The mental health and wellbeing of athletes have become increasingly topical over the last few years, in part, because of the public discussions by high-profile athletes like Kevin Love, Naomi Osaka and Simone Biles. Having an integrated care team that includes sports medicine (including sports cardiology), rehabilitation, and mental health specialists is paramount to maximizing athlete health and performance. This team can be especially important considering athletes presenting symptomatically for medical care may in fact may be experiencing physical manifestations of psychological/emotional issues and not the general medical problem they may have been referred for in the first place. Below is a case describing the type of athlete that would commonly be referred for mental health services by the medical team. The discussion is intended to provide a brief overview of how an athlete may benefit from being cared for within an integrated health and sport psychology practice.

Case

The athlete is a 20-year-old male, high-level collegiate athlete, presenting with heart palpitations, shortness of breath and sternal chest pain that has mostly been related to exertion though also occurred at rest with spontaneous resolution. He reports that at times he has difficulty taking in a deep breath or exhaling completely when symptoms are occurring. He has not noticed any specific triggers or patterns. He underwent an extensive cardiac evaluation: (1) 12-lead electrocardiogram (ECG) showed sinus bradycardia and was normal; (2) 2-D echocardiogram demonstrated normal biventricular function, left ventricular ejection fraction (LVEF) 60%, normal left and right ventricular wall thickness, normal 4-chamber dimensions, no valvular abnormalities, normal aortic dimensions, no pericardial effusion, and no intracardiac shunting; (3) cardiopulmonary exercise testing showed peak VO₂ of 130% predicted for age- and gender-matched controls, normal augmentation in heart rate and oxygen pulse, normal ventilatory rate, normal oxygenation, normal ventilatory efficiency, no cardiopulmonary abnormalities, pre- and post-spirometry with no evidence of obstructive or restrictive pulmonary physiology, and stress ECG showed no abnormalities.

As part of his comprehensive medical evaluation and after his normal cardiac testing with atypical symptoms, he was also referred to a sports psychologist for behavioral medicine evaluation to investigate other contributing factors. The patient-athlete shared that his prior coach was verbally abusive and often used humiliation, screaming, and throwing objects as "methods" to coach. Over the course of several years, the athlete became so fearful of this coach's behaviors that he would ignore his own bodily sensations of pain and push through to avoid the coach's ire. This resulted in the development of a lower limb stress fracture. While the athlete was no longer with the same coach, he continued to experience residual symptoms including fear, flashbacks, and an exaggerated startle response when he heard someone raise their voice or a sudden loud noise during practice/training. He also had several instances in which he became physically ill (vomiting) and had to remove himself from competition. He would sometimes also express worry and concern with heart rate elevations, although this was consistent with normal physiological tachycardia related to exercise.

From a psychological standpoint, the patient's symptoms were consistent with post-traumatic stress disorder (PTSD). The athlete had premorbid elevated anxiety that served to motivate to improving performance while concomitantly leading to uneasiness when not performing or practicing. The patient's interpretation of his symptoms was a physiological problem, either cardiac or pulmonary, often prompting him to seek medical evaluation with subsequent repetitive cardiac testing showing no abnormalities.

Psychological stressors can activate the sympathetic nervous system even in the absence of a bona fide threat.^1,2 Arousal of the sympathetic nervous system in a prolonged and repetitive manner can have detrimental effects on health.^3-5 At the very least, mental stressors can serve as a distraction for an athlete, potentially resulting in the athlete failing to attend to necessary cues during competition and thereby increasing the risk for injury.⁶ Stressors can also lead to increases in muscle tension⁷ and can lead to increased risk for injury or complicated recovery.⁸

An essential element in treating anxiety in athletes is education about the role of the autonomic nervous system (ANS) in mediating the stress response, particularly in the setting of training and competition.^9-11 Athletes are taught about the effects of psychological stressors on the ANS that may be beneficial in competition but detrimental if the level of physiological arousal escalates into a range that becomes dysfunctional.⁷ Athletes are then taught practical strategies to regulate physiological arousal such as diaphragmatic breathing training in combination with guided imagery, progressive muscle relaxation, autogenic training (temperature training), biofeedback, and mindfulness.¹¹ Athletes are also taught to focus on psychological triggers, specifically their internal dialogue before, during, and after events. These techniques are categorized as cognitive behavioral therapy (CBT) and involve identifying cognitive distortions (e.g., black and white thinking, catastrophizing, etc.) and their role in interfering with effective coping.¹² Athletes are encouraged to write about and analyze their internal dialogues to identify 'stuck' points and alternatives to what may often be presumed to be automatic thoughts. This can extend to a reality testing and is often missing without the targeted interventions of a mental health professional. Through this approach, it is possible to help an athlete gain more insight and control of their own psycho/physiological experiences. This serves as a building block for more detailed psychological work in more complex cases. For example, in the case described above, the athlete would benefit from more formalized treatment for PTSD to be able to maximize recovery and minimize the impact on athletic performance.

