Mental Health Disorders in Ultra Endurance Athletes per ICD-11 Classifications: A Review of an Overlooked Community in Sports Psychiatry
3.1. Mood Disorders
3.1.1. Depression (6A7Z)
3.1.2. Anxiety or Fear-Related Disorders (6B0Z)
3.1.3. Feeding or Eating Disorders (6B8Z), Other Specified Feeding or Eating Disorders (6B8Y)
3.1.4. Schizophrenia or Other Primary Psychotic Disorders (6A20.Z)
3.1.5. Attention Deficit Hyperactivity Disorder, Presentation Unspecified (6A05.Z)
3.1.6. Harmful Pattern of Use of Alcohol, Unspecified (6C40.1Z)
4.1. Current Literature on Mental Illness in UEAs
4.2. Diagnostic Considerations and Awareness of EXD/Exercise Dependence, Overtraining Syndrome, and ED
4.3. The Need for Increased Awareness, Scholarly Inquiry, and Regulatory Emphasis
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
- Onate, J. Depression in ultra-endurance athletes, a review and recommendations. Sport. Med. Arthrosc. Rev. 2019, 27, 31–34. [Google Scholar] [CrossRef] [PubMed]
- Finn, A. Rise of the Ultra Runners; Pegasus Books: London, UK, 2019. [Google Scholar]
- Raglin, J.S. Exercise and mental health. Sport. Med. 1990, 9, 323–329. [Google Scholar] [CrossRef] [PubMed]
- Bernstein, E.E.; McNally, R.J. Exercise as a buffer against difficulties with emotion regulation: A pathway to emotional wellbeing. Behav. Res. Ther. 2018, 109, 29–36. [Google Scholar] [CrossRef] [PubMed]
- Stubbs, B.; Vancampfort, D.; Hallgren, M.; Firth, J.; Veronese, N.; Solmi, M.; Brand, S.; Cordes, J.; Malchow, B.; Gerber, M.; et al. EPA guidance on physical activity as a treatment for severe mental illness: A meta-review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH). Eur. Psychiatry 2018, 54, 124–144. [Google Scholar] [CrossRef][Green Version]
- Wipfli, B.M.; Rethorst, C.D.; Landers, D.M. The Anxiolytic effects of exercise: A Meta-analysis of randomized trials and dose–response analysis. J. Sport Exerc. Psychol. 2008, 30, 392–410. [Google Scholar] [CrossRef][Green Version]
- Bonanni, R.; Cariati, I.; Tarantino, U.; D’Arcangelo, G.; Tancredi, V. Physical Exercise and Health: A Focus on Its Protective Role in Neurodegenerative Diseases. J. Funct. Morphol. Kinesiol. 2022, 7, 38. [Google Scholar] [CrossRef]
- Colucci-D’Amato, L.; Speranza, L.; Volpicelli, F. Neurotrophic Factor BDNF, Physiological Functions and Therapeutic Potential in Depression, Neurodegeneration and Brain Cancer. Int. J. Mol. Sci. 2020, 21, 7777. [Google Scholar] [CrossRef]
- Bueno-Antequera, J.; Munguía-Izquierdo, D. Exercise and Depressive Disorder. Adv. Exp. Med. Biol. 2020, 1228, 271–287. [Google Scholar] [CrossRef]
- Scheer, V. Participation trends of ultra endurance events. Sport. Med. Arthrosc. Rev. 2019, 27, 3–7. [Google Scholar] [CrossRef]
- Knechtle, B.; Nicolaidis, P. Ultra-marathon running. Dan. Sport. 2015, 19, 6–10. [Google Scholar] [CrossRef]
- Dallam, G.M.; Jonas, S.; Miller, T.K. Medical considerations in Triathlon Competition. Sport. Med. 2005, 35, 143–161. [Google Scholar] [CrossRef] [PubMed]
- Galsworthy, W.J.H.; Carr, J.A.J.; Hearn, R.P. Common health issues encountered by Ultraendurance Ocean rowers. Wilderness Environ. Med. 2022, 33, 97–101. [Google Scholar] [CrossRef] [PubMed]
