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Review
Post-traumatic stress disorder (PTSD) and other trauma-related mental disorders in elite athletes: a narrative review
  1. Cindy Miller Aron1,
  2. Sydney Harvey2,
  3. Brian Hainline3,
  4. Mary E Hitchcock4,
  5. Claudia L Reardon5
  1. 1 Department of Psychiatry, Samaritan Health Services, Corvallis, Oregon, USA
  2. 2 Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
  3. 3 National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
  4. 4 Ebling Library for the Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
  5. 5 Department of Psychiatry, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
  1. Correspondence to Ms Cindy Miller Aron, Department of Psychiatry, Samaritan Health Services, Corvallis, OR 97330, USA; cind152001{at}gmail.com

Abstract

This narrative review examines post-traumatic stress disorder (PTSD) and other trauma-related disorders—mental health conditions with complex diagnosis and treatment considerations—in elite athletes. Athletes may exhibit greater rates of PTSD (up to 13%–25% in some athlete populations) and other trauma-related disorders relative to the general population. We describe common inciting events leading to symptoms of PTSD in elite athletes, including trauma incurred in sports participation through direct physical injury, secondary/witnessed traumatic events, or abusive dynamics within sports teams. Symptoms of PTSD may significantly impact athletes’ psychosocial and sport-related function through avoidance, hypervigilance and dissociative behaviours, which, in turn, may delay recovery from musculoskeletal injury.

While PTSD may be common among elite athletes, recognition by providers who do not routinely screen for trauma-related disorders may be challenging because of the tendency of athletes to mask symptoms of PTSD and other trauma-related disorders. Early identification of athletes suffering from trauma-related symptoms, including those of acute stress disorder, may prevent progression to PTSD, while treatment of athletes already meeting criteria for PTSD may improve life functioning and sports performance outcomes. Current evidence supports increasing awareness of PTSD in athletes and use of screening tools to identify athletes who may benefit from trauma-informed medical or psychotherapeutic interventions.

  • athlete
  • sport psychology
  • elite performance
  • psychology
  • psychiatry

https://doi.org/10.1136/bjsports-2019-100695

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    Introduction

    Trauma-related mental health disorders in elite athletes may be common, with rates possibly higher in this population than in the general population.1 Athletes may experience trauma prior to sport (in childhood), in sports participation, or outside of sport during their athletic careers.

    Trauma-related symptoms and disorders may manifest in several ways. The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 divides symptoms into four categories: intrusion symptoms; negative mood and cognitions; dissociative symptoms; and alterations in arousal (table 1). Constellations of these symptoms are seen in both acute stress disorder (ASD) and post-traumatic stress disorder (PTSD), with ASD lasting 3 days to 1 month following trauma exposure. PTSD is defined as lasting more than 1 month following exposure to trauma and may represent a chronic condition (table 2).2 Other stressor and trauma-related disorders include adjustment disorder, in which disruptive emotional symptoms (ranging from depression or anxiety to disturbance of conduct) occur within 3 months of an acute stressor, which may be a traumatic event (table 2).2 All of these trauma-related disorders are characterised by impaired daily function and, among elite athletes, may significantly negatively impact athletic performance or recovery from injury.1 3–5 While the impact of trauma-related disorders carries considerable morbidity, early identification and treatment can mitigate those effects.6

    View this table:
    Table 1

    Symptom categories in DSM-5 trauma-related disorders2

    View this table:
    Table 2

    Diagnostic criteria for DSM-5 trauma-related disorders2

    Methods

    We aimed to summarise the prevalence, manifestations and impact of trauma-related disorders in elite athletes. One of the authors (MEH—an experienced librarian) searched key databases (PubMed, SportDiscus, PsycINFO, Scopus and Cochrane) in February 2018 and repeated the searches in November 2018. Search terms relating to the disorders, sports participation and the elite nature of participation were combined. No limits were placed on the search. Databases required slightly modified terminology to adhere to the databases’ controlled vocabulary. Elite athletes were defined as those competing at professional, Olympic or collegiate/university levels. Papers must have been available in English to be included in this manuscript. References in the resulting papers were reviewed to identify additional related publications. Other literature was also reviewed, where there were gaps in elite athlete-specific literature, for guidance on diagnosis, prevalence, functional impairment and management.

