Associate Clinical Professor, University of California, San Diego, School of Medicine
Psychiatry (Edgemont) 2008;5(7):58-61
The integrity of sport is predicated on the assumption that all athletes compete on a level playing field. Unfortunately, the use and abuse of performance-enhancing drugs has become ubiquitous, creating complex challenges for the governing bodies of individual sports. This article examines the complexity of these issues within the world of professional golf, major league baseball, and Olympic competition. Integral concepts like, "What is a therapeutic exemption?" and "When does restorative function end and performance enhancement begin?" are discussed in detail.
When it comes to the world of sports, we now live in the age of doping. Baseball historians will contemplate describing the current time as the "steroid era." Baseball's greatest pitchers and hitters are now portrayed as villains. The sport of professional cycling has been decimated by doping scandals; Tyler Hamilton tested positive after winning the Olympic gold medal in 2004 in Athens, and Floyd Landis was stripped of his 2006 Tour de France title. Olympic track and field star Marian Jones was not only stripped of her Olympic medals, but was sentenced to six months in prison for perjury concerning her admitted use of performance-enhancing drugs. This year in the professional sport of golf, which has always been characterized by integrity and honesty, the governing body, or PGA Tour, has implemented its own doping policy. As a sports psychiatrist who works with PGA players while on tour and is familiar with this issue, I find it noteworthy that in early June, 2007, Dick Pound, former president of the World Anti-Doping Agency (WADA) stated in an article that the PGA Tour Commissioner, Tim Finchem, told him that there is no drug problem in golf. Mr. Finchem correctly reversed his opinion several weeks later. Now for the first time I am hearing the PGA Tour golfers complain, "Have things gone overboard with drug testing?" The reality is that performance-enhancement drugs can insidiously infiltrate the sport of golf and have the serious potential to threaten the integrity of almost all professional sports.
Most of the issues involving the definition of performance-enhancing drugs in the past have been relatively clear cut. However, with the continuing advancement of medicine and particularly the application of psychotropic medicines, the sports psychiatrist will need to become an integral player in this complex social, moral, and medical drama. Psychiatrists who work with professional athletes will be faced with unique challenges that must be identified, acknowledged, and acted upon in agreement within the sport to ensure the integrity of the profession.
The stated mission of the United States Association of Drug Agencies (USADA), the official antidoping agency for America's Olympic athletes, is to preserve "the wellbeing of Olympic sport, the integrity of competition, and the ensuring health of athletes." A primary example that has often required the policing of USADA is use of erythropoietin (EPO), which provides performance enhancement in endurance sports like cycling. This protein is produced by the kidneys and accelerates erythrocyte production, thereby increasing the oxygen-carrying capacity of an individual's blood. The use of EPO clearly violates the USADA objective of preventing an unfair advantage to fellow competitors.
The World Anti-Doping Agency (WADA) was organized under the 1999 initiative from the International Olympic Committee (IOC) and defines the term therapeutic exemption as the use of a drug for restoration of normal health. But one of the central problems in defining a therapeutic exemption lies in understanding the evolving power of medical science. Medicine historically has focused on restoring normative health for those with pathologic conditions. As medical science advances, however, the focus of treatment transcends the long-standing goal of normalizing pathologic conditions and extends into the concept of wellness and helping individuals feel better than they have ever felt. The emerging questions are the following: (i) "What does the restoration of normal function mean?" (ii) "Who should define its characteristics?" Perhaps the most important question stated from a medical therapeutic perspective is, "Where does restoration of normative function end and the beginning of performance enhancement start?"
Further complicating these critical issues are the subtle ways in which performance-enhancement drugs are sport specific. For example, in sports like golf, archery, or pistol shooting, where a steady hand is critical, beta blockers provide a performance-enhancing function that combats the normal physiologic tremor that is exacerbated in high-pressure situations. Conversely, in an endurance sport like cycling or long-distance running, beta blockers adversely affect performance and would not necessarily be prohibited. An interesting recent doping violation comes from the Canadian snowboarder Ross Rebagliati, who had to return his Olympic Gold medal due to testing positive for marijuana, only to have it later returned for a variety of reasons. This situation raises the unexpected question of whether marijuana is a performance-enhancing drug. Another interesting question to consider is whether athletes with adult attention deficit hyperactivity disorder (ADHD) are better athletes when treated with stimulants? It has been reported9 that some athletes actually perform better when their ADHD symptoms are not treated with medication. For example, a basketball point guard who has symptomatic ADHD may actually be more spontaneous or unpredictable for the opponent. In contrast, the center player with ADHD who has difficulty disciplining him- or herself to stay near the basket may find that he or she is often out of position unless his or her ADHD symptoms are treated with medication.
The most controversial current policy issue has occurred in baseball, where stimulant abuse has plagued the sport for decades. Although no well-controlled scientific studies conclusively support claims that stimulants provide ballplayers with an unfair performance-enhancement advantage, these chemicals have long been thought to do so because of their physiologic and psychoactive properties. The question then arises, "If an individual truly has adult ADHD, is the use of stimulants actually providing a performance-enhancement edge or simply providing a restorative function?" Furthermore, if the governing bodies deny athletes effective and standard treatment for psychiatric disorders, are they discriminating against the mentally ill? In this context it is not surprising that Major League Baseball (MLB) in 2007 gave out 103 therapeutic exemptions for the use of stimulants for ballplayers with ADHD. This figure is disconcerting when juxtaposed with the 26 therapeutic exemptions given just one year earlier in 2006. It is also no surprise that this dramatic increase temporally coincided with the Mitchell investigation. George Mitchell was a former United States senator, who was appointed by the commissioner of Major Leagues Baseball to conduct a 20-month inquiry of performance-enhancing drugs. This high-profile investigation resulted in a 409-page report that not only made recommendations but also identified a number of high-profile baseball players who admitted illegal drug use. The subsequent media attention has certainly made athletes more careful when using performance-enhancing drugs and seeking therapeutic exceptions. The dramatic increase in asking for a therapeutic exemption suggests that some baseball players may be looking for a loop hole to continue stimulant abuse by seeking them through fictitious therapeutic exemptions, whereas in the past they would take the drugs covertly. If so, are these violations being addressed by physicians with expertise in diagnosing ADHD and whose allegiance is to maintain baseball's integrity? Although sport psychiatrists are now finally being consulted, it is disconcerting that they do not sit on any major sports medical advisory boards. For example, the drug policy of the MLB is administered by a pediatrician. The USADA has a 12-member board that consists of three physicians, a gynecologist, orthopedist, and urologist. The time has come for these agencies to develop a published, standardized policy that clearly and fairly defines which athletes meet criteria for psychiatric disorders and what drugs provide psychoactive properties that enhance performance.
