Depression Among Athletes and the Potential Impact on Performance
Summary and Keywords
Major depressive disorder, dysthymia, and bipolar disorder are very common diagnoses seen among athletes, and they are serious conditions that can be debilitating if not properly addressed. These disorders warrant careful attention because they can adversely affect multiple domains of an athlete’s life, including athletic motivation, performance outcomes, interpersonal well-being, health, and overall daily functioning. Key foci include the prevalence of, clinical characteristics of, causes of, and risk factors for major depressive disorder, persistent depressive disorder/dysthymia, bipolar I disorder, and bipolar II disorder. Sport psychologists should integrate such important information into their overall case conceptualization and decision-making processes to ensure that athletes and performers at risk for, or struggling with, such mental health concerns receive the most effective, efficient, and timely care possible.
The fans are cheering, the lights are flashing, and playoff buzz is in the air. Tonight, the mood is right for a great competition! But in the locker room, not every athlete’s emotional well-being matches his/her physical condition. One primary reason for the mismatch is the presence of clinical disorders that negatively impact an athlete’s mood state. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association [APA], 2013), the disorders predominantly include major depressive disorder, persistent depressive disorder/dysthymia, and bipolar I and II disorders (although the latter are no longer listed among the classic “depressive” disorders). These clinical diagnoses afflict athletes worldwide, and are some of the most common reasons for referral for psychological treatment. Not unlike depressed individuals in the general population, clinically and subclinically (below diagnostic levels) depressed athletes struggle with substantial deviations from normative mood states and exhibit cognitive, behavioral, and physical symptoms (Truax & Shelton, 2003). The symptoms include low mood, fatigue, diminished interest in previously pleasurable activities, mania, altered sleeping and eating patterns, disrupted concentration and attention, interpersonal difficulties, and compromised occupational (including athletic) functioning. Such disorders warrant careful attention within the sport environment, because they possess the potential to hinder several aspects of an athlete’s life. Athletic motivation, performance outcomes, interpersonal well-being, and overall daily functioning are all domains that can be adversely affected when an athlete suffers from an undiagnosed and consequently untreated clinical disorder (Cuijpers, Smit, & van Straten, 2007). This article provides an up-to-date discussion of the prevalence of, clinical characteristics of, causes of, and risk factors for the current DSM-5 diagnoses of major depressive disorder, persistent depressive disorder/dysthymia, and bipolar I and II disorders. This review will be useful to on-the-go practitioners and support personnel who need dedicated resources that can instantly benefit their practice. Ideally, sport psychologists will integrate this important information into their overall case conceptualization and decision-making processes.
Major Depressive Disorder
Prevalence, Development, and Course of Major Depressive Disorder
Major depressive disorder (MDD) is typically considered to be the most common psychological condition among adolescents and adults. While prevalence rates differ for specific age groups (APA, 2013), lifetime prevalence rates for females and males are quite high, reportedly ranging from 10% to 25% for women and from 5% to 12% for men (APA, 2000; Kessler et al., 2005). Onset of MDD can occur at any time throughout the lifespan, yet onset typically is between puberty and the 20s, and incidence rates usually peak in the 20s, as well (APA, 2013). The onset data are particularly applicable for sport psychology practice, since the middle-school through post-college age range is precisely the age range of most athletes with whom sport psychologists work. Furthermore, while the day-to-day experience of the classic form of depression can be incapacitating (see “Characteristics of Major Depressive Disorder”), depression also is associated with a high mortality rate (primarily suicide-related), and increased risk of cancer, diabetes, stroke, and heart attack (Demyttenaere et al., 2004). Perhaps not surprising, according to World Health Organization (WHO) data, MDD is a leading cause of disability worldwide in comparison to other psychological and physical disorders (Lopez, Mathers, Ezzati, Jamison, & Murray, 2006).
Although it is difficult to predict which athletes will become clinically depressed, data show that approximately two-thirds of those who experience even one depressive episode will experience future episodes, and recurrence rates rise sharply with each subsequent episode (Kessler, Tat Chiu, Demler, & Walters, 2005; Teasdale et al., 2000). Depressed athletes are also prone to additional psychological complications, as data indicate that 76% of those with MDD meet diagnostic criteria for another psychological disorder (Kessler et al., 2005). Disorders such as persistent depressive disorder/dysthymia, anxiety disorders, eating disorders, and substance/alcohol use disorders are all known to co-occur with MDD and are themselves common among athletes. Thus, recognizing co-occurring diagnoses is imperative, as the onset, frequency, complications, course, and duration of MDD are all influenced by the presence of comorbid issues.
