Female Athlete Triad: Sport Gone Bad

By Claudia L. Reardon, M.D.

Psychiatrists encourage nearly everyone to participate in sports and exercise. Sports not only improve physical health but also can greatly improve mental well-being. However, if girls and women take involvement in sports too far, they can suffer a well-described triad of symptoms. The so-called female athlete triad consists of the following three inter-linked health problems:

1. Insufficient caloric intake/disordered eating
2. Menstrual problems
3. Weak bones

Girls and women who participate in “leanness sports” that emphasize thinness (running, ballet, gymnastics, figure skating, and others) are particularly at risk. If they receive the message that being thinner could result in greater athletic success, they may try to cut down on their caloric intake to levels too low to support their levels of physical activity. This can result in full-blown eating disorders, irregular menstrual cycles, and weak bones (including osteoporosis at young ages).

Some common myths about the female athlete triad include the following:

• If an athlete’s performance has not started suffering, then she must not have a problem. FACT:  Even if an athlete’s performance has not started suffering, it eventually will.  Not taking in enough calories to match activity level is not sustainable in the long-run.
• It is normal for female athletes to stop menstruating. FACT:  It is never normal for a female athlete to stop menstruating. There are serious health risks, especially bone loss, to not menstruating. Studies show that after three years of not menstruating, bone loss is likely to be permanent. Loss of future reproductive function could also occur.
• If an athlete is not eating enough to match activity level, she is aware of what she's doing. FACT: Denial is powerful. Athletes will very often feel that they are being as healthy as possible, and that meticulous attention to diet is a sign of dedication to sport. Coaches, parents, and professionals will need to help the athlete see the problems with the behaviors.
• An athlete who eats “healthy," is a top performer on the team, and excels in class is unlikely to have an eating disorder. FACT: Traits that are desirable in an athlete can make them more at risk of developing an eating disorder. Mental toughness, pursuit of excellence, performance despite pain, commitment to training, and being a team player are very similar to excessive exercise, perfectionism, denial of discomfort, and being self-less.

What can you do if someone you know might be suffering from the female athlete triad?

1. Share your concerns with the athlete.
2. Talk with the coach, athletic trainer, or school counselor.
3. Encourage the athlete to see a physician and dietitian. Not all health care professionals are familiar with the details of the female athlete triad; to help them out, you can send along this brochure with the athlete to the appointment.

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Why Women Must Exercise for Mental Health

By Claudia Reardon, M.D.

Exercise has mental health benefits for men and women of all ages.  However, there are unique factors to consider in thinking about the mental health benefits of exercise for women in particular.  Compared to men, women have a two-fold increased prevalence of major depression throughout their reproductive life cycle.  Exercise can be a very useful treatment for depression in women at any of a number of different times in their lives:   

• During pregnancy and breastfeeding:  Depression is highly prevalent in women of childbearing age.  Medications are often necessary to treat moderate to severe depression.  However, many women wish to avoid treatment with medications during pregnancy and while breastfeeding.  At least one study has shown that women who exercised regularly reported less depression in the first and second trimesters compared with women who did not exercise.  The American College of Obstetricians and Gynecologists has recommended 30 minutes of moderate exercise on most days.

• During the postpartum period:  Exercise can also help to treat and prevent postpartum depression.  One study has shown that postpartum women who exercised three times per week had less depression than postpartum women who did not exercise. 

• During the premenstrual period:  Exercise can be useful to treat physical and emotional premenstrual symptoms.  It is less clear if exercise by itself can treat the most severe of premenstrual syndromes (called “premenstrual dysphoric disorder”), but it is still a first-line treatment strategy that most physicians would recommend. 

• During menopause:  Several studies have shown that aerobic exercise can improve both depression and insomnia occurring during menopause.  Additionally, lower intensity exercise such as yoga has been shown to improve psychological well-being in menopausal women.

Importantly, women may experience barriers to exercise.  Here are some examples of these barriers, and strategies to help address them:

• Childcare issues:  Women are often responsible for childcare, which makes it difficult for them to find opportunities to exercise.  Gyms that offer childcare services can be helpful.  Also, partners can share the workload. 

• Intimidation:  Some women may feel uncomfortable working out in the coed environment of a gym.  Consider taking women-only exercise classes, or walking or doing other exercise with women exercise buddies.

• Self-consciousness about appearance:  If a woman is already uncomfortable about her appearance, then she might worry that she’s drawing even more attention to her body by exercising, especially if wearing skimpy sports clothes.  One strategy is to try walking, which can be done almost anywhere and in almost any type of clothing.

• Guilt:  Women, especially those who are family caretakers, sometimes describe feeling guilty about taking time for themselves to exercise.  Remember, it is not a selfish thing to exercise.  You are taking time to improve your physical and emotional health, which will allow you to more effectively be there for others.  Besides, you deserve to experience the benefits of exercise!   