- Morgan, W.P.; Brown, D.R.; Raglin, J.S.; O’Connor, P.J.; Ellickson, K.A. Psychological monitoring of overtraining and staleness. Br. J. Sport. Med. 1987, 21, 107–114. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Morgan, W.P.; Costill, D.L.; Flynn, M.G.; Raglin, J.S.; O’Connor, P.J. Mood disturbance following increased training in swimmers. Med. Sci. Sport. Exerc. 1988, 20, 408–414. [Google Scholar] [CrossRef]
- Raglin, J.S. Psychological factors in sport performance. Sport. Med. 2001, 31, 875–890. [Google Scholar] [CrossRef]
- Shephard, R.J.; Åstrand, P.-O. Endurance in Sport: An IOC Medical Commission Publication, 6th ed.; John Wiley & Sons Incorporated: Hoboken, NJ, USA, 2008; pp. 211–214. [Google Scholar]
- Millet, G.P.; Groslambert, A.; Barbier, B.; Rouillon, J.D.; Candau, R.B. Modelling the relationships between training, anxiety, and fatigue in elite athletes. Int. J. Sport. Med. 2005, 26, 492–498. [Google Scholar] [CrossRef]
- Henriksen, K.; Schinke, R.; Moesch, K.; McCann, S.; Parham, W.D.; Larsen, C.H.; Terry, P. Consensus statement on improving the mental health of high performance athletes. Int. J. Sport Exerc. Psychol. 2019, 18, 553–560. [Google Scholar] [CrossRef][Green Version]
- Reardon, C.L.; Hainline, B.; Aron, C.M.; Baron, D.; Baum, A.; Bindra, A.; Budgett, R.; Campriani, N.; Castaldelli-Maia, J.M.; Currie, A.; et al. Mental health in elite athletes: International Olympic Committee Consensus statement (2019). Br. J. Sport. Med. 2019, 53, 667–699. [Google Scholar] [CrossRef][Green Version]
- Currie, A.; Blauwet, C.; Bindra, A.; Budgett, R.; Campriani, N.; Hainline, B.; McDuff, D.; Mountjoy, M.; Purcell, R.; Putukian, M.; et al. Athlete mental health: Future directions. Br. J. Sport. Med. 2021, 55, 1243–1244. [Google Scholar] [CrossRef]
- Hoffman, M.D.; Krishnan, E. Health and exercise-related medical issues among 1212 ultramarathon runners: Baseline findings from the Ultrarunners Longitudinal TRAcking (ULTRA) Study. PloS ONE 2014, 9, e83867. [Google Scholar] [CrossRef][Green Version]
- Hanson, N.; Madaras, L.; Dicke, J.; Buckworth, J. Motivational Differences Between Half, Full and Ultramarathoners. J. Sport Behav. 2015, 38, 180–191. [Google Scholar]
- MacNairn, I. Trails to Community: An Ethnography of Ultrarunning. Ph.D. Thesis, University of Calgary, Calgary, AB, Canada, 2019. [Google Scholar]
- Colangelo, J.; Henry, S. Unpublished interview with Sika Henry, Ironman World Champion Triathlete and Ultrarunner. November 2022. [Google Scholar]
- Colangelo, J. How Can We Make Tri Better for Athletes with Autism or ADHD? Triathlete. 2022. Available online: https://www.triathlete.com/training/how-can-we-make-tri-better-for-athletes-with-autism-or-adhd/ (accessed on 30 November 2022).
- Colangelo, J. What’s It Like to Be a Triathlete with Autism Spectrum Disorder or ADHD? Triathlete. 2022. Available online: https://www.triathlete.com/training/whats-it-like-to-be-a-triathlete-with-autism-spectrum-disorder-or-adhd/ (accessed on 30 November 2022).
- Wilcox, I.R. Man of Steel Veteran Runs 30 Marathons in 30 Days. Burton Mail. 2021. Available online: https://www.staffordshire-live.co.uk/news/local-news/man-steel-veteran-runs-30-6299501 (accessed on 24 November 2022).
- Michelson, M.; Arnold, K.; Averill, G.; Beresini, E.; Siber, K. This Woman Used Ultrarunning to Heal from Abuse. 2022. Available online: https://www.outsideonline.com/health/running/devon-yanko-ultrarunning-abuse/ (accessed on 24 November 2022).