When exploring the complete clinical picture, the need for early detection and effective intervention among athletes is critical. Untreated (or unsuccessfully treated) MDD can be debilitating and long-standing, possibly resulting in acute or chronic complications in interpersonal, intrapersonal, social, family, recreational, occupational, and self-care domains (Truax & Shelton, 2003). It may also lead to suicidal thoughts or attempts. In fact, even subclinical depression (depressive feelings not quite meeting the full criteria for the disorder) has been shown to significantly affect quality of life (Cuijpers et al., 2007). This is in fact the case for each of the disorders covered herein.
Characteristics of Major Depressive Disorder
The DSM-5 criteria for MDD reflect some minor changes to the previous DSM-IV-TR (APA, 2000) criteria. For an athlete to fulfill diagnostic criteria for MDD under the new diagnostic system (APA, 2013), five or more of the following symptoms must exist the majority of the time on most days for a minimum of 2 consecutive weeks. At least one of the 5+ criteria must be either: ongoing depressed mood, which may present as sadness or feelings of emptiness or hopelessness; or limited interest in once pleasurable activities. A special note about the above criteria is that among children and youth, MDD characteristics may include irritability rather than sadness. Further, while outward behavioral indicators, such as tearfulness, are likely to be present for youth and adults alike, outward indicators do not necessarily indicate MDD, just as a lack of outward indicators does not necessarily suggest the absence of MDD. Indeed, the two criteria listed above embody the central features of MDD, and thus either one or both are necessary as a foundation upon which the other clinical features accumulate. To fulfill the remainder of the criteria, additional symptoms may include: an unusual increase/decrease in the athlete’s psychomotor characteristics that stems from mental distress, such as restlessness or purposeless motor activity (i.e., atypical twisting of hair, pacing, biting of inside of lips), or reduced physical movement or cognitive activity; uncharacteristic fatigue or reduced energy; a nonpurposeful increase/decrease in the athlete’s weight (which exceeds 5% of total body weight within 1 month) or a distress-induced increase/decrease in daily appetite; sleep disturbance; disproportionate feelings of guilt or worthlessness, which exceed the athlete’s typical levels of self-criticism or self-blame, during the depressed state; reduced concentration or increased indecisiveness; and, finally, persistent suicidal thoughts or general thoughts of death.
One of the most interesting yet disheartening realities of MDD is how vast the complications can be. Complications with daily functioning in a number of life domains are so common that emotional distress or behavioral impairment in such life domains is an additional formal criterion that must be satisfied in order to fulfill the diagnostic criteria (APA, 2013). The depressed athlete may exhibit emotional distress and behavioral impairment in these domains of life that are quite similar to those in non-athletes. Common experiences may be decreased contact with relatives, unwarranted aggravation with a significant other, reduced interest in recreational activities, and sluggish behavior leading to a reduction in self-care. Sport psychologists may also notice how depression-related distress and impairment can complicate athletic pursuits. For example, the depressed athlete may begin to struggle with a short temper and associated aggressive outbursts with teammates and coaches, lose interest in strength training, delay game preparation, sluggishly depart the playing field, and struggle with a wandering mind during practice and competition. If this example sounds familiar, it is because athletes are no more immune to psychological struggle than individuals in the general population (Maniar, Chamberlain, & Moore, 2005) and frequently face depression and a host of additional concerns at subclinical and clinical levels. The National Collegiate Athletic Association (NCAA) agrees, and provides numerous articles and resources on NCAA.org to promote awareness of athletes’ very real struggles with depression and suicidality. Yet, it may not be surprising that MDD symptom presentations can easily be overlooked or misinterpreted in the sport environment. For instance, instead of signaling a serious clinical disorder or subclinical concern that deserves therapeutic attention, outwardly expressed depression symptoms such as those just noted may be misinterpreted in the sport culture as a “sign” of alcohol or drug abuse. Or, player personnel may think the athlete “lacks heart” or “lacks passion,” or perhaps may make the ever-baseless assumption that the athlete “doesn’t want it bad enough” (Cogan, 2000). Incorrect assumptions by coaches, teammates, scouts, staff, family, and the media can lead to a delay in effective treatment. Unfortunately, this may simultaneously increase the athlete’s depressive symptoms and lead others to treat the athlete as if she or he is doing something wrong.