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When Divorce Happens

By Gariane Gunter, M.D. 

A recent study was published in Health Day that discusses the mental health of children of divorced parents. While I am not in the position to support or deny the findings, the topic of divorce when children are involved is often a difficult one. Every family is different, but the following are some general tips for divorcing parents that can be helpful.

1. Attempt to keep a positive attitude during the point of separation. This is often a very trying time for the family. Stick to a routine and embrace the activities your children have always enjoyed.

2. Don’t forget to nurture yourself. Going for a walk, having coffee with a friend, or reading a good book are ways to rest and regain energy. It’s normal to feel exhausted when separating; and possibly for many months to follow.

3. Encourage kids to openly discuss their feelings, positive or negative, about what's happening.

It's important for divorcing, as well as already divorced parents, to sit down with their kids and encourage them to say what they're thinking and feeling. But you'll need to keep this separate from your own feelings. Most often, children experience a sense of loss of family and may blame you, the other parent, or both of you for what is going on in their lives. You really need to be prepared to answer questions your kids might raise. They might feel guilty and imagine that they "caused" the problem. Kids and teenagers may feel angry or frightened, or worried about their future. Counselors can assist with this difficult conversation and provide a safe environment if safety is a concern.

4. Although very tempting, try not to speak negatively about your former spouse when your children are present. This issue, often called “parental alienation” can be a problem. Doing things such as putting your child in the middle, saying negative things about the other parent, and using your child as a messenger puts your child in a “no win” situation and creates lifelong relationship issues for all involved. The reasons include the following:

• The comments may confuse and frighten children.
• Many of your concerns about your former spouse are difficult for you to express. It is very important that you keep these concerns to yourself. Children just do not have the emotional maturity to withstand information/situations that adults find stressful.
• Your child’s identity and self concept is based on parental behavior. Even if it is next to impossible to say anything good about your former spouse, try to do so. If this is impossible then don’t say anything.
• Children love to eavesdrop. Telephone conversations are their favorite snooping ground. Make all effort to not discuss your divorce-related difficulties on the telephone when your children are around.

5. During the crisis point of separation try to remember that your children need you both parents more than ever. This is not a time to deny access unless a professional deems it necessary to do so for safety related reasons.

6. It is important to accept the fact that a separation involves feelings of loss for children. Try not to panic if the following behaviors occur during the first few months of separation:

• Sleep difficulties like disrupted sleep, an inability to sleep, exhaustion etc.

• Social isolation

• Anger, intolerance, grumpiness

• Avoidance of divorce related conversations

• Obsessing about the divorce

• Appetite changes

• Feelings of worthlessness

• Tears and feelings of overwhelming sadness

7. Although many children do not ask to see a counselor when their parents separate, they usually find counseling very helpful.

8. It is important to acknowledge that children are very loyal and protective of their parents. If children are placed in loyalty binds they can experience anxiety. Try to alleviate their anxiety if they decided to “pick a side.” This is a coping skill which teens in particular use. If your child engages in “picking a side” try not to feel rejected.

9. Think of yourself as a survivor not a victim. And be patient. Everyone takes different times to heal.
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The Truth About Domestic Violence

By Roberto Blanco, M.D.

In my work with patients across the world, I can´t help but notice how many come to psychiatric clinics as a result of domestic violence. Despite its prevalence in other countries, domestic violence is also quite common in the United States. In the United States alone, 22 percent of women are physically assaulted by an intimate partner during their lifetimes and over 5 million are victims every year. Domestic violence touches all elements of society regardless of age, race, or socioeconomic status.

As a child psychiatrist, I can´t help but think of the smallest victims of domestic violence as I often see them in my clinical work. These are the children who are either involved secondarily by witnessing the abuse or become victims directly themselves. The effects of domestic violence on this population are far ranging and long lasting. As these children develop, they may struggle to deal with conflict. They may also become aggressive or experience severe depression, nightmares and other symptoms of post-traumatic stress, as well as other anxieties or fears.

The effects of domestic violence on children are dependent on the nature and severity of the abuse and on the developmental level of the child. Young babies and infants cannot understand why violence occurs in the home and so violence in this population can cause deep-seated changes in personality, self-esteem, and ways of interacting with others that can last for a lifetime. Often older children have a better understanding of what is going on, but still often blame themselves for the abuse and can have excessive guilt or anger as a result.

Domestic violence does not need to be only physical to qualify as a form of abuse. Abuse can also take the form of emotional, financial, or sexual control or disregard. Initially, characteristics of an abusive relationship can often be endearing such as wanting to be with you all of the time. Over time, this can become intense jealousy for no reason, excessive control over relationships and behaviors, and aggression or violence. Options for milder forms of emotional abuse can include family and/or individual therapy. For severe cases, there may be a need to get out of the situation or to a safe house. For more information on domestic violence, please see the American Pyschiatric Association's brochure  Let´s Talk Facts About Domestic Violence.
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Working with Schools When your Child has Problems

By Gariane Gunter, M.D.