- O’Mara, K. Triathlon Is Just Part of Recovery for This Indigenous Athlete. Triathlete. 2022. Available online: https://www.triathlete.com/culture/people/triathlon-is-just-part-of-recovery-for-this-indigenous-athlete/ (accessed on 24 November 2022).
- Forys, W.J.; Tokuhama-Espinosa, T. The athlete’s paradox: Adaptable depression. Sports 2022, 10, 105. [Google Scholar] [CrossRef] [PubMed]
- Kobiella, A.; Reimold, M.; Ulshöfer, D.E.; Ikonomidou, V.N.; Vollmert, C.; Vollstädt-Klein, S.; Rietschel, M.; Reischl, G.; Heinz, A.; Smolka, M.N. How the serotonin transporter 5-HTTLPR polymorphism influences amygdala function: The roles of in vivo serotonin transporter expression and amygdala structure. Transl. Psychiatry 2011, 1, e37. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Van Breda, K.; Collins, M.; Stein, D.J.; Rauch, L. The COMT VAL158MET polymorphism in ultra-endurance athletes. Physiol. Behav. 2015, 151, 279–283. [Google Scholar] [CrossRef]
- Smith, A.J.; Buadze, A.; Claussen, M.C.; Seifritz, E.; Liebrenz-Rosenstock, M. On the same team: A call for increased medicolegal knowledge exchanges between forensic psychiatry and sports psychiatry. Front. Psychiatry 2022, 13, 1041891. [Google Scholar] [CrossRef]
- World Health Organization (WHO). International Classification of Diseases, Eleventh Revision (ICD-11). Licensed under Creative Commons Attribution-NoDerivatives 3.0 IGO license (CC BY-ND 3.0 IGO). 2022. Available online: https://icd.who.int/browse11 (accessed on 25 November 2022).
- World Health Organization. Mental Disorders. Available online: https://www.who.int/news-room/fact-sheets/detail/mental-disorders (accessed on 1 December 2022).
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders; American Psychiatric Association: Washington, DC, USA, 2013. [Google Scholar] [CrossRef]
- DeBate, R.D.G.; Wethington, H.; Sargent, R. Sub-clinical eating disorder characteristics among male and female triathletes. Eat. Weight. Disord. Stud. Anorex. Bulim. Obes. 2002, 7, 210–220. [Google Scholar] [CrossRef]
- Blaydon, M.; Lindner, K. Eating disorders and exercise dependence in triathletes. Eat. Disord. 2002, 10, 49–60. [Google Scholar] [CrossRef]
- Harrison, A.M.; Yaldoo, D.T.; Fiesler, C.M.; Connor, J.T. Pre-to-post race changes in self-reported depression scores in ultra-distance triathletes—A pilot study. S. Afr. J. Sport. Med. 2004, 15, 11–16. [Google Scholar] [CrossRef]
- Kiraly, B.; Joy, E.A. Anorexia nervosa and psychosis in a male triathlete. Curr. Sport. Med. Rep. 2003, 2, 317–319. [Google Scholar] [CrossRef]
- Yates, A.; Edman, J.D.; Crago, M.; Crowell, D. Eating disorder symptoms in runners, cyclists, and paddlers. Addict. Behav. 2003, 28, 1473–1480. [Google Scholar] [CrossRef]
- Hoch, A.Z.; Stavrakos, J.E.; Schimke, J.E. Prevalence of female athlete triad characteristics in a club triathlon team. Arch. Phys. Med. Rehabil. 2007, 88, 681–682. [Google Scholar] [CrossRef] [PubMed]
- Riebl, S.K.; Subudhi, A.W.; Broker, J.P.; Schenck, K.; Berning, J.R. The prevalence of subclinical eating disorders among male cyclists. J. Am. Diet. Assoc. 2007, 107, 1214–1217. [Google Scholar] [CrossRef] [PubMed]
- Axelsen, M. The power of leisure: “I was an anorexic; I’m now a healthy triathlete”. Leis. Sci. 2009, 31, 330–346. [Google Scholar] [CrossRef]
- Magee, C.A.; Buchanan, I.; Barrie, L. Profiles of exercise dependence symptoms in Ironman participants. Psychol. Sport Exerc. 2016, 24, 48–55. [Google Scholar] [CrossRef]
