My name is Dr. Bharu and the very fact that I have 27 people in the audience gives me a lot of hope. I had told my bus driver this morning when he was driving me, I was the only one in the bus, the shuttle, and he said, good luck with your presentation and I said I'll be happy to have 10 people in the audience because if it were me at 8 o'clock in the morning I probably would not have made it. So I thank you all for coming today, I hope we'll make it worth your time. The topic today is addiction in sports. I will tell you it's a little bit off, as I was thinking this morning, maybe we should have titled it a little more focus point and I shall tell you why, but the second half of it is an athlete's Achilles heel. Me and my three co-presenters whom I often refer to as the creme de la creme of Walter Reed, no offense, they've been with me through thick and thin and we have spoken once before on this topic but in a more generic manner. Last year we had the same topic in San Francisco and we spoke about mental illness in the athletes. This time the topic being addictions as mentioned by Dr. Livonis, we decided to hone in a little more. Of course we left out one important person in that whole group and that I will talk to you in a few moments. I'll introduce the speakers as we go along. This is the usual slide which we are obligated to present, nothing to it, we don't have any financial disclosures, none of us do, and whatever we are expressing today is our and our opinion only. This is the abstract, those who have downloaded the app on your phone will be able to see this. Sorry. Yeah. So today we have a very specific topic that we'd like to discuss with you and these will be some of the points that we'll be discussing. The behavioral traits of a person and how that could increase or reduce the risk factor for addictions amongst the athletes. We'll identify through the lifespan of an athlete what are the crucial points in their lifespan where, whether they're active, not so active, retired, what stages of life are they most prone to. We'll distinguish between different types of sports and what type of addictions are there. And let me correct myself here, despite the common notion in DSM that addictions chapter is strictly chemical addictions, though they made a change this time with addition of one behavioral addiction, there are a lot more that I hope I will see in my lifetime come in DSM. We have a lot of behavioral addictions which are still in research stage and I hope to see it in DSM six, definitely seven. We'll also see what happens as an interrelationship between the athlete and the addictions, what type of mental status occurs and what changes occur. As I mentioned, I'm Dr. Bharu, I'm the chairperson for this. I'm just going to be introducing, I'll take my five minutes of fame and then I'll move over and stay quiet while the three elite people here will speak. And each one has their work cut out. This is me. I am still the assistant professor. Hopefully I spoke to the department chair and he said, put in your papers for become the associate or the professor soon. This is at the military academy. I'm also the teaching faculty. That's why I'm able to bring in the residents from the past residents. Marissa in the center, she's PGY4 and graduating in a couple of months. Dr. Wynn, he's a fellow in forensic, child and adolescent psychiatry. And his wife, Katrina Wachter, fellow in forensics, both of them will be finishing off this year and they're moving on to exotic places called South Korea and Japan. I hope they will follow us there next year and come back to do a presentation. Just my little speech. Okay, so what is an athlete? Different dictionary meanings, but they all come down to basically the same thing. An athlete is one who trains, who's skilled in certain games or sports or activities. I'd like you to pay attention to one aspect of that, physical strength. Can anybody think of anything which is a sports which doesn't require your physical strength, but your mental strength? And what would that sport be? Anybody in the audience? Chess. Bingo, chess. Do we call a chess person an athlete? We don't. We do? One thing to remember, there are certain sports. I am not a chess master. I play Chinese checkers and I'm happy with it. To me, that is as far as I can go with my mental acuity. And when I play with my grandkids, they always beat me. Talk about mental acuity. All right, so exercises and athletes. This is a common conception, missed or otherwise, but it is still a common conception. Those who exercise lifelong have better life status and a longer life expectancy. The other one is athletes are always fit and healthy. And these comparisons have always been done with those who are non-athletes. Maybe accurate, but not always so. There are so many other factors which come into the picture. What is the criteria of an active athlete? Certain things go hand in hand. They're always training, actively participating, member of some club. How do I get this out? Spend a lot of time, sometimes leaving little time for other activities. And that is one crucial area where when you are evaluating your patients, you should often ask how much of your hours of a day are spent in the activity that you like to do, and what else do you do for fun. Sorry about that. We'll keep going there. Went back to the beginning. Okay, there are certain basic caveats we all remember, when you're active, whether sports or something else, you will always have a good level of some of the neurotransmitters that you need to function in an adequate manner. You will also have other activities which will be reduced, such as stress will be reduced, provided you're not stressed about the activity. Remember that's an important aspect. Those who are actively participating in exercise and sports often are seen to have better cognitive abilities. And one important thing is amongst the teenagers, we have often seen, and this is not 100% true, it is often a statement made that those who participate in team sports, they have less substance abuse and other reckless behaviors, because they're spending more time improving themselves. So we are at a point where we have decided participation in sports and exercise is good for us, and that it's an interdependent trait, what goes around comes around. Better mental health leads to better sports activities, better sports activities leads to better sports. Okay, jeez, circles here, and back to it. So what are the elements of addiction? We are all familiar with the DSM version. This is something very close to work into it. Now we come to the harmful part. When there is uncontrolled training, what happens then? It could occur as a primary reason, meaning I want to keep bettering, I want to keep bettering myself, I want to keep bettering myself, to the point where you reach such a stage now it's becoming harmful for you. But not as easily recognizable by the individual. I can give you an example here. I hope this doesn't reach my patient. Recently I saw a 20-year-old cyclist, professional cyclist. Anybody can guess in the audience what is his addiction? Professional cyclist, 20-year-old. He's finished his high school but not gone to college, he hopes to go this fall. What do you think? I'm going to hone in a little bit, no chemical, it's behavioral. Which addiction do you think he would be having? Any thoughts? Cycling. Cycling. Binge eating during the period of cycling. One week in a month he binge eats and he restricts himself for the remaining three. Eating disorder part. Of course, there's a whole gamut of hyper-sexual behaviors amongst some elite athletes during the Olympics. We all know that. It comes with the image of being very virile and sort of superman type. And who are the ones who are at highest risk? The youngest people, the ones who have injuries. Because after injury comes the medication in the form of painkiller. And if they do not achieve their goals, they have to drown their sorrow in something, right? Here is another thing that is not commonly mentioned. Athletic identity can also be an addiction. And no offense to the military, I have often seen that amongst patients in the military who used to come to me. Doc, what will I be when I'm medically boarded out? I will have no identity left because all my identity is in my uniform. Here is another one, addicted to the identity. Of course, society always glorifies those who are in sports to the point where they are deemed demigods, hence the fall. The next part is difficulty transitioning because activity in athletes can be time limited depending upon the sport. What do we do once that identity is no longer there? While my chapter is coming to an end, hopefully I took a little more time than I should have, I want to bring another point which I thought of this morning. It's not in the slides. And that is that of the coach. Remember when you're evaluating the athletes, also if by chance you meet a patient who's a coach, think of the coach and his addictions which may be there. One of the most common ones is they're highly anxious and what better medication for anxiety than a Big B, right? Comes in various forms, starting with an X and going all the way to D, diazepam. So think of it that way, where I come from, I originated from India and there we used to call a teacher as guru. I'm sure everybody here is familiar with that. It's become a part of the culture. But nobody remembers the student. In Sanskrit it's called shishya. The guru-shishya relationship is equally important and that can transfer back and forth, as important as a parent-child bond. If you ever see a coach as one of the people you're helping, remember to talk about what they are going through. All right? I want to thank you for being patient with me and I'm going to hand it over to my esteemed colleague, Dr. Kannan. All