Risk Factors for and Causes of Major Depressive Disorder
Since MDD is a common condition that is studied exhaustively in clinical research, the discipline knows a great deal about numerous risk factors and causative factors associated with the disorder. Years of epidemiological (risk factor) research have determined that a variety of risk factors are associated with the onset and maintenance of MDD. One particular risk factor is general negative affect, which is also commonly referred to as neuroticism. Presence of this highly dispositional personality characteristic is considered to be a particularly strong risk factor for the onset and maintenance of depression (and for many other diagnoses as well). This is especially true when general negative affect is paired with stressful life events (APA, 2013). Another significant contributor is interpersonal difficulties, particularly those resulting from ongoing efforts at seeking both negative feedback and reassurance from others, irritability, behavioral displays of hostility and anger, and social skill deficits (APA, 2013; Joiner & Timmons, 2009; LeMoult, Castonguay, Joormann, & McAleavey, 2013). These contributing factors are often long-lasting, due to the vicious cycle between depression and interpersonal/social supports. Namely, because individuals experiencing interpersonal discord often have fewer social supports and/or push others away, they are at greater risk for the onset and maintenance of depression. Conversely, those struggling with depression often withdraw from the interpersonal environment and their social support system and alienate themselves from others with behaviors like excessive emotional displays, reassurance seeking, negativity, and rejection of well-intentioned advice. An additional risk factor is a personal history of negative childhood experiences, which may vary in type and chronicity. A final major risk factor is a biological/genetic vulnerability. Data show that first-degree family members of individuals diagnosed with MDD have a 2 to 4 times greater risk for developing MDD than those without this family history. Forming an appropriate connection between a number of the risk factors noted herein, DSM-5 states that “heritability is approximately 40%, and the personality trait neuroticism accounts for a substantial portion of this genetic liability” (APA, 2013, p. 166).
With the primary risk factors addressed, it is important to consider the most evidence-based causes for MDD. Currently, the most empirically substantiated pathological process associated with MDD is the stress-diathesis model. According to this model, psychological and biological vulnerabilities may be triggered by a significant event or series of events. Schemas are learned cognitive frameworks/internal rule systems that individuals use to appraise and interpret the world. As is true for all humans, schemas can be helpful in shaping the athlete’s understanding of the self and the world, as schemas allow athletes to consolidate, organize, and make sense out of the vast amount of information they take in. The schemas can also lead to biased interpretations of events, the self, and others, and can further trigger additional cognitive biases. They can similarly restrict the assimilation and accommodation of alternative ways of viewing events, the self, and others. Along this more negative line, a few schemas that are particularly related to the onset and maintenance of depression include schemas associated with abandonment, insufficient self-control, vulnerability to harm, competence, and failure (Young, Klosko, & Weishaar, 2003). When triggered, such schemas can lead the athlete to negatively interpret information about the self, other individuals, and future outcomes, and can result in withdrawal (whether physically or cognitively) from activities that were previously valued and rewarding. Such withdrawal is known to reduce the positive reinforcement in the athlete’s life (particularly social reinforcement) and can further increase the athlete’s depressive symptoms.
Certain cognitive biases represent additional causes for MDD. Research indicates that “depressed individuals exhibit cognitive biases in all aspects of information processing, including memory, attention, and interpretation, which increase the risk for onset and maintenance of depressive episodes” (LeMoult et al., 2013, p. 29; Mathews & MacLeod, 2005). Depressed athletes will more readily recall historical negative information than nondepressed counterparts. Although depressed athletes do not necessarily attend to current negative information more than their nondepressed counterparts, once it has been presented, they are likely to hold on to negative information for longer periods of time (Joormann & Gotlib, 2007). Furthermore, depressed individuals are far more likely to possess a biased interpretation of negative self-directed information, and to demonstrate a substantially more brooding cognitive style.
Another causative influence on MDD and numerous additional diagnoses is the construct of emotion regulation. Emotion regulation “involves both internal and external processes responsible for experiencing, expressing, and modulating one’s emotions in the service of goal achievement” (Moore & Gardner, 2011, p. 249). In essence, emotion regulation is a critical process that influences whether one’s emotion promotes goal-directed action or action aimed at the avoidance of, or escape from, the experience of emotion itself. While empirical findings demonstrate that depressed and nondepressed individuals react similarly to negative life events, clinically depressed clients find it much harder to rebound from distress. It is not surprising, then, that clinically depressed athletes are far more likely to engage in maladaptive emotion regulation strategies when attempting to manage their negative cognitive and affective experiences, while their nondepressed counterparts typically engage in more effective emotion regulation strategies. While this is not an exhaustive list, some common maladaptive emotion regulation strategies include (Aldao, Nolen-Hoeksema, & Schweizer, 2010): rumination (brooding); thought suppression, which is an effort to reduce perceived negative emotional and cognitive content, yet ironically often leads to the opposite effect of increasing negative internal states; and catastrophizing, a cognitive style that accompanies many disorders, in which individuals over-interpret the level, significance, and possible consequences of negative events.
