Transcript Dr. Ron A. Thompson

Eating Disorders
and the Student-Athlete
Ron A. Thompson, PhD, FAED, CEDS
Consulting Psychologist
Indiana University Department of Intercollegiate Athletics
Email: [email protected]
Be humble in victory; be gracious in defeat.
Outline

Introduction

Special Treatment Issues

Potential Risk Factors:


Non-sport Related

Sport-Related
Identification Challenges

Sport Body Stereotypes

Possible ED Symptoms Misperceived

Similarity of “Good Athlete” Traits and ED Symptoms

Presumption of Health with Good Performance
Acknowledgement
Roberta Trattner Sherman, PhD, FAED, CEDS
NCAA Mental Health Task Force

An NCAA Mental Health Task Force met in
November, 2013. From that meeting, the
handbook Mind, Body and Sport:
Understanding and Supporting StudentAthlete Mental Wellness was developed.

In addition to emphasizing early
identification and treatment and
decreasing the stigma associated with
mental health problems and treatment,
specific mental health problems targeted
included: Depression, anxiety, disordered
eating/eating disorders, disordered
sleeping, substance abuse, and sexual
abuse.
Eating Disorders: What They Are
and Are Not

Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder in females and males.

Although many ED patients are underweight, EDs can occur at any weight.

EDs are NOT choices; they are serious disorders that are driven by strong
internal and external forces, which are usually out of the person’s awareness.

EDs are NOT simply disorders of eating; they are emotional disorders that
manifest themselves in a variety of eating and weight-related symptoms.
Unhealthy exercise is usually a part of an eating disorder.

EDs are difficult to overcome, even with timely and effective treatment.
Treatment involves not only changing how the patient eats, it also involves
changing many other behaviors. Even more important and more difficult, the
patient must change how he/she thinks and manages his/her emotional life
without resorting to symptoms related to eating, food, or weight. Not everyone
will get well.

Individuals with eating disorders are not weak; on the contrary, they are usually
mentally tougher than most people.
Common Comorbid Problems
with Eating Disorders

Eating disorders (EDs) seldom if ever occur without other psychiatric
disorders/problems.

Many EDs and comorbid disorders have a genetic component.

Anxiety, Mood/Depressive, Substance Use, and Personality Disorders
frequently occur with an Eating Disorder. Sleep difficulty is also common
among ED patients. ADHD may be overrepresented in ED.

Any comorbid disorder may occur before the ED or as a consequence of
the ED.

It is not uncommon for an ED patient to have a mood disorder, one or
more anxiety disorders, and a personality disorder. 30% have been
sexually abused.

All comorbid disorders complicate eating problems and treatment.
Potential Scope of the Problem

The NCAA is the largest sport governing body in the world
with more than 450,000 student-athletes at more than 1200
institutions.

Half of these college athletes are college age females
(high risk age group).

Many of the females participate in the so-called “lean”
(higher risk) sports.

We may be “gender biased” when it comes to identifying
and treating male athletes, thereby under identifying and
under treating males with eating disorders.
Relationship Between Sport Participation
and Eating Disorders

Direct: Sport plays an integral role in the ED;
sport participation precipitates and/or
maintains ED; choice of sport may have
resulted from ED; athlete feels pressure to
decrease body fat, lose weight, maintain a
suboptimal weight, or attain a small body, size,
or shape based on a sport body ideal and/or
demands of a coach.

Indirect: Sport plays a minor role in ED; sport
participation may play a role in maintaining the
ED; athlete would likely have an ED without
sport; may use ED to relieve pressure, anxiety,
or frustration associated with sport
performance. Sport participation may be used
by the athlete as a rationalization for needing
to lose weight/maintain a suboptimal weight.
Athletes and Eating Disorders: The Facts

EDs occur in all sports but prevalence rates
differ with athlete age, gender, sport, and
competition level.

Sports do not cause EDs but may play a
role.

Coaches do not cause EDs but may play a
role.

EDs are more prevalent in athletes than
non-athletes, and especially in lean sport
athletes.

EDs are more prevalent in aesthetic,
endurance/gravitational, and weight-class
sports.

Having an ED does not mean an athlete
has to give up his/her sport.
Athletes and Eating Disorders
by the Numbers

College age women constitute a high risk group for ED. Research suggests
that the prevalence is higher for athletes, especially those in lean sports.