Another reason to involve psychiatric consultation in professional sports stems from recent reports that antidepressant drugs have been implicated as performance-enhancement agents. It is now well known that the selective serotonin reuptake inhibitors (SSRIs) are recognized as first-line treatment for anxiety disorders and their various subtypes. Additionally, a selective serotonin-norepinephrine re-uptake inhibitor (SNRI), such as venflaxine, also has received approval for generalized anxiety disorders. Although this situation may sound counterintuitive or even absurd, consider the hypothetical example of a professional athlete who is anxious by nature but does not meet DSM criteria for an anxiety disorder. If this athlete is regularly competing on a public stage, he is likely to experience more anxiety than if working daily at a desk job. The more patients are symptomatic, the more aggressively physicians treat them. Are these athletes being given an unfair advantage if they can biologically increase their capacity to calmly compete in high-stress competition, even if the medication used is permitted? If so, who is ethically responsible to define this subtle issue and enforce fair policy? It seems that the burden falls less on the athlete, who is likely to be naïve to these implications, and more on the clinical experts who create policy with each sport's governing body.
Another developing concern is the use of antidepressants for treating what is commonly termed over-training syndrome. Overtraining refers to a negative response to training stress and is often due to chronically high training levels without periods of lower training loads. Overtraining also can lead to fatigue and depression. It has been hypothesized that overtraining syndrome may involve disregulation of brain serotonin and neuroendocrine function.[15,16] Treatment logically dictates that SSRIs and SNRIs should be effective, and these have anecdotally been reported to help athletes with this common problem. Moreover, the use of SNRIs for various pain conditions makes one consider if this class of drug can benefit endurance athletes who inherently cope with tremendous pain during training and competition. The question should be asked if the use of an antidepressant in these situations is fair.
Physicians involved in professional sport need to fully understand the complexity of performance-enhancing drugs and where we draw the line. To do so, not only must the physiologic and psychotropic properties of each drug be considered, but also the individual characteristics of each sport and, more important, the individual biology of each athlete. A medical system for athletes that ensures a fair and accepted standard for all individuals in a given sport needs to be established. In a world of advancing neuroscience and concomitant psychotropic drug development, the psychiatrist must become an advocate for the appropriate uses of psychoactive medicines. The issues involved are complex and potentially have far reaching cultural effects in how psychotropic medicines are perceived by the public. Unfortunately, the majority of prescriptions given for psychotropic drugs are not given by psychiatrists and probably the world of sport is no exception.[18,19] If the integrity of the practice of medicine and professional sport are to be maintained, all involved must be more informed and directly involved in the decision making about medication efficacy and appropriateness. To address the issue of where the line is drawn and who draws it, the world of sports is unknowingly calling for physicians who possess expertise in psychopharmacology, psychiatry, and athletics. It is time that the burgeoning field of sport psychiatry answers the call.
1. Holway J. Outlook: Baseball's steroid era. Washington Post. March 12, 2004. http://discuss.washingtonpost.com/wp-srv/zforum/04/r_outlook031504.htm. Access date: July 9, 2008.
2. Pound RW. The PGA Tough needs drug testing now. Golf.com. http://www.golf.com/golf/tours_news/article/0,28136,1625943,00.html. Access date: June 4, 2007.
3. Hack D. PGA tour moves closer to adopting drug policy. New York Times. http://www.nytimes.com/2007/06/21/sports/golf/21golf.html. Access date: June 21, 2007.
4. United States Anti-doping Agency. Mission statement. http://www.usantidoping.org/who/mission.html. Access date: July 8, 2008.
5. Eichner ER. Blood doping: Infusions, erythropoietin and artificial blood. Sports Med 2007;37:389–391.
6. World Anti-Doping Agency. What is a therapeutic use exemption? http://www.wada-ama.org/en/exemptions.ch2. Access date: July 8, 2008.
7. Kruse P, Ladefoged J, Nielsen U, et al. Beta-blockade used in precision sports: Effect on pistol shooting performance. J Appl Physiol. 1986;61:417–420.
8. Juhlin-Dannfelt A. Beta-adrenoceptor blockade and exercise: Effects on endurance and physical training. Acta Med Scand Suppl. 1983;672:49–54.
9. Conant-Norville DO, Tofler IR. Attention deficit/hyperactivity disorder and psychopharmacologic treatments in the athlete. Clin Sports Med. 2005;24:829–843.
10. Curry J. With greenies banned, up for a cup of coffee? New York Times April 1, 2006. http://www.nytimes.com/2007/06/21/sports/golf/21golf.html. Access date: July 9, 2008.
11. Mitchell GJ. Report to the commissioner of baseball of an independent investigation into the illegal use of steroids and other performance-enhancing substances by players in major league baseball. http://en.wikipedia.org/wiki/. Access date: December 13, 2007.
12. Stahl SM. Psychopharmacology: Neuroscientific Basis and Practical Applications, Second Edition. Cambridge: Cambridge University Press, 2000:302–303.
13. McCann S. Overtraining and burnout. In: Murphy SM (ed). Sport Psychology Interventions. Champaign, IL: Human Kinetics, 1995:347–365.
14. Kamm RL. Principles for the psychiatrically aware sports medicine physician. Clin Sports Med. 2005;24:745–769.
15. Pearce PZ. A practical approach to the overtraining syndrome. Cur Sports Med Rep 2002;1:179–183.
16. Cristina I, Sampaio L, Celso W. Relationship of the overtraining syndrome with stress fatigue, and serotonin. Rev Bras Med Esporte 2005;11(6):333e–337e.
17. Begré S, Traber M, Gerber M, von Känel R. Change in pain severity with open label venlafaxine use in patients with a depressive symptomatology: an observational study in primary care. Eur Psychiatry. 2008;23(3):178-86. Epub 2008 Mar 6.