- Sanhuenza, J.; Zambrano, T.; Bahamondes-Avila, C.; Salazar, L. Association of Anxiety-Related Polymorphisms with Sports Performance in Chilean Long Distance Triathletes: A Pilot Study. J. Sport. Sci. Med. 2016, 15, 554–561. [Google Scholar]
- Cook, B.; Luke, R. Primary and secondary exercise dependence in a sample of cyclists. Int. J. Ment. Health Addict. 2017, 15, 444–451. [Google Scholar] [CrossRef]
- Mayolas-Pi, C.; Simón-Grima, J.; Peñarrubia-Lozano, C.; Munguía-Izquierdo, D.; Moliner-Urdiales, D.; Legaz-Arrese, A. Exercise addiction risk and health in male and female amateur endurance cyclists. J. Behav. Addict. 2017, 6, 74–83. [Google Scholar] [CrossRef][Green Version]
- Buck, K.; Spittler, J.; Reed, A.; Khodaee, M. Psychological attributes of ultramarathoners. Wilderness Environ. Med. 2018, 29, 66–71. [Google Scholar] [CrossRef][Green Version]
- Schüler, J.; Knechtle, B.; Wegner, M. Antecedents of exercise dependence in ultra-endurance sports: Reduced basic need satisfaction and avoidance-motivated self-control. Front. Psychol. 2018, 9, 1275. [Google Scholar] [CrossRef][Green Version]
- Torstveit, M.K.; Fahrenholtz, I.L.; Lichtenstein, M.B.; Stenqvist, T.B.; Melin, A.K. Exercise dependence, eating disorder symptoms and biomarkers of relative energy deficiency in sports (red-S) among male endurance athletes. BMJ Open Sport Exerc. Med. 2019, 5, e000439. [Google Scholar] [CrossRef][Green Version]
- Hauck, C.; Schipfer, M.; Ellrott, T.; Cook, B. The relationship between food addiction and patterns of disordered eating with exercise dependence: In amateur endurance athletes. Eat. Weight. Disord. Stud. Anorex. Bulim. Obes. 2019, 25, 1573–1582. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Muros, J.J.; Ávila-Alche, Á.; Knox, E.; Zabala, M. Likelihood of suffering from an eating disorder in a sample of Spanish cyclists and triathletes. J. Eat. Disord. 2020, 8, 70. [Google Scholar] [CrossRef] [PubMed]
- Bueno-Antequera, J.; Oviedo-Caro, M.A.; Legaz-Arrese, A.; Paris-Garcia, F.; Guille’n-Correas, R.; Munguı´a-Izquierdo, D.; Mayolas-Pi, C. Exercise addiction stability and health effects. A 6-month follow-up postcompetition study in amateur endurance cyclists. J. Addict. Med. 2022, 16, e140–e149. [Google Scholar] [CrossRef] [PubMed]
- Cook, O.; Dobbin, N. The association between sport nutrition knowledge, nutritional intake, energy availability, and training characteristics with the risk of an eating disorder amongst highly trained competitive road cyclists. Sport Sci. Health 2022, 18, 1243–1251. [Google Scholar] [CrossRef]
- Koppenburg, C.; Saxer, F.; Vach, W.; Lüchtenberg, D.; Goesele, A. Eating disorder risks and awareness among female elite cyclists: An anonymous survey. BMC Sport. Sci. Med. Rehabil. 2022, 14, 172. [Google Scholar] [CrossRef]
- Colledge, F.; Buchner, U.; Schmidt, A.; Wiesbeck, G.; Lang, U.; Pühse, U.; Gerber, M.; Walter, M. Individuals at risk of exercise addiction have higher scores for depression, ADHD, and childhood trauma. Front. Sport. Act. Living 2022, 3, 761844. [Google Scholar] [CrossRef]
- Høeg, T.B.; Olson, E.M.; Skaggs, K.; Sainani, K.; Fredericson, M.; Roche, M.; Kraus, E. Prevalence of female and male athlete Triad risk factors in ultramarathon runners. Clin. J. Sport Med. 2021, 32, 375–381. [Google Scholar] [CrossRef]
- Fennessy, C.; Michelson, M.; Huber, M.F.; Kissane, J.; Berger, E. America’s Fastest Ultrarunner and His Race against Depression. 2022. Available online: https://www.outsideonline.com/health/running/rob-krar-ultrarunner-depression/ (accessed on 24 November 2022).