    Epidemiology

    There is a paucity of research on trauma-related disorders in athletes. PTSD is found in about 8.7% of the general population; by contrast, Thomson and Jaque7 found that 13% of a cohort of nationally ranked athletes met criteria for PTSD, with rates even higher in certain sports (eg, 25% in professional and preprofessional performance dancers).7

    The DSM-5 broadened the criteria for stressors that may lead to trauma-related symptoms. Events that subjectively place a person in a life-disrupting circumstance may also lead to PTSD.8 Injury during participation in sport occurs commonly and may serve as an inciting traumatic event. The Centers for Disease Control and Prevention reports that between 2009 and 2014, there was an average of 210 674 athletic injuries per year in the USA.9 During the 2014 Winter Olympic Games, 12% of athletes had at least one injury or illness during the relevant training or competition period, with 39% of the recorded injuries expected to prevent the athlete from competing or training.10

    There is increasing evidence that physical injury alone may induce a trauma-related response. For example, athletes experience clinically significant increased levels of PTSD symptomatology following a musculoskeletal injury.1 Younger athletes (eg, those in high school or college), female athletes and those who have a strong athletic identity may experience greater emotional trauma following injury, particularly ACL rupture.11 Musculoskeletal injuries are closely linked with specific symptoms of hyperarousal and avoidance behaviours, potentially compromising athletic performance, when repeatedly exposed to circumstances similar to the inciting event that led to their original injury.1 12 Symptoms of ASD have been reported as soon as the second day following a traumatic physical injury and occur in 23%–45% of patients following injury; importantly, up to 50% of those meeting criteria for ASD later meet criteria for PTSD.13

    Traumatic injuries may pose an even greater risk of progression to a chronic trauma-related disorder such as PTSD among athletes who entered their sport with pre-existing trauma exposures.14 Adverse childhood experiences (ACE)—which include exposure to domestic violence, parental substance abuse or incarceration, and history of child abuse and neglect—may negatively impact an elite athlete’s mental health. In a study examining ACEs in elite athletes, those with higher ACE scores were more susceptible to somatisation and behavioural concerns than those with lower scores.15 This study lacked a direct comparison sample to help characterise attributes specific to athletes versus the general population. There may also be poor test–retest reliability of ACE scores in elite athletes when recalling abuse and neglect. Thus, further study may be needed before implementing ACE screening of athletes more broadly.16

    Studies examining the effects of vicarious or witnessed trauma on individual athletes have shown trauma-related symptoms in teammates and coaches. One study analysed interviews with two trampoline coaches who witnessed serious athletic injuries. The coaches experienced distressing horror, fear and helplessness, re-experiencing avoidance, numbing and impaired function following the events.17 In a study of 459 Alpine skiing academy athletes, O’Neill18 described increased fear and anxiety among athletes who had been exposed to injured team members. He hypothesised that vicarious trauma may contribute to ‘injury contagion’ on affected teams, in which team members change their performance, thereby increasing their risk of personal injury.

    In Thomson and Jaque’s study of professional dancers and nationally ranked athletes, 24.4% of participants with a diagnosis of PTSD had been sexually assaulted.7 Among elite and club-level athletes in Australia, sexual trauma before or during participation in sport was reported by 31% of female athletes and 21% of male athletes during their lifetimes; of those, 41% of sexually abused women and 29% of sexually abused men were abused by sports personnel.19 The same study found that 46.4% of elite athletes reporting sexual trauma had been abused by sports personnel, compared with 25.6% of the club-level athletes.

