Athletes Tread Delicate Balance Between High Performance, Addictions

Nile Wilson, a British gymnast and Olympic bronze medal winner, has described himself as obsessive, a risk taker, and a competitor. In a “Ted Talk,” he discussed how these very traits, which were his greatest strengths as an athlete, also haunted him in his battle with addiction.

He brought the same intensity to nights out drinking that he brought to competitions. “It was a mission,” Wilson said. “I wanted to win. I wanted to be the best at drinking.”

Lt. Marissa Anne Connolly, D.O., showed a portion of Wilson’s talk at APA’s Annual Meeting during a session about addiction among athletes. Connolly, a fourth-year psychiatry resident at Walter Reed National Military Medical Center, was joined by Bhagwan Bahroo, M.D., an assistant professor of psychiatry at the Uniformed Services University; Lt. Thanh Nguyen, M.D., a child and adolescent psychiatry fellow at Walter Reed; and Capt. Katrina Wachter, M.D., a forensic psychiatry fellow at Walter Reed National Military Medical Center.

“We talk about the remarkable abilities and dedication that we see in our athletes, but they also face a lot of unique challenges and vulnerabilities that can predispose them to substance use disorders or behavioral disorders,” Wachter said.

Connolly spoke about perfectionism, which might drive an athlete to great success or influence their development of an addiction. “There’s an intersection between compulsive behavior and perfectionism,” she explained. “These intertwine together in athletes to almost create a perfect storm that really puts these individuals at risk for developing addictions.”

People with perfectionist tendencies may place a great deal of pressure on themselves to live up to their high personal standards, which, if taken too far, can push an individual to develop intense anxiety and self-doubt, Connolly explained. “Engaging in substance use, such as alcohol or other sedatives, might provide an individual with a way to escape their punishing superegos and alleviate their high levels of stress and anxiety,” she said.

Addictions among athletes may include substance use disorders, gambling disorders, and exercise addictions, among others. These disorders may also be entwined with eating disorders, the speakers pointed out.

Nguyen explained the difficulties in delineating function from dysfunction in this group. “Where we draw that line of function is sometimes hard because people’s goals are different, including the parents’ goals, the coach’s goals, and the athlete’s goals.”

One of the ways to understand when athletes’ perfectionism has crossed the line into dysfunction is when they are evaluated for an addiction, Connolly said. There are some notable similarities between the diagnostic criteria for addiction and the compulsive and perfectionist tendencies in which high-performing athletes engage. Some of those criteria include engaging in a behavior to a greater extent than was originally intended, unsuccessful efforts to stop or reduce that behavior, or continued use of the substance or engagement in the behavior despite obvious negative consequences.

In considering when athletes may be most at risk for addictions, Wachter pointed to times of transitions. Some transitions are expected, such as when an athlete’s contract with a team comes to an end. Other transitions are not planned, such as injuries or illnesses that prevent the athlete from competing. These transitions can put the athlete at a higher risk for developing an addiction, especially if their identity is wrapped up in the sport, Wachter said.

“Athletic identity is how the individuals view themselves within their sports,” she said. “When an identity outside of the sport is not developed alongside the athletic identity, the risk for addiction becomes significantly higher.”

Wachter outlined considerations that psychiatrists should keep in mind when considering pharmacological treatments for elite athletes. These include both the potential negative impacts of a medication on athletic performance, as well as the unintended positive or negative impacts (stimulants, for example, could have a performance-enhancing effect or go against competition rules). Further, unique safety risks may need to be considered (the impact of medications that require patients to have a specific water intake per day, for example, may need to be monitored carefully among athletes who sweat more than an average person).

She also pointed out that athletes in general are more likely to accept treatments that don’t involve daily medications. That means that treatment options that are currently gaining more widespread use, such as transcranial magnetic stimulation or ketamine, hold a lot of potential among this patient population.

“The future is looking bright for treatment,” she said. “By focusing on the whole athlete throughout the lifespan, I do think we can really make a difference and reduce addictions in our athletes.” ■