- Lobby, M. A Long Trail to Recovery. ESPN. 2014. Available online: https://www.espn.com/espnw/news-commentary/story/_/id/11143993/espnw-western-states-favorite-nikki-kimball-finds-salvation-depression-running (accessed on 24 November 2022).
- Smith, A.; Buadze, A.; Colangelo, J.; Liebrenz, M. A narrative review of sleep deprivation in ultra-endurance cycling. Sport. Psychiatry 2022, 2, 1–6. [Google Scholar] [CrossRef]
- Prince, M.; Patel, V.; Saxena, S.; Maj, M.; Maselko, J.; Phillips, M.R.; Rahman, A. No health without mental health. Lancet 2007, 370, 859–877. [Google Scholar] [CrossRef]
- Hoffman, M.D. State of the science—Ultraendurance sports. Int. J. Sport. Physiol. Perform. 2016, 11, 831–832. [Google Scholar] [CrossRef]
- Rogers, M.L.; Duffy, M.E.; Buchman Schmitt, J.M.; Datoc, A.E.; Joiner, T.E. Exercise dependence: Associations with capability for suicide and past suicidal behavior. J. Clin. Psychol. 2018, 75, 165–177. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Nogueira, A.; Molinero, O.; Salguero, A.; Márquez, S. Exercise addiction in practitioners of endurance sports: A literature review. Front. Psychol. 2018, 9, 1484. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Baker, F.; Griffiths, M.D.; Calado, F. Can cycling be addictive? A qualitative interview study among amateur female cyclists. Int. J. Ment. Health Addict. 2021. [Google Scholar] [CrossRef]
- Brand, M.; Rumpf, H.-J.Ü.; Demetrovics, Z.; Müller, A.; Stark, R.; King, D.L.; Goudriaan, A.E.; Mann, K.; Trotzke, P.; Fineberg, N.A.; et al. Which conditions should be considered as disorders in the International Classification of Diseases (ICD-11) designation of “other specified disorders due to addictive behaviors”? J. Behav. Addict. 2020, 11, 150–159. [Google Scholar] [CrossRef] [PubMed]
- Freimuth, M.; Moniz, S.; Kim, S.R. Clarifying exercise addiction: Differential diagnosis, co-occurring disorders, and phases of addiction. Int. J. Environ. Res. Public Health 2011, 8, 4069–4081. [Google Scholar] [CrossRef]
- Colledge, F.; Cody, R.; Buchner, U.G.; Schmidt, A.; Pühse, U.; Gerber, M.; Wiesbeck, G.; Lang, U.E.; Walter, M. Excessive exercise—A meta-review. Front. Psychiatry 2020, 11, 521572. [Google Scholar] [CrossRef]
- Muela, I.; Navas, J.F.; Ventura-Lucena, J.M.; Perales, J.C. How to pin a compulsive behavior down: A systematic review and conceptual synthesis of compulsivity-sensitive items in measures of behavioral addiction. Addict. Behav. 2022, 134, 107410. [Google Scholar] [CrossRef]
- Armstrong, L.E.; VanHeest, J.L. The Unknown mechanism of the overtraining syndrome. Sport. Med. 2002, 32, 185–209. [Google Scholar] [CrossRef]
- Varghese, F.P.; Brown, E.S. The hypothalamic-pituitary-adrenal axis in major depressive disorder. Prim. Care Companion J. Clin. Psychiatry 2001, 3, 151–155. [Google Scholar] [CrossRef]
- Kreher, J. Diagnosis and prevention of overtraining syndrome: An opinion on education strategies. Open Access J. Sport. Med. 2016, 7, 115–122. [Google Scholar] [CrossRef][Green Version]
- Keay, N. Hormones, Health, and Human Potential; Sequoia Books: London, UK, 2022. [Google Scholar]
- Mountjoy, M.; Sundgot-Borgen, J.K.; Burke, L.M.; Ackerman, K.E.; Blauwet, C.; Constantini, N.; Lebrun, C.; Lundy, B.; Melin, A.K.; Meyer, N.L.; et al. IOC consensus statement on Relative Energy Deficiency in sport (red-S): 2018 update. Br. J. Sport. Med. 2018, 52, 687–697. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Bedkowski, J. Medical—IAU—International association of Ultrarunners. IAU. 2018. Available online: https://iau-ultramarathon.org/medical.html (accessed on 24 November 2022).