Importantly, psychological intervention is also beneficial for athletes diagnosed with cardiac conditions that may impact candidacy for sport participation.¹³ Many of the interventions outlined above are viable treatment strategies with the most significant differences being reflected in the CBT branch of therapy. Discussions regarding real versus perceived risks and benefits of competitive sports participation are enhanced by integrating both medical and psychological care teams throughout this process. Most athletes are not typically faced with such a consequential and binary "yes or no" decision when addressing whether they continue in sport. When this does happen, such as in the cases of serious medical concerns, even with shared decision-making, these discussions can be unnerving and distressing. Being prepared to address the psychological distress associated with these decisions can be enormously beneficial for a medical provider. Specifically, having a strong relationship between the medical/cardiac and psychological teams is essential and can be established as standard of care in clinics that provide this type of shared environment.^13,14 Otherwise, it would be prudent to identify providers in the area that can assist in the process and create a small referral network to connect athletes as needed.

References

1. Campbell J, Ehlert U. Acute psychosocial stress: does the emotional stress response correspond with physiological responses? Psychoneuroendocrinology 2012;37:1111–34.
2. Selye H. Stress and the general adaptation syndrome. Br Med J 1950;1:1383–92.
3. Musazzi L, Tornese P, Sala N, Popoli M. Acute or chronic? A stressful question. Trends Neurosci 2017;40:525–35.
4. Janak PH, Tye KM. From circuits to behaviour in the amygdala. Nature 2015;517:284–92.
5. Ketchesin KD, Stinnett GS, Seasholtz AF. Corticotropin-releasing hormone-binding protein and stress: from invertebrates to humans. Stress 2017;20:449–64.
6. Roozendaal B, McEwen BS, Chattarji S. Stress, memory and the amygdala. Nat Rev Neurosci 2009;10:423–33.
7. Buss KA, Jaffee S, Wadsworth ME, Kliewer W. Impact of psychophysiological stress-response systems on psychological development: moving beyond the single biomarker approach. Devl Psychol 2018;54:1601–05.
8. Sonesson S, Kvist J, Ardern C, ÖSterberg A, Silbernagel KG. Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy. Knee Sur Sports Traumatol Arthrosc 2017;25:1375–84.
9. Abaied JL, Stanger SB, Wagner C, Sanders W, Dyer WJ, Padilla-Walker L. Parasympathetic and sympathetic reactivity moderate maternal contributions to emotional adjustment in adolescence. Dev Psychol 2018;54:1661–73.
10. McKernan CJ, Lucas-Thompson RG. Autonomic nervous system coordination moderates links of negative interparental conflict with adolescent externalizing behaviors. Dev Psychol 2018;54:1697–1708.
11. Fogaca JL. Combining mental health and performance interventions: coping and social support for student-athletes. J Appl Sport Psychol 2021;33:4–19.
12. Sutcliffe JH, Greenberger PA. Identifying psychological difficulties in college athletes. J Allergy Clin Immunol Pract 2020;8:2216–19.
13. Schnell F, Behar N, Carré F. Long-QT syndrome and competitive sports. Arrhythm Electrophysiol Rev 2018;7:187-92.
14. Glick ID, Stillman MA, McDuff D. Update on integrative treatment of psychiatric symptoms and disorders in athletes. Phys Sportsmed 2020;48:385–91.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Stress, Sports and Exercise and ECG and Stress Testing

Keywords: Sports, Athletes, Mental Health, Autogenic Training, Stress Disorders, Post-Traumatic, Stroke Volume, Behavioral Medicine, Bradycardia, Catastrophization, Exercise Test, Exhalation, Fractures, Stress, Heart Rate, Imagery, Psychotherapy, Physical Exertion, Practice, Psychological, Psychosocial Intervention, Reality Testing, Standard of Care, Ventricular Function, Left, Sports Medicine, Athletic Performance, Stress, Psychological, Risk Assessment, Sympathetic Nervous System, Autonomic Nervous System, Mental Health Services, Psychological Distress, Dyspnea, Electrocardiography, Delivery of Health Care, Integrated, Biofeedback, Psychology, Tachycardia, Lower Extremity, Patient Care Team, Chest Pain, Spirometry, Adaptation, Psychological, Fear

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