right, good morning, everybody. As Dr. Baru mentioned, my name is Dr. Marissa Connolly, and in my part of this general session, I'm going to discuss the intersection between perfectionism, compulsion, and addiction, specifically as it relates to high-performing individuals like athletes. I'll talk about how there are different types of perfectionism, which might drive an individual to great success, or even cripple them with burnout, depending upon whether it's an adaptive perfectionism or a maladaptive perfectionism. I'll highlight the relationship between perfectionism and compulsive behavior, and explore some of the common compulsive behaviors that might be found by high achievers and athletes alike. I'll then discuss the intersection between perfectionism, compulsion, and addiction. And I'll also emphasize how these athletes and high performers might be at higher risk for addiction as a result. I'll also demonstrate how the very traits that drive them to the great success that they find in their sports may also put them at risk for struggling with addiction. What do I mean when I say perfectionism? I want everyone to take a moment and think about what perfectionism means to you. How would you define it, and more importantly, how would you recognize it in your patients? I'm sure each of us in this room could come up with a slightly different definition, but in general, I think most of us could agree on some common themes. At its simplest form, I think of perfectionism as the tendency to pursue extremely high standards, which may or may not, depending upon the individual, be actually attainable. Depending upon the person, they might strive for this perfection or flawlessness in a variety of different domains, such as personal appearance, work performance, or even leisure activities. Depending upon how strong this drive is for perfectionism, it can dominate a person's life. Like any personality trait or behavioral characteristic, perfectionism can have both adaptive or maladaptive consequences depending upon the individual. And so, you know, in this short, perfectionism is not necessarily always a bad thing. Some examples of the adaptive nature of perfectionism are character traits, such as persistence, grit, striving for achievement, or overall drive and motivation to perform at the highest level. This is best highlighted with an example. So let's say we have a gymnast who has a goal of competing at the highest level, which, for these purposes, could be, you know, making a Division I team. In order to accomplish this goal of competing at this high level, she would have to set high standards for her practices, she would have to have the persistence to keep working at her skills and techniques, and she would have to use that drive to perform at the highest level and reach her goals. Sitting in a room here full of psychiatrists and other professionals, I'm sure this hits home. You don't become a physician without some sort of relentless pursuit of a goal. But what happens when this pursuit of perfectionism or high standards becomes too much or too all-consuming? As I mentioned, like all personality traits, there can be maladaptive consequences. So what happens when these high standards of performance become so high that they're unattainable, ever-changing, or the individual keeps setting higher and higher bars for themselves? The persistence and grit to achieve these standards may turn into an all-consuming drive, an excessive amount of pressure and stress. And under this pressure to be perfect, these individuals might be paralyzed by anxiety, self-doubt, or fear of failure. Sticking with our example that I talked about of our gymnast who wants to make an NCAA Division I collegiate team, let's imagine that these perfectionistic tendencies have pushed her to set impossibly high standards. Her routines must now be perfect, so now that she spends hours berating herself for the smallest of mistakes. She might find herself plagued by anxiety, self-doubt, and excessive pressure that she puts on herself may eventually lead to burnout and overall decreased enjoyment and satisfaction from her sport. In reading more about this dual nature of perfectionism, I came across this systematic review and meta-analysis. The researchers in this study reviewed the literature looking to establish what relationship, if any, exists between perfectionism and burnout in elite athletes as measured by the multidimensional perfectionism scale and athlete burnout questionnaire. The inclusion criteria for this study yielded 14 articles and revealed some key relationships that highlight this dual nature of perfectionism that I described on the previous slide. So they talk about these two or three main types of perfectionism, one being self-oriented perfectionism, which is described as having individual goals or internal high standards, having this internal drive and pressure to execute things perfectly, whereas socially or other oriented perfectionism is when an individual is motivated to pursue high standards by influences other than themselves or their own internal goals, such as mutually aligned goals with their teammates, coaches, or parents. Individuals with self-oriented perfectionistic drives were more likely to have a negative perception of their sport and even a negative desire to continue playing, whereas those with other motivations besides their own goals had an overall positive effect on their rates of emotional or physical exhaustion. There were some limitations of the study which I think are important to note. Just due to the nature of what they're trying to measure, there's a high heterogeneity between the included articles, and that's mainly attributed to the many different types of sports that there are, so it's kind of hard to get a cohesive data set. And also it's important to note that there was a disproportionate number of men as compared to women in this particular meta-analysis. And so while these results might be variable, it does highlight what we discussed, that this type of character trait or this drive towards perfectionism can be both adaptive or maladaptive depending upon the individual and how it's framed. Some of you may have heard of this story in the news, but if you haven't, Katie Meyer was a young woman and standout soccer star for Stanford University. She tragically lost her life to suicide in 2022 in the setting of facing some disciplinary action from the university. As we are all trained as mental health professionals and psychiatrists, we know that suicide is multifactorial and that there can be many different bio, psycho, and social aspects that can contribute to an individual's struggle with suicidal thoughts. In a statement that Katie made to her school prior to her death when she was going through these disciplinary proceedings, she wrote, my whole life I've been terrified to make any mistakes. No alcohol, no speeding tickets, no A minus marks. Everything had to be perfect to get in and stay in at Stanford. I suffer from anxiety and perfectionism as so many female athletes do. What struck me when I heard about this case was, of course, obviously the tragedy of it. Another young athlete and another young life that was lost to suicide. But also what Katie's mother had talked about in an interview that she did with the press following the death of her daughter. She was quoted saying, there is anxiety and there is stress to be perfect, to be the best, to be number one. While we cannot know for sure how much this played a role in Katie's individual struggles, I think this case highlights that when we as psychiatrists see an athlete, or any patient for that matter, that looks to be like someone who's highly driven, high performing individual, maybe with some perfectionistic tendencies, that we might need to keep these in mind and think about how these traits might influence our suicide risk assessments. So moving on to compulsive behavior. So compulsive behavior, as we as psychiatrists understand it, is defined as repetitive or ritualistic actions or mental behaviors that are aimed at reducing feelings of uncertainty, doubt, or discomfort. We commonly see this when we are evaluating or diagnosing patients with OCD, obsessive compulsive personality disorder, or obsessive compulsive personality disorder. However, as we all see in clinical practice, impulsive behavior can manifest in a variety of different ways outside of any DSM diagnosable condition. And like any other diagnosable condition, it can exist on a spectrum. Individuals that fall on the spectrum often have a preoccupation with things like orderliness, perfectionism, and control, often at the expense of being able to maintain things like flexibility, openness to change, and even in some cases, efficiency. As we saw in our discussion about perfectionism, what tips a person towards disorder is the level of dysfunction that the behavior or symptoms cause. So what does this spectrum look like in high achievers and performers like athletes? For example, the benefits of maintaining a routine might turn into an overly rigid or inflexible pregame ritual that leaves little room for flexibility or adaptability in the setting of any kind of stressor or change. The importance of regular practice could turn into excessive training or overexercising, putting the athlete at risk for developing stress injuries or overuse injuries. The performance enhancement that comes with maintaining a healthy diet when pushed too far can turn into overly strict dietary protocols, or in some cases, even an eating disorder like anorexia or orthorexia. As I mentioned earlier, we understand that compulsions are performed as a way to reduce some kind of internal stress or anxiety. And as we saw with perfectionism, these compulsive behaviors do exist on a spectrum. What makes an adaptive behavior