInternationalSocietyforSportsPsychiatrynewsletter,statepsychiatricassociationnewsletter,etc.).Theexactprojectchosendependsoninterestofthelearner,durationoftheelective,timeavailableforworkontheproject,mentorshipavailableatthetimeoftheelective,andscholarlyopportunitiesatthetimeoftheelective.Evaluationofthelearner:Seeattachedforasampleevaluationformthatmaybeespeciallyrelevanttopsychiatryresidents,asitiswrittentoalignwiththeACGMEMilestonesforpsychiatryresidents(availablehere:https://www.acgme.org/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf).

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Thus,thisevaluationformcanbepartofanoverallMilestones-basedassessmentofaresident,asthatistheapproachthatmostresidencyprogramsarenowtaking.NotethatMilestonelevelsonthisevaluationformonlygouptolevel4,aslevel5isregardedbytheACGMEas“stretch”goalsthatmany/mostresidentswillnothaveachievedbythetimeofgraduation,andthiscurriculumisnotdesignedtoachievelevel5Milestones.Theevaluationformismostlybasedonspecificanswersprovidedbythelearnertovariousreadingassignments,andthus,itwouldbehelpfulforthesupervisortocollecttheassignmentsastherotationgoeson,soastobeabletoreferencethemwhencompletingtheevaluation.Thisevaluationformcanbesupplementedwithorreplacedbyanystandardevaluationformsusedforlearnerscompletingotherrotations/electivesatalearner’sinstitution.Answerkey:Uponalearnercompletingthiscurriculum,theymayemailDr.Reardon([email protected])torequestananswerkey,ifdesired,fortheirownlearningpurposes.Inmakingsucharequest,theyshouldattestthattheyhavecompletedtheirelectiveandshouldcctheirattendingsupervisor(toensureanswersarenotgivenoutpriortocompletingthecurriculum).Ifanattendingsupervisordesirestheanswerkeypriortotheirlearnercompletingthecurriculum,theymayemailDr.Reardonwiththatrequest.PleasedonotdisseminatetheanswerkeybeyondthecurrentlearnerandattendingsupervisorwithoutpermissionfromDr.Reardon.Evaluationofthecurriculumbythelearnerandbytheattendingsupervisor:Whenyouhavecompletedyoursportspsychiatryelective,thelearnerandattendingsupervisorareaskedtopleasecompleteanonymous,approximately5-minute,evaluationsofthecurriculum.Thesewillhelpshapefutureiterationsofthecurriculum.Curriculumauthorswillnotviewsurveyresultsuntilatleast5responsesarecollected.Thelinkstothesurveysareasfollows:Learnersurvey:https://uwmadison.co1.qualtrics.com/jfe/form/SV_cSkILWffb7RlJRjAttendingsupervisorsurvey:https://uwmadison.co1.qualtrics.com/jfe/form/SV_dgqInTEZhJDcvZPReadingsandassignments:Block# Topic Reading/assignment1 Thefieldofsportspsychiatry Reading:ReardonCL,Factor

RM.Sportpsychiatry:asystematicreviewofdiagnosisandmedicaltreatmentofmentalillnessinathletes.SportsMedicine2010;40(11):961-980.

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Writingassignment:• Whatisthefieldofsports

psychiatry?Howdoesitdifferfromsportspsychology?

• List3causalrelationshipsbetweensportandmentalillness,andatleast1example(eitherfromthisarticleorfromanyotherinformationyouhave)ofeachofthoserelationships.

2 Depressioninathletes Reading:WolaninA,HongE,MarksD,etal.Prevalenceofclinicallyelevateddepressivesymptomsincollegeathletesanddifferencesbygenderandsport.BritishJournalofSportsMedicine2016;50:167-171.Writingassignment:

• WhatNCAAsporthadthehighestratesofdepressioninthisstudy?Listatleast3reasonswhythissportmighthavehigherratesofdepressionthanothersportsinthestudy.

• Findatleastoneotherresearcharticlethatdiscussesdifferencesinratesofdepressionbetweenindividualandteamsportathletes.Givethecitationforthearticle,andwrite2-4sentencestosummarizeanyhypothesesdiscussedinthearticleaboutwhytheremightbesuchdifferences.