18. Schulberg HC, Burns BJ. Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions. Gen Hosp Psychiat 1988;10:79–87.
19. Yates DF, Wiggns JG, Lazarus J, Scully JH. Patient safety forum: Should psychologists have prescribing authority? Psychiatr Serv 2004;55:1420–1426.
20. International Society of Sports Psychiatry. Home Page. http://www.theissp.com/. Access date: July 8, 2008.
A person with an eating disorder may have started out just eating smaller or larger amounts of food than usual, but at some point, the urge to eat less or more spirals out of control. Eating disorders are very complex, and despite scientific research to understand them, the biological, behavioral and social underpinnings of these illnesses remain elusive.
The two main types of eating disorders are anorexia nervosa and bulimia nervosa. A third category is "eating disorders not otherwise specified (EDNOS)," which includes several variations of eating disorders. Most of these disorders are similar to anorexia or bulimia but with slightly different characteristics. Binge-eating disorder, which has received increasing research and media attention in recent years, is one type of EDNOS.
Eating disorders frequently appear during adolescence or young adulthood, but some reports indicate that they can develop during childhood or later in adulthood. Women and girls are much more likely than males to develop an eating disorder. Men and boys account for an estimated 5 to 15 percent of patients with anorexia or bulimia and an estimated 35 percent of those with binge-eating disorder. Eating disorders are real, treatable medical illnesses with complex underlying psychological and biological causes. They frequently co-exist with other psychiatric disorders such as depression, substance abuse, or anxiety disorders. People with eating disorders also can suffer from numerous other physical health complications, such as heart conditions or kidney failure, which can lead to death.
Psychological and medicinal treatments are effective for many eating disorders. However, in more chronic cases, specific treatments have not yet been identified.
In these cases, treatment plans often are tailored to the patient's individual needs that may include medical care and monitoring; medications; nutritional counseling; and individual, group and/or family psychotherapy. Some patients may also need to be hospitalized to treat malnutrition or to gain weight, or for other reasons.
Anorexia nervosa is characterized by emaciation, a relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight, a distortion of body image and intense fear of gaining weight, a lack of menstruation among girls and women, and extremely disturbed eating behavior. Some people with anorexia lose weight by dieting and exercising excessively; others lose weight by self-induced vomiting, or misusing laxatives, diuretics or enemas.
Many people with anorexia see themselves as overweight, even when they are starved or are clearly malnourished. Eating, food and weight control become obsessions. A person with anorexia typically weighs herself or himself repeatedly, portions food carefully, and eats only very small quantities of only certain foods. Some who have anorexia recover with treatment after only one episode. Others get well but have relapses. Still others have a more chronic form of anorexia, in which their health deteriorates over many years as they battle the illness.
According to some studies, people with anorexia are up to ten times more likely to die as a result of their illness compared to those without the disorder. The most common complications that lead to death are cardiac arrest, and electrolyte and fluid imbalances. Suicide also can result.
Many people with anorexia also have coexisting psychiatric and physical illnesses, including depression, anxiety, obsessive behavior, substance abuse, cardiovascular and neurological complications, and impaired physical development.
Other symptoms may develop over time, including:
TREATING ANOREXIA involves three components:
Some research suggests that the use of medications, such as antidepressants, antipsychotics or mood stabilizers, may be modestly effective in treating patients with anorexia by helping to resolve mood and anxiety symptoms that often co-exist with anorexia. Recent studies, however, have suggested that antidepressants may not be effective in preventing some patients with anorexia from relapsing. In addition, no medication has shown to be effective during the critical first phase of restoring a patient to healthy weight. Overall, it is unclear if and how medications can help patients conquer anorexia, but research is ongoing.
Different forms of psychotherapy, including individual, group and family-based, can help address the psychological reasons for the illness. Some studies suggest that family-based therapies in which parents assume responsibility for feeding their afflicted adolescent are the most effective in helping a person with anorexia gain weight and improve eating habits and moods.
Shown to be effective in case studies and clinical trials, this particular approach is discussed in some guidelines and studies for treating eating disorders in younger, nonchronic patients.
Others have noted that a combined approach of medical attention and supportive psychotherapy designed spe-cifically for anorexia patients is more effective than just psychotherapy. But the effectiveness of a treatment depends on the person involved and his or her situation. Unfortunately, no specific psychotherapy appears to be consistently effective for treating adults with anorexia. However, research into novel treatment and prevention approaches is showing some promise. One study suggests that an online intervention program may prevent some at-risk women from developing an eating disorder.
Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food (e.g., binge-eating), and feeling a lack of control over the eating. This binge-eating is followed by a type of behavior that compensates for the binge, such as purging (e.g., vomiting, excessive use of laxatives or diuretics), fasting and/or excessive exercise.
Unlike anorexia, people with bulimia can fall within the normal range for their age and weight. But like people with anorexia, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Usually, bulimic behavior is done secretly, because it is often accompanied by feelings of disgust or shame. The binging and purging cycle usually repeats several times a week. Similar to anorexia, people with bulimia often have coexisting psychological illnesses, such as depression, anxiety and/or substance abuse problems. Many physical conditions result from the purging aspect of the illness, including electrolyte imbalances, gastrointestinal problems, and oral and tooth-related problems.
Other symptoms include:
As with anorexia, TREATMENT FOR BULIMIA often involves a combination of options and depends on the needs of the individual.
To reduce or eliminate binge and purge behavior, a patient may undergo nutritional counseling and psychotherapy, especially cognitive behavioral therapy (CBT), or be prescribed medication. Some antidepressants, such as fluoxetine (Prozac), which is the only medication approved by the U.S. Food and Drug Administration for treating bulimia, may help patients who also have depression and/or anxiety. It also appears to help reduce binge-eating and purging behavior, reduces the chance of relapse, and improves eating attitudes.
CBT that has been tailored to treat bulimia also has shown to be effective in changing binging and purging behavior, and eating attitudes. Therapy may be individually oriented or group-based.
