Dr. Amit’s Story

1. Give a short biography of yourself, particularly your occupation and experience in sport.

I am a Sports Psychiatrist with clinical expertise in elite athlete mental health, eating disorders and exercise promotion for mental illness. I pursue these interests as chair elect of the Royal College of Psychiatrists Sport & Exercise Special Interest Group, lecturing in Sport & Exercise Medicine at Queen Marys University London and being an NHS Clinical Entrepreneur.

During my working day I work with clients experiencing stress, depression, anxiety, behavioural addictions, eating disorders or memory problems. On a personal sporting level, I have played different rugby codes at county and international representative level.

2. What personal experiences with mental health do you have?

Like many on this platform, I have both family and friends who have experienced mental illness. During my teenage years, a close relative ended their life and I remember the devastation that had on my family and community.

I have been through periods of stress (haven’t we all!) and possess “obsessive/perfectionistic” traits. Traits can be deemed positive or negative dependent on how we channel them. I am a big advocate of championing the voice and learning from people with lived mental illness (experts by experience). I truly believe that being at ‘rock bottom’ can sometimes be a great foundation towards recovery. Despite these progressive approaches, there still remains societal stigma towards mental illness.

3. How do you feel sport/fitness affects mental health?

We need to think about context and understand the term moderation. For the general population (i.e. us), physical activity should be deemed a ‘miracle drug’ given the robust evidence for it’s universal, physical and mental health benefits e.g. depression, anxiety, psychosis and memory impairment (if only pharmaceutical companies could put it into a bottle!)

This is particularly important for those with severe mental illness (SMI) as they are at higher risk of sedentary behaviour and physical health problems. In these situations, it is important to emphasise that ‘any exercise is better than nothing’ and that any form of movement is a bonus e.g. taking the stairs rather than escalators, gardening, walking commutes etc. This should be promoted using motivational interviewing (MI) techniques and one should not get too bogged down on numbers e.g. step counts, distances, calories etc as this can induce undue stress too. There will be times when patients struggle to exercise due to lack of motivation as part of mental illness and this should be appropriately respected by the sensitive clinician.

A smaller percentage of patients with SMI may have medical problems that prevent them from engaging in vigorous levels of physical activity. Further guidance on this can be found from the American College of Sports Medicine (ACSM) Exercise Pre-Participation guidelines. Basically if patients have known cardiorespiratory or metabolic conditions, only recommend sensible case-specific or mild-moderate activity e.g. walking and always seek medical expertise if in any doubt.

Despite the clear benefits, there are two circumstances when mental health professionals need to express caution with exercise. Firstly, it is unclear whether high-intensity exercise can induce manic symptoms in those with Bi-Polar Affective Disorder (BPAD). Secondly, our research found that those with eating disorders are more than 3.5 times more likely to have exercise addiction (secondary exercise addiction) compared to exercise addicts without disordered eating behaviours (primary exercise addiction) (pictured below). This is particularly seen in high achievers and those with perfectionistic traits (perfectionism related to concerns about how others will perceive them, fear of failure etc). To complicate matters further, particular perfectionistic traits (e.g. striving for goals) often overlap with those seen in successful elite athletes.

Elite athletes can possess atypical relationships with exercise as high level activity is a ‘functional’ part of their occupation. Athletes are at greater risk of over-exercising when going through challenging transitions such as injury, retirement and de-selection. Athletes can intentionally reduce or increase their energy intake and exercise levels, respectively, which can lead on to Relative Energy Deficiency in Sport (RED-S) and Over Training Syndrome (OTS).

Please note, professionals working in sport and exercise are at higher risk of poor body image, disordered eating and orthorexia (obsession with healthy eating). Therefore, it’s really important that we recognise our own vulnerabilities, over-valued athletic identities and understand how our working/ social media environments may impact on our lifestyle behaviours.

In terms of moderation, relationships with exercise can go from recreational fun to that of an insidious, compulsive behavioural addiction. This is best described as a spectrum as per the second picture attached. Initially, recreational exercise is primarily fun and used to improve general fitness, quality of life and is positive health behaviour. This can turn into at risk and problematic exercise when increasing exercise amounts start to cause localised injuries (e.g. ankle injury whilst running) or when used to solely deal with emotional trauma. This becomes further complicated when core identities turn into being an ‘exerciser’ and activity levels start to cause systematic, bodily changes e.g. bone thinning, irregular menstrual cycles and compromised immune function.

At the severe end, exercise addiction is akin to psychoactive substance addiction e.g. tolerance (higher levels required to get the same hit), salience (rigid exercise regimes prioritised over other social obligations) along with guilt and compulsion to exercise. Eventually, the primary motivation for exercising is to avoid withdrawal symptoms rather than experience pleasure from the recreational act. This spectrum is highly fluid meaning that people can slide along with scale. In summary, make sure you keep your relationship with exercise in check and diversify your hobbies!

4. Do you have an extra message you wish you add?

If you are interested in learning more about managing elite sport mental health, we are publishing a book with Cambridge University Press called ‘Case Studies in Sports Psychiatry’. It is a joint venture between sport clinicians and many high profile, professional athletes. The book follows a case-study format with realistic, every-day athlete psychiatric presentations and provides MCQ’s to help consolidate learning for the reader. The book will be due out at the Tokyo 2020 Olympics, if it does go ahead! (pictured below).