3 Anxietyinathletes Reading:ReardonCL.Psychiatriccomorbiditiesin

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sports.NeurologicClinics2017;35:537-546.Writingassignment:

• Imagineyouhaveapatientwhoisa19yearoldcollegiateswimmerwhohasdevelopedsport-relatedperformanceanxiety.Shebecomesveryanxiousleadinguptoallcompetitionstothepointthatshehasfeignedillnessesandinjuriestoavoidhavingtocompete.Whenshedoescompete,shefeelsthatherperformancesuffersrelatedtotheanxiety.Thisanxietyseemedtohavestartedwhenshehadasinglepoorperformancemuchbelowthatexpectedofher.Shedoesnothavesignificantanxietyoutsideoftheathleticsphere.Howwouldyoutreatheranxietyinthissituation?Commentonanypsychotherapeutic,psychopharmacologic,orotherapproachesyoumighttake.

• Describewhypanicdisordersufferersmayexperienceaworseningofsymptomsduringacuteexercise.

• Find2examplesfromthelaypressthatillustratewhatyouwouldconsidersuperstitiousritualsinathletes(asopposedtoactualobsessive-

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compulsivedisorder).Whatpsychologicalroledoyousupposetheseritualsplayfortheathletes?

4 Post-traumaticstressdisorderandothertrauma-relateddisordersinathletes(*Note:Theassignedreadingisfromatextbooktowhichlearnersmightnothaveaccessthroughtheirinstitution’slibrarylendingsystemsortheirownortheirmentors’bookcollections.Ifthelearnerhasnoaccess,thenthistopicmaybeskipped,asthereisnoequivalentjournalarticleintheliterature).

Reading:Posttraumaticstressinathletes.WenzelT,ZhuLJ.In:BaronDA,ReardonCL,BaronSH,eds.ClinicalSportsPsychiatry:AnInternationalPerspective.UnitedKingdom:Wiley,2013.Writingassignment:

• ListeventsthatmayleadtoPTSDsymptomsinathletes,andwhysomeofthesesameeventsmaybelesslikelytocausePTSDsymptominnon-athletes.

• DescribehowPTSDsymptomsinanathletecanspecificallyinterferewithathleticperformance.

• Youhavea25yearoldmaleprofessionaltrackandfieldathletewhotrippedoverahurdleinamajorinternationalcompetition,sufferedaseriousleginjuryrequiringseveralsurgeriesandayearofrecovery,andhasnowcompletedallnecessaryrehabilitationtobeabletofullyreturntosport.However,heisexhibitingPTSDsymptomsandishavinggreatdifficultyreturningtosport.Whenhetriestopractice,heclearsthehurdleswithhesitationanddoesnot

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getlowenoughtothehurdles.Describeyourgeneraltreatmentapproach,includingpsychotherapyandpsychopharmacologyasappropriate.

5 Eatingdisordersandotherbodyimagedisordersinathletes

Reading1:• JoyE,KussmanA,Nattiv

A.2016updateoneatingdisordersinathletes:acomprehensivenarrativereviewwithafocusonclinicalassessmentandmanagement.BritishJournalofSportsMedicine2016;50:154-162.

Writingassignment1:

• Whichsportsareassociatedwiththehighestriskfordevelopmentofeatingdisorders?

• Listatleast5factorsthatshouldbetakenintoaccountwhenconsideringclearance/returntoplayforanathletewithaneatingdisorder.

• Find1researcharticleonthefemaleathletetriadand1researcharticleonRelativeEnergyDeficiencyinSport(RED-S).Givethecitationsforthearticles,andwrite1paragraphcomparingandcontrastingtheconceptsofRED-Sandthefemaleathletetriad.Itisnotuniversallyacceptedthat1oftheseconstructsis

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morevalidthantheother,butwhichdoyoufindmorecompelling?

Reading2:

• MurraySB,RiegerE,TouyzSW,etal.MuscledysmorphiaandtheDSM-Vconundrum:wheredoesitbelong?Areviewpaper.IntJEatDisord2010;43:483-491.

Writingassignment2:

• MuscledysmorphiaisnotanofficialdiagnosisincludedintheDiagnosticandStatisticalManualofMentalDisorders.However,listtheproposeddiagnosticcriteriaforthiscondition.