Prevalence rates for ED typically run from 2-7% for college female athletes
(e.g., Johnson et al., 1999; Reel et al., 2007), and about 1% for males (Petrie
et al., 2007); in reality, the rates are probably higher.

Prevalence rates for Disordered Eating typically run in the range of 25-60%,
depending on the sport and competition level.

Even though the prevalence of EDs is higher for athletes in lean sports, the
actual number of athletes with eating disorders is higher among nonlean
because there are simply many more nonlean than lean athletes.

Even though the prevalence of eating disorders is higher for athletes in lean
sports, sportswomen in nonlean sports report more body dissatisfaction and
more frequent use of pathogenic weight loss methods.
Why Athletes with Eating Disorders
Must be in Treatment

Recovery without treatment is unlikely.

The athlete can become isolated from
the team.

The athlete deteriorates physically and
psychologically over time.

Performance is eventually negatively
affected.

Poorer performance increases pressure.

Pressure increases the need for the
disorder.
Why Specialized Treatment for
Athletes with Eating Disorders?

Athletes are more at risk than non-athletes because they
not only have the same risk factors as non-athletes, they
also have additional risk factors that are unique to the
sport environment or to a particular sport.

Because of their increased/special risk factors, athletes
need specialized approaches to identification,
management, prevention, and especially treatment.

The same personality factors that are related to good sport
performance may increase the risk of an eating disorder in
an athlete but also can be used to facilitate treatment.

Relapse prevention for athletes returning to training and
competition is different than for their non-athlete
counterparts.

They have additional reasons to resist treatment.
Athlete’s Resistance to Treatment

Same as non-athletes plus...

Assumes weight will increase and
competitive edge will decrease

Fears loss of status or playing time

Fears time away from sport will
result in a loss of conditioning
and/or competitiveness

Fears displeasing others involved in
sport (i.e., coach, teammates), as
well as, significant others outside of
sport (i.e., family)

Fears treatment providers will not
value sport
Potential Non-sport Risk Factors for
Student-Athletes

Genetics; socio-cultural pressures regarding the
idealization of thinness (which is pronounced in the
college environment); “normative discontent” (Rodin
et al., 1984) regarding female body dissatisfaction

Age: College students are in the high risk age group for
developing an ED as most cases develop in
adolescence or young adulthood (APA, 2013).

Transition: ED’s often begin/worsen during transition
periods (Berge et al., 2012).

EDs are often used to manage stress/pressure, which
tend to increase in college—stresses related to life,
relationships, academics, and athletics.
Potential Sport-Related Risk Factors for
Student-Athletes

Belief that decreasing weight/body fat enhances sport
performance, weight pressures: Coaches/athletes

Body image issues including competitive thinness,
revealing uniforms, body comparisons

Identification difficulties
Effects of Weight Pressures
from Coaches

Research suggests that athletes often feel weight pressures
from coaches (Anderson et al., 2011, 2012; Reel et al., 2013)-pressures that increase the risk of restrictive dieting (Berry &
Howe, 2000), the use of pathogenic weight loss methods
(Rosen & Hough, 1986; Rosen et al., 1988), and disordered
eating (Arthur-Cameselle & Baltzell, 2012; Kerr et al., 2006;
Muskat & Long, 2008; Woods, 2004) among athletes. Coaches
have considerable power and influence with their athletes,
such that even the athlete’s perception that her coach thinks
she needs to lose weight can heighten weight pressures and
increase the risk of disordered eating (de Bruin et al., 2007;
Harris & Greco, 1990).
Coach-Related Issues and
Athlete Eating Problems

Weight pressures related to coaches:


Coaching/training climate:


Athletes sometimes feel weight pressures from coaches (e.g.,
Anderson et al., 2011, 2012; Reel et al., 2013) that increase the
risk of disordered eating (Arthur-Cameselle & Baltzell, 2012; Kerr
et al., 2006; Muskat & Long, 2008).
An ego/performance-centered motivational climate (vs. a
skills-mastery climate) has been associated with an increased
risk of disordered eating (De Bruin et al., 2009).
Relationship issues with coaches:

A relationship between coach and athlete characterized by
high conflict and low support has been associated with an
increased risk of eating pathology in athletes through low selfesteem, increased self-critical perfectionism, and depression
(Shanmugam et al., 2011, 2012, 2013a, 2013b).
Weight Pressures Related to Teammates

Recent research by Petrie and colleagues
(Anderson, Petrie, & Neumann, 2011, 2012; Reel,
SooHoo , Petrie, Greenleaf, & Carter, 2010)
suggests that teammates are a source of weight
pressure for athletes. In fact, Reel et al. found that
teammates noticing weight-gain represented the
strongest weight pressure for female athletes.