turn into a compulsion is when it begins to have a negative impact on a person's health, performance, or functioning. In other words, it's the dose that makes the poison. This compulsive behavior, whether adaptive or maladaptive, has a bidirectional relationship with perfectionism. The need for perfection and achievement may encourage the development of some of these behaviors, which then may in turn reduce some of that internal stress and anxiety, and provide the athlete with a sense of control and purpose. We can see how athletes might find themselves kind of stuck in this feedback loop, which may over time contribute to dysfunction. As I discussed in the previous slides, we've been talking a lot about this spectrum, spectrum of perfectionism, spectrum of compulsive behavior. And as for many of these high-performing athletes, these tendencies are incredibly adaptive and allow them to succeed and reach their high-level goals. But as I've illustrated here, there's a line that can be crossed into dysfunction. One of the ways that we might best see and understand where this line is is when we evaluate patients for addiction. As we know from the DSM, addiction can take a wide variety of shapes, but generally patients can either struggle with an addiction to a substance or an addiction to a behavior. Classic examples might include things like alcohol use disorder and opiate use disorder when we're talking about substance addictions, or even gambling disorder when we're talking about behavioral addictions. Despite these differences, as we know, the diagnostic criteria are generally the same. But if we think and kind of review some of these diagnostic criteria in our mind, you'll note some of the similarities between what I discussed earlier about compulsive behavior and perfectionism in diagnosing patients with addiction. Some of the criteria that I found to be most applicable include using a substance or engaging in a behavior more than what was originally intended, unsuccessful efforts to stop or cut down on this behavior, continued use of the substance or engagement in the behavior despite obvious negative consequences to a person's health or their well-being, as well as continued use and engagement in the behavior takes up a lot of their time. As I will discuss in the coming slides, there's an intersection between compulsive behavior perfectionism and these kind of intertwined together in athletes and kind of can almost create this perfect storm that really puts these individuals at risk for developing an addiction. These addictions may include substance use disorders, exercise addiction, gambling use disorder, and even eating disorders. For this part of the general session, I'll highlight this interrelationship, and we'll learn in the next parts of the general session more kind of specifically what some of these addictions look like, and then more importantly, how can we manage it and treat it. So as I mentioned on the previous slide, there are some notable similarities between the diagnostic criteria for addiction and compulsive and perfectionistic tendencies that these high-performing athletes might engage in. I think of these similarities as occurring in kind of two main varieties. Escapism or self-medication and reward and reinforcement. As we learned earlier about people with perfectionistic tendencies, they 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. 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. They may begin to engage in substance use or other addictive behaviors as a maladaptive coping mechanism, almost like a pressure release valve from their otherwise highly controlled and regimented lifestyles. For some athletes, there might also be an element of something like reward or reinforcement. Elite athletes driven by the pressure to perform and achieve their high-level goals might be more at risk for developing addiction because of their relentless pursuit to these high standards, which may temporarily seem to give them a competitive edge. For an example, an athlete might turn to use of performance enhancing drugs or steroids in order to excel their sport. Or conversely, an athlete that's dealing with injury might turn to substance use to bounce back from an injury faster so they can stay in the game. We have seen this relationship play out in the media countless times, and I want to share one of these popular media examples I found that really highlights this relationship between high-performing individuals and how these very traits that can bring them their success can also put them at risk for developing addiction. Niall Wilson, he is a former Olympic bronze medal winner. He openly discussed his struggle with addiction while pursuing his dream to become an elite men's gymnast in a TED talk entitled, What Can Make Me an Olympic Champion Can Also Kill Me. He was quoted saying, I brought the same intensity to a night out as I did to gymnastics. It was a competition I wanted to win. He discussed his struggles with addiction to gambling as well as alcohol use. He described himself as obsessive, a risk taker, and most importantly a competitor. He talked about how these traits helped him find success not only as an Olympic caliber gymnast, but also in his entrepreneurial pursuits. He also discussed how it was these very traits that were his greatest strengths also haunted him in his battle with addiction and mental health. This is just one example, but I'm sure we've all seen, you know, how many times these stories come up in the news of these brightest of star athletes that seem to have the world of opportunity, you know, at their fingertips that struggle with the same sorts of problems that Niall Wilson discussed. Now I'm going to share a short clip from his TED talk. The talk itself was only about 15 minutes and it's really great if you, you know, want to watch the whole thing. It's short, manageable. But I'm going to share just a short clip of it so we can kind of hear Niall Wilson discuss this relationship in his own words. Hopefully it works. It might be a miracle, but let's see. Okay, fast forward again, I'm now 18. I'm doing some pretty cool stuff in gymnastics world now. I've made history at the Junior Europeans, winning five gold medals. I shocked the world at the Commonwealth Games. I made history again at the World Championships, making a high bar final at just 18 years old. Brilliant. Also at 18 years old, I discovered alcohol and gambling. Oh, dear. Oh, dear. This wasn't good for this little old brain. The existence a professional athlete lives is quite unusual. It's like walking a tightrope. Narrow-mindedness, the discipline, the focus, the graft. I'd describe it as like this pressure cooker, and you're constantly building, building, building up. Then all of a sudden, you just need this release, and boom. Partying, it's like the food, was a good way to do that. So, of course, when I went on a night out, it wasn't to have a good time, or sometimes it was. I brought the same intensity to that. It was like a competition, it was a mission. I wanted to win, I wanted to be the best at drinking as well. Gambling was a tough one for me. I think gambling is a silent killer for athletes because there's no physiological effects as a consequence of gambling. I binged over the weekend, I'd be five kilos heavier, I'd struggle to perform. I'd go on a big night out, be hungover, feel sick, sleep deprived, struggle to perform. I could spend five hours in the casino spinning the roulette wheel. And besides the horrific guilt and shame the next day, for the most part, I could perform to the best of my ability. OK, fast forward again, I'm now 18. All right, that concludes my portion of the general session. It's now my pleasure to introduce Dr. Thanh Nguyen. He is a fellow at Walter Reed in Child and Adolescent Psychiatry. He's going to be talking more about these specific behavioral addictions in athletes at the intersection of high-performing athletes and addiction. All right, hi everyone. Yes, I am Dr. Nguyen. I'm a lieutenant commander in the Navy. That is my wife over there. And even though she, you know, on paper I outrank her in the marriage, she's the general. And she said, Thanh, if there's anything I want, I want to make sure the notes are on here. So just bear with me for one second while we pull the notes back up. Yeah, don't look at that. All right, it kind of struck me that some of the traits to become an athlete also are the traits to become a provider. And also with an 8 AM session, I can also imagine that it's population selecting where it might be the athletes themselves. So who would consider themselves here an athlete by a raise of hand? OK, let me hear out some of the primary sports that folks engage in. Fencing. Boxing. Hockey. Oh, hockey. Running. OK, OK. So I think it's fair to say that more than anyone else, there's a high propensity to engage in sports. And there's a lot of purposes that come from that, right? Whether it's health, whether it's fun, or my favorite, whether it's playfulness. And as a child psychiatrist, I can say that goes a long way. I like to think that that comes from my background in sports, but I really think it actually came from the Marine Corps before. The guys who are known to eat crayons, as my colleagues here would say. But that spirit in them kind of keeps them going where they work hard and then play hard. But I think we heard about that a little bit. So moving on from this, I think the first thing that I kind of realized as I was going through a lot of this literature as I did in med school was, did I have a compulsion? Did I have an addiction? And it kind of brought me back to this idea of, well, I remember playing tennis for seven to eight hours during a 90-degree Minnesota weather. I remember asking myself, like, why? I just remember I just had to practice keeping the ball over the net, getting it in. And if I do, I'll make varsity one day. And then the friend that I practiced with made varsity, and then I didn't. I remember, like, oh my gosh, I have to change sports. So I did, and I went to Ultimate Frisbee. And that's where I found the rest of my self-esteem and joined the Marine Corps. But all of this is to say that the definition that we brought up before from the Merriam-Webster as well as Dictionary.com kind of highlighted at least one half of what A. Sam says. I kind of want to introduce that here because I believe it's a very kind and inclusive definition, right? So addiction is a treatable chronic medical disease involving complex interactions among brain circuits, genetics, environment, and individuals' life experience. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. And one of the things that I keep seeing over and over again when it comes to this topic is the idea of compulsion, right? And there's two diagnoses out there that we know that have that word, OCD and OCPD. The idea of a highly valued athlete that I've found out as well is that these are kind of these core values that when I see athletes talk about, try to reach for, right? For a high performance, they are, I am faster and stronger. Actionism is, I don't make mistakes. Resilience is, I can handle anything. Mental toughness, I can take pain. Discipline, I can stick to the plan. Competitiveness is, I win. Maybe you guys also got med student vibes from there as well. Or for me, I got some special forces vibes. But outside of that, in the military, these things are the things that sometimes get ingrained to you either at the right time or at the wrong time. Moving on, the behavioral scope that I want to talk about, and, you know, it'll be much less philosophical here. We'll be very narrow in our scope. And those are exercise compulsion, disordered eating, compulsive gambling, and sex addiction. Maybe you have examples of all of these or maybe you just have an example of just the last one in your mind that was blown up about 10 years ago. Either way, I'll try to keep to that. And if you have questions coming along, try and save them until the end. I think we're doing good on time, but I can never keep track up here. So, as a child psychiatrist, we are very much encouraged to think about things developmentally. So, let me throw this in here in case my program director is here. Does anybody know the Ericksonian stage between the ages of 13 to 25? Yeah. Oh, I heard it. Identity versus role. Real confusion. And during this time, you can imagine, like, while folks are trying to figure out their identity in this high school adolescent to early adult age, that how they perform, their team, for themselves, for their school, really matters. I kind of want you to imagine that you're that quarterback or you're that receiver at the homecoming game. You're down, you need one catch, and you did it, and the crowd goes wild. All of a sudden, you're now known as that receiver or that quarterback, right? And during that time, you can imagine how impressionable it can be that, hey, I am the guy who works miracles. I've seen it happen, I've seen the rise, and I've seen the fall, and after a while, as what Dr Connolly was talking about, where that perfectionism, once it was imposed by the team, is now directed inward and expected upon ourselves. Whenever that transition happens, I think it's probably critical when you perform or become compulsive for the team versus when it becomes for your own expectations. So, that's kind of what segues me into my first, I guess, compulsion in this, exercise compulsion, right? Probably thought I was real creative with these titles, too, exercise compulsing when runner highs gets too high. So, the idea behind this is most addictions in itself, right? The behavior begins to take over our life where it becomes dysfunctional. And to go back to this idea of when that transition actually happens, of when you begin to perform for your school or someone else versus opposed to your own expectations, the science that you can identify is that, hey, this is the athlete that cannot sit still at home when they're injured and trying to get better and goes against their doctor's orders, or they feel compelled to work out because if they're not, they are letting the team down. The cycle that I hear is that this is a soccer player who gets injured, and afterwards, she's just watching videos of the team and trying to make sure that she can catch up once the team gets back into the game. Even though I'm putting these numbers up here in regards to, say, 41% of athletes are at risk for exercise addiction, the ranges I've seen can be from, like, 3% to 41%. And the reason why is that it's kind of hard to measure these things, right? Like, what would be an exercise compulsion for golfing and what would be an exercise compulsion for, well, I guess for those that consider it out there, like chess or e-sports. And that's all, like, definitive on how we define a functionality in itself. So, you know, we are talking about these athletes now who cannot stop working out, who cannot stop trying to find an edge in their improvement by training. And the other half of all this is whether or not they take care of themselves through nutrition. And this is the next idea that I want to bring out of the prevalence of disordered eating in athletes. When you go through the literature, something that's interesting is they kind of put sports into boxes, right? I guess we do those things. Into aesthetic sports, weight-based sports, as well as endurance sports, right? Endurance sports, this includes cycling, track, skiing, swimming. Weight-based sports is, well, wrestling. Those that need to make weight, boxing, and MMA, if you guys watch that. And then aesthetic sports is the figure skating, the gymnastics, the synchronized swimming, and dance. And out of all three of these, I may want to guess which one had the highest prevalence in regards to... Weight. Weight-based. Anybody else? Aesthetic? All right. Well, it turned out to be aesthetic. That doesn't mean that it can't be weight either based on how they measure these things. But that was the high number that I found. So the figure skaters, the gymnastics, and the synchronized swimming. I don't know if anybody else was surprised by that. Because, like, we always get, like, you know, board-tested on track runners. Regardless, those are the ones that I found. And then there is this more fringe, I guess, literature out there kind of talking about the idea of e-sports. Won't open that can today, right? But I would consider it something for a thought coming up just because that domain in itself begins to grow exponentially. As the events in themselves are... Yeah, I'll just stop myself there. So, again, now you are this athlete who breathes and lives your sport, right? Know the rules in and out, know the players, and you know the games, right? You know the big teams, and you know who to look out for and who not to look out for. So you're like a little mini-expert on this sport. So I bet, or they would bet, that in themselves they can make some pretty good predictions as to what's going to happen in the game. Now, betting in sports has been a little bit interesting. I don't know if anybody follows NFL, but I think more recently there were five players that were suspended for betting, just in general. Like, they weren't even betting in, like, their own team or on another team in the NFL, right? It was just betting while they were there. And the first thing that struck me was, well, if you were to bet on your team, isn't that a good thing? But then, you know, if you bet 100 and your friend bet, like, 1,000, like, you have a $900 deficit in hope. So just, so I guess the integrity of the game is what the NFL is looking after, and that might be their rationale. All of this is to say that now that you've become a little mini-expert in the game, it can lead you to that drive to want to make those predictions. One of the ways that has really accelerated this is actually the access to betting. I think looking over the Super Bowl ads and how many advertisements are now geared towards betting has increased quite a bit. I think it was two-folds in the last four years. And now, SNL has even made a skit about betting, and maybe that's saying something. All of this is to say that that thrill that they get from betting becomes that same loop and the same thrill of performing. As Dr. Connolly's last clip kind of demonstrated, they brought that competitive to a night out or to playing as well as they did to the game. How does one win a night out? I don't know. And then the last one I'm gonna touch on is the idea of sex addiction. This had probably the least amount of literature. However, this probably had one of the most amount of media coverage. And sex violence and drugs are some of those things that really get people to tune in, and that's probably why we kind of know it. And out of all of the addictions that I've talked about, only one of them is recognized in the DSM as the behavior. Anybody know which one it is? All right, pass your boards. All right. And so these other ones are always in like an area of consideration. And the one that they point out specifically near the end is the next area is esports. But there really is no consideration there for sex addiction or the other behaviors that I talked about with exercise. The example that you guys might think of is, yes, the Tiger Woods stuff that happened quite a while ago. During that time, when he was talking about it and when he was going through this thought process on his decision making, he said, yes, I felt as if I was entitled. I felt as if I had the license to. I felt as if like I was powerful enough not to get in trouble, right? He was sincerely sorry