• Describewaysinwhichmuscledysmorphiaissimilarto:bodydysmorphicdisorder;obsessive-compulsivedisorder;andeatingdisorders.

6 Substanceusedisordersinathletes:Part1

Reading:• ReardonCL,CreadoS.

Drugabuseinathletes.SubstanceAbuseandRehabilitation2014;5:95-105.

Writingassignment:

• Listatleast4reasonswhyathletesasauniquepopulationmayusesubstances.

• A21yearoldfemalecollegiatebasketballplayerhasbeenreferredtoyoubyherteam

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trainerforanxiety.ShereportsusinghighdosesofAdderall(mixedamphetaminesalts)fromafriend,asitseemstohelpherspeedandfocusonthecourt.Shedoesnotnoticeittobecausinganyproblemsforher.Herultimategoalistogotomedicalschooltobecomeanorthopedicsurgeonorsportsmedicinephysician.Listfourstatements,usingeachofthe4importantelementsofmotivationalinterviewingthatarementionedinthearticle,thatyoumightmaketoheraspartofamotivationalinterviewingapproachtohersubstanceuse.Forexample,toillustratetheuseofclinicianempathy,youmightstate,“Itgoeswithoutsayingthatyouhavesomanypressuresanddemandsonyourtime,thatIcanjustimaginewhenyoufindsomethingthatseemstohelpanddoesn’tseemtocauseanyproblems,onewouldbehardpressednottowanttouseit.”

7 Substanceusedisordersinathletes:Part2

Reading:HainlineB,BellL,WilfertM.Chapter3.Substanceuseandabuse.In:Mind,Body,andSport:UnderstandingandSupportingStudent-AthleteMentalWellness.NCAA.2014.Availableat:http://www.ncaa.org/sport-

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science-institute/introduction-mind-body-and-sport(scrolltoseespecificchaptersub-topicassigned)Writingassignment:

• Howdoratesofalcoholandmarijuanausebycollegestudent-athletescomparetousebynon-athletecollegestudents?

• Listatleast3potentialnegativeeffectsonsportsperformanceforstudent-athletesforuseofeachofthefollowingsubstances:alcohol,stimulants,andmarijuana.

8 Gamblingdisorderinathletes Reading:DerevenskyJ,PaskusT.Chapter3.Gamblingamongstudent-athletes:causeforconcern.In:Mind,Body,andSport:UnderstandingandSupportingStudent-AthleteMentalWellness.NCAA.2014.Availableat:http://www.ncaa.org/sport-science-institute/introduction-mind-body-and-sport(scrolltoseespecificchaptersub-topicassigned)Writingassignment:

• Describethedemographicsofgamblingincollegiatestudent-athletesbyansweringthefollowing:1)whatpercentageofmaleandfemalestudent-athletesexhibitclinicalsignsofproblemgambling?;2)athletesfromwhichsportareatgreatestriskforproblem

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gambling?;3)inwhattypeofgamblingarestudent-athletesrelativelymorelikelytoparticipatecomparedtotheirpeers?

• DescribeNCAAregulationssurroundingstudent-athleteparticipationingambling.Whatdoyouthinkisthepointofhavingtheseregulations?Canyouthinkof1possiblewaytotrytoimprovecompliancewiththeseregulations?

• Describeatleasttwowaystechnologyhasinfluencedtrendsingambling.

9 Bipolardisorderinathletes Reading:• SylviaLG,FriedmanES,

KocsisJH,etal.Associationofexercisewithqualityoflifeandmoodsymptomsinacomparativeeffectivenessstudyofbipolardisorder.JournalofAffectiveDisorders2013;151(2):722-727.

Writingassignment:

• Whatistherelationshipbetweenfrequencyofexerciseandmoodstatesasdescribedinthisstudy,andwhatareatleast2possibleexplanationsforthisfinding?

• Doyouthinktheabovefindingwouldbecompellingenoughtochangeyourpracticein

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anywaywhenworkingwithathleteswhohavebipolardisorder?Ifso,inwhatway(s)?

10 Attention-deficit/hyperactivitydisorderinathletes

Readings:• ReardonCL,FactorRM.