Binge-eating disorder is characterized by recurrent binge-eating episodes during which a person feels a loss of control over his or her eating. Unlike bulimia, binge-eating episodes are not followed by purging, excessive exercise or fasting. As a result, people with binge-eating disorder often are overweight or obese. They also experience guilt, shame and/or distress about the binge-eating, which can lead to more binge-eating.
Obese people with binge-eating disorder often have coexisting psychological illnesses including anxiety, depression, and personality disorders. In addition, links between obesity and cardiovascular disease and hypertension are well documented.
TREATMENT OPTIONS FOR BINGE-EATING DISORDER are similar to those used to treat bulimia. Fluoxetine and other antidepressants may reduce binge-eating episodes and help alleviate depression in some patients.
Patients with binge-eating disorder also may be prescribed appetite suppressants. Psychotherapy, especially CBT, is also used to treat the underlying psychological issues associated with binge-eating, in an individual or group environment.
Eating disorders are ubiquitous among athletes, especially those involved in sports that place great emphasis on the athlete to be thin. Sports such as gymnastics, figure skating, dancing and synchronized swimming have a higher percentage of athletes with eating disorders, than other sports.
Many female athletes fall victim to eating disorders in a desperate attempt to be thin in order to please coaches and judges. Many coaches are guilty of pressuring these athletes to be thin by criticizing them or making reference to their weight. Those comments could cause an athlete to resort to dangerous methods of weight control and can do serious emotional damage to the athlete.
Coaches and trainers really need to educate themselves on the dangers and on the signs to look for in an athlete that may be suffering from an eating disorder. They must be able to recognize when healthy training routines turn into an obsession where the athlete turns to drastic measures to become thin and succeed in their sport.
Research suggests that the most effective treatment for an eating disorder is multidisciplinary. That means that a treatment team, instead of a solitary practitioner, designs and executes a treatment plan that addresses the multidimensional nature of anorexia nervosa and bulimia.
The treatment team: how it works
As the client and treatment team members combat the eating disorder, a physician monitors and treats physical problems associated with starving, stuffing and purging.
If necessary, a psychiatrist prescribes medications that help correct underlying mood disturbances such as depression and anxiety.
A mental health therapist helps the client unravel and solve emotional and psychological problems underlying the eating disorder.
A dietitian provides nutritional counseling and debunks myths surrounding food and dieting.
A family therapist helps identify and change patterns of communications that have been troublesome and unsatisfying in the past.
A group therapy facilitator helps the client see that s/he is not alone in her/his disorder and that s/he can learn from peers.
An athlete's coach is enormously important in her/his life. The coach at different times is teacher, parent figure, confidant, disciplinarian, and demigod. The coach decides when an athlete will compete, how much s/he will compete, and what s/he must do to compete. Because the coach is so significant to the athlete, s/he must not be omitted from the treatment team. For further treatment information go to: www.casapalmera.com or www.nationaleatingdisorders.org.
However, acute performance failure is not a homogenous phenomenon. In the sport of golf there appears to be at least three entities that produce acute performance failure - panicking, choking and the yips.
All three of these phenomena are precipitated by perceived stress. In order to understand the differences of these three causes of acute performance failure, it is instructive to review the basic neuroscience concept of two general forms of memory. Explicit (declarative) memory governs the recollection of facts, events and associations. In contrast, implicit memory deals with procedural memory that does not require conscious awareness; for example, how one recalls riding a bicycle or playing a piano after many years of not performing the function.
Explicit (declarative) memory appears to be centered in the part of the brain called the hippocampus. When an individual incurs severe stress there is a secretion of epinephrine and glucocorticoids. It is well known that severe stress response can harm the hippocampus, preventing consolidation of conscious explicit memory. This is often experienced by the individual as feeling as if "their mind has gone blank." This stress response with concomitant impairment in explicit memory also leads to the inability of the individual to think appropriately during a time of stress. Psychologists often report that these individuals experience what is called "perceptual narrowing." Because of the inability of the individual to access explicit learning and memory, the individual then relies on instinct and this is the phenomenon that is present when the athlete has a panic attack.
An excellent example of this phenomenon in golf occurred in the 1999 British Open when Jean Van de Velde had a three shot lead going into the final hole. Thousands of fans watching the event, including the commentators, acknowledged that all Jean needed to do on the dangerous 18th hole at Turnberry was to hit three conservative iron shots, two-putt for bogey and receive his first Claret jug as British Open Champion. However, Jean made a critical strategic error, relied on instinct and chose his driver to tee off on the final hole. This serious strategic error eventually resulted in an untenable position where his ball was actually in the water and the famous image of Jean going into the water to hit the ball haunts golf fans to this day. As Jean set up to hit this shot, fortunately he was able to access his learned experience and make the proper decision of not hitting this shot and taking a penalty stroke and a drop. Jean was able to make a miraculous putt and force a playoff but subsequently lost in the playoff, and his strategic choices remain infamous to this day in golf lore. This is an excellent example of an athlete panicking and making poor choices yet still being able to execute shots. Essentially, Jean's mind went blank and he relied on instinctive behaviors, i.e., being aggressive by taking a driver off the tee unnecessarily and almost choosing to hit an extraordinarily low-percentage shot out of the water.
In contrast, choking is something else all together. In panic, we have the loss of an individual's cognitive abilities, thus resulting in the reversion to instinct. However, choking is about the loss of instinct. Motor programs that are normally implicit (are not in conscious awareness) partially reside in the deep brain structure, the basal ganglia. However, in conditions of severe stress when an individual chokes, the explicit system takes over and an individual who has had mastery of certain motor execution programs (golf swing) starts to consciously think about their swing, thus resulting in the loss of fluidity and kinesthetic touch. In a sense, the athlete becomes a beginner again because they start relying on a learning system that is no longer implicit and subconscious.
Crews, Debra J. and Landers, Dan; "Electroencephalographic Measures of Attentional Patterns Prior to the Golf Putt," Med. & Sci. in Sports & Exercise, Vol. 25, #1, Jan 1993, pgs. 116-126). Dr. Crews found that the best putters had a distinctive brain wave pattern in the seconds leading up to the putt. The left side of their brain (which controls logical and analytical processing) was active. Then, just before the subject putted, the left side quieted and the right side (which controls spacial orientation, timing and balance) became more active. Dr. Crews hypothesized that chokers exhibited a different pattern where their left brain never shut down and raised the question if this led to a possible obstruction of the right brain hemisphere taking over (please see Mayo Clinic study).