about it. And he had a fall from grace for the nine years after that involved alcohol use. And maybe you guys saw the mugshot of that. But then he returned back to performance quite well. And the thing that kept going over and over in the media about this, and I keep going back to the idea of compulsions and addiction as not something that you should approach on a moral stance. That's exactly how they approached it with, I guess, Tiger Woods. There would be segments on the news that would talk about, hey, no, this is an excuse. He's a terrible man. And another one says, well, this is an actual compulsion. Where we are now on this idea of incorporating this into a full-blown F code somewhere in the DSM. I don't know. Again, it's one of the least amounts of literature that I have right now that gives me firm numbers. Moving on. I already covered the Tiger Woods one, but for Michael Phelps himself, the idea of identity was big for him after the Beijing Olympics, right? And then going on to the London Olympics, something that you might not know is that he had a lot of strife going up to it. He didn't want to swim. He really, really didn't want to swim at that point. He didn't want to be known as the guy who just swam for the United States. He had a lot of fights with his coach, and somehow he still made it through when he got the London Olympics and got his six gold medals, right? But as he was talking about it, he hit his breaking point two years after when he was driving home from the casino, inebriated, and got pulled over and got a DUI. And after that, he got himself into treatment, and now he talks about it quite openly. But at least for him, the thing that he kept going back to was the idea of who his identity was at that time. And the big picture out of all of this, as Dr. Baru was talking about, as Dr. Connolly was talking about, was the idea of function behind this, right? I think sports, once upon a time, was the idea of, hey, we need to survive in the wild, to, well, we're gonna pit two nations against each other, and we're gonna put some sports out there and avoid war. And now it can be for, well, social clout, health, fitness. But where we draw that line of function is sometimes hard because people's goals are different. The parent's goals, the coach's goals, and the athlete's goals. So defining those markers in themselves, I mean, they can be some pretty obvious ones of whether or not you will medically hurt yourself if you keep doing what you're doing, is gonna be important. The idea of parenting and coaching as a preventative measure for athletes, I cannot stress enough. And the reason why is, in my line of work with child and adolescent work, some of the most impressionable people are teachers, they're friends, and if they're in a sport, they're coaches. I'd like to say that it takes about two and a half years to be licensed to drive on the road, right, from permit to hours, you're actually doing your driving test, but to have a child is you have a child. And so not all parenting is the same, right? Same thing with the children that grow up in this impressionable age, the coaching in itself can be that parenting. I like to say that a lot of the enlisted folks that I work with, sometimes their first parent is the military. And so those values can be good, depending on who their drill instructors and drill sergeants are, or not so much. And then they're usually a reflection of how we decide to look at the world. I'm going to be much less philosophical. If there's anything that you guys should take away from this, it is multifaceted. There's definitely not the best ways to study this yet. Maybe AI will help us in that regard. Everyone has a different definition of what a compulsion is, as well as a function, which is why I sorrowly cannot give you as firm of numbers as I wish I could. The questionnaires in themselves, and I think Dr. Walker will go over that, as well as some of the treatment measures, are a little bit much more firm now that it's come to light. But outside of that, the call to action for better markers for these things is the same as it was last year as when I was giving a similar conversation. So with that being said, let me turn it over to my general here. So she'll talk about the lifecycle of athletes, vulnerability and addictions, and treatment recommendations. So Dr. Walker, she's finishing up her forensic psychiatry fellowship, and she'll be over in Korea. And I'm sure she'll want to be there and ask for a cup of sugar. If that does, I'll be like, OK, cool. All right, well, let me introduce her and bring her up. And thanks for listening. Thanks for bearing with me. Thank you. Thank you, Dr. Nguyen. All right, so to start off my section, I wanted to take basically what we've been talking about the last 55 minutes and put it into a conceptual chart for you guys. So you can see, when you think about an athlete, we think the easiest way to think about it is through a developmental model that looks at the athlete lifespan. So this isn't necessarily talking about from birth to death, and I'm talking more about the initiation of sports throughout their sports career, and then initially that discontinuation stage. So thinking about this, initiation of an athlete's lifespan can start, this is as early as 10 years, but I know people, you start t-ball at like five, six years old, for example. I think they're actually starting at like four. I see people who may have kids in the audience nodding. So we're starting the initiation of sports earlier and earlier as time goes on. Around this time, children are still very heavily interacting with their peers. They're in the midst of their elementary or early education schooling. And as they progress to their teenage years, sports become more competitive. You have tournament leagues, competitive summer leagues. I know I played softball in high school, middle school, elementary school, and I was playing year round. So indoor training over the winter, spring and summer softball, spring for school, summer for tournaments, and then fall ball as well. So we see this year round as you get into the teenage years. And this is really the time that coaches start, not always, but sometimes become not the parents. So you start having that extra influence on the athletes when a coach becomes someone that they're getting to know at that time. And these people may push those individuals harder and help them understand and realize what their athletic goals may be. So many athletes will then move from their high school years into playing for colleges or universities. When the influence of parents may not be quite as strong, they're starting to figure out who they are. Dr. Wynn mentioned early adulthood. And that's when romantic interests may start taking the front seat, for example. So finding a life partner, for example, or not. And then between 20 and 30 is when we see that mastery stage within athletic endeavors. So this is what we'll see when we watch professional sports. For those of us that watch, I just watched the draft a couple of weeks ago for the NFL, for example. These are 20, 21-year-old, very elite athletes that are being picked to pursue their career professionally within sports. And then finally, retirement or discontinuation in the sport typically happens between 30, 40 years, give or take, depending on the sport. But when you think about the general lifespan of an adult, that leaves them 30, 40 years after they've retired from their sport to figure out what they're going to do. So some may have families at this time. Some might have already planned for the future. Some may have absolutely no idea what they're going to do with themselves after they're done playing their sport. And this will become really important in a few minutes, as we'll talk about what makes athletes vulnerable to addiction next. So despite, you know, we've talked about the remarkable abilities and dedication that you see in a lot of different athletes, but they also face a lot of unique challenges and a lot of unique vulnerabilities that can predispose them to substance use disorders or behavioral disorders. So as I mentioned, they usually begin their sports careers at a pretty young age, which could be a risk factor because they may be introduced to highly competitive environments or substance use sooner than some of their peers. So as we know, early age of first use of any substances can lead to a greater likelihood of developing addiction later in life. So just given the environment that they may be growing up in, in a competitive sports environment, may be at higher risk for use. There's also a lot of harsh discipline in training regimens for athletes, especially when you get to those teenage, early adult years. So that strict, sometimes punitive environment can increase the risk of substance use and that punitive environment can increase stress and anxiety, which may push athletes towards substances or other coping mechanisms that may not be as healthy. Thinking about peer pressure, especially we're thinking in college age kids, this can be a huge factor in substance use. So if everyone else on the team is doing it, you don't want to be the odd one out that's not doing it, become ostracized from your peers, may not be the cool kid, not get along with the people you're supposed to be playing on, especially in team sports, when you have to rely on each other to be competitive and successful in your sport. The big one, which I'll focus on a little bit more, is transition. So moving from amateur to professional levels, retiring from the sport, these can be extremely stressful times for athletes. And these can kind of lead to identity loss, which can make athletes more susceptible. And then thinking about just chronic stress in general, chronic stress is a constant in the lives of many athletes. So