Psychiatric considerations in the injured athlete

Transcription

1 Psychiatric considerations in the injured athlete Arman Taghizadeh, M.D. Child, Adolescent and Adult Psychiatry Sports Psychiatry Faculty Instructor Johns Hopkins Department of Child and Adolescent Psychiatry

2 None Disclosures

3 My background in sports Various sports throughout youth/ms/hs: Swimming, baseball, tennis, sports camps, football Competitive wrestling: High School All-American wrestler College NCAA Division I wrestler Coached HS/Jr league wrestling Served as Ambassador to Iranian Olympic wrestling team World Cup 1999, 2000 Current: Weightlifting, running, cycling, TRX, boxing

4 Objectives Discuss case examples with psychiatric effects of physical injuries Utilize a four-step model of injury recovery Evaluate how to approach treatment of adolescents with sports-related injuries

5 Case #1: Volleyball player with Anxiety and Depression s/p concussion

6 Case #1: Anxiety and Depression s/p concussion Feb 2016: 16 y/o F no previous psych history referred by HA specialist with 18 months of persistent HA, anxiety, depression after head injury in Volleyball Sept 2014: Hit in head with ball in practice, no immediate symptoms, no LOC Later in same practice: missing serves, dizziness, lightheadedness, HA

7 Medical Injury course Missed school x 2 weeks for constant HA Began having fainting spells, anxiety so had further w/u including MRI, CT scan (both negative) Jan 2015: after winter break went on Home/Hospital for persistent HA, fainting episodes, anxiety August 2015: medical hospitalization x 4 days for persistent pain Meds attempted: Gabapentin, Amitriptyline, Topiramate, Fluoxetine with minimal or no benefit

8 Psychiatric course Pre-concussion: general worries about family, money, easily stressed but no major depressive symptoms. Social, athletic, enjoyed school Post-concussion: anxiety attacks resulting in fainting spells, academic worries about falling behind, worries about health, feeling sick all the time, poor sleep, weight gain despite poor appetite, low energy, frequent sadness, isolation, thoughts of death

9 Evaluation and treatment FH of major depression and anxiety in immediate and extended family Unable to attend school again since Sept 2015 Sertraline (Zoloft) started for anxiety/depression, later added Bupropion (Wellbutrin) to help augment for depression and energy Clonazepam (Klonopin) to address acute panic and help her slowly return to school Modified school schedule to slowly reintroduce her Referred to therapist to address anxiety and depression from CBT approach

10 Outcome Completed 11 th and 12 th grade IN school and successfully graduated HS Competed and had successful volleyball season Moods are stable, minimal anxiety only specific to school, occasional sleep difficulty but improved HA minimal, not pervasive Meds: Wellbutrin, Zoloft, D/C Klonopin Considering college to major in Marine Biology

11 Case #2: Runner with depression, poor school performance s/p torn hip labrum

12 Case #2: Depression, poor school performance s/p torn labrum 17 y/o lacrosse, track star currently in treatment for ADHD and anxiety with new onset depressive symptoms and decreased school performance after diagnosed torn labrum Nov 2016: after persistent pain and inability to exercise was diagnosed with torn labrum and told I cant do anything. Jan 2017: received cortisone injection and told if minimal or no improvement, may need surgery Involved in Physical therapy

13 Psychiatric history Initially presented at age 13 for worsening attention issues, distraction in school, poor academic performance Formally diagnosed with ADHD age 11 Previous trials of stimulants for ADHD with significant side effects: stomachaches, jittery, not myself, boring. Also, long history of anxiety, general worries, somatic complaints, safety worries, easily emotional

14 Evaluation and treatment At time of injury, was well controlled on Sertraline (Zoloft) and Methylphenidate ER (Concerta) Since injury, patient felt more anxious, easily irritated, crying spells, less communicative, upset she cannot play college sports (her interpretation) Overwhelmed at school, poor motivation to do HW, procrastinates Plan: Start Bupropion (Wellbutrin) for energy, motivation, attention. Refer to therapist or anxiety coach to help deal with loss and managing what she can control, work with sports med team to understand true nature of illness, options, and create rehab program

15 Objectives Discuss case examples with psychiatric effects of physical injuries Utilize a four-step model of injury recovery Evaluate how to approach treatment of adolescents with sports-related injuries