- Kennedy, M.D.; Knight, C.J.; Falk Neto, J.H.; Uzzell, K.S.; Szabo, S.W. Futureproofing Triathlon: Expert suggestions to improve health and performance in triathletes. BMC Sport. Sci. Med. Rehabil. 2020, 12, 1. [Google Scholar] [CrossRef] [PubMed]
- World Ultracycling Association. 2022. Available online: https://www.ultracycling.com/ (accessed on 30 November 2022).
- Union Cycliste Internationale. Home. Available online: https://www.uci.org/ (accessed on 30 November 2022).
- Phelps, M.; Drehs, W. Michael Phelps: ‘This Is the Most Overwhelmed I’ve ever Felt’. ESPN. 2020. Available online: https://www.espn.com/olympics/story/_/id/29186389/michael-phelps-most-overwhelmed-ever-felt (accessed on 30 November 2022).
- Beals, C. Growing Pains. Cody Beals. 2022. Available online: https://www.codybeals.com/2019/04/growing-pains/ (accessed on 30 November 2022).
- Sturm [@sarah_sturmy] SZ. Posts [Instagram profile]. Instagram. Available online: https://www.instagram.com/sarah_sturmy/?hl=en (accessed on 1 December 2022).
- Pae, C.-U. Why systematic review rather than narrative review? Psychiatry Investig. 2015, 12, 417–419. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Daley, M.M.; Reardon, C.L. Bipolar disorder and athletes: A narrative review. Curr. Sport. Med. 2021, 20, 638–644. [Google Scholar] [CrossRef] [PubMed]
- Byrne, J.A. Improving the peer review of Narrative Literature Reviews. Res. Integr. Peer Rev. 2016, 1, 12. [Google Scholar] [CrossRef] [PubMed][Green Version]
- Pautasso, M. Ten simple rules for writing a literature review. PLoS Comput. Biol. 2013, 9, e1003149. [Google Scholar] [CrossRef]
- McCabe, T.; Peirce, N.; Gorczynski, P.; Heron, N. Narrative review of mental illness in cricket with recommendations for Mental Health Support. BMJ Open Sport Exerc. Med. 2021, 7, e000910. [Google Scholar] [CrossRef]
|Reference||Year||Sample Size||Relevant ICD-11 Classifications||Description of Findings|
|Morgan et al. ||1987||n = 400||Depression||Summary of 10-year study of endurance swimmers evaluated for mood using Profile of Mood States (POMS) over a 6-month training block. In all years, mood decreased during the highest-volume training period. A total of 80% were diagnosed with clinical depression.|
|Morgan et al. ||1988||n = 12||Depression||Swimmers assessed daily with POMS during a 12-day high-volume block. As training volume increased, sense of well-being and mood decreased, depression increased.|
|DeBate and Wethington ||2001||n = 583||Eating disorder||Triathletes assessed for disordered eating using Eating Attitudes Test-26 (EAT-26). A total of 28% of females, 11% males at risk for eating disorder (ED). Evidence of preoccupation with food/weight, calorie control. A total of 100% of participants express body dissatisfaction using Body Test Material.|
|Blaydon and Lindner ||2002||n = 203||Eating disorder||Triathletes assessed for EXD and ED using Exercise Dependence Questionnaire (EDQ) and EAT. A total of 30.6% of cohort at risk for primary EXD, 21.6% at risk for secondary EXD, 12.3% at risk for ED.|
|Harrison et al. ||2003||n = 33||Depression||Study designed to evaluate the effect of triathlon race on depression using Beck Depression Inventory II. A total of 21% of participants were diagnosed with, and 12% in treatment for, mood disorders. Depression score not associated with mood during race.|
|Kiraly and Joy ||2003||n = 1||Depression, psychosis||Case study of male Ironman triathlete with ED, depression, and psychosis.|
