**3. Disordered eating and eating disorders and comorbidity**

Disordered eating is often paired with other mental health disorders, some of the disorders that have comorbidity include mood disorders, anxiety disorders, substance use disorders and personality disorders. It is often believed that athletes do not experience psychological difficulties the same as the general population; however, more recent evidence is supporting a different prevalence in athletes. The sport context is pressure-filled with constant evaluation from those who can impact an athlete's opportunity to perform. In addition, lack of skills to effectively cope with the pressure make collegiate athletes at risk.

#### **3.1 Mood disorders**

Depression is a mental health disorder, in which the person experiences mood disturbance, appetite changes, sleep changes, anhedonia, and a lack of energy. Collegiate athletes experience depression at similar rates to the nonathlete population. They are particularly vulnerable for their experience of depression being overlooked or even misdiagnosed. Symptoms of depression may present differently, and inconsistently, and the athlete may or may not continue to perform well. The presence of depression may be subtle, if clear to others at all. An awareness of the possibility that an individual could be depressed is important for appropriately intervening. Depression is frequently comorbid with Bulimia Nervosa and can guide a student athlete down a spiraling and potentially destructive path. A collegiate athlete with Bulimia Nervosa and depression may also engage in excessive exercise as a form of weight control or to alter their shape, but some also use it to modulate their mood (Fairburn, 2008). Excessive exercising is a form of noncompensatory purging; however, for collegiate athletes, it increases the risk of injury and other physical ailments due to lack of consistent caloric intake and compensatory purging (e.g., self-induced vomiting, laxative misuse). Depression is also hallmarked by thoughts of hopelessness, worthlessness, and helplessness, and when paired with the obsessiveness and lack of control with Bulimia could be a deadly combination.

#### **3.3.1 Suicide**

42 New Insights into the Prevention and Treatment of Bulimia Nervosa

be used to treat symptoms of eating disorders (e.g., depression or anxiety), rather than solely treating the eating disorder alone. Previous research supports that antidepressants promoted a decrease in bulimic patients' preoccupation with food and weight; and a decrease in a patients'

With collegiate athletes, the psychiatrist would have to keep in mind the sport context and types of psychotropic medications and the associated side effects in addition to the constraints of the drug testing policies and procedures in athletics. It is important to be aware of the side effects of antidepressants. The most common may cause diaphoresis (i.e., excessive sweating), gastrointestinal distress, nausea, drowsiness, and dizziness (Lacy et al., 2002), all of which may decrease or limit an athlete's performance. If an athlete reports any of these symptoms, the medication dosage may have to be altered or daily routine depending on the symptoms. For example, if an athlete is becoming drowsy, the timing of the medication should be changed. It is recommended that the athlete takes two smaller doses per day or takes the medication at night before bed and then gradually increase dosage if necessary (Joy et al., 1997; Zetin & Tate 1999). Another recommendation would be to increase fluid intake if the athletes has increased sweating. Alternative medications should also be considered. Lithium carbonate (a mood stabilizer) and clonidine (an appetite stimulant) have also been used to

treat patients with Bulimia Nervosa (Hudson, Pope, & Carter, 1999; Kaye, 1999).

Disordered eating is often paired with other mental health disorders, some of the disorders that have comorbidity include mood disorders, anxiety disorders, substance use disorders and personality disorders. It is often believed that athletes do not experience psychological difficulties the same as the general population; however, more recent evidence is supporting a different prevalence in athletes. The sport context is pressure-filled with constant evaluation from those who can impact an athlete's opportunity to perform. In addition, lack