Dr. Sian Beilock in the Department of Psychology at Miami University in Ohio hypothesized that limiting putting time would actually help execution by preventing skilled golfers from allocating too much attention to task control and guidance (Beilock, S.L., Bertenthal, B.I., McCoy, A.M., and Carr, T.H.; "Haste Does Not Always Make Waste; Expertise, Direction of Attention and Speed Versus Accuracy in Performing Sensory Motor Skills," Psychonomic Bulletin and Review, 2004). In her experiment, Dr. Beilock's results demonstrated that golfers were more accurate under speed instructions. She anecdotally reports that several golfers said that speed instructions aided their performance by keeping them from thinking too much about execution. Her research has shown that expert swing execution does not require constant monitoring, and limiting the time experts have to overthink prevents interference with performance and execution of various shots. In choking, the opposite goes on. The individual loses the capacity to access their implicit learning, starts to overthink and relies on explicit learning models, resulting in acute performance failure.
An excellent example of this choking phenomenon what evident in the final round of the 1996 Masters, when Greg Norman had a six-shot lead going into the final hole against Nick Faldo. Greg Norman, who was the number one golfer in the world at that time, poorly executed a number of shots that were markedly uncharacteristic for him. He did not panic and make a variety of poor choices like our Jean Van de Velde example, but rather was unable to properly execute shots of which he had previous mastery. In essence, Greg Norman lost his instinct and was probably thinking too much, resulting in acute performance failure. In contrast, Jean Van de Velde lost the ability to think, relied on instinct and made a variety of poor choices that led to his demise.
A third type of acute performance failure is often known as the "yips." A great example of the yips is on the final hole of the 1992 Masters when Scott Hoke had a 12-inch putt to win. Scott not only missed the putt but he missed the hole entirely. On television replay examination of Scott's stroke, he demonstrated a twitching motion which somehow appeared on this critical putt instead of his smooth patented stroke. Announcers gasped while commenting how could he yip that short putt to lose the Masters. The yips is often referred to as a focal dystonia. Dystonias are characterized as a movement disorder where an unwanted muscle contraction, or twitching, leads to an involuntary movement. In golf, it is seen most commonly in putting but also seen on other shots. Symptoms of the yips, like jerks during execution of shots, often result in mis-hits. This phenomenon is not circumscribed to the average golfer but is often cited with the world's elite golfers and has derailed the careers of Johnny Miller, Ian Baker-Finch and Mark O'Meara. The neurophysiology of focal dystonias has been best elucidated by Dr. Jonathan Mink (Mink, J.W., M.D., Ph.D.; "The Basal Ganglia and Involuntary Movements," Archives of Neurology, Vol. 60, Oct 2003, pgs. 1365-1368). Essentially Dr. Mink postulates that the basal ganglia (the area of the brain where implicit learning lives) is organized to facilitate voluntary movements and to inhibit competing movements that interfere with the desired movement. The idea is that in the basal ganglia there are various motor programs that operate on the subconscious level. When an athlete experiences the yips, or a focal dystonia, the pathways that govern the inhibition of competing motor programs break down thus resulting in the contamination of the original motor program.
Therefore, instead of the individual making one smooth stroke engaging the appropriate motor program, the individual's smooth stroke is interrupted with a twitch, suggesting that two motor programs are operating simultaneously leading to mis-hit shots. The neuroanatomy of the basal ganglia and concomitant neurophysiology is currently of great research interest in the neuroscience community. It appears clear that stress causes release of the neurotransmitter glutamate which in turn causes release of dopamine in basal ganglia pathways that result in the disinhibition of competing motor programs. This is the reason why yips become more pronounced under stressful circumstances.
The renowned golf teacher, Hank Haney, has recently written a series of articles about overcoming the yips with both drivers and putters in December 2004's Golf Digest. Hank describes his own personal problems with the yips over his twenty-year golf career and describes how he has had success in helping Mark O'Meara regain his putting abilities and his elite world golf ranking. Hank's premise is that one has to understand doing the same stroke over and over again does not work. Essentially, Hank's philosophy is to make a small change in the individual's grip, thus engaging a slightly varied stroke and subsequent new motor program. The idea is that by engaging a new motor program, one is able to avoid the phenomenon of a competing motor program contaminating the stroke. A strategy that Hank has taught Mark O'Meara and a variety of other elite players seems to at least be successful in the short term. However, long-term results and longitudinal studies are still needed to confirm the efficacy of this intervention.
Dr. Ross of the Cleveland Clinic used functional MRI and asked individuals of varying golf levels to use mental imagery, imagining their golf swing. Correlation was noted that individuals with high handicaps showed greater activation of cortical areas of the brain, thus reinforcing the idea that as skill level advances conscious awareness of activity lessens and implicit learning becomes the predominant mode. (Ross, J.S., Tkach, J., Ruggieri, P.M., Lieber, M., and LaPresto, E.; "American Journal of Neuroradiology," June-July 2003; Vol. 24 #6, pgs. 1036-1044).
In summary, we have discussed three important causes of acute performance failure.
Choking, which has been used as a ubiquitous term for all acute performance failures, in fact is a specific type of acute performance failure where the individual no longer relies on instinct and starts to consciously think about what was previously a learned behavior. In many ways, this phenomenon is antithetical to flow experience (Csikszentmihalyi, M.; "Flow: The Psychology of Optimal Experience," Harper Collins, 1990), or what is commonly known at the athletic zone.
Panicking is another frequent cause of acute performance failure and is characterized when an individual has autonomic hyperarousal and sympathetic overload, experiences their mind going blank and reverts to instinct, much the opposite of the choking phenomenon. However, the end result is often the same.