Considerationsintheuseofstimulantsinsport.SportsMedicine2016;46:611-617.

• GarnerAA,HansenAA,BaxleyC,etal.Theuseofstimulantmedicationtotreatattention-deficit/hyperactivitydisorderineliteathletes:aperformanceandhealthperspective.SportsMed2018;48:507-512.

Writingassignment:

• List3argumentsforand3againststimulantsbeingprescribedtoeliteathletes.

• Withwhichoftheabovearticlesdoyouagreemorewhenitcomestoprescriptionofstimulantmedicationsforeliteathletes?Write1paragraphwithyourrationale.

11 Sleepinathletes Reading:HalsonSL.Stealingsleep:issportorsocietytoblame?BritishJournalofSportsMedicine2016;5:381.Writingassignment:

• Listatleast5reasonswhyathletesmaybeatuniqueriskforsleepdeprivation.

• Youareworkinginadministrativeleadership

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ataDivisionIcollegeathleticdepartmentandhavebeenputinchargeofdevelopinginitiativestoimproveoverallsleepofthestudent-athletepopulationatyourinstitution.Describe2initiativesyoumightundertake,andbarriersthatmightexisttoimplementationofeachone.

12 Suicideinathletes Reading:LesterD.Chapter3.Suicidaltendencies.In:Mind,Body,andSport:UnderstandingandSupportingStudent-AthleteMentalWellness.NCAA.2014.Availableat:http://www.ncaa.org/sport-science-institute/introduction-mind-body-and-sport(scrolltoseespecificchaptersub-topicassigned)Writingassignment:

• Whatistherelativeriskofsuicideincollegestudent-athletescomparedtothegeneralcollegepopulation?Describespecificdemographicvariableswithinthatgenerality.

• List6riskfactorsforsuicideinprofessionalathletes.

13 Mentalhealthimpactofconcussionsinathletes:Part1

Reading:McCrory,Paul,MeeuwisseW,DvorakJ,etal.Consensusstatementonconcussioninsport—the5thinternationalconferenceonconcussioninsportheldinBerlin,October2016.BritishJournalofSportsMedicine

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2017;51:838-847.Writingassignment:

• Definesport-relatedconcussion,includingseveralclinicallydefiningfeaturesaslaidoutbythe5thinternationalconferenceonconcussioninsport.

• Return-to-sportandreturn-to-schoolstrategiesfollowingsport-relatedconcussionhaveevolvedovertime.Thispapernotesthatafterabriefperiodofinitialrest(24-48hours)followingasport-relatedconcussion,symptom-limitedactivitycanbebegun.Onceconcussion-relatedsymptomshaveresolvedatagivenlevelofactivity,theathleteshouldcontinuetothenextlevel.Generally,eachstepshouldtakeaminimumof24hours.Listthe6aims(levels)ofagraduatedreturn-to-sportstrategyandthe4aims(levels)ofagraduatedreturn-to-schoolstrategy(specificactivitiesandgoalsofeachaimneednotbelisted).

• List6clinicaldomainsthatcanleadtoasuspecteddiagnosisofsport-relatedconcussion.

• Themanuscriptnotesthatthelargemajorityofathleteswithsport-

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relatedconcussionrecover,fromaclinicalperspective,withinthefirstmonth,thoughtherearedefiniteexceptions.Listatleast5riskfactorsfordelayedrecovery,includingspecificmentionofthestrongestandmostconsistentpredictorofslowerrecoveryfromsport-relatedconcussion.

14 Mentalhealthimpactofconcussionsinathletes:Part2

Reading:RiceSM,ParkerAG,RosenbaumS,etal.Sport-relatedconcussionandmentalhealthoutcomesineliteathletes:asystematicreview.SportsMedicine2018;48:447-465.Writingassignment:

• Describethelevelofevidenceforanyassociationbetweensport-relatedconcussionanddepression,andbetweensport-relatedconcussionandanxiety.

• Describeabiopsychosocialmodelfornegativeoutcomesinsport-relatedconcussion.