Last, interpersonal factors and developmental issues (e.g., negative early events) are known risk factors for MDD. Yet a number of specific interpersonal and developmental factors also have distinct causal relevance (Davila, Stroud, & Starr, 2009; Joiner & Timmons, 2009; LeMoult et al., 2013). From a causal perspective, such factors can include: parental deficits, such as child-directed aggression, inattentiveness, inconsistency, neglect, abuse, chronic familial conflict, and under- or over-involvement; parental death; parental history of depression; poor spousal/family support and/or lack of approval; intimate relationship conflict; social humiliation; insecure attachment style; occupational loss or perceived failure, which can certainly include being dropped from an athletic team; ongoing reassurance-seeking, seeking negative feedback to confirm one’s self-perceived inadequacy; relational enmeshment; social/peer isolation or exclusion; and injury, including but not limited to, postconcussion depressivity (Kontos, Covassin, Elbin, & Parker, 2012; Newcomer Appaneal et al., 2009).
Of course, sport psychologists must appreciate and anticipate the interconnectedness of each of the risk factors and causal variables. There is no exclusive pathway for the development and maintenance of depression, or any other psychological condition that our athlete-clients face. One athlete may struggle with depression as a result of a strong biological vulnerability mixed with ineffective coping styles and emotion regulation deficits. Another athlete may develop depression due to the intersection of extreme parental criticism and schemas related to failure and competence. And, another athlete may struggle with cognitive impairments and depressive symptoms after a series of concussions. In order to accurately diagnose and treat such concerns, it is imperative that sports psychologists resist seeing MDD as a one-size-fits-all phenomenon, because there are often numerous variables involved and the combinations of factors are endless.
Persistent Depressive Disorder/Dysthymia
Persistent depressive disorder/dysthymia is known to be a chronic disorder and is a challenging disorder to effectively treat. The term persistent depressive disorder/dysthymia is an update of the DSM-IV-TR term dysthymic disorder (for ease, the term dysthymia is used herein) and the diagnostic criteria have also been slightly revised. Previously, the DSM considered the chronic form of depression known as dysthymia to be distinct from the chronic form of MDD. DSM-5 now incorporates both types of chronic depressive conditions into one diagnostic category. For many years, dysthymia and chronic MDD had long been seen as distinct disorders in terms of course, prevalence, cause, and treatment foci (hence the previous diagnostic distinctions). However, the most notable dysthymia researcher, James McCullough, welcomed the new conceptual and diagnostic integration (McCullough, Schramm, & Penberthy, 2015). McCullough claimed that dysthymic clients and those struggling with chronic depression have never really been any different. If, then, the previous diagnostic distinctions were indeed arbitrary and merely led to confusion, the new terminology and minor criteria changes are likely to resolve diagnostic confusion and clear the path for the effective treatment of what is now seen as one distinct form of chronic depressive illness.
Prevalence, Development, and Course of Dysthymia
The lifetime prevalence rate for dysthymia is roughly 6% in the United States (APA, 2000; Kessler et al., 2005), with worldwide prevalence rates and athlete-specific rates undetermined. Dysthymia typically has an early onset, with children, adolescents, and young adults representing the most vulnerable group. While prevalence appears fairly equal among males and females when the onset of the disorder occurs during childhood, those who develop the disorder after young adulthood are significantly more likely to be women (APA, 2000). Dysthymia is unfortunately a more chronic condition than many of the other depression-spectrum disorders. Considering dysthymia’s fairly high prevalence rate, chronic nature, and early age of onset (during the prime years of sport participation), a discussion of the clinical characteristics, risk factors, and causal factors is warranted.
Characteristics of Dysthymia
For adult athletes (≥18 years old), the core feature of dysthymia is low/depressed mood, most often and on most days, for at least 2 consecutive years (APA, 2013). For children and adolescents, the mood disturbance may appear as irritability instead of depression, and uncharacteristic decrements in social skills may also be present. Furthermore, in children and adolescents, the symptom cluster needs to be seen for only 1 year. On top of the core feature, two or more additional criteria must accompany the chronic depressive state, including diminished self-esteem, sleep disturbance, reductions in energy or increases in fatigue, eating/appetite changes, hopelessness, and concentration/decision-making difficulties. As the combined symptoms must compromise personal functioning, a number of life domains can be affected. The symptom set and associated dysfunction must remain nearly ever-present throughout the course of dysthymia, because the diagnosis cannot be given if symptoms subside for more than 2 consecutive months of the required 2 (adult) years. Finally, an interesting diagnostic possibility to remember is that a diagnosis of MDD can simultaneously be given to a dysthymic athlete if she or he also meets full MDD criteria during the ≥ 2-year dysthymic episode. Referred to as double depression (McCullough et al., 2015), the dual diagnosis of MDD and dysthymia is warranted in cases in which the MDD essentially “sits on top” of the more chronic dysthymic condition. Like the general population, athletes struggling with this comorbid presentation are especially at risk for compromised well-being and personal safety.
