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| >>FROM THE EXPERTS When Worrying Is Complicated by Alcohol, Caffeine, and Tobacco Use in Sports: The Case of Jim Driver david r. mcduff, m.d.  A. Identifying DataJim 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 Atlanta. He took the job as head coach of a high-profile program in another state last November after spending seven years building a successful smaller college program. He works 12 hours every day. B. 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 last year, but it gave him morning grogginess. Jim rarely worked out, and his weight had increased 30 pounds. He rarely ate breakfast but drank strong coffee to” get going.” He was healthy except for acid reflux controlled by antacids. C. 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 10 mg of zolpidem 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 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 mid-day exercise routine of cardio, stretching, and lifting. He also agreed to a 30-minute postpractice break consisting of a walk or campus library visit to read news. D. Discussion Jim is a typical case of a hard-working college or professional coach, but he could just as easily be a corporate executive or physician. To produce and maintain energy and unwind, people like Jim 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 a 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. References: McDuff D: Sports Psychiatry: Strategies for Life Balance and Peak Performance. American Psychiatric Publishing Inc 2012; chapters 3-5 McDuff D; Morse E: White R: Professional and Team Assistance Programs: Services and Utilization in Clinics in Sports Medicine. Edited by Toffler I and Morse E, Elsevier Inc 2005; 24: 943-958 Loehr J; Schwartz T: The Power of Full Engagement. New York (NY): The Free Press 2003
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