16 Injury Recovery: 4 stages 1. Acute Injury 2. Rehabilitation 3. Return to Play 4. Departure from Sports

17 Stages of Injury Recovery: Emotions & Critical Issues Acute Injury Rehab/Recov ery Return to Play Departure from Sport Reactive Emotions Hurt Anxiety Fear Disappointment Sadness Doubt Annoyance Frustration Anger Stress Doubt Anxiety/Fear Tension Anxiety Fear Guarding Intensity Doubt Depression Uncertainty Anxiety/Fear Resentment Loss/Grief Contemplative Emotions Apprehension Uncertainty Embarrassment Shame Pressure Confusion Concern Optimism Pessimism Hopelessness Certainty Distrust Distraction Guilt Apathy Fear (Re-injury Fear (Injuring Others) Tentativeness Intensity Confidence Resentment Remorse Regret Jealousy Contempt Critical Issues Pain Control Sleep Energy Information Support Persistent Pain Boredom Social Isolation Complications Motivation Substance Use Range of Motion Speed/Quickness Endurance Confidence & Focus Soreness Chronic Pain Loss of Function Financial Strain Lifestyle Change Career & Identity Substance Use McDuff, DR, 2012, Table 6-2.

18 Strategies: Injury Treatment 1. Help athlete learn/understand injury, intervention, rehab course, symptom recognition 2. Support network: family, friends 3. Improve in other areas: same sport or other interests 5. Pain control 6. Manage anxiety/mood 7. Mental preparation 8. Motivational/Supportive therapy 9. Coordination of care 4. Sleep hygiene

19 Objectives Discuss case examples with psychiatric effects of physical injuries Utilize a four-step model of injury recovery Evaluate how to approach treatment of adolescents with sports-related injuries

20 Management of Injuries based on age/developmental stage

21 Management: Pre- adolescence (6-11 y/o) Developmental stage: Short attention span, high distractibility, limited ability to plan in accordance with potential consequences to actions Challenge to injury management: Difficult to relate the importance of adherence to treatment Clinical approach: Involve parent, siblings, and other adults to reinforce recommendations; frequent followup Concussion in pediatric and adolescent populations PM&R 2011

22 Management: Early adolescence (12-14 y/o) Developmental stage: Concrete thinking, narcissistic type concern for one s appearance and social status Challenge to injury management: Under-reporting of symptoms, poor compliance with plans Clinical approach: Involve parents and coaches Concussion in pediatric and adolescent populations PM&R 2011

23 Management: Middle adolescence (15-16 y/o) Developmental stage: Working toward independence and separation from parents, typically understand potential consequences for noncompliance Challenge to injury management: May be highly motivated to return to play for the sake of peer acceptance; may lead to underreporting Clinical approach: Establish rapport with patient and accurately relate potential outcomes of noncompliance Concussion in pediatric and adolescent populations PM&R 2011

24 Management: Late adolescence (17-19 y/o) Developmental stage: Abstract thinking and comprehension for potential long-term consequences have developed Challenge to injury management: Improved compliance with treatment recommendations; maybe less parental involvement with older teens Clinical approach: Accurately relate the potential consequences and importance of compliance Concussion in pediatric and adolescent populations PM&R 2011

25 When to refer to Mental Health Specialist Symptoms cannot be fully explained by injury/continue to exist well beyond what is expected Pre-existing psychiatric conditions worsen after injury (ADHD, anxiety) Emergence of psychiatric conditions after injury (attention/affective/sleep disturbances) Family conflict/pressure to return too soon or reluctance to return once cleared Unexpected/pre-mature end of athletic career

26 Therapeutic Approach to injured adolescents Understand injury from athletes point of view: what happened, how it happened, treatment course, expected return, limitations Understand and validate emotions related to injury Educate athlete and support system about stages of recovery Develop plan to improve in other areas Help athlete stay connected to sport/team Manage associated psychological/psychiatric issues Consider plan for life after sports

27 Conclusions Knowledge and management of injuries is critical Psychological and psychiatric factors are associated with injury and recovery Approach to treatment varies based on age and developmental stage There is low percentage of athletes that actually return to same level of competition prior to serious injury

28 Questions???

29 Bibliography McDuff, DR., Sports psychiatry: strategies for life balance and peak performance. American Psychiatric Association, 2012 Adirim TA1, Cheung TL., Overview of injuries in the young athlete. Sports Med. 2003;33(1):75-81 Karlin, A. Concussion in the Pediatric and Adolescent Population Different Population, Different Concerns. PM&R 2011; 3:S369- S379 Halstead, ME. et al., Sport-Related Concussion in Children and Adolescents. Pediatrics 2010; 126: CDC- Heads Up: Halstead, ME. et al., Return to Learning Following a Concussion. Pediatrics 2013; 2867 Fleminger S. Long-term Psychiatric Disorders after Traumatic Brain Injury. Eur J Anesthesia Suppl 2008; 42: Strauss, AS., Concussion: Identification, management, mental health implications and effects on development in adolescents, AACAP, Harmon, K. et al., American Medical Society for Sports Medicine Position Statement: Concussion in Sport, Clin J Sport Med 2013; 23;1-18