|Yates et al. ||2003||n = 190||Eating disorder, anxiety disorder, fear-related disorder||Ultra-endurance runners, cyclists, and paddlers examined for ED using Exercise Orientation Questionnaire (EOQ) and self-report of psychiatric symptoms. Risk of ED found in 12% runners, 14% cyclists, and 18% paddlers. Self-loathing was associated with ED symptoms for the entire group (F(1) = 4.8, p < 0.05) and for females specifically (F(1) = 9.30, p < 0.001). More anxiety/panic symptoms were found in paddlers (χ2 = 7.91, p < 0.01). Paddlers had higher self-loathing scores than cyclists (F(2) = 6.91, p < 0.01). The most anxiety/panic symptoms were reported by the female-only paddler group (χ2(1) = 10.27, p < 0.001) than the other groups.|
|Millet and Groslambert ||2005||n = 4||Anxiety disorder||Elite triathletes evaluated for fatigue and anxiety using a questionnaire unique to the study over a 40-week training block. Increased training loads were correlated to higher anxiety and fatigue.|
|Hoch et al. ||2007||n = 15||Eating disorder||Study of disordered eating measured by EAT-26 and bone-mineral density measured by dual-energy x-ray absorptiometry in club triathletes. A total of 60% in caloric deficit, 40% with history of amenorrhea.|
|Riebl et al. ||2007||n = 61||Eating disorder||Male cyclists were assessed for ED using EAT-26 and Survey of Eating Disorder Among Cyclists (SEDAC). Risk of ED found in 19.7%. A total of 45.9% of cyclists believed ED to be common in cycling.|
|Axelsen ||2009||n = 1||Eating disorder||Autoethnographic case report of one female triathlete with anorexia nervosa.|
|Magee et al. ||2016||n = 345||Eating disorder, depression||Study designed to reveal correlations between exercise dependence (EXD), eating patterns as measured by the Three Factor Eating Questionnaire (TFEQ), and psychological distress/depression symptoms as measured by the Kessler 6 Scale in Ironman triathletes. Exercise Dependence Scale (EDS) used to find 30% participants at risk and symptomatic of EXD.|
|Sanhuenza et al. ||2016||n = 192||Anxiety disorder, alcohol-use disorder||Triathletes were assessed by psychiatric interview (MINI international neuropsychiatric interview, 5.0), genotyping analysis of ACE rs1799752 (I/D), and serotonin transporter 5HTT (5-HTTLPR). Anxiety disorder was a risk for 44.3% of total participants and 57% of Inferior Performance (IP) group. IP showed higher frequency of polymorphisms for 5-HTTLPR, which is associated with increased anxiety; 5HT1AR-1019C > G, which is associated with anxiety disorder; and NK1R r56715729, which is associated with stress homeostasis, alcohol dependence, and alcohol abuse.|
|Cook et al. ||2017||n = 179||Eating disorder||Study of male cyclists used EDS, Drive for Thinness, and Leisure Time Exercise Questionnaire to find that 8.24% were at risk and 70% were symptomatic for primary exercise dependence. A total of 1.18% were at risk and 10.59% were symptomatic for secondary exercise dependence, suggesting presence of ED. EXD more prevalent with more frequent workouts.|
|Mayolas et al. ||2017||n = 859||Anxiety disorder, depression||Amateur endurance cyclists assessed for exercise addiction using Exercise Addiction Inventory (EAI), Quality of Life (QoL), and anxiety and depression (Hospital Anxiety and Depression Scale). Evidence of EA found in 17% of cyclists. Lower QoL, assessed by Short Form Survey version 2.0–12, was observed in the at-risk group. EA not related to training volume.|
|Buck et al. ||2018||n = 98||Depression||Ultramarathoners assessed for exercise addiction and depression using EAI and PHQ-2. A total of 20% of athletes were positive for EA risk and 20% were positive for depression risk.|
|Schüler et al. ||2018||n = 323||Anxiety disorder||Study designed to assess predictors of exercise addiction in ultra endurance athletes using Balanced Measure of Psychological Needs Scale (BMPN), the anxiety-oriented self-control subscale of the Volitional Components Inventory, and EAI. Overall sample scored high on EAI with the mean score at cut-off for EA.|
