Evidence-Based Reviews

Playing through the pain: Psychiatric risks among athletes

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Injuries, other factors increase athletes’ vulnerability to psychopathology



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Dr. O’Connell: What you need to know about treating athletes

Suck it up. Tough it out. There is no “I” in team. These are a few of the messages athletes receive from coaches, teammates, and fans. There are norms, values, and expectations in every culture, including sports, that affect behavior and emotional expression. When taking a patient’s history, clinicians may ask about participation in sports because it provides health and lifestyle information. However, many clinicians fail to consider the extent to which sport participation can influence a person’s explanatory style, experience of injury, and attitude toward medications. Whether your patient is an elite athlete or someone who participates in sports solely for exercise, the extent to which he or she identifies as an athlete is worth exploring.

Research on athletes has focused on physical aspects of injury, but this may be just a small component of an athlete’s devastation after serious injury. In this article, we discuss athletes’:

  • psychiatric risks after injury
  • expression of pain
  • risks of having an identity driven solely by sports
  • distress tolerance.

We also provide tips for making a differential diagnosis and providing treatment. This information is based on our experience treating athletes, supplemented by relevant literature.

Psychiatric risks after injury

Research has explored eating disorders and substance use among athletes, but clinicians generally are less aware of the prevalence of mood and anxiety disorders in this population. Although participating in sports can protect against emotional distress, athletes who sustain an injury are at risk for major depressive disorder, posttraumatic stress disorder (PTSD), or an adjustment disorder.1 Only about 10% of injured athletes have severe, long-term psychological consequences,2 but the prevalence of anger and depression after an injury is well documented.3,4 Researchers have found that injured athletes experience clinically significant depression 6 times as often as non-injured athletes.5 Injured athletes also exhibit significantly greater anxiety and lower self-esteem than non-injured controls immediately after injury and at 2-month follow-up; those with more severe injuries are more likely to become depressed.6 Non-injured athletes seem to experience depression at the same rate as the general population.7

Injury and expression of pain

Psychiatric illnesses often are underreported and undertreated in athletes.8 This may be because athletes feel that admitting they have a psychiatric illness or symptoms could threaten their status with their team. One professional figure skater we treated failed to seek recommended treatment for a psychiatric disorder because she feared she would be asked to leave her skating company. Her symptoms dangerously escalated before she was hospitalized.

Based on our clinical experience, many athletes feel acute pressure to play through psychological and physical pain. Some athletes continue to play with an injury to hold on to a paycheck or scholarship. Some continue to play even though they no longer enjoy the sport to prevent letting down parents or coaches; others know no other way but to “tough it out.” Supporters such as coaches, parents, or teammates may encourage athletes to play with injury, and sometimes provide medication to do so.

Mostly, however, the pressure to continue to play despite injury comes from athletes themselves. The culture of sport may lead athletes to minimize pain, fear, and self doubt.9 Athletes who fuse the culture of sport with their own being may underreport physical and psychiatric symptoms. In a survey of National Collegiate Athletic Association Division I athletes, Nixon9 found that 70% of respondents reported having been injured at least once, and more than one-half felt pressure to play while injured. Feeling pressure to perform with injury was affected by “starter” status, and whites and men scored highest on pressure scales, although women showed a roughly equal probability of playing through injury. Students who received an athletic scholarship experienced more injuries that required surgery. There was no difference in pain expression between players of contact and non-contact sports. Finally, athletes may be less likely to seek pharmacologic treatments because of cultural messages that emphasize ideas such as “the body is a temple.”

Loss of identity

An athlete’s injury should be analyzed for meaning; what may seem insignificant to one person may be quite different for another. When injury makes athletic activity impossible, an athlete may suffer more distress than someone who does not exercise regularly. Understanding the significance of the experience for an athlete is crucial to achieving recovery.10 For example, to a non-athlete a fractured wrist may be an annoyance, but it may be disastrous to a collegiate pitcher who is forced to be inactive when scouts for Major League Baseball teams search for prospects.


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