That male athletes are also affected by weight
pressures from teammates has been suggested by
Filaire et al., (2007), as well as by Galli and Reel
(2009). Engle et al.. (2003) found that an athlete’s
restrictive eating was associated with her or his
perception that team members were excessively
dieting to control their weight.
“Fat Talk,” Body Dissatisfaction, and
Eating Problems

“Fat talk” involves interactions between
females in which they talk about body
dissatisfaction and the need to lose
weight (Stice et al., 2003). It can also
involve talking about others’
appearance and be related to eating
pathology (Ousley et al., 2008).

It is common among female athletes
(Smith & Ogle, 2006) and occurs among
female athletes in the locker room, and
sport personnel need to stop it when
they hear it.
Potential Sport-Related Risk Factors for
Student-Athletes

Belief that decreasing weight/body fat enhances sport
performance, weight pressures: coaches/athletes

Body image issues including competitive thinness,
revealing uniforms, body comparisons

Identification difficulties
Body Image Issues

The relationship between body image and eating disorders in athletes
appears to be different than in the general population. It is more
conflicted and confused.

Sportswomen have more than one body image—one within sport and
one outside of sport (de Bruin et al., 2011; Krane et al., 2001; Loland,
1999; Russell, 2004; Steinfeldt et al., 2012). DE/ED can occur in either.

Some female athletes are conflicted about having a strong, muscular
body that facilitates sport performance that not only does not conform
to the socially desired body type (Cole, 1993; Greenleaf, 2002; Krane et
al., 2001; 2004), but which may also be perceived as being too
muscular and violating societal norms of femininity (Cole, 1993; Krane
et al., 2001; 2004; Greenleaf, 2002; Steinfeldt et al., 2010).

Women are more negative about themselves in situations where their
bodies have greater exposure or when in body focused situations
(Haimovitz et al., 1992; Tiggeman, 2001). Many athletes wear revealing
sport attire.
Research Related to Revealing Sport Attire:
Females

Objectification theory: Culture socializes females to adopt
observers’ perspectives on their physical selves—females are
socialized to treat themselves as objects to be evaluated
based on appearance (Fredrickson & Roberts, 1997).

Self-objectification increased body shame and decreased
math performance while in a swimsuit (Fredrickson et al., 1998)

58% of cheerleaders surveyed indicated revealing uniforms as
the highest pressure related to weight (Reel & Gill, 1996).

Feather et al. (1996): Body satisfaction was related to uniform
satisfaction in female basketball players.

Dancers reported costumes and comparison with other
dancers as sources of pressure (Reel, 1998; Reel et al., 2005).
Research Related to Revealing Sport Attire:
Females (cont’d)

Ballet students reported lower self/body-perception ratings
wearing a leotard and tights versus wearing looser fitting
clothing (Price & Pettijohn, 2006).

45% of swimmers surveyed reported a revealing swimsuit as a
stressor (Reel & Gill, 2001).

Toro et al. (2005): Highest prevalence of induced vomiting
occurred in swimmers who had the greatest concerns
regarding “public body exposure” (revealing swimsuit).

Uniforms made athletes more aware of their shape and
physique and influenced feelings of body dissatisfaction
(Greenleaf, 2002).

Revealing volleyball uniforms contributed to decreased body
esteem and distracted players/impacted performance
(Steinfeldt et al., 2012).
Research Related to Revealing Sport Attire:
Males

Uniform pressure involves the extent to which athletic
apparel draws undesired attention and accentuates
aesthetic flaws (Galli et al., 2013).

Of athletes in 16 sports, athletes in endurance sports
reported the highest degree of uniform pressure (Galli
et al., 2013).

As one former college wrestler said, “a wrestling singlet
shows everything you have and maybe what you don’t
have.”