15 Relationshipbetweeninjuriesandmentalillness

Reading1:PutukianM.Chapter4.Howbeinginjuredaffectsmentalhealth.In:Mind,Body,andSport:UnderstandingandSupportingStudent-AthleteMentalWellness.NCAA.2014.Availableat:http://www.ncaa.org/sport-science-institute/introduction-mind-body-and-sport(scrolltoseespecificchaptersub-topicassigned)

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Writingassignment1:

• Describehowaneatingdisordermayresultfromanathleticinjury.

• Provide3reasonswhybeinginjuredwithaconcussionisdifferentfromotherinjuriesinhow/whyitmayaffectmentalhealth.

• Describeonepotentialnegativeimpactofincreasedmediaattentiononchronictraumaticencephalopathyamongathletes.

Reading2:Psychologicalissuesrelatedtoillnessandinjuryinathletesandtheteamphysician:aconsensusstatement-2016update.CurrentSportsMedicineReports2017;16(3):189-201.Writingassignment2:

• Describeatleast2waysinwhichpsychologicalstressmaypredisposetoathleticinjury.

• List3prominentpsychologicalfactorsthathavebeenshowntobeimportantinillnessandinjurytreatmentandoutcomes.Foreachofthese,explaintheimpactin1-2sentences.

• List9characteristicsofpoorprogressionofrecoveryfrominjury.

16 Medicationuseforpsychiatricdisordersinathletes

Reading:ReardonCL,CreadoS.Psychiatricmedicationpreferencesofsports

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psychiatrists.ThePhysicianandSportsmedicine2016;44(4):397-402.Writingassignment:

• List3importantvariablestoconsiderinprescribingpsychiatricmedicationstoathletes.

• Consideringtheresultsdescribedintheassignedreading,aswellasyourownclinicalexperienceswithmedications,whatwouldbeyourfirstchoiceforapsychiatricmedicationforanathleteineachofthefollowingcategories:depressionwithoutanxietyandwithoutbipolarspectrumdisorder;generalizedanxietydisorder;insomnia;ADHD;bipolarspectrumdisorders;psychoticdisorders?Forresidents/fellowsonly(thiswouldbeanadvancedquestionformedicalstudents):Whatwouldbeyourfirstchoiceforapsychiatricmedication,andwhy,foranathleteinthefollowingdiagnosticcategoriesnotconsideredexplicitlyinthisarticle:OCD;PTSD;panicdisorder?

• How,ifatall,doyourfirst-linechoicesinallofthesecategoriesdifferfromyourfirst-linechoicesforgeneral,non-athletepatients?Ifthere

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aredifferences,aretheyjustifiable(inotherwords,doanydifferencessuggestthatwewouldn’tbetreatingathletes“aggressively”enoughwithmedication,orthatwearetootolerantofsideeffectsinnon-athletepatients?)?

17 Psychotherapyforpsychiatricdisordersinathletes

Reading:StillmanMA,BrownT,RitvoEC,etal.Sportpsychiatryandpsychotherapeuticintervention,circa2016.InternationalReviewofPsychiatry2016;28(6):614-622.Writingassignment:

• Listatleast1reasonwhyeachofthefollowingtypesofpsychotherapy,incertaincircumstances,maybeuniquelyhelpfuland/orcomfortableforathlete-patients:CBT;marital/familypsychotherapy;grouppsychotherapy.

• A21yearoldfemaleswimmerisreferredtoyouforpsychiatricassessmentandtreatmentforsymptomsofsevereanxietyandpossibleeatingdisorder.Youcontacthertoscheduleanintakeappointment,andofferheravarietyoftimeslotsinwhichyouseepatients(8:30-4pm,exceptfor12-1forlunchbreak/meetings)andduringwhichyourcollegecounselingcenterisopen.

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However,theswimmer,whoisinthemidstofaveryheavyswimpracticescheduleasshepreparesfortheOlympicTrials,saysthatitwouldbeverydifficultforhertoseeyouduringyouropentimeslots,andshewondersifyoucouldseeherat4pm.Howwouldyoudealwiththissituation?Whataretheprosandconstoavarietyofoptionsforscheduling?

18 Exerciseaddiction Reading:FreimuthM,MonizS,KimSR.Clarifyingexerciseaddiction:differentialdiagnosis,co-occurringdisorders,andphasesofaddiction.InternationalJournalofEnvironmentalResearchandPublicHealth2011;8:4069-4081.Writingassignment:

• List7proposedcriteriaforexerciseaddictionthatparallelDSM-5criteriaforsubstanceusedisorders.