that ongoing demand to perform can be a vulnerability that puts them at higher risk. So I mentioned how transitions are a big vulnerability part of athletes when thinking about risk for addiction. But I really wanted to focus, there's two types of transitions that are frequently talked about within the literature. So you have your normative transitions, which are just the things that will happen naturally, they're expected. And then you have things called non-normative transitions. So non-normative transitions are the things that you don't see coming. They kind of blindside you or take you by surprise, or something that you can't necessarily plan for for the future. So these could be things such as injury. No one expects and hopes to get injured when they're playing sports. If anything, they hope for the opposite. So things such as injury and figuring out how to come back from that is considered a non-normative transition. In addition, something like deselection, so being an undrafted free agent, for example, and not actually making the team or making the team and then being cut afterwards is something unexpected that can lead to a higher vulnerability for addiction. Things such as illness or reselection, so after being dropped from a team, maybe being picked up by another team, needing to prove yourself, feel like you need to be the absolute best you can be to show them you deserve to be there, can add just an extra level of stress to any professional athlete. Or a coaching or team change, so having to completely learn a new style of coaching. You may have a coach that you love that leaves and he or she is replaced by someone that you don't get along with. Personalities just don't click with each other. So these are all what we call non-normative transitions that can lead to higher risk or higher vulnerability to develop different addictions. So I would be remiss if we did not talk at least a little bit about performing enhancing drugs when thinking about athletes. So obviously, performance enhancing drugs are defined as substances that athletes can use to improve their athletic ability, very broad definition. So these drugs can do things such as enhance strength, enhance endurance, increase muscle mass, increase speed. And oftentimes, it'll give athletes an unfair advantage compared to their competitors. So common types of PEDs would include things such as anabolic steroids, which could help the muscle tissue, build muscle tissue and increase strength. Things like erythropoietin, which can boost the production of red blood cells to enhance oxygen delivery to muscles, as well as things like human growth hormone, which can be used to increase muscle mass and overall physical capacity. Other things that you may not think of quite as commonly for performance enhancing drugs could be things such as diuretics. Those can be used to mask drug use or perhaps in people like boxers, MMA fighters, things like that to be able to cut weight enough to make their weight, narcotics to mask pain, or even cannabinoids to help with relaxation. And then some performance enhancing drugs like caffeine are obviously legal, or all of us would be participating in a lot of legal activity if it wasn't. Things like that aren't banned in professional sports, whereas a lot of the performance enhancing drugs are. So thinking just a little bit more about performance enhancing drugs, few athletes go into their craft thinking that they're going to need a drug or a substance to help them. But when things like injury, I think that's the most prominent one or the most common one talked about, when they creep up, the temptation of something such as opioids, for example, may make the athlete feel that they can get back on the field right away. It's a quick fix. It's something that will take away the pain. That plus the adrenaline of the sport may get them back on the field. And that very quickly can turn from a crutch to an actual addiction. So we talked a little bit about the risk factors with non-normative transitions seen within the active part of the athlete's life cycle. What about that final transition that they face, which is the discontinuation of the sport? So this can be a really jarring time for a lot of athletes, especially, as I mentioned, the athletes who haven't really thought about what the future looks like after the sport. When you spend 20, 25 years solely focusing on one singular thing, that being the sport, you eat, drink, breathe, sleep this sport, when that goes away, what do you do? So there was a research study that was done that looked at athletes who were about to finish or had recently finished their athletic career. And the results that they found were actually pretty staggering. So almost 3 4ths of the people that they interviewed were considered moderate or high risk for developing an addiction or had the risk for addictive behavior. So 55% were found to be at moderate risk, while 15% were found to be at high risk. As I said, many retired athletes may just not know how to fill their time, while others may be seeking that dopamine burst that you can frequently get when you're playing a sport. As Dr. Nguyen mentioned, when you're the person that makes the catch, that wins the game, that feeling, I would imagine, is indescribable sometimes. So when you don't have that available to you, or even the prospect of that available anymore, athletes or recently retired athletes may seek something else that will give them that dopamine burst as well. As Dr. Baru mentioned, and we did mention a couple other times as well, when we think about athletes, it's important to think about the athlete identity. So the athlete identity is basically how the individual views himself within their sport. And unfortunately, a lot of times it's how they view themselves completely throughout their life. It's not just about the sport. So when an identity outside of the sport is not developed alongside the athlete identity, the risk for addiction does become significantly higher. So I pulled just a couple of slides from our presentation from last year, because I thought it would be important to mention this in case I think there are definitely new faces in the audience this year as well. So we talked about the need for a framework for treatment of mental health, just general mental health in athletes. This is not a new topic. However, over the last 10 years or so, there has been a pretty large explosion of research conducted looking at this unique population. So this was highlighted by an event that happened in 2018. On the 12th to the 14th of November, the International Olympic Committee met for a several-day conference to talk about treatment guidelines and consensus statement writing. And that came out in 2019 and was published in the British Journal of Sports Medicine. So this looked at mental health symptoms and disorders. And it also looked at both individual and systemic interventions. And this did include substance use. So in general, the IOC consensus statement mentioned that treatment should be comprehensive, integrative, athlete-centered, and holistic. And it should, if possible, include both psychotherapy and or pharmacological treatment to optimize the treatment for athletes. Now, obviously, this is easier said than done, especially with schedules that athletes hold frequently. One of the biggest things and one of the biggest emphasis One of the biggest things and one of the biggest emphasis that they emphasized the most was the fact that it needs to be athlete-centered. So the treatments need to be centered around what the athlete needs, as well as when it would be best for the athlete to receive the treatment. So obviously, pulling them out of a game, for example, probably not the best option. But finding time in between weeks, by weeks, off season, finding things that don't require long periods of time at once. These are all things that the IOC recommended for treatment. And then, again, the four key considerations when thinking about pharmacological treatment for an elite athlete. And this does also apply to substance use treatment. So you have to think about the potential negative impact on athletic performance. So what side effects is the medication or the treatment going to give the athlete? And is it going to impact how they're able to perform? Similar but different vein, is there a potential unintended positive impact of the medication? For example, if you're treating terrible ADHD with a stimulant, that can be something that could have a performance-enhancing effect. And you need to make sure that you're following guidelines for approved medications when treating these athletes. And then, obviously, things like potential safety risks. So we think about high, we think about athletes, they're sweating a lot, maybe their hydration isn't always the best. So if you're using medications that require x number of glasses of water a day, like lithium, for example, we need to monitor your water levels. You have to be thinking about these things when prescribing them within professional elite athletes. So there are a variety of measures that you can use to determine use or misuse. Most commonly, we see this in the military all the time, are urine drug tests, for example. They're quick and easy. You can screen for a variety of substances when using urine drug tests. And then, you can also build on that by using things such as biological passport baselines. So what those do is they track an athlete's biomarkers over time. And anomalies can suggest drug use. So these are really good when you're looking at performance-enhancing drugs like human growth hormone, anabolic steroids, erythropoietin. So you'll see those actual biological changes with those substances. So it's a little bit more specific to that, rather than just substances like opioids, benzos, things like