Pressures to look good in their uniforms may increase
male athletes’ risk of body dissatisfaction and use of
pathogenic body change behaviors (Petrie &
Greenleaf, 2012).
Risk Factors for Competitive Thinness in Sport

Belief that the leaner athlete will perform
better (and look better?)

Aesthetic sports in which appearance
(athlete’s body) is “judged” (i.e., diving,
figure skating, gymnastics, synchronized
swimming etc.)

Revealing sport attire

May create unhealthy body consciousness,
discomfort, and/or dissatisfaction

Facilitates unhealthy body comparisons for
the purpose of appearance and/or sport
performance
Body Comparisons, Body Dissatisfaction,
and Disordered Eating

Women compare to other women to determine
weight status, and such comparisons may result in a
woman feeling “fat,” which can in turn increase the
tendency to engage in body comparisons (StriegelMoore et al., 1986).

“Body-related social comparisons” (Hamel et al.,
2012) or “upward appearance comparisons” (Arigo
et al., 2013) are related to body dissatisfaction and
disordered eating.

When women compare themselves to a “fit” (thin)
peer, body dissatisfaction tends to increase (Krones
et al., 2005; Lin & Kulik, 2002; Stice, 2002).
Body Comparisons Among Sportswomen

“I definitely feel like we’re a lot bigger because we’re
working out so much and lifting weights all the time. I
definitely feel like we have bigger bodies compared to
women who don’t…comparing, I feel like a man
sometimes…then you see little petite women who are, a
lot smaller” (Steinfeldt et al., 2012).

“Everyone walks around in their swimsuits and everyone’s
wearing next to nothing—you can’t hide…I felt like
everyone was comparing me to the next person”
(Greenleaf, 2002).

“Due to body comparisons with other athletes, I did not
feel good enough…everyone was thinner, stronger, and
more beautiful than me. I was always preoccupied with
the others, watching how thin they were” (de Bruin et al.,
2007).
Potential Sport-Related Risk Factors for
Student-Athletes

Belief that decreasing weight/body fat enhances sport
performance, weight pressures: coaches/athletes

Body image issues including competitive thinness,
revealing uniforms, body comparisons

Identification difficulties
Identification Issues and Challenges

18% of 2894 NCAA coaches of female athletes reported
having not coached any athletes with EDs or DEs.

26% reported becoming aware after the fact that athletes
they coached had EDs or DEs but were not identified while
they had competed for them.

In two qualitative studies (Nowicka et al., 2013; Plateau, et al.
2014), coaches attributed part of the difficulty in
identification to athletes’ denial of symptoms.

There are factors within the sport environment and/or within a
particular sport that can complicate identification.
Identification Issues and Challenges
(cont’d)

Sport body stereotypes (Sherman & Thompson, 2001); Coaches
reported difficulty distinguishing between athletes whose
appearance met their sport-type expectations from those with an
eating disorder (Plateau et al., 2014).

ED symptoms (i.e., menstrual irregularity, weight loss, excessive
training, etc.) may be (mis)perceived as “normal” or even
desirable

Similarity between “Good Athlete” traits and ED symptoms
(Thompson & Sherman, 1999)

Presumption of good health with good sport performance;
coaches appeared to respond to a decrease in performance as
a possible indicator of difficulty but were less apt to intervene if
performance was good (Plateau et al., 2014).
Sport Body Stereotypes

We (sport personnel, athletes, lay public, sometimes even parents)
have size or shape expectations for certain sports.

Basketball players are tall (and usually lean).

Jockeys are short.

Gymnasts are tiny.

Distance runners are thin.

These stereotypes can affect perceptions by those (i.e., coaches)
who may identify an at-risk/symptomatic athlete.

Coaches reported difficulty distinguishing between athletes whose
appearance met their sport-type expectations from those with an
eating disorder (Plateau et al., 2014).
Identification Issues and Challenges
(cont’d)

Sport body stereotypes (Sherman & Thompson, 2001); Coaches
reported difficulty distinguishing between athletes whose
appearance met their sport-type expectations from those with an
eating disorder (Plateau et al., 2014).