• Distinguishprimaryexerciseaddictionfromsecondaryexerciseaddiction.

• Listthe4proposedphasesofexerciseaddiction.Writeonesentencetodescribeeachphase(4sentencestotal).

19 Harassmentandabuse(non-accidentalviolence)insport:Part1

Reading:DiamondAB,CallahanST,ChainKF,etal.Qualitativereviewofhazingincollegiateandschoolsports:consequencesfromalackofculture,

Page 21: Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports psychiatry • Senior medical students intending a career in psychiatry, sports medicine,

knowledgeandresponsiveness.BritishJournalofSportsMedicine2016;50:149-153.Writingassignment:

• Definesports-specifichazing.

• Listthe3maincategoriesofhazing,andprovide1-3specificexamplesofhazingactivitieswithineachofthosecategories.

• Table2listspossiblerolesforadministrators,coaches,studentathletes,andteamcaptainstoplaywithregardstohazingawarenessandprevention.Arethereanypossiblerolesinthisregardforthesportspsychiatristand/orsportsmedicinephysician?If,asthephysician,youwouldtalktoyourathlete-patientsaboutthisissue,shareexamplelanguagethatyoumightuse.

20 Harassmentandabuse(non-accidentalviolence)insport:Part2

Reading:MarksS,MountjoyM,MarcusM.Sexualharassmentandabuseinsport:theroleoftheteamdoctor.BritishJournalofSportsMedicine2012;46:905-908.Writingassignment:

• Definesexualharassmentandsexualabuse.

• Riskfactorsforsexualabuse/harassmentinsportcanbebrokendownintoathlete,coach,andsportvariables.List1-3specificriskfactors

Page 22: Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports psychiatry • Senior medical students intending a career in psychiatry, sports medicine,

withineachofthesecategories.

• Listseveralpotentialpsychologicalconsequencesofsexualharassmentandabuseinsport.

• YouhavebeenaskedtogiveatalktotheprimarycaresportsmedicinephysiciansataDivisionINCAAinstitutiononthetopicofsexualharassmentandabuseinsport.Listatleast6keytenetstosharewiththeteamphysiciansastohowtheyshouldrespondanddealwithasituationinwhichanathletehasdisclosedsexualabuseorharassmentinsport.

21 Childandadolescentsportspsychiatry

Reading:Conant-NorvilleDO.ChildandadolescentsportspsychiatryintheUS.InternationalReviewofPsychiatry2016;28(6):556-563.Writingassignment:

• Definephysicalliteracy,includingdefinitionsofthe3componentsofit.Listatleast4groupsofyouthwho,underthecurrentmodelofyouthsportsintheUS,haveinsufficientopportunitiesfordevelopmentofphysicalliteracy.

• List8challenges,identifiedbytheAspenInstitute’sProjectPlayworkgroup,thatlimityouthsportsinvolvementintheUS.Imagineyouaretaskedwith

Page 23: Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports psychiatry • Senior medical students intending a career in psychiatry, sports medicine,

developingasummeryouthsportsprogramfor5-6yearoldsinyourcommunity.Howwouldyoustructuretheprogram,keepinginmindsomeofthe8challengesyoulisted.

• Distinguish“earlyspecializationinsport”versus“sportsampling”inyouth,andlistatleast3benefitsofthelatter.

22 Retirementinathletes Reading:KnightsS,SherryE,Ruddock-HudsonM.Investigatingeliteend-of-athletic-careertransition:Asystematicreview.JournalofAppliedSportPsychology2016;28:291-308. Writingassignment:

• Distinguishbetweenthe2typesoftransitionsthatathleteswillfacethroughouttheirathleticcareer,andgiveexamplesofeach.

• Listatleast3factorsthatmayleadtoamoredifficulttimetransitioning,andatleast3factorsthatmaybeprotectiveagainstadifficulttransition.

• Listatleast3strategiesthatmighthelpathletestotransitionmoresmoothly.

23 Exerciseasatreatmentformentalillness

Readings:• CooneyGM,DwanK,

GreigCA,etal.Exercisefordepression.Cochranedatabaseofsystematicreviews2013.