Depression is a mental health disorder, in which the person experiences mood disturbance, appetite changes, sleep changes, anhedonia, and a lack of energy. Collegiate athletes experience depression at similar rates to the nonathlete population. They are particularly vulnerable for their experience of depression being overlooked or even misdiagnosed. Symptoms of depression may present differently, and inconsistently, and the athlete may or may not continue to perform well. The presence of depression may be subtle, if clear to others at all. An awareness of the possibility that an individual could be depressed is important for appropriately intervening. Depression is frequently comorbid with Bulimia Nervosa and can guide a student athlete down a spiraling and potentially destructive path. A collegiate athlete with Bulimia Nervosa and depression may also engage in excessive exercise as a form of weight control or to alter their shape, but some also use it to modulate their mood (Fairburn, 2008). Excessive exercising is a form of noncompensatory purging; however, for collegiate athletes, it increases the risk of injury and other physical ailments due to lack of consistent caloric intake and compensatory purging (e.g., self-induced vomiting, laxative misuse). Depression is also hallmarked by thoughts of hopelessness, worthlessness, and helplessness, and when paired with the obsessiveness and lack of control

**3. Disordered eating and eating disorders and comorbidity** 

of skills to effectively cope with the pressure make collegiate athletes at risk.

**3.1 Mood disorders** 

with Bulimia could be a deadly combination.

binging and vomiting episodes (Hudson, Pope, & Carter, 1999).

One of the key symptoms of a major depressive episode is the presence of suicidal ideation. When one is considering suicide, it is the person's perception of a sense of helplessness and/or worthlessness. The decision to commit suicide is an act of desperation and highlights the individual's inability to see other options or less disastrous consequences. Collegiate athletes as a group are formulating their identity, self-image, and self-worth throughout their undergraduate career. They may be particularly susceptible to criticisms from numerous sources about their performance as well as their physical appearance. The loss of control during binge eating, the guilt and other emotions present, and concerns about image all suggest that suicidal ideation for athletes should be monitored more effectively. Hospitalization is clinically indicated if the eating disorder has comorbidity with depression and suicidal ideation. Close supervision is prudent upon discharge.

#### **3.3.2 Anxiety disorders**

Anxiety disorders are related to how a person perceives threat in their environment and the way in which they cope with their emotions. They are the class of disorders that are characterized by worry, apprehension, and fearfulness, and are exhibited by physical manifestations, such as muscle tremors, nausea, or heart palpitations (American Psychiatric Association, 2000). In athletes, the presence of an anxiety disorder could hurt performance, and if the anxiety disorder is comorbid with an eating disorder, a complicated diagnostic picture as well as intervention plan is the result. When comorbid with Bulimia Nervosa, anxiety disorders seem to magnify and intensify the experience of the disordered eating behaviors. Anxiety features tend to be more characteristic of individuals who have high levels of dietary restraint (Fairburn, 2008). People with eating disorders set multiple demanding, and highly specific, dietary rules designed to limit the amount that they eat, and as a result of these rules their eating becomes restricted in nature and inflexible (Fairburn, 2008). They adjust their lives around their preoccupation with food and the presence of an anxiety disorder further exacerbates the impairment that develops. Concentration is affected and socializing with friends and family are problematic, the individual worries about the pressure to eat in the presence of others.


As with mood disorders, anxiety disorders often implicate similar cognitive errors to those structuring eating disorders (Steiger & Israel, 2010). For example, a collegiate athlete with Bulimia Nervosa can experience general worry and anxiety regarding food intake and weight gain, obsessive preoccupations with body shape, compulsive reactions (such as the need to compensate after eating), or phobic elements (such as fear of weight gain; Steiger & Israel, 2010). Interventions need to categorize the symptoms of Bulimia Nervosa as well as the existence of an anxiety disorder, then applying strategies to control the persistence of cognitive errors.