that. Other things that were recommended are team urine surveillance and post-game testing. So these both ensure compliance immediately after events when the temptation for drug use may peak. And then, you can also do hair testing when you want to detect drug use over longer periods of time. So that can provide you more of that historical record of drug use. As I alluded to, early out-of-season testing is pretty crucial, because usually, athletes aren't expecting the testing right when they're out. You can target those off-season periods when they might attempt to gain an unfair advantage, or they may be using something that can be dangerous to get them ready for the next season. And then, also, doing things such as administering the attitude scale, it can help assist an athlete's views and potential inclination towards doping. So that can be both a deterrent and an educational tool for the athletes. And then, lastly, the good old interviews. So talking with athletes, talking with their teammates, talking with coaches, even parents sometimes, this can be invaluable. It can provide deeper insights into the athlete's environment, and that can be crucial for understanding and curbing drug misuse. Never underestimate the power of just talking to people. So the research has shown a couple pretty promising treatments for behavioral addictions. I won't go too in-depth. A lot of these may actually be common to some of us in the room here. But things such as motivational interviewing, really utilizing that technique of rolling with the resistance rather than trying to confront things directly, can be helpful. It avoids the direct opposition, which sometimes athletes don't respond well to. And it can make it possible for athletes to explore their motivations without feeling like they're being judged. When you're in an environment where people are constantly judging you, and you're under a microscope, and you're constantly being evaluated, having that space to be able to explore without judgment can be really powerful, especially when dealing with behavioral addictions. We don't talk about this a lot, but I think it's up and coming, the idea of contingency management. So we've seen some studies come out that look at, for example, cocaine use using contingency management. Basically, what it does is reinforces positive behavioral changes. So individuals are often rewarded for evidence of improvement, such as clean drug tests or successful completion of treatment milestones. So these rewards can often take the form of vouchers or opportunities to win prizes, which can make the process of recovery more engaging and motivating. So we've seen some success with contingency management in things such as cocaine use, for example, but there's a lot of promising research out there that it can also be used for behavioral addictions as well. And then the good old cognitive behavioral therapy, so being able to help athletes develop coping strategies to handle their triggers, be able to have them correct their cognitive distortions related to their abilities or performance, finding that idea of good is good enough, perfect doesn't need to be 100% of the time, and utilizing the cognitive behavioral therapy approaches to be able to get there. So by integrating these approaches, we can create a pretty robust framework for athletes that not only can address substance use, but also enhance their overall mental resilience and life skills. And then for substance addiction, if possible, obviously prevention is the best thing that we can do. So talking about it early and often, targeting the younger population before they start using. As I mentioned, the age of first use is a huge risk for addiction. So being able to talk about these things openly early is very important. But then we have our normal things such as naltrexone, nicotine replacement therapy, obviously treating any underlying behavioral health disorders, so anxiety, depression. And then I wanted to make just one specific note. So if treating an opioid use disorder, thinking about methadone and buprenorphine, those are banned by the World Anti-Doping Agency. So if you're treating athletes that specifically have an opioid addiction, just keeping that in mind, again, emphasizing the idea that there are specific substances that we use pretty regularly in some of our clinics that are not compatible, essentially, with an elite athlete and their treatment. And then just a little teaser maybe for the future here. So future directions for treatment. So athletes as a whole are much more likely to accept treatment that doesn't require a daily medication. And they really try to avoid treatment that has side effects, as I mentioned, that can affect their performance. So things such as neuromodulation, there's more and more research coming out looking at this, things like TMS, like transcranial direct current stimulation. These are things that don't require medications, although they do have a time requirement, and they're definitely still in the early experimental stages. These are techniques that have been identified as possible areas of future study, especially in athletes, so they don't have to take that medication daily. Again, things such as ketamine. Although ketamine itself has actually been a substance of abuse at times, small sub-anesthetic doses in medically monitored settings haven't really demonstrated a high risk for the outcome for addiction. So it's suggested a possible benefit in substance use disorders, such as cocaine, alcohol, opioids. There's been increases in abstinence, reduction of cravings, and a lower likelihood of relapse. Again, this isn't an FDA-approved treatment for substance use disorder, but it is something that they're currently looking at. And then you have spravato as well, so you don't need the IV ketamine as well. And then finally, the most physically non-invasive treatment that there might be, which is training your coaches. So engaging the in-coaches to help them know the warning signs of use, or the warning signs of maybe pending, maladaptive behaviors, or excessive perfectionism. Being able to teach them how to have conversations with their athletes in a non-judgmental way. That, we think, is going to be a large piece in the prevention aspect, as well as the early intervention aspect of treating addictions within athletes. So the future really is looking bright for treatment, and by focusing on the whole athlete throughout their lifespan, I do think we can really make a difference and reduce addiction in our athletes. So at this time, we will open it up for any questions you have. We'll also monitor the online chat for any questions. And these are our references. So thank you so much. So before we open up to questions, I'd like to thank each and every one of you who persisted through the whole 75-minute session with such great attention. I salute each and every one of you for coming today. Listening to us and bearing with us on this very, very important topic that has probably not received its due importance in our careers. So thank you very much for coming, and now we open it up to the questions. This is also, by the way, a session that is online. So we might be getting questions live and online. We are told we have to alternate if there are any. Thank you. Thank you. Hi, thanks very much for that presentation. I heard a lot of things that I was hoping to learn about since I'm quite inexperienced, really, in working with this group of patients. But I did wanna share a case just to hear a little bit about your comments because my experience with it has been just to be intrigued by the multiple dimensions involved. So this is a former championship college male gymnast who has addiction and bipolar disorder, alcohol primarily. And he's doing quite well right now. But it's been fascinating to hear him talk about the relationship between his bipolar symptoms and his performance ethic that led to his championship accomplishment. For example, he would talk about probably being in a manic episode, breaking into the weight room in the middle of the night so that he could work out. So one of the challenges that he's had is that at one level, that accelerated way of life worked for him. And of course, he has a great attachment in his own identity to the experience of winning that championship. He also has a history of trauma, childhood trauma. And it seems pretty clear that his athletic accomplishment, his identification with coaches, all of that process was very compensatory for him in terms of his childhood experience. But one of the challenges with him that I find is to, on the one hand, take advantage of his high motivation to do well, which he is applying now more so to his mental illness, but certainly to his substance use. But at the same time, helping him to moderate some of that because for the reasons that you talked about, his perfectionism and drive are also contributory to his stressors and are not a sustainable way for him to manage his life. And I kind of have this image of him at times, as a male gymnast, sort of being like this with his addiction and mental illness. So I'd love to hear if you guys have some thoughts about that case and how to work effectively with him. First off, I love that imagery, the idea of just holding fast, essentially. I love that. I think, I think, wow, that's really loud. I think, I think you hit the nail right on the head, though. That is a perfect example of the idea of when does perfectionism turn into compulsion, lead to addiction, right? So, and I think it's really important. I had it on my slide, I didn't mention it out loud, but the idea of adverse childhood events being a strong risk factor of addiction. So the idea that they don't learn that emotional regulation in a healthy way, they don't learn the coping mechanisms in a healthy