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• EnsariI,GreenleeTA,MotlRW,etal.Meta-analysisofacuteexerciseeffectsonstateanxiety:anupdateofrandomizedcontrolledtrialsoverthepast25years.DepressionandAnxiety2015;32:624-634.

Writingassignment:

• Listatleast4hypothesesastowhyexercisemighthaveanantidepressanteffect.

• In3-4sentences,summarizetheresultsoftheCochranereviewonexerciseasatreatmentfordepression.Basedontheseresultsandanyotherinformationyouhave,doyoufinditjustifiedtorecommendexerciseforyourpatientsasatreatmentfordepression?Whyorwhynot?

• In1-2sentences,summarizetheresultsoftheEnsaristudyonanacuteboutofexerciseasatreatmentforanxiety.Basedontheseresultsandanyotherinformationyouhave,doyoufinditjustifiedtorecommendexerciseforyourpatientsasatreatmentforanxiety?Whyorwhynot?

24 Overtrainingsyndrome Reading:ReardonCL.Psychiatriccomorbiditiesinsports.NeurologicClinics2017;35:537-546.

Page 25: Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports psychiatry • Senior medical students intending a career in psychiatry, sports medicine,

Writingassignment:

• List2waystohelpdistinguishovertraininganddepressioninathletes.

• Findoneotherscientificarticleonovertrainingsyndromethatprovidesdefinitionsofrelevantterms.Specifically,listthearticlecitationandprovidedefinitionsfromthatarticlefor:1)overtrainingsyndrome,and2)overreaching/nonfunctionaloverreaching.

25 Barrierstoathletesaccessingmentalhealthresources

Reading:GulliverA,GriffithsKM,ChristensenH.Barriersandfacilitatorstomentalhealthhelp-seekingforyoungeliteathletes:aqualitativestudy.BMCPsychiatry2012;12:157..Writingassignment:

• Listatleast5potentialbarriersforathleteswhenitcomestoseekingmentalhealthtreatment.

• Howdoestheroleofstigmadifferwhenitcomestoathletesseekinghelpforclinicalconditionsversusforathleticperformanceconcerns?

• Inwhatconcretewayscouldamentalhealthprofessionalhelpimprovefacilitativefactorswhenitcomestoathletesseekingmentalhealthtreatment?

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Specifically,listonewaythementalhealthprofessionalcoulddosothatmightinvolvecoaches,onethatmightinvolveadministration,andonethatmightinvolvetheathletesdirectly.

26 Theroleofcultureinsports Reading:GillD.Genderandculturaldiversityinsport,exercise,andperformancepsychology.OxfordResearchEncyclopediaofPsychology.2017.Availableat:http://psychology.oxfordre.com/view/10.1093/acrefore/9780190236557.001.0001/acrefore-9780190236557-e-148Writingassignment:

• Describehowgenderstereotypesanddifferentialmediacoverageofmen’sversuswomen’ssportsmayinfluencesportsperformanceand/orparticipation.

• Describehowstereotypethreatmightimpactathleticperformanceforathletesofracialorethnicminorities.

• Listatleast3barrierstosportsparticipationforpeoplewithphysicaldisabilities.

• FindatleastoneotherresearcharticlethatdiscussesanymentalhealthrisksorconcernswithinanLGBTQathletepopulation.Providethecitation,andwrite2-4

Page 27: Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports psychiatry • Senior medical students intending a career in psychiatry, sports medicine,

sentencestosummarizethefindingsdescribedinthearticle.

• Reflectonyourownculturalbackgroundand,ifapplicable,yourownhistoryofsportsparticipation.Writeaparagraphonhowthisbackgroundmightaffectinteractionswithathlete-patientsfromavarietyofdemographicgroups.

27 Ethicalissuesinsportspsychiatry(*Note:Theassignedreadingisfromatextbooktowhichlearnersmightnothaveaccessthroughtheirinstitution’slibrarylendingsystemsortheirownortheirmentors’bookcollections.Ifthelearnerhasnoaccess,thenthistopicmaybecompletedwithoutreferencingtheassignedchapter,knowingthatitwillbemoredifficulttodoso,butwillstillgeneratereflectiononanddiscussionofthetopic).

