The APA has recently revised its diagnostic criteria for eating disorders. The changes were necessary because too many cases were categorized as eating disorders not otherwise specified (EDNOS) and did not accurately reflect how many people were struggling with anorexia nervosa, bulimia nervosa, or binge eating. Prior to revision, EDNOS was the most commonly diagnosed eating disorder. The updated DSM reduced some criteria for anorexia nervosa and bulimia nervosa and created a new category, called binge eating. The EDNOS category remained but is much less used than before. Table 9-1 outlines the key features of each type of eating disorder. Binge eating is distinct from bulimia because there are no attempts to get rid of the excess calories. Binge eating is also different from overeating because of the negative emotions experienced by the binge eater.
An estimated 10 million females and 1 million males have an eating disorder in the United States.12 Nearly all are young people between the ages 12 and 26 years, with 86% reporting an onset prior to age 20 years. Depression frequently accompanies eating disorders. The mortality rates are higher for eating disorders than for other psychological concerns.13 The prevalence of any eating disorder in Americans aged 13 to 18 years is 2.7%, with females (3.8%) being 3 times more likely than males (1.3%)4 to self-report. Binge eating disorder is more common than anorexia and bulimia. A survey of college students found that 3% of female and 0.4% of males had been diagnosed with anorexia nervosa. Bulimia diagnoses were found in 2% of women and 0.2% of the men according to the 2007 National College Health Assessment. Napolitano and Himes14 reported that 8.4% of female undergraduates met the criteria of binge eating disorder. Adults report a lifetime prevalence of 0.9% for anorexia nervosa, 0.6% for bulimia nervosa, and 2.8% for binge eating. Smink et al8 found that anorexia nervosa has the highest mortality rate of all mental health conditions. Suicide occurs in 5.1/1000 cases of anorexia nervosa, and health complications from obesity combined with depression are thought to contribute to the 3.3/1000 deaths in those with EDNOS.15
Several studies have found that college athletes have higher rates of eating disorders than nonathletic peers16-18 and that athletic females in particular have the greatest risk.7 Factors related to the prevalence of eating disorders in sport along with suggestions for screening and return to play are discussed later in this chapter.
Changes in sleep patterns are a well-known sign of depression. Ninety percent of patients with depression complain of insomnia.46 There is evidence that insomnia is a risk factor for depression, and its existence prior to the onset of depression has been documented in youth and young and older adults.47 A longitudinal study of adults who were depression free at baseline found that the incidence of depression 4 years later increased linearly with the number of sleep issues that were reported and measured objectively. The relative risk of depression was 3.23 for participants that had 3 or more symptoms of insomnia.48 This may be a contributing factor in college students because lack of sleep is an often-reported health concern. Brand et al49 concluded that athletes have less insomnia than nonathletes and that volume of exercise predicted sleep quality.
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Overtraining is a neurological, physiological, and psychological maladaptive response to high volumes or high intensities of physical activity without sufficient recovery.50 This syndrome has many signs and symptoms, some of which are similar to depression. Signs and symptoms of overtraining syndrome include decreased physical performance, fatigue, malaise, difficulty sleeping, depressed mood, changes in appetite, decreased ability to concentrate, increased irritability or anxiety, and lower motivation for sport.50 Changes to mood during periods of overtraining have been well documented. College swimmers, for example, showed significant increases in feelings of tension, depression, anger, and fatigue during peak training volumes.51,52 A questionnaire called the Profile of Mood States (POMS) was given to athletes prior to and during periods of intense training. The POMS measures change in 6 aspects of mood (tension, depression, anger, vigor, fatigue, and confusion). Athletes who develop overtraining syndrome consistently have higher scores than peers, so the POMS is a suggested screening tool.53 Mood disturbance improves when training is reduced, but return to baseline is slower for athletes with overtraining syndrome.
Overtraining and depression share one or more mechanisms in their etiologies. According to Raglin and Kentta,53 8 0% of athletes with overtraining syndrome have clinically significant depression. Changes in serotonin and cortisol are thought to impact the hypothalamus regulation of neurotransmitters and growth factors,50 resulting in physiologic and neurologic fatigue.
There is a tendency to diagnose athletes with overtraining and prescribe rest rather than consider depression as the broader concern.5,6 Suspicion of overtraining and depression should be particularly high for endurance athletes because annual prevalence rates range from 7% to 21%.53 Research on overtraining syndrome among team sport and power sport athletes is almost nonexistent, but anaerobic training has been thought to create a greater sympathetic response, leading to insomnia, increased heart rate, and restlessness rather than fatigue and depression.50 Similar to depression, prior history of overtraining syndrome leaves one more vulnerable to future episodes.53