    Diagnosis

    The diagnosis of PTSD and other trauma-related disorders in elite athletes must include sport-specific considerations. In athletes, symptoms of PTSD and other trauma-related disorders may include inconsistencies in athletic performance, increased somatic complaints and avoidance symptoms specific to sport, particularly where the inciting event involved athletic participation.3

    Symptoms may persist after physically recovering from an associated injury.20 21 In Thomson and Jaque’s study,7 athletes with PTSD had difficulty regulating emotions, which could impact interpersonal dynamics between the affected athlete and the team. Overtraining may be a form of adjustment disorder occurring after stressful events. Thus, consideration of stressors, including traumas, when evaluating athletes with apparent overtraining may be warranted.22

    Atypical signs and symptoms of PTSD may involve hesitation to attend physical therapy, which then may interfere with recovery.4 Lower immune function may further delay healing and impede the athlete’s ability to appropriately participate in rehabilitation following an injury.4 Reluctance to train with full intensity, protecting/guarding a past injury site, suboptimal performance and other unanticipated rehabilitation complications are potential indicators of underlying emotional distress and maladaptive coping styles.1 There can be gender and racial differences in addition to individual differences in coping styles.23

    To assess comorbidity of PTSD and concussion, PTSD symptom screening tools may be useful in athletes who have suffered sport-related concussion since postconcussion athletes may be at risk of chronic PTSD symptoms.24 Screening tools for trauma-related disorders have been relatively widely used in the general population and include the Primary Care PTSD Screen for DSM-5; the Startle, Physically Upset by Reminders, Anger, and Numbness Self-Report Screen; Short Post-Traumatic Stress Disorder Rating Interview; and Trauma Screening Questionnaire (table 3).25

    View this table:
    Table 3

    Validated PTSD screening measures.

    Athletes may engage in behaviours that are adaptive in competitive sport but mask trauma-related symptoms, thereby making diagnosis more difficult. High-performing athletes may use compartmentalisation, perfectionism and dissociation.26–28

    Compartmentalisation

    Compartmentalization—learning to subconsciously place simultaneous experiences in separate psychological spaces—can be a common strategy elite athletes use to keep their sporting life separate from the rest of their life.26 Compartmentalisation allows individuals to live with otherwise irreconcilable conflicts.29 This separation allows athletes to believe they can keep external stressors from influencing performance.26 30–32 As a psychological defence, compartmentalisation allows conflicting ideas or experiences to coexist.33 An individual can develop a subjective sense of ‘compartmentalization’ regarding a traumatic experience, which can lead to emotional detachment from the event.

    High-performing athletes may compartmentalise to manage emotions, effectively concealing mental health symptoms.34 This process could mask the underlying trauma by ‘protecting’ them from the reality of the problem.12 Athletes may reduce painful memories by compartmentalising thoughts regarding the event; this is described as an “active defense strategy by ‘not getting upset’.”12 However, compartmentalisation could interfere with the ability to effectively work through and recover from acute traumatic responses.12 Such detachment and overmodulation of affect could allow the athlete to continue to practise and compete in the short term, but interfere with the necessary cognitive and affective capacities to process the trauma in the long term.34

    Howells and Fletcher35 reported that Olympic swimmers who initially perceived an adversity-related experience as traumatic made efforts to cope by maintaining a state of ‘normalcy’ through an emotional and embodied relationship with the water; they described ‘water as a getaway—a silent sanctuary’. These initial efforts eventually became maladaptive, including non-disclosure of traumatic experiences and development of problematic behaviours in the non-performance parts of their lives. Over time, they reported the need to confront their thoughts and feelings and their behavioural choices. During this process, they accepted support and sought meaning in the experience. As a result, the athletes evolved personally and athletically as indicated by improved performances, enhanced relationships and prosocial behaviour. These experiences support the notion of post-traumatic growth. Hammer et al 36 assert that it is not the challenging event itself that is necessarily the most troublesome; instead, disruption to the athlete’s assumptive safe world can be the most problematic, but can also precipitate growth with the proper interventions.