Reading:Sportspsychiatristsworkingincollegeathleticdepartments.MorseED.In:BaronDA,ReardonCL,BaronSH,eds.ClinicalSportsPsychiatry:AnInternationalPerspective.UnitedKingdom:Wiley,2013.Writingassignment:

• Describehowyouwouldhandlethefollowingethicalchallenges:a) Youareasalaried

employeeintheathleticdepartmentataDivisionIuniversity,employedtotreatstudentathletes.Youaretreatingafemalesoftballplayerforrecurrentmajordepressivedisorder,PTSD,andborderlinepersonalitydisorder.Shehashad3hospitalizationsinthelast18months,andthishasprovendisruptivetoherteam.Theathlete’s

Page 28: Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports psychiatry • Senior medical students intending a career in psychiatry, sports medicine,

athletictrainerandcoachcontactyoutoaskaboutprognosisandlikelihoodoffuturedecompensationsandhospitalizations,astheyareconsideringcuttingherfromtheteamduetohermentalhealthabsences.Commentonthisspecificsituation,aswellasanylargerstrategiesforaddressingthepotentialconflictofinterestinrolesyoufill.

b) YouaretreatingafootballplayerataDivisionIuniversityforgeneralizedanxietydisorderandalcoholusedisorder.YouareawarethatitiscommonknowledgeamongthefootballplayersthatinternaldrugtestinghappensonMondayafternoons.Herecentlyadmitstohavingbeenusingafriend’smethylphenidatetohelpwithstudying.HeisawareofNCAAprohibitionsagainstthis,intheabsenceofanofficialdiagnosisandappropriatedocumentation.Heasksifyouareabletomakethatdiagnosis,

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ashebelievesitispresent,andinthemeantime,heasksaboutthehalf-lifeofmethylphenidatesothathecanavoidtestingpositiveonMondayafternoons.

c) YouaretreatingasprinterataDivisionIuniversityforpanicdisorderandmajordepressivedisorder.ShewinstheNCAANationalChampionship100meterdash.Shewouldliketogiveyouhertrackjerseytoaddtoyourofficedecorasatokenofherappreciation(sheobservesthatyouhavesomegenericsportsdecorationsbutnothingrelatedtotrackandfield,anditwouldmakeherfeelgoodtohavehersportrepresentedonyourwalls).Shepointsoutthatnothingonthejerseywillindicatefromwhomitcame.

Nowthatyouhavecompletedthecurriculum,thelearnerandattendingsupervisorareaskedtopleasecompletebriefevaluationsofthecurriculum.Seeaboveforweblinkstodoso.

Page 30: Sports Psychiatry Curriculum · • Sports medicine fellows desiring an elective in sports psychiatry • Senior medical students intending a career in psychiatry, sports medicine,

Otherinformation:MembershipintheInternationalSocietyforSportsPsychiatry(ISSP)isavailabletomedicalstudents,residents,andfellowswhoareinterestedinthefield,atdiscountedratesfortrainees.Moreinformationisavailableat:https://sportspsychiatry.org.TheISSPholdsitsannualBusinessMeetingandScientificSessioninconjunctionwiththeAmericanPsychiatricAssociationAnnualMeetingeveryMay,andanyonewithinterestisinvitedtoattend(informationaboutthiseventpostedontheISSPwebsiteinadvanceofthemeeting).Additionally,amentorshipprogramisavailabletointerestedmedicalstudents,residents,fellows,andearlycareerpsychiatristsaspartofISSPmembership.Additionalreferenceforthoseinterestedinfurtherreading:BaronDA,ReardonCL,BaronSH,eds.ClinicalSportsPsychiatry:AnInternationalPerspective.UnitedKingdom:Wiley,2013.BegelD,BurtonRW,eds.SportPsychiatry.NewYork:NortonProfessionalBooks,2000.GlickI,KamisD,StullT,eds.TheISSPManualofSportsPsychiatry.NewYork:RoutledgePress,2018.McDuffDR,GarvinM.Workingwithsportsorganizationsandteams.InternationalReviewofPsychiatry2016;28(6):595-605.McDuffDR.SportsPsychiatry:StrategiesforLifeBalanceandPeakPerformance.Arlington(USA):AmericanPsychiatricPublishing,2012.


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