Dysthymia is marked by a slow, gradual onset over a number of years. While full onset can occur at any point during the life span, the disorder is typically formalized during adolescence or early adulthood. Because of this, one of the most fascinating aspects of dysthymia is that, due to its typical early onset, many dysthymic athletes may not actually describe themselves as depressed. This is because they have been mildly depressed for so long (and starting so early in life) that they often don’t recall what it was like to feel any other way, and/or have habituated to the chronic low-level affective state. This is precisely why sport psychologists may find that dysthymic athletes often fail to endorse depressive symptoms during an interview. Alternatively, dysthymic athletes may state, “This is just my personality,” or “This is just how I am,” despite noteworthy depressive symptoms. Comorbidity with other disorders is also common, and as noted, a particularly toxic combination is the comorbid pairing of dysthymia and MDD (double depression). Double depression may actually be what motivates the athlete to seek services; when dysthymic clients do endorse depressive symptoms, it is often during discrete periods in which their mood state worsens from their typical dysthymic state. Because double depression can have important consequences, it is even more imperative that practitioners understand the unique clinical nuances of both dysthymia and MDD, and watch for signs of both sole and comorbid presence.
As noted, dysthymia typically begins its gradual development in childhood or adolescence, with full onset often taking hold during the adolescent to young adult years. Because sport psychologists commonly work with adolescent and young adult athletes, they are very likely to encounter clients with dysthymia. So, how do we recognize specific cases if they have many of the same symptoms as MDD? The answer to this question lies in a more descriptive picture. Children and young adolescents with dysthymia are often irritable, chronically unhappy individuals who seldom experience consistent joy, and their low mood, of course, well exceeds “developmentally typical” adolescent angst. They are also likely to be more difficult to soothe when distressed than their nondysthymic peers. For both youth and adults with dysthymia, common experiences include low self-esteem, a pervasive sense of vulnerability, underlying hostility, diminished energy and concentration, and low frustration tolerance. For athletes who experience an early onset of dysthymia, it would not be surprising if the symptom picture marked by low mood, diminished energy, reduced self-esteem, feelings of helplessness, and impaired concentration made ascension to elite competitive athletics less probable than for the more normatively emotionally regulated young athlete. However, this supposition is based on the typical symptom picture and impairments that accompany dysthymic psychopathology, and sport psychologists certainly see cases of dysthymia in athletes across all forms and levels of athletic engagement.
Aside from the above internal characteristics, though, what is the sport psychologist really likely to see among most clients with dysthymia? Unfortunately, the baseline affective states of athletes with dysthymia are often a milder form of depression that does not quite look as “heavy” as MDD, and associated behavioral manifestations of the disorder can qualitatively differ from MDD. Thus, at times it can be difficult to identify dysthymia simply from outward signs. Some of the most telling information can actually come from those close to dysthymic athletes. Family, friends, and teammates/coaches may describe feeling worn down by them. These individuals may report that athletes are too brooding, negative, irritable, cynical, difficult to please, critical, and pessimistic. They may further suggest that the clients complain too much, are chronically bored, lack enjoyment in life (including athletic) pursuits, frequently express guilt and self-doubt, and are frequently unhappy. While these characteristics may not seem “negative” enough to warrant a clinical diagnosis, consider that dysthymia is a chronic condition that typically lasts for at least 10 years, and that can persist for a lifetime (Pettit & Joiner, 2006).