    Dissociation

    Dissociation is a psychological defence often associated with trauma, in which psychological mechanisms set the traumatic memory apart from consciousness.37 Dissociation can be an adaptive, active mental skill that athletes use to enhance performance in high-stress situations.28 However, this disruption in the conscious ability to observe oneself can be non-adaptive if it occurs when stress demands are low.28 Compartmentaliation can be a feature of dissociation; dissociation includes an altered state of consciousness or detachment from one’s environment.38

    Dissociation can be used by athletes to focus their attention externally and distract from internal feelings of pain or fatigue39—a methodology commonly used by endurance athletes.40 41 Elite athletes can withstand competitive, personal and organisational stressors associated with sport by ‘remaining fully focused on the task at hand in the face of distractions.’42 Thomson et al 28 reported that dissociation may enhance performance in the short term and simultaneously indicate a non-adaptive response to stress and/or a way to manage unresolved past experiences. If ignored altogether, the possible presence of a serious mental health symptom or disorder may be overlooked. They suggest that depersonalisation—the feeling of being disconnected from one’s body—may not be perceived by an athlete as abnormal, and thus the athlete may not report it. Leahy37 notes that athletes’ inclination to minimise or avoid distress may lead them to underplay symptoms during a clinical encounter, thereby precluding an accurate assessment of mental health symptoms or disorders. Philippe43 found that women tend to use more dissociative strategies than men, speculating that women are culturally conditioned to avoid pain compared with men, in whom tolerance of pain may be a cultural indicator of strength and endurance.

    Shuer and Dietrich12 found that chronically injured athletes develop post-traumatic symptoms and coping strategies similar to people traumatised by natural disasters, both in intrusive thoughts and avoidance thinking. The avoidance subscales used in their study reference the use of ‘psychological numbing’ through attempts to actively remove thoughts and avoid situations that are reminiscent of the traumatic situation.12 Their avoidance subscales also include dissociation as an active defensive mechanism. Athletes who use dissociation in this way may minimise the extent and nature of their injury. Non-adaptive dissociation numbs the individual from positive feelings of joy and can contribute to an inappropriate numbing to dangerous future circumstances. Lanius et al report that acute dissociative responses predict chronic PTSD.34

    Perfectionism

    Among competitive athletes, perfectionism has been associated with functional and dysfunctional psychological, affective and behavioural tendencies.27 Adaptive perfectionism, defined as deriving satisfaction from intense effort and tolerating imperfections without self-criticism,44 45 is useful for protection from symptom manifestation.46 Perfectionism can morph into maladaptive perfectionism, which may manifest as unrealistic personal standards.44 The long-term effects of perfectionism could be debilitating to athletic potential and, unless appropriately managed, could result in mental health symptoms or disorders.47

    Egan et al 48 found perfectionism and PTSD to be significantly correlated. In addition, rumination was a significant mediator of the relationship between ‘concern over mistakes’ and PTSD.48 Additionally, ‘concern over mistakes’ could be a manifestation of obsessive-compulsive disorder, which can be comorbid with trauma-related disorders.46

    Athletes with lost movement syndrome or ‘yips’—both conditions involving loss of fine and/or gross motor skills in athletes—report a history of significant life events, such as traumatic loss of a loved one or traumatic injury.49 Additionally, individuals with high levels of perfectionism are more susceptible to the negative consequences of traumatic life events.49 In their study of lost movement syndrome, Day and colleagues50 report that psychologically significant experiences in sport (eg, injury, failure, vicarious trauma) were equivalent to traumatic experiences, triggering comparable behavioural responses to those of trauma victims.50 Athletes who exhibit characteristics of unhealthy perfectionism combined with a high perceived stress response are at greater risk for experiencing performance breakdown (eg, lost movement syndrome) as a traumatic event.49