Lastly, the "yips" is best characterized using the focal dystonia model where stress induces a cascade of biochemical events that lead to the disinhibition of competing motor programs resulting in a loss of fluidity of shot execution and also resulting in acute performance failure. It is essential for the clinician to understand these three varied forms of acute performance failure. Each etiology is treated differently and inappropriate recognition will not lead to improved performance. Although the detailed treatment is beyond the scope of this article, briefly the panic phenomenon is best treated with relaxation techniques, breathing techniques, centering techniques and learning to use process cues. In contrast, the choking phenomenon described is best addressed by using desensitization techniques coupled with attentional shift techniques, promoting instinctive execution of shots. Lastly, the "yips" or focal dystonia phenomenon described may be most effectively treated through slight modification in the golfer's swing, thus engaging a different motor program that has not yet been contaminated by the disinhibition of competing motor programs.
Can we really choose to always think positive?
The concept of free will refers to our ability to choose what we do and what we think. Imagine an Olympic ski jumper moments before leaving the gates suddenly flashing on the possibility of crashing. The athlete must make a choice to let the thought pass and refocus his attention to the task at hand or dramatically increase his chance for disaster. Free will is the cornerstone of mental toughness for elite athletes. But the question remains, can we choose to think what we want?
Thoughts are a series of biologic processes in which millions of neurons communicate with one other by passing electrical charges via chemical messengers called neurotransmitters. The neurotransmitters that regulate mood and anxiety are norepinephrine, serotonin, and dopamine.
Our brain releases dopamine when we see our son hit a homerun in Little League. It is also released when we smoke cigarettes and more potently when drugs like amphetamines and cocaine are used. Our moods and thoughts are inextricably interwoven. They both create self-perpetuating cycles. When we feel good we tend to think positive and when we feel bad we tend to think negative.
When we are engaged in the cycle of feeling down and thinking negatively, our automatic or, as it's technically called, our autonomic nervous system gets out of balance. The autonomic nervous system is made up of two components: the parasympathetic system which slows our heart rate and relaxes our muscles, and the sympathetic system which mediates our fight or flight response and releases adrenaline.
There is a delicate balance between the harmonies of these two halves of our nervous system. When an athlete is in The Zone or really on his game, he is relaxed yet focused. The parasympathetic system becomes proportionately more active. However, this is not an easy task even for the great athlete during the heat of competition. A little bit of nervousness is good. The increase in natural adrenaline increases our focus and increases our strength. However, too much activation causes our muscles to get tight and if we get so nervous we panic, we lose our ability to focus and process the environment around us.
Learning to use yogic breathing techniques or simply learning to breathe rhythmically with our diaphragm increases the influence of the parasympathetic system and helps relax our muscles regardless of the situation. Conversely, when we are depressed or thinking negatively, a chronic stress state ensues increasing our sympathetic tone beyond what is healthy. This makes our muscles very tight and we do not perform our best. It is therefore essential that our thought and mood be in harmony because they influence our nervous system, which in turn guides the precise action of our muscles.
Jimmy Shea was the world's champion in skeleton (similar to luge but head first). His grandfather Jack Shea was a past Olympic champion and his father was also an Olympian. Jimmy had tremendous pressure coming into the 2002 Winter Olympics as America's first third generation Olympian and medal favorite. Several weeks before the Olympics, Jimmy's grandfather Jack was killed in a tragic automobile accident. Jimmy spiraled into a deep depression and was referred to me for treatment. The trauma and natural sadness around his beloved grandfather's death exacerbated a severe depression. Jimmy could not think positive. His sleep, appetite, energy, and motivation were also severely disregulated. He publicly admitted to suicidal thoughts. I placed him on an antidepressant medication that increases all three of the brain's major mood neurotransmitters. Jimmy started to feel better and to think more positive. In dramatic fashion, he won the gold medal by 0.05th of a second. The scene of him taking the picture of his grandfather out of his helmet and holding it up for the world to see is one of Olympic history's indelible images.
For a person with a severe depression, a combination of medicines and therapy are most effective. Increasing evidence has shown that exercising at least 30 minutes a day, three to five times a week, improves mood and probably increases serotonin. Other research has shown that diets low in the amino acid tryptophan cause depletion in brain serotonin levels and this deficit creates depression in certain groups of people, so it is important to not only exercise but eat a healthy diet. The biology of thought is more than free will. Diet and exercise play central roles in how we feel and how we feel plays a central role in how we think. But so do the thoughts we choose.
Mood disorders are very common and, in fact, some studies suggest that each individual has up to a 20% chance to develop a mood disorder in his or her life. Mood disorders come in two common variations. Generally individuals will either have a depressive disorder or a bipolar disorder.
Depression is characterized by periods of sadness resulting in changes in appetite or sleep, irritability, anger, worry, agitation, loss of energy, and an inability to concentrate among other symptoms. Depression can include all or just some of these symptoms and they may either be mild or very severe.
Bipolar disorders (previously known as manic depression) are marked by extreme changes in mood, thought, energy and behavior. Bipolar disorders can be mild (type 2) or severe (type 1).
It is of paramount importance for individuals to know that if they have a bipolar or a depressive disorder that it is not a character flaw or any sign of personal weakness. Today we have strong evidence that suggests that there is not only a strong biologic basis to these disorders, but they also have a genetic etiology. The basic idea is that there are several neurotransmitters in the brain that regulate mood - serotonin, norepinephrine, dopamine, and others - which become dysregulated. When these neurotransmitters are in a state of dysregulation, the individual will experience significant changes in their mood, thoughts, sleep patterns, and behavior.
I like to imagine the 405 freeway in Los Angeles. It's like one big traffic jam, where no-one is going anywhere fast. When we are depressed the neurotransmitters systems are not firing properly and they could be considered in a big traffic jam. When the brain is functioning well, the traffic flows normally and feels much better.
Conversely, when the individual becomes manic, imagine that the cars on the freeway are running wild, disregarding traffic rules and speed limits. This biological chaos will cause the individual to do things that they normally would not do. Often times, people engage in destructive behavior including drinking, gambling, and spending sprees. This chaos can destroy both personal and professional and can be quite dangerous for the individual.
Today we have very good treatment for both of these types of mood disorders. The typical medicines that are used include antidepressants and mood stabilizers. It is important for the individual to know that these medicines are not addictive and if your mood is already in the normal range they should not alter it. Mood disorders are very treatable.