|Torstveit et al. ||2019||n = 53||Eating disorder||Exercise dependence, measured by EDS, correlated with higher training volume in male cyclists and triathletes. Those at risk for EXD were also at risk for ED, measured by the ED Examination Questionnaire (EDE-Q), and showed evidence of low energy availability.|
|Hauck et al. ||2020||n = 1022||Eating disorder||In a study of amateur endurance athletes, the prevalence of food addiction, measured by the Yale Food Addiction Scale 2.0, was 6.2%. Prevalence of ED, measured by the Eating Disorder Diagnostic Scale (EDDS), was 6.5%. Prevalence of exercise addiction, measured by the Questionnaire to Diagnose Exercise Dependence in Endurance Sports (FESA), was 30.5%. Results unrelated to the number of training hours per week.|
|Muros et al. ||2020||n = 4037||Eating disorder||Study of endurance cyclists and triathletes found 17.9% at risk for ED measured by the revised restraint scale (RRS), SCOFF questionnaire, and Mediterranean Diet Adherence Screener (MEDAS); higher in females and cyclists, lower in males and triathletes.|
|Bueno-Antequera et al. ||2022||n = 330||Alcohol-use disorder||Amateur endurance cyclists assessed for exercise addiction using EAI, QoL, using Health Survey 2.0. EXD risk found in 64% of males and 60% females. Lower mental QoL and increased alcohol use was found in 14.8% of participants.|
|Cook and Dobbin ||2022||n = 36||Eating disorder||Male cyclists assessed for ED risk using the Sports Nutrition Knowledge Questionnaire (SNKQ) and Brief Eating Disorder in Athletes Questionnaire (BEDA-Q). Risk for ED was high in 11% of group and negatively correlated with understanding of nutrition (r = −0.55, p = 0.006).|
|Koppenburg et al. ||2022||n = 122||Eating disorder||Female cyclists were assessed for ED risk (EAT-26). A total of 32% were found to be at risk and 80% percent of those surveyed believed cycling to be associated with high ED risk.|
|Colledge et al. ||2022||n = 123||Depression||High-performance athletes were assessed for EXD using the EXD Scale, evidence of childhood trauma using the Childhood Trauma Questionnaire (CTQ), ADHD using the Homburger ADHS Skalen für Erwachsene (HASE), and depression using the BDI. EXD risk found in 23.6% and those with EXD had higher likelihood of depression (t(121) = 4.944, p < 0.001), ADHD (t(121) = 2.915, p = 0.004), and childhood trauma (t(121) = 2.297, p = 0.024).|
|Høeg et al. ||2022||n = 123||Eating disorder||Ultramarathoners assessed using proprietary survey consisting of questions from Female Athlete Triad Screening Questionnaire and Eating Disorder Examination Questionnaire. Risk of ED found in 44.5% of males and 63.5% females. Evidence of bone-stress injury (BSI) found in 37.5% of females and 20.5% of males using dual-energy X-ray absorptiometry (DXA).|
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Colangelo, J.; Smith, A.; Buadze, A.; Keay, N.; Liebrenz, M. Mental Health Disorders in Ultra Endurance Athletes per ICD-11 Classifications: A Review of an Overlooked Community in Sports Psychiatry. Sports 2023, 11, 52. https://doi.org/10.3390/sports11030052
Colangelo J, Smith A, Buadze A, Keay N, Liebrenz M. Mental Health Disorders in Ultra Endurance Athletes per ICD-11 Classifications: A Review of an Overlooked Community in Sports Psychiatry. Sports. 2023; 11(3):52. https://doi.org/10.3390/sports11030052Chicago/Turabian Style
Colangelo, Jill, Alexander Smith, Ana Buadze, Nicola Keay, and Michael Liebrenz. 2023. "Mental Health Disorders in Ultra Endurance Athletes per ICD-11 Classifications: A Review of an Overlooked Community in Sports Psychiatry" Sports 11, no. 3: 52. https://doi.org/10.3390/sports11030052