Risk Factors and Causes of Dysthymia
The most evidence-based etiological theory of dysthymia originates from the work of James McCullough: namely, his cognitive behavioral analysis system of psychotherapy (CBASP) model. According to the model, dysthymia usually evolves fairly early in an individual’s life, due to a historical pattern of chronic early aversive events (upbringing and environment) that are marked by ongoing negativity, harshness, hostility, and/or loss. Those who develop dysthymia from these chronic aversive events are typically those who developed ineffective coping styles. Ineffective and maladaptive coping styles subsequently affect their perceptions of relationships with others and the world, and disconnect them from important environmental nuances (McCullough et al., 2015). Dysthymic individuals are thus typically those who learned to respond to perceived relational challenges, their own ineffective coping responses, and the resultant environmental disconnection by further restricting their engagement with others and the world or the manner in which they remained engaged. They therefore receive limited or misinformed social feedback and reinforcement, leading to additional hopelessness, helplessness, and hostility. This creates a circular pattern of low mood/dissatisfaction, disengagement, and withdrawal (even if only cognitive), which they typically carry through adolescence into adulthood, and perhaps throughout the course of their lives. The presence of chronic low-level aversive events appears to be the most salient etiological consideration and risk factor. In particular, athletes most at-risk for this pervasive disorder will be those who experienced a childhood or early adolescence marked by chronic negativity, harshness, hostility, and loss. Additionally, those most at risk have a lower personal tolerance for negative emotion; learn through repeated harsh experiences that the world and relationships, in particular, are unpredictable and uncontrollable, and that they have little personal impact on the world; struggle to realize how personal actions affect outcomes; and struggle to develop effective emotion- regulation and social problem-solving skills (McCullough et al., 2015). The ultimate consequence is typically a chronic reduction in quality of life, across many domains. Dysthymic athletes can often function well and achieve their athletic and personal goals. Yet, what athletic and overall personal potential could they realize if they were no longer struggling with a chronic, low level of depression? That powerful question should drive our willingness to screen for and address this challenging clinical concern among athlete-clients.
Bipolar disorders were previously considered mood disorders, along with MDD and dysthymia, in DSM-IV-TR. Although bipolar psychopathology certainly involves mood (specifically, an extreme range of moods varying from high to low), the DSM no longer categorizes bipolar disorders with MDD and dysthymia. Instead, DSM-5 allocates an entire chapter to the challenging class of “Bipolar and Related Disorders” (APA, 2013). Yet, despite the differentiation between depressive and bipolar conditions, bipolar disorders still retain their close link with depressive disorders, because bipolar disorders do primarily affect mood (often with toxic behavioral outcomes).
Prevalence, Development, and Course of Bipolar Disorders
Lifetime prevalence rates indicate that bipolar disorders affect approximately 1% to 3% of the population, largely regardless of culture (Kessler, Tat Chiu, Demler, & Walters, 2005), and are fairly equally distributed among women and men. While formal data on prevalence rates among athletes are lacking, the highly biological nature of the disorders makes differences in prevalence highly unlikely. While the onset of an athlete’s first bipolar episode can occur at any time, the typical age of onset is during adolescence for clients with bipolar I, and the mid-20s for clients with bipolar II (APA, 2013). The two bipolar disorders are persistent, and both are known to run a long and recurrent course, especially in those who experience an earlier age of onset. To illustrate the severity of the disorders and how critical it is to properly screen for and/or treat these conditions among our athletic clientele, it has been estimated that approximately 25% of people with a bipolar disorder attempt suicide, and that 25% of all suicides may be attributed to bipolar conditions (APA, 2013).
Characteristics of Bipolar Disorders
Bipolar disorders are severe, persistent, and cyclical disorders characterized by disturbances of mood, cognition, and behavior (APA, 2013; Johnson, Applebaum, & Otto, 2013). The core element of both bipolar disorders is significant emotional turbulence that consists of alternating high (hypomanic or manic) and low (depressive) mood states. However, these are not simply “mood swings,” as mood swings are completely natural for people of any age (and they are even a trademark feature of adolescence!). Unlike normal shifts in mood, the emotional fluctuations of a bipolar disorder and their associated impact on thoughts and behaviors are true disturbances that greatly impair major life domains (APA, 2013). Unfortunately, bipolar disorders may in some cases destroy interpersonal and occupational relationships. Disruptions in major life domains not only are common among athletes with bipolar disorder, they are in fact the norm. Bipolar disorders are also highly comorbid with a number of additional diagnoses and concerns, including substance and alcohol use; childhood externalizing disorders; anxiety disorders; personality disorders; eating disorders; attention-deficit/hyperactivity disorder (ADHD) and other disorders that involve disruptiveness and deficits in impulse control; medical problems, such as migraines, cardiovascular disease, and metabolic issues; and suicide (Brown, Beck, Steer, & Grisham, 2000; Kessler et al., 2005; Laursen, Munk-Olsen, Nordentoft, & Mortensen, 2007).