Well, we have made it through the first months of a new school year! However, for some students the start of a new year has been difficult. I have received many calls and heard numerous concerns from parents who are wondering how they can work with their child’s school to ensure a success. Below is a list of the Top Ten Tips for Working with Schools that was shared with me by a Lead School Psychologist in my area. I hope you have a great year!

Top Ten Tips for Working with Schools

1. Let the school know up front if you have concerns
2. It helps to be visible in the school but do not intrude on the learning
3. Every school is a little different in its approach

4. There are lots of different ways of working with student problems in schools. Not just one of them is right. 
5. If you want to talk to a classroom teacher, ask to make an appointment with them. When teachers are with students, their first responsibility is to teach and supervise them.
6. School folks got into education for the joy of working with students.
7. School Psychologists and Special Teachers are there to study individual students. Help them by giving your specific observations. Your observations matter.
8. Lots of teachers and other school folks use e-mail, but remember that teachers check e-mail when they have planning or breaks.
9. If you have made a request and you haven’t received a response, don’t wait too long before asking about it. Sometimes requests do get lost.
10. Schools can be fun places to be; it is where all children gather to learn. Enjoy your time there too!

Reference: Shirley A. Vickery, PhD

Maternal Mental Health: Can Stress Harm Your Chances of Getting Pregnant?

By Felicia K. Wong, M.D.

Getting pregnant is an exhilarating experience for some couples. But it can also be a very frustrating, and heart-wrenching, experience for others. Age, smoking, obesity, and alcohol are studied and known factors to effect pregnancy success.


Anecdotal reports have long linked stress with infertility, but to-date, there has not been much scientific evidence to prove the connection. On August 11, 2010, the BBC published an interesting article describing an Oxford University study that demonstrates for the first time that high stress levels may delay pregnancy. Their findings suggest that perhaps the best thing a couple can do to prepare for pregnancy is to relax.


Dr. Cecilia Pyper, of the National Perinatal Epidemiology Unit at the University of Oxford, measured stress hormones in 274 healthy women aged 18-40 planning to have a baby naturally. They found that those who were most stressed had a reduced chance of becoming pregnant that month. Dr. Pyper said: "The findings support the idea that couples should aim to stay as relaxed as they can about trying for a baby....In some people's cases, it might be relevant to look at relaxation techniques, counselling and even approaches like yoga and meditation."


The study, aimed to improve understanding of the factors that influence pregnancy in normal healthy women, was published in the journal Fertility and Sterility. The research was carried out in collaboration with the Eunice Kennedy Shriver National Institute for Child Health and Human Development in the US. It is part of a larger study looking at the effect of factors like smoking, alcohol, and caffeine on chances of pregnancy.


This being the first of such studies, more research is needed to further link the role of stress and pregnancy. In the meantime, it can’t hurt to relax! 
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Women's Mental Health: The Facts

By Gariane Phillips Gunter, M.D.

We have all heard the saying; Women are from Mars and Men are from Venus. Well, when it comes to our mental health we may not be from separate planets but there are differences.

For example*:

• Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men.

• Leading mental health problems of the elderly are depression, organic brain syndromes and dementias. A majority are women.

• An estimated 80% of 50 million people affected by violent conflicts, civil wars, disasters, and displacement are women and children.

• Lifetime prevalence rate of violence against women ranges from 16% to 50%.

• At least one in five women suffers rape or attempted rape in their lifetime.

• Mental disorders following childbirth, including post-partum depression, are estimated to affect about 13% of women within a year of delivery.

• Eating Disorders are more common in women however this is a growing concern for males as well.

• Suicide is the top cause of death globally for women aged 20-59 years of age.

So why are women more at risk? Well, it is known that our genes play a role in ones susceptibility to developing a mental illness. However, environment is also a huge factor. Pressures created by women’s multiple roles, gender discrimination and associated factors of poverty, hunger, malnutrition, overwork, domestic violence and sexual abuse, combine to account for a woman's poor mental health in many cases. There is a correlation between the frequency and severity of such poor social factors and the frequency and severity of mental health problems in women. In addition, the presence or lack of support during difficult times is also a factor.

Stigma surrounding mental illness is a huge barrier that keeps both men and women from seeking help in many cases. However, even in cases where stigma is not a concern, there are still differences in the way that men and women seek help for psychological difficulties. According to the World Health Organization, women are more likely to seek assistance from their primary care physician while men may seek a specialist or use the hospital system. Also, gender stereotypes of women’s proneness to emotional problems versus men may lead health care providers in discussing symptoms with women or prescribing medication.

So whether you are from Mars, Venus or somewhere in between, women are more susceptible to certain mental illnesses, our environment plays a role and treatment options vary. So women, take the time to take care of yourselves, you are worth it! And please ask for help if you should need it.


* Stats are from the World Health Organization