way. So I think that's a really good thing that you're at least identifying, it sounds like. In terms of, when you were talking, it made me think of the idea of sublimation, is kind of where my mind went when you were thinking about that. So turning those perfectionistic tendencies that led to the addiction into something that's healthy and productive. So not necessarily saying, don't be productive, but how do you take that and turn it into something positive? I know it's not necessarily, that's just kind of my thoughts when you were talking. I don't know if anyone else has anything. I would say it's also almost like, I'm not sure if he's still competing, but in a way it's almost like grieving a loss, and so a loss of an identity, and as well as if his manic symptoms are treated, a perceived loss of his superpower, to be able to kind of hyper-focus on something. And so maybe working at it, approaching it from almost like managing grief in a way. Love that. Yeah, and I'll foot-stomp the identity part. I just had a conversation not too long with a colleague about military folks who come back to Walter Reed, and now they have lost a limb, and they cannot get back into the fight, and all they knew how to be was a Marine soldier or sailor. And you see them go through that grieving process, and sometimes it is through self-medication. But yeah, I already said it. Thank you. Thank you for the lecture. I'm a clinician from Finland, and we have a magnetic stimulation clinic where we treat pain, and we have been discussing about the athletic groups and the treatment. So how do you see, like, you mentioned that injury is like a gateway to addiction, because people start taking opioids and stuff, but do you see, like, TMS having, like, spots in this field or, you mentioned it briefly, but what are your experiences? Yes, I do see it having a pretty large role in this field, actually, because it's one of those interventional techniques that doesn't require medication. Thinking about transcranial magnetic stimulation, it's not approved for any, like, substance use necessarily yet, but there have been trials that have been looking at it. So I think it's going to play a bigger role. Also with pain, so again, like, when we can minimize medication use and maximize interventional psychiatry in some way, shape, or form, I think that's going to be the future, or the primary treatment that we're gonna reach towards in the future. I had a question about orthorexia. So I think as, like, someone who's maybe not knowledgeable in, like, specifics of specific sports, like basketball or rock climbing or whatever it is, are there any, like, questions that you could ask to get at, like, this eating regimen, like with the supplements or X number of calories or whatever that can identify, like, what might be a normal eating pattern for that athlete versus, like, what's disordered eating or anorexia or orthorexia or binge eating? That's a really great question. And it's tough to answer because it depends on the patient. And I know I talked a lot about things existing on a spectrum in terms of where does that line exist between some behavior that's advantageous versus a behavior that then becomes maladaptive. And so I would be concerned. I think collateral would be helpful in cases like this if the patient's consenting in terms of talking to their coaches, family members, seeing if there's concern for their behaviors outside of the norm of their team or the individual group that they're with. I think that might be helpful to tease that out. Yeah, I will also say there are a couple different apps or websites that talk a little bit about appropriate nutrition for athletes. So I know, for example, the World Anti-Doping Agency actually has a page on what appropriate nutrition looks like for different athletes. I can't remember the name of the app off the top of my head, but there is one that also kind of helps athletes create personalized, healthy, appropriate nutrition plans. So that might be a resource if you have concerns to get them kind of plugged into something that's telling them what's healthy and what's not. Last 10 seconds. The first question will always be where's the dysfunction? And if they keep going the next six months to a year, what harm is gonna come to them? And then the second part of all of this is the preventative piece might be the education piece. So if you suspect it's okay to talk about it and bring it out into the open, you won't know how that might sit or get internalized in their mind. Yeah. Hello, Quentin Shambly, Phoenix. I know that this is a developing field for what can truly be identified as a special population. We all, I guess, essentially within the entertainment industry, we wanna see people performing at a high level, but it can be difficult to connect with the difficulties and the challenges that people in that realm experience in going to that high level. And so I feel like we as clinicians have great opportunity to speak to and support that special population. Yeah, I guess my question is, looking at this seminar, and I remember seeing you guys from San Francisco this past year, and then I think there's one this afternoon, but relatively limited number of these sort of sessions, these sort of informational talks within the larger scope of the whole conference, how can one continue to learn, continue an education, really familiarizing themselves with this special population, and how to best go about supporting the individuals who find themselves within these circumstances? Yeah. When I stepped into being an intern in a military hospital, one of the things that I realized was, wow, there are three branches, and wow, I don't know any of their jobs. I don't know any of these ranks. And the best advice that I was given was just to ask and to learn from my patients, right? So I will say that if there is a knowledge gap that I have about a patient, say a fencer, I don't know what their system is like, and all I'm left with is usually asking and maybe looking it up later. So that's one. And then two, figuring out good sources of information. Hopefully that's a little bit easier, and you have your own repository of where to go for that, right? Find YouTube videos, like don't watch it when you go home, right? But the other idea is, hey, if there already is some literature on that, say in PubMed that is from a respectable journal, I would say, hey, it's okay to maybe prime yourself before the next clinical encounter for that. Sometimes the best teachers I have are my patients when it comes to this realm, right? So that's all I got. I don't know if anybody else here had any other. I was just gonna say, I know the APA has actually made this an area of focus that they're working towards. So they, in I think summer of 2023, they partnered with Athletes for Hope, which was one of the nonprofits we talked about last year. It's one of the largest nonprofits that looks at athlete mental health. People like Mia Hamm, Muhammad Ali, they were involved. So I think the APA realizes that we need more information about it as well. So I foresee a lot of maybe informational packets. I hope that there'll be more topics in future years as well. But I think it's something the APA has now kind of jumped in on and we're gonna have more information coming, books, blogs, things like that. Let me also thank you for that question. You brought up a great topic about being in the library and being in the limelight. And that goes for many industries. What's being one of them, which we honed on today, is also the entertainment industry, which Dr. Katrina Wachter wanted to speak about last year, never got accepted, hopefully in the future. So yes, there are certain specific populations that need special and differentiated evaluations, first of all, understanding of what they're going through and then formulating a plan how to manage that. Thank you so much. We'll take this last question, yeah. Thank you so much for the wonderful presentation. And I wanna comment on one thing you said, consider Cochise addiction. I really think that it's home because most of the patients that I treat, they have all eating disorder, addiction, and trauma. And when we see patients with the eating disorder, we always ask about their parents' relationship with the food. So when you said that parent-children-child relationship mimics Cochise relationship to athletes, I think that's a really good point. None of my patients are professional athletes, but they used to play a lot of sports in high school and they don't really continue in a college career, but they do affect, that experience does affect their mental health in their adulthood. So one thing that I found that's helpful to treat their exercise addiction was actually using naltrexone. What is your experience or if you have any input on using naltrexone in behavior addiction, including exercise addiction and sex addiction? I can't answer that one. You're right on the dot. Even though it's not FDA approved, we do think outside the box. In fact, we have to. And I've used naltrexone many a time. But in addition to naltrexone, I've also used bupropion as another tool that I can add. Both of them can be given together at the right appropriate patient. And while they are not 100% effective, they do bring down some of the conditions that need help. So yes, definitely. I'm all for trying out these two medications at the best. After a trial, if you succeed, you succeed. And if you don't, you have nothing to lose. Thank you. All right. Thanks everyone for joining us today and hopefully we'll see you guys in LA next year, huh?

addiction

sports

athletes

mental health

vulnerabilities

managerial strategies

behavioral addictions

perfectionism

performance-enhancing drugs

treatment

prevention

motivational interviewing

cognitive behavioral therapy