Bipolar disorders are classified as either bipolar I, which involves mania, or bipolar II, which involves hypomania (APA, 2013; Truax & Shelton, 2003). Mania is the hallmark of the bipolar I condition because its presence differentiates the disorder from bipolar II disorder and MDD. To be diagnosed with bipolar I disorder, the athlete must experience one or more manic episodes. A manic episode consists of “a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy.” This experience occurs most of the time throughout the day, on more days than not, for at least 1 week; if the episode is so severe that it requires hospitalization, the 1-week time criterion does not have to be met (APA, 2013, p. 124). During the episode, three or more additional symptoms must be present, or four symptoms if the athlete’s mania is of the more irritable type (e.g., the client is agitated, short-tempered, or grumpy). Additional symptoms include: a decreased need for sleep; exaggerated self-esteem or a sense of grandiosity; fast-paced speech, which may also be loud and difficult to interpret; “flight of ideas” (i.e., a rapid shift in topics/ideas); distractibility/disrupted attention; increased goal-directed behavior (e.g., multiple projects, even in the middle of the night); and goal-directed behavior that often involves high-risk or self-destructive activities (e.g., binge drug use, sexual activity, spending). Interestingly, for bipolar I disorder, there is no requirement of depression in any form. Although the disorder was long called “manic depression/manic depressive disorder,” more recent and current diagnostic conceptualizations of bipolar I disorder posit that while some clients do struggle with depression in addition to their manic symptoms, depression is not necessary for the bipolar I diagnosis.
Certainly, some athletes talk faster than others, naturally need less sleep, tackle multiple projects at once, and possess more than their share of self-esteem. Would such athletes fit the criteria? To satisfy the above criteria, the described variables must be out of proportion to the athlete’s characteristics when not in a manic state. Bipolar athletes may function fairly well between episodes, so determining baseline functioning is important in assessing for bipolar I (or II) disorder. Reports from those close to the athlete can be particularly helpful, including reports from an athlete’s coaches, teammates, parents, or friends (with the athlete’s consent). If such individuals are available, their feedback on both the athlete’s baseline functioning and the consequences of her/his manic-based behavior may be invaluable. Accurate diagnosis is critical, as maladaptive behavioral tendencies can occur (e.g., suicide, self-harm, recklessness, promiscuity, aggression), and short- and long-term consequences, such as financial, marital, addictive, and legal issues, are common. When bipolar psychopathology is involved, direct athletic consequences can also quickly accumulate, such as performance decrements, improper conduct during competition, and ongoing behavioral issues leading to team suspension or formal dismissal.
Somewhat different from bipolar I disorder, bipolar II disorder is a highly cyclical hybrid condition requiring both high-end and low-end mood states. For diagnosis of bipolar II disorder, the athlete must have experienced at least one major depressive episode (as described in the MDD section), as the presence of fully diagnosable depression is one of the two characteristics that distinguish bipolar II disorder from bipolar I disorder. The other differentiating factor is that instead of a manic episode, bipolar II disorder includes one or more hypomanic episodes. The differences between mania and hypomania are both qualitative and quantitative. Specifically, the same criteria are required for a hypomanic episode as a manic episode, but the hypomanic episode can be of shorter duration (only 4+ days instead of 1+ week) and symptoms are much less severe. It is not uncommon for athletes with bipolar II disorder to view hypomania as helpful, because during hypomania, they may have more energy to train hard, watch videos of past athletic performances, attend to chores, and spontaneously correspond with old friends. DSM-5 agrees, stating that, instead of being caused by hypomania, “impairment results from the major depressive episodes or from a persistent pattern of unpredictable mood changes and fluctuating, unreliable interpersonal or occupational functioning” (APA, 2013, p. 135). Perhaps for this reason, bipolar II disorder is often thought of as a disorder of lesser intensity and lower levels of functional impairment than bipolar I disorder, and previous DSM diagnostic conceptualizations agreed with that view. Yet DSM-5 does not support that particular contention, and instead proposes that due to the increased likelihood of rapid cycling (frequently fluctuating between highs and lows) and the prominence of depression, bipolar II disorder can be no less debilitating than bipolar I disorder.
Because bipolar disorders may present in numerous and complex ways among athletes, the two disorders may be misunderstood and misdiagnosed. A typically level-headed lacrosse player may begin to engage in more aggressive, abrupt, and uncharacteristic behaviors; a gymnast may begin to engage in risky or destructive behaviors with no regard for consequences; and a baseball player may exhibit some symptoms that are misperceived as hyperactivity, and other symptoms that are misperceived as sluggishness and an unfocused attitude. Not surprisingly, while manic episodes are typically easily recognizable (as mania is more severe), hypomanic episodes are often misinterpreted to be the result of alcohol, drugs, or attention deficit disorders. Yet, while there is no “typical” bipolar presentation, the extreme emotional turmoil associated with bipolar disorders frequently culminates in erratic behaviors (e.g., missed practices, shopping sprees, atypical sexual activity, uncharacteristic interpersonal disputes), and can lead to acute and/or chronic athletic problems (e.g., uncharacteristic fighting with teammates/opponents, abruptly quitting the team, and/or behaviors leading to suspension from play and early career termination).
