Case Study: When Worrying Is Complicated By Substance Use in Sports

Jim D. is a 50-year-old married Caucasian male Division I college lacrosse coach. He lives alone in a two-bedroom apartment near campus. He has three daughters (ages 15, 13, and 11). His family lives in Georgia. He took the job as head coach of a high-profile program in another state last year after spending seven years building a successful smaller college program. He works 12 hours a day.

History and Presenting Illness

Jim approached the college’s sports psychiatrist after an energy/sleep seminar for coaches. He jokingly said, “I thought you were talking about me even though I don’t know you.” He described consistent difficulty falling asleep and frequent early morning awakening dating back to his college lacrosse-playing days. He noted a recent pattern of an overactive mind (constantly reviewing the day, upcoming games, daily schedules, and his family). He tried to reduce this overthinking with glasses of wine, TV channel flipping, dipping oral tobacco, eating microwave dinners, or talking to his family. Despite these strategies and the use of 150 mg of trazodone, it often took Jim 90 minutes to fall asleep. Even if he fell asleep from exhaustion, he would frequently awaken at 3 a.m. thinking about the next day’s challenges. He tried a controlled-release sleeping pill, but it gave him morning grogginess. Jim rarely worked out, and his weight had increased by 30 pounds. He rarely ate breakfast but drank strong coffee to “get going.” He was healthy except for acid reflux, which was controlled by antacids.

Diagnosis and Treatment

Axis I: 300.00 anxiety disorder NOS; 305.1 nicotine dependence; 291.1 alcohol misuse NOS, 292.9; caffeine misuse NOS; 327.02 insomnia related to above; V62.89 phase of life problem (job change, family separation).

Jim’s awakening and unwinding routines were changed. Upon awakening, he ate fruit and yogurt and drank cold water. He followed this with three 60-second, high-intensity cardiovascular exercises (that is, pushups, jumping rope) with rest in between. He also made sure to go outside and find the sun and breathe rapidly through his nose for at least 60 seconds. Once at work, he ate a heartier breakfast of oatmeal or an egg-white omelet. He limited his coffee to two cups.

For unwinding, he ate dinner before coming home and eliminated wine and late-night TV. He added 30 minutes of music or nonsports reading under low light and established an 11 p.m. bedtime. In addition, he learned relaxation breathing and did this before bed. He continued his trazodone 50 mg or 100 mg, but took it earlier (90 minutes before lights out). To prevent accommodation to trazodone’s sedating effects, he skipped it a few nights a week and occasionally used zolpidem 10 mg if he didn’t fall asleep in 30 minutes. Finally, he purchased a white-noise machine for his nightstand.

For lifestyle change, he increased his exercise, improved his nutrition, and halved his oral tobacco use in preparation for a summer quit attempt. He established a goal of losing 30 pounds and began by eating three smaller meals a day with snacks in between. For stress control, he added a midday exercise routine of cardio, stretching, and lifting and a 30-minute postpractice walk or campus library visit to read news.

Discussion

Jim is a typical case of a hard-working college or professional coach, but this case could just as easily been about a corporate executive or physician. To produce and maintain energy and unwind, such professionals often resort to using stimulants and sedatives. Once the dosage gets higher, then toxic effects on sleep, stress control, and mood can occur. Jim’s very high dose of moist snuff (one can/day) was likely producing nocturnal nicotine withdrawal and early awakening. His overthinking and worrying are typical of busy coaches under pressure and need to be countered with lifestyle change.

Simple modifications of awakening and unwinding routines along with improved nutrition, exercise, and mini-stretch/breathing breaks are very powerful. If reduction of substances and lifestyle changes are not fully effective, then an anxiolytic medication trial is warranted. The key for any hard-working professional is to manage energy using sound stress-control strategies. ■