ED symptoms (i.e., menstrual irregularity, weight loss, excessive
training, etc.) may be (mis)perceived as “normal” or even
desirable

Similarity between “Good Athlete” traits and ED symptoms
(Thompson & Sherman, 1999)

Presumption of good health with good sport performance;
coaches appeared to respond to a decrease in performance as
a possible indicator of difficulty but were less apt to intervene if
performance was good (Plateau et al., 2014).
Possible Eating Disorder Symptoms are
Sometimes Misperceived as “Normal” in Sport

Menstrual irregularity is common in eating disorder patients
(APA, 2013).

Menstrual irregularity is also common among sportswomen
with prevalence rates ranging from 2%-65%, depending on
the sport (Mountjoy et al., 2014).

Because menstrual irregularity is common in female
athletes, it has sometimes been assumed to be “normal” in
the sport environment and not treated with medical
intervention (Sherman et al., 2005).
Possible Eating Disorder Symptoms are
Sometimes Misperceived as Desirable in Sport

Excessive or inappropriate exercise is common among eating
disorder patients (APA, 2013). Athletes who exercise/train more
than their teammates may be viewed as a “good athlete”
(Thompson & Sherman, 1999), and such behavior may be
rewarded.

As difficult as unhealthy exercise is to identify in non-athletes, it
is even more difficult to identify in the sport environment. More
training is usually viewed more positively than less training in
sport. Again, an athlete who trains more than her teammates
may be viewed positively. Interestingly, U.S. male high school
coaches were less likely to view exercising more than required
for a sport as a problem than were female coaches (Kroshus et
al., 2014).
Identification Issues and Challenges
(cont’d)

Sport body stereotypes (Sherman & Thompson, 2001); Coaches
reported difficulty distinguishing between athletes whose
appearance met their sport-type expectations from those with an
eating disorder (Plateau et al., 2014).

ED symptoms (i.e., menstrual irregularity, weight loss, excessive
training, etc.) may be (mis)perceived as “normal” or even
desirable.

Similarity between “Good Athlete” traits and ED symptoms
(Thompson & Sherman, 1999)

Presumption of good health with good sport performance;
coaches appeared to respond to a decrease in performance as
a possible indicator of difficulty but were less apt to intervene if
performance was good (Plateau et al., 2014).
Why an Athlete with an Eating Disorder May
Look Like the “Ideal” Athlete to a Coach

Coaches want an athlete who will:

Work harder than most athletes in terms of training

Compete despite pain or injury

Not be satisfied with his/her performance and will
accept nothing less than perfection in some sports

Comply completely with coaching instructions

Selflessly commit to the team (“There is no I in team!”)

Do whatever is necessary to perform better, including
lose weight and/or train excessively
*Identification can be further complicated if the
athlete is in a “lean” sport and is performing well.
“Good Athlete Traits,” Anorexic Characteristics, and
Why an Athlete with an ED may look “Ideal” to Coaches*
“Good Athlete”
Anorexic Patient

Mental toughness

Asceticism

Commitment to training

Excessive Exercise

Pursuit of Excellence

Perfectionism

Coachability

Overcompliance

Unselfishness

Selflessness

Performance despite pain  Denial of discomfort

*Thompson & Sherman, 1999
Identification Issues and Challenges
(cont’d)

Sport body stereotypes (Sherman & Thompson, 2001); Coaches
reported difficulty distinguishing between athletes whose
appearance met their sport-type expectations from those with an
eating disorder (Plateau et al., 2014).

ED symptoms (i.e., menstrual irregularity, weight loss, excessive
training, etc.) may be (mis)perceived as “normal” or even
desirable

Similarity between “Good Athlete” traits and ED symptoms
(Thompson & Sherman, 1999)

Presumption of good health with good sport performance;
coaches appeared to respond to a decrease in performance as
a possible indicator of difficulty but were less apt to intervene if
performance was good (Plateau et al., 2014).
Presumption of Health
with Good Sport Performance

It is difficult for coaches, athletes, and parents to believe
that athletes have a serious eating disorder when their sport
performance is good, and often performance is good early
in the process. In fact, performance may improve with early
weight loss in a developing eating disorder.

Coaches in Plateau et al.’s study (2014) appeared to
respond to a decrease in performance as a possible
indicator of difficulty but were less apt to intervene if
performance was good. If sport performance is good and
the athlete is not noticeably underweight, coaches are
probably less apt to identify a problem.
Questions?
Be humble in victory; be gracious in defeat.