Risk Factors for and Causes of Bipolar Disorders
Recent scientific progress provides valuable insight into the epidemiology and etiology of bipolar conditions. In fact, a broad list of causative variables and possible risk factors appear to be associated with bipolar I and II disorders. First, clinical data implicate a remarkably strong genetic/biological vulnerability (Johnson et al., 2013). Bipolar disorders are highly hereditable; data indicate that children of parents with a bipolar disorder are four times more likely to develop the disorder than those whose parents do not have a bipolar disorder, and bipolar disorders show a remarkable concordance rate of approximately 70% in identical twins (LaPalme, Hodgins, & LaRoche, 1997). As for the depressive components of bipolar conditions, social and psychological risk factors include neuroticism, stressful life events, low self-esteem, few perceived social supports, negative cognitive styles, and excessive expressed emotion (EE). EE is the ongoing presence of familial criticism, hostility, and over-involvement with the bipolar client (Yan, Hammen, Cohen, Daley, & Henry, 2004; Johnson et al., 2008; Lozano & Johnson, 2001).
Concerning the manic (and hypomanic) component of bipolar disorder, two particular risk factors have been implicated: goal dysregulation and schedule disruption. The goal dysregulation model posits that manic states can result from heightened and targeted engagement in goal-directed activities (Johnson et al., 2013); therefore, excessive goal-directed engagement during a baseline state may actually trigger a new manic episode for such athletes. Along this line, bipolar clients appear to possess heightened mental and physical reactivity to positive factors (Johnson et al., 2013) and become more frustrated than those in the general population when goals are not achieved (Wright, Lam, & Brown, 2008). In essence, then, extreme sensitivity to rewards and goal attainment can increase how the athlete reacts to success/failure. A new manic episode is even more likely to begin after life events that involve efforts at achieving major goals or rewards (Johnson et al., 2013). It is important that clinicians working with athletes keep this particular risk factor in mind. Since athletes are often goal-directed individuals to begin with, and athletics promotes goal attainment, hard work, and steady progress, athletes with this particular sensitivity may be quite vulnerable to the onset of a new episode.
The second risk factor for mania (and hypomania) is schedule disruption, which is most clearly linked to mania when good sleep practices become compromised. Data indicate that sleep disruption and an overall disruption in one’s schedule often precipitate the onset of a manic episode for at-risk individuals (Plante & Winkelman, 2008). Disruptions can range from a long overnight trip to the next competition, to a schedule packed with endorsement meetings, to consecutive days involving a workout-class-practice-class-study-workout-class-study schedule, and athletes (especially at advanced levels) are known for their hectic lives and for the numerous life roles that require ongoing attention. Thus, when daily social rhythms are compromised or chronically adjusted, athletes at risk for bipolar disorder will be vulnerable to its first occurrence. Further, those who already struggle with a bipolar disorder will be at greater risk for the onset of a new episode (Miklowitz & Johnson, 2009). Helping the athlete maintain the best individualized balance and routine possible is thus a primary goal of the sport psychologist. Overall, considering the toxic intrapersonal and interpersonal outcomes associated with bipolar conditions, the sport psychologist treating a client with bipolar disorder should form a cooperative intervention team with other psychologists, psychiatrists, and sports medicine personnel with whom the athlete may work.
Disorders involving mood states are fairly common among athletic clientele, and they are serious conditions that can be debilitating if not properly addressed. Athletes can be at risk for depression along a variety of pathways, such as life events, a genetically transmitted pathophysiological process, and a chronic childhood history of aversive events and interactions, to name a few. Depressive and bipolar disorders are leading causes of disability, have high rates of comorbidity and suicidality, and are associated with physical health, athletic, occupational, social, and familial ramifications. Sport psychologists need to maintain at least a basic knowledge of the subclinical and clinical variants of the conditions, in order to identify when to treat these challenging clinical concerns or to recognize when it is necessary to refer to another professional. Whether the sport psychologist notes the warning signs and refers the affected athlete to an evidence-based practitioner, or personally conducts the assessment and intervention process, athletes at risk for, or struggling with, such mental health concerns must receive the most effective, efficient, and timely care possible.
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