In fact another good metaphor is to think of a thermostat that should be kept at 72 degrees, the normal mood. If we are manic the temperature is too high and if we are depressed the temperature is too low. The medicines, if used correctly, only take the temperature towards the desired 72 degree set point. If your mood is normal they do not change the system. The only change the system if the brain neurotransmitters are to high or low (dysregulated). They do not take a normal mood and make that individual high. In fact they do not have any intoxicating or euphoric properties like those of addictive medicines. It is also important to know that psychotherapy and exercise help mood immensely. Both of these non-medicine interventions also cause brain chemistry to normalize.
If you want to know more about mood disorders please see the Sports Illustrated article titled "Prisoners of Depression" on our Media Center. If you want to learn more go to the National Institute of Mental Health website (http://www.nimh.nih.gov/) or see your local mental health expert.
Our own mental health lives on a continuum like our own physical health. Both are not static entities. Our mental health fluctuates as a function of what is happening in our lives. The vast majority of sport psychologists are not clinically trained to help people with life problems whether it is handling the spotlight, martial discord, substance abuse, anxiety disorders or many other life experiences. All of these issues profoundly effect the way an athlete performs in competition. You can not get in the "zone" unless your life is in balance and you are in good relaxed state of mind first. Sport psychologists are educators who teach techniques to help the athlete better handle competitive situations but they don't help athletes get their life in order.
Clinical psychologists and psychiatrists help with life issues but do not possess the skill set of performance enhancement techniques. The sport psychiatrist does both.
In addition to possessing these broad range of skills, Dr. Lardon is also trained in internal medicine and has been a pioneer in utilizing neuroimaging techniques to understand the biologic action of the brain when athletes find peak performance or what is commonly called being in the "zone". His work is an extension of Dr. Csikszentmihalyi pioneering research into "flow" states or peak performance states of consciousness.
Dr. Lardon helps the athlete from the perspective of a human being not a corporate commodity. His focus not only includes what goes on in the heat of battle but all the components that lead up to setting the optimal conditions for the peak performance experience to unfold. His training, experience and understanding of peak performance is unparalleled in the field.
Anxiety disorders are extremely common. Women have a 30% chance of developing an anxiety disorder in their life and men have about a 20% chance. Everyone experiences anxiety. Anxiety is characterized by an unpleasant, vague sense of apprehension that often is accompanied by increased heart rate, tightness in the chest, and mild stomach discomfort.
Anxiety is considered an alerting signal to warn one of impending danger. However fear and anxiety should be differentiated. Fear is a response to a known external threat whereas anxiety is a response to a threat that is vague and unknown.
Most anxiety disorders fall into two general categories. Either an individual has discreet panic attacks, which is called panic disorder, or a chronic feeling of uneasiness throughout the day, which is called a generalized anxiety disorder. Less common anxiety disorders are phobias, post-traumatic stress disorder, and obsessive-compulsive disorder.
A good way to imagine a panic attack is to simply visualize yourself swimming in the ocean and coming upon a Great White shark. In this hypothetical case, your heart rate would increase, you would start trembling and feel shortness of breath, chest discomfort, abdominal distress and fear. In this hypothetical case (coming upon a great white shark while swimming) a panic attack is a normal physiologic response to danger (it is also called the "flight or fight" response). However, when an individual has panic attacks in situations that are not life-threatening or dangerous, then these panic attacks are maladaptive and may be considered part of a panic disorder. Sometimes panic disorders are not full-blown and have more limited symptoms. Sometimes panic attacks are only circumscribed to special situations which can include competition or performance-related activities.
In contrast, general anxiety disorders are characterized by excessive anxiety and worry that is difficult to control and causes difficulty concentrating, irritability, sleep disturbance, decreased energy and muscle tension. Individuals experience anxiety most days throughout the day.
All of these disorders are medical conditions that can be successfully treated. They are not psychological weaknesses. The biologic basis of anxiety disorders is fairly-well understood, implicating three major neuro-transmitter systems which include norepinephrine, serotonin, and GABA. Genetic studies have shown that there is a large genetic component to many anxiety disorders and, additionally, there are specific areas of the brain (and the amygdala) that mediate the anxiety reaction.
Biofeedback is a treatment for anxiety and stress related disorders that has demonstrated efficacy in research spanning nearly 30 years. An individual receiving biofeedback training receives real time information regarding the biological markers of the fight or flight response (increase heart rate, increased blood pressure, increased muscle tension). Armed with this information, the individual is taught specific techniques to reduce anxiety, improve focus and concentration, and ultimately achieve peak performance. The biofeedback therapist acts as a coach, standing at the sidelines setting goals and limits on what to expect and giving hints on how to improve performance. Medicines are also very effective coupled with cognitive-behavioral therapies.
When an athlete develops a panic attack during competition that athlete is often said to be "choking." If you want to learn more about choking in sport, please see the article titled "Acute Performance Failure." If you would like to learn more about anxiety disorders in the world of athletics, please click on the Sports Illustrated article titled "Prisoners of Depression" in our Media Center. If you want to learn more go to the National Institute of Mental Health website (http://www.nimh.nih.gov/) or see your local mental health expert.
In 1976, I was in the final of the United States Junior Table Tennis Championships in Caesars Palace, Las Vegas, Nevada, when a strange event happened to me that forever changed my life.
My opponent, Perry Schwartzberg, was the United States' best junior player and I certainly was not of his caliber. However, prior to the match I had been practicing a meditative technique I learned several months earlier while training in Japan.
In world class table tennis, the balls move at speeds greater than 100mph, with tremendous spin. My friends said I never missed a ball during the warm-up and I looked like I was in a trance. For the first 45 minutes of the match I experienced the ball moving in slow motion. I remember seeing myself smashing the ball as if I were looking down from above. Perry's great high-toss serve looked like a lollipop waiting to be smashed. I won the first two games easily and then the fatal moment occurred—I started to think. I thought if I won the next game I would be the national champion and soon there would be endorsements and so on.
In that brief moment of thought everything changed. I lost the national championship. Perry's blazing backhand and bullet high-toss serve became a blur. I fell out of the Zone and Perry became the national champion. However, that experience profoundly changed my life and today I work in professional sports, mostly on the PGA Tour as a psychiatrist helping athletes find that holy grail: the Zone.
