by Paul Schienberg, Ph.D.
Often exercise and participation in sport is thought to be negatively related to mental problems. In fact, exercise has been used prescriptively for depression and other disorders. A myth supported by our culture is that athletes are invulnerable. Real stories have shown that they are human too and suffer from the same degree of stresses, if not more so. Athletes suffer from the same types of psychiatric disorders as the general population in roughly the same proportion. A list of common psychological disorders and their related symptoms should include certain sport and exercise behaviors.
Previous articles in Psyched dealt with substance abuse (“Drugs & Sports: Drug Types”; “Drugs & Sports: Who’s Getting High?”; “Stop Enabling and Help Athletes Abusing Substances”) and eating disorders (“Weight Management and Athletics”). This article will attend to a variety of other mental problems experienced by athletes including mood and panic disorders, schizophrenia, adjustment disorders, PTSD, and personality disorders.
A Developmental Perspective and the Selection Process
Important psychological issues in youth sports are different from those in college or the professional level. Each stage of development has different physical challenges from rolling over, to sitting up to walking. With each success we warmed to the cheers of our spectators. The tremendous excitement and joy occurring at each mastered motor task formed the foundation for all future athletic movement.
The process of selection and de-selection of athletes is on-going and of a dualistic nature. Athletes are selected based upon psychological and physical strengths and limitations. The more severe an athlete’s psychiatric symptoms and the more competitive the level, the less likely he or she will be able to participate and compete. This process operates to exclude most athletes with more serious mental disorders. Reality testing and problem solving, the ability to relate to others and some self-directed impulse control are required for selection. Very few delusional or otherwise psychotic or severely anxious or depressed individuals will be able to continue to participate.
Data and Resistance
Psychiatric disturbance in athletes is underreported, and individuals, couples and families are under-treated. The athletic community’s mental health needs are vastly under-served. There are simply too many forces opposing an athlete’s getting adequate treatment. The individual athlete is afraid to disclose any psychiatric symptoms for fear that it will be revealed and exploited as a sign of weakness and used as a reason for de-selection. To admit to a psychological or emotional problem not only threatens the individual’s own confidence. It also threatens one’s status with teammates and coaches.
Mood Disorders
Athletes appear to be more susceptible to depression than bi-polar affective disorder. Perhaps the strenuous nature of athletic training eliminates people with manic episodes and severe mood instability. Or, it is possible that bi-polar disorder athletes are covering their symptoms with substances. They use cocaine to modify the depression and alcohol to counter the mania. Instead of being identified and treated for bi-polar disorder, they end up in rehabs over and over again. The most common disorder found in the athletic population is depression.
There are several sports specific factors that contribute to depression. It is almost impossible to train and compete adequately when struggling with depression’s symptoms. Exercise and sport participation act as agents against depression. Athletes commonly train or exercise when sad, angry or frustrated in order to feel better – at least temporarily. Exercise can be health promoting if it is not the only defense mechanism used and it is not used to completely avoid dealing with a serious underlying issue. Overtraining can lead to athletic burnout referred to as overtraining syndrome. The physical demands of the athletic activity could conceivably deplete necessary biological factors such as neurotransmitters. One response to less than satisfactory performance is to push themselves even harder in their training, leading to a state of chronic fatigue and depression. An athlete with an inadequately developed repertoire of defenses might rely too heavily on exercise, over-utilize it, find it inadequate or its effects too transient and become depressed. An athlete may seek treatment for depression two or three years after retirement from their competitive sport. There are a combination of losses at play here – the positively reinforcing activity itself, the preferred coping mechanism has been removed, and the physiological benefits of the exercise stops.
The inevitable losses that come with injuries associated with athletic participation pose additional risks for depression. The more successful the athlete, the more serious the injury, the more likely the athlete will experience an episode of severe depression, even to the point of contemplating or attempting suicide. This is especially true with young men and women. The inability to return to pre-injury performance levels and being replaced by a teammate will provide an extra push to depression. Finally, the expectations of coaches and teammates, heightened public visibility, time demands, social behavior, fatigue, academic pressure, and racial and gender stereotyping add to depressive pressures.
Schizophrenia and Other Psychotic Disorders
Schizophrenia illnesses occasionally have been reported in elite athletes. The process of selection probably operates most mercifully on those individuals suffering acutely from these disorders. The developmental time course for their onset result in individuals becoming most symptomatic at the very time that the pressures to perform are the greatest. It also is the time that athletes are at the peak of their physical skills. The most likely cause for a psychotic disorder among athletes is substance-induced psychosis. However, when elite athletes suffer from recurrent brief psychotic episodes for which no additional cause can be determined, they can return to training at the professional level between episodes.
Anxiety Disorders
Anxiety is one emotional experience that athletes are willing to discuss. However, most will deny any problems with anxiety. An effective approach is to consider the anxiety a symptom – an indication of a variety of problems as well as an opening for a helping professional to talk about the issue. Within the culture of athletes, it is a relatively acceptable reason for an athlete to seek help.
Since athletes are judged on a moment-to-moment basis for their performance, it should not be surprising that they are likely to admit to performance anxiety as their chief complaint. The first level of assessment, is whether the anxiety is of clinical concern or whether it is a natural response to the pressures to perform at a high level. Beyond the anxiety that is generally appropriate to the situation, athlete’s anxiety may be an indication of a success neurosis, a symptom of marital discord or a sign of an impending panic disorder.
Adjustment Disorder
In addition to the real and potential loses that contribute to athletes’ susceptibility to depression and anxiety, sheltered lifestyle can leave them with limited coping mechanisms. The defenses and personality structure that they do have are often rigid and concrete. Their personalities tend to be strongly goal-oriented and perfectionistic. A narcissistic personality disorder can be considered an occupational hazard. In addition, athletes would seem to be at risk for a variety of other forms of personality difficulties, all of which would predispose them to adjustment disorders. Athletes deprived of the usual type of hardening experiences of childhood would be likely to have limited or inadequately developed abilities to cope with life’s more difficult moments and may become symptomatic.
Attention Deficit Disorder
Athletes with attention-deficit/hyperactive disorder may be over represented when compared to the general public. Young people with this disorder are more drawn toward physical activity, probably as a way of managing affect and/or anxiety. They may rightly or wrongly perceive their physical skills as more substantial than their mental or verbal ones. We are all drawn to what we do best. Their behavior outside of the sport setting will get them into serious troubles that will threaten, if not preclude, their continued participation. Coaches and others are required to have more patience and make extra efforts to encourage the verbal and social interaction that is a necessary and inherent part of sport.
Posttraumatic Stress Disorder
Injuries to athletes are very often career-threatening and any serious injury, defined as one requiring surgery or a significant withdrawal from participation or training, should be considered traumatic. The injury-causing incident can become an intrusive memory and avoidant behavior and excuses may result. The more severe, painful, or threatening the injury to the athlete, the greater the potential for it to be traumatizing. Listening closely to an athlete talk about his or her experience of an injury will give the helping professional plenty of clues that he or she has been traumatized.
Conclusion
Sport participation incurs a certain amount of stress on athletes. This stress, along with certain behaviors promoted in the name of training or competition, puts individuals at risk for developing a mental illness. Fortunately there are ways to limit some of the stresses and disturbed behaviors and protect many sport participants. The challenge is to identify the vulnerable individuals as soon as possible and to recognize when the stresses are becoming overwhelming, the behaviors present risk, and actual symptoms are developing. Early detection and intervention can allow athletes to recover from their illness and resume training and competition if they wish to do so.