Treatment Strategies for Eating Disorders in Collegiate Athletics 45

helped to engage individuals in treatment who would otherwise have been unlikely to ask for help through more traditional therapy (Robinson & Serfaty, 2003). It is common that most cases of Bulimia Nervosa in the community are unknown to their general practitioners

It is known that many ethical and practical questions have been asked in relation to the delivery of this therapy; however it is not recommended for all patients. This type of therapy may work for those that may not have access for a specialist in the eating disorder field or for patients who wish to receive individual therapy in a more anonymous setting. This new method of treatment delivery may have many advantages over the face-to-face methods; such advantages are related to increasing empowerment, accountability, affordability, convenience and privacy (Fingeld, 1999). Additionally, there are some benefits for the clinician as well. Robinson and Serfaty (2003) stated that E-therapy is a strategy that can be used to identify therapist competence by providing a method to monitor general

Social networking sites (e.g., Facebook) are starting to be utilized for clients to interact with fellow treatment members, clinicians, and to access resources. These sites have tremendous potential to further aid the therapeutic process over time. As a best practice and to maintain appropriate ethical standards for clinicians, these new forms of therapeutic strategies (i.e., Etherapy, text messaging) are best utilized in conjunction with traditional therapeutic approaches. Specific strategies to ensure confidentiality are essential, such as encryption software on the clinician's computer, password protections on mobile devices, and address

In conducting clinical practice research more work is needed to evaluate the effectiveness of interventions such as cognitive-behavioral therapy, interpersonal therapy, and dialectical behavior therapy with the athletic population. It is imperative that the research designs for studying effectiveness of interventions involve control groups, comparative trials, sequencing of treatment applications, randomization, and significant sample sizes to give sufficient statistical power. Clinical practice research needs to have clear, precise procedures for interventions being evaluated. The focus on clinical practice research should be on developing promising treatment approaches. The emphasis should be on symptom presentation and specific populations (ethnic minority groups, athletes, etc.). Other issues such as levels of care

Collegiate student athletes who have Bulimia Nervosa are a specialized population who need particular consideration for treatment interventions. The sport environment is influential on the presence, development, and maintenance of disordered eating symptoms. Clinicians treating collegiate student athletes with Bulimia Nervosa should be knowledgeable about the sport culture and its overarching influence on their experience with the eating disorder. Empirically supported treatments for Bulimia Nervosa include cognitive-behavioral therapy specifically enhanced cognitive-behavioral therapy, interpersonal therapy, and dialectical behavior therapy. All of these treatments have promise for the collegiate student-athlete population; however, more rigorous clinical practice research needs to be done as well as

(e.g., inpatient, outpatient) also need to be evaluated in terms of effectiveness.

(van Hoeken, Lucas, & Hoek, 1998) and receive no treatment (Fairburn et al., 1996).

competency and adherence to a specific therapeutic model.

books privacy protected.

**7. Summary** 

**6. Clinical practice research** 

#### **3.3.3 Personality disorders**

Personality disorders are difficult to identify in individuals with eating disorders because many features of personality disorders are directly affected by the presence of the eating disorder (Fairburn, 2008). Borderline personality disorder, for example, is a personality disorder that is marked by erratic or odd behaviors. Borderline personality disorder has a higher prevalence rate in females, and is considered to be marked by emotional difficulties, instability in relationships, fear of abandonment, and unpredictable emotional reactions. Specific psychopathological tendencies may accentuate specific components of eating disturbances – impulsivity driving high-frequency purging, compulsivity accentuating relentless dieting and pursuit of thinness, narcissism fueling overinvestments in achieving bodily (and other forms of) perfection (Steiger & Israel, 2010).

Personality disorder diagnoses are commonly given to individuals with eating disorders, thus when considering collegiate student athletes, two traits in particular—perfectionism and low self-esteem are evident, however, both are typically present before the eating disorder began (Fairburn, 2008). Additionally, it may be speculated that individuals who are perfectionist, independent, persistent, achievement oriented, and tolerant of pain and discomfort and who have high self-expectations yet low self-esteem are more susceptible to the development of disordered eating (Garfinkel, Garner, & Goldbloom, 1987). These personality traits have been shown to be the key to success in sports, which may help clarify the increased risk of eating disorders among athletes (Garner, Rosen, & Barry, 1998).