In the early 1990s Dr. John Polich and I studied many of the world's greatest athletes. Our studies applied brain imaging technology to elite athletes while they performed various behavioral tasks. The results suggested that Olympic-caliber athletes processed stimuli faster and earlier than non-athlete controls. Through this research, as well as my extensive work with athletes, it has become clear to me that the "Zone" is a paradoxical state in which great physical feats are accomplished while the mind is almost still. Simply put, the Zone is a mental state in which our thoughts and actions are occurring in complete synchronicity. The thinking part of the brain, the cerebral cortex, is bypassed and our mind is actually operating at a more primitive, reflexive level. Since the thinking brain is quiet, one can react (or act) more efficiently, sampling increments of time in smaller intervals, which is why people who have experienced the Zone talk about feeling as if time passes more slowly. People also describe it as the place where and when things happen effortlessly. The 100mph baseball comes in slow motion; the feeling is calm and the result is often beyond expectation. Children playing are in the Zone. They do not have to have a magic drug or mantra. They don't need a $400-per-hour shrink. The Zone is not a magical place although it feels that way. It is the baseline of the unencumbered mind. There is truth to the old Zen proverb, "those who think do not know and those who know do not think."
And though we are all born in the Zone, we spend most of our lives living a great distance from it in a world of worries that we self-create. Sometimes trauma, loss, and love shock us back to this primordial place, but mostly we never find it—except by accident. The research we conducted at the University of California at San Diego and Scripps Research Institute suggested that there were four essential components that characterize the Zone:
But most interestingly, our research also showed that these athletes reported peak performance states outside of athletics, in regular life. Peter Vidmar, two-time gymnastic Olympic gold medalist, told us that he can get so absorbed in various tasks that his wife tells him that it takes a few moments before he can recognize his own children. Scott Tinely, triathlete and twice Ironman World Champion, described that when he plays guitar he feels the same timelessness that he feels during his best Ironman performances. Steve Scott, Olympian and one of the greatest milers in the history of track and field, spoke about feeling like he is in the Zone while playing video games—that things seemed "like he was in a bubble" of concentration.
What my research has shown is that some people, specifically high-level athletes, have a predisposition for the Zone. But our research also demonstrated that it is not any kind of genetically exclusive club; it's a combination of multiple factors—most of which are based on very simple actions and decisions—that enable these athletes to achieve the Zone time and time again.
Working backwards from the results of my research, I began to isolate and distill what exactly made Eric Heiden different from other speed skaters; what made Lance Armstrong overcome a deadly illness in order to win seven world-title championships; what made one PGA golfer better than another. Surprisingly enough, despite all the science proving the Zone, attaining the Zone was less about innate human biologic science; it was more about human determination and will.
As a psychiatrist, I see this apparent paradox all the time: medicines can help reverse or prevent some illnesses, but it is often the heart and soul of a person, those elements invisible and untouchable, that bring true healing. In working closely with all kinds of athletes, helping them to maximize their talents and learn to win under pressure, often I am simply helping them get out of their own way. When they learn to reduce their distractions, increase their focus, tap into their will, and build their confidence, they often find the Zone. And they often win.
So much has been written about Athletic Peak Performance - being in the zone or being in "flow states."
It is a state of mind where athletes perform at their highest level. Time may slow down. A 90 mph fastball may come in slow motion, a phenomenon that baseball great Ted Williams would often cite. A golfer may have a premonition that he or she will make their chip shot. A basketball player may have a sense that there are players on either side of him, although this may be outside his peripheral vision.
It is a place in us where our mind is free from anxiety, free from distracting thoughts, free from our own doubt and self-imposed limitations.
The "ZONE" is a place where confidence soars. If we are lucky enough to fall into the "ZONE" during sports, we often quickly snap out of it by not so much the realization but the evaluation of our performance.
The "ZONE" is not a place one can control. It is a state of mind, a state of being, that we can facilitate. It has many similarities to meditation and hypnotic states.
In 1993, during my psychobiology fellowship at UCSD, we performed studies on some of the world's greatest athletes. We looked at brain waves, hypnosis, and many other neuropsychological variables. Through these studies and many other scholarly studies, we have gained an understanding of this unique phenomenon. We cannot switch an athlete into the "ZONE", but we can certainly help facilitate the chances of an athlete finding his or her into athletic peak performance.
In 1981 in "Introduction to Organic Chemistry," I found myself sitting next to five-time Olympic Speed Skating Champion and U.S. Pro Cycling Champion, Eric Heiden.
To this day, people ask me what it was like and I remember that Eric was on the cover of Time Magazine, Life Magazine and Sports Illustrated only one year before and the coincidence of my interest in athletic peak performance and my newfound friend, one of the greatest athletes of all time, seemed too uncanny. As Sigmund Freud had once said, "In life there are no accidents."
Personal statement for medical school entrance
Stanford University, 1984
"Throughout much of my life I have been considered a very goal-oriented person. Much of the success I have had has been the result of some dreaming, lots of planning, plenty of hard work and sweat, and a great deal of focus, dedication and concentration.
At age 14 I set my sites on becoming an Olympic speed skater and that goal took me three years to realize. Next I decided to become a world champion at the sport and that too I realized, but I continued to push on. Even today people ask me what kept me motivated when it appeared that I had reached a pinnacle in excellence. Speed skating is a sport that is decided by a stopwatch, not according to the judgment of your peers. Because of this I was able to continue to strive for personal excellence by setting new personal and world records. I enjoyed the challenge of pushing myself to new personal limits by skating faster than ever before.
From my experience in speed skating, and other experiences, I have found myself to be a person who does not necessarily use the praise of others as the fuel for the pursuit of a goal. Instead, it is the hard work and the desire to discover my limitations that drives me toward realizing my dreams.
I have been able to incorporate this philosophy into many other endeavors, which include professional cycling, education, and sports commentating. Although I have always not been as successful at some things as with skating, I still find tremendous satisfaction in knowing that I have given 100% in pursuing a goal. By giving 100% no one, including yourself, can ever be considered a failure. By giving your all you understand your limits and you have grown in self-knowledge. By using this philosophy, and focusing my concentration and efforts, I know I can fulfill another long-standing dream. It is a goal that I have and that will continue to be intellectually stimulating and challenging. This long-standing goal is to become a physician."
Eric Heiden, 1984