    Management

    Early identification of and intervention for suspected trauma-related disorders mitigate associated morbidity.6 It is helpful for clinicians to be aware of any ACEs to assess an athlete’s premorbid vulnerabilities.14 This knowledge could assist in earlier diagnosis and management of symptoms, so that the increased symptom complexity that results from cumulative childhood trauma can be minimised.14 Thomson et al 28 recommend that providers working with elite athletes have comprehensive training in assessment of dissociative disorders. Finally, clinicians might consider repeat screening for PTSD based on early subsyndromal symptoms within the first 6 months after a trauma exposure.51

    The 2004 American Psychiatric Association Practice Guidelines for PTSD, and a 2018 systematic review of psychological and pharmacological treatments for PTSD in adults by the Agency for Healthcare Research and Quality (AHRQ), recommend employing various treatment measures including psychotherapeutic, psychoeducational and, if necessary, pharmacological interventions for PTSD.52 53 Combination therapy is widely used; specifics of treatment are generally determined by an individual’s symptoms and severity of impairment.52 Treatment guidelines specifically targeting athletes have not been established. Psychotherapy often used in the treatment of PTSD includes trauma-focused cognitive–behavioural therapy (TF-CBT), prolonged exposure (PE) therapy, cognitive processing therapy (CPT) and, to a lesser extent, eye movement desensitisation and reprocessing (EMDR) therapy.52–54 These therapies are typically highly structured and time limited, with CPT, TF-CBT and EMDR all typically occurring in 16 sessions or less.54

    CPT, PE and EMDR focus on the patient’s experience of the trauma, with the goal of creating a coherent narrative of the trauma and reducing distress around those memories.54 TF-CBT shares a similar focus, though mixed CBT (CBT performed with both trauma-focused and non-trauma-focused techniques) also emphasises development of strategies to address acute symptomatology.54 All forms of CBT may be performed in individual or group settings. The AHRQ review of psychological treatments for PTSD found the highest strength of evidence for CBT therapies (both mixed CBT and TF-CBT). Therapies with moderate evidence included CPT, EMDR and narrative exposure therapy.53 The American Psychological Association has found strong evidence for PE therapy in the treatment of PTSD symptoms.54 Lower levels of evidence were noted for seeking safety, trauma affect regulation, brief eclectic psychotherapy and image rehearsal therapy.53 There is currently insufficient evidence to provide guidance on specific therapeutic methodologies based on the nature of an individual’s trauma.53 In addition to traditional psychotherapeutic interventions, there is evidence for mindfulness/meditation in treatment of trauma-related disorders.55 56 There is also some evidence to support more conservative and supportive case management-style approaches in early treatment of trauma-related symptoms, such as those of ASD.52

    None of the above research on psychotherapeutic modalities examined efficacy in elite athletes. However, data specific to athletes suggest that team-based approaches may support individuals directly and indirectly affected by trauma. Coordination with an experienced mental health professional and careful debriefing of traumatic events may provide benefit.8 Team-based approaches support members who are affected by vicarious trauma and provide an outlet for them to express their experience of distress.18 Conversely, passive attitudes, non-intervention denial and silence by those in power may compound the initial trauma.57 Blaming the individual for the trauma may lead to a negative, catastrophic evaluation of the circumstances, perpetuating symptoms of trauma.58 The support of other team members and non-judgemental management of trauma by athletic staff is beneficial in mitigating the psychological complications of the inciting events.58 Interventions aimed at increasing an athlete’s sense of self-efficacy may increase an athlete’s ability to cope with the stress of injury, improving rehabilitation times.1

    Selective serotonin receptor inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitors (SNRI) are considered first-line pharmacological treatments for PTSD within the general population, with best evidence for venlafaxine (SNRI), paroxetine (SSRI) and fluoxetine (SSRI).25 53 In general (not specific to a PTSD diagnosis), fluoxetine is regarded as a top medication option among the serotonergic classes for athletes.59 However, there are too few comparative effectiveness trials to suggest an algorithm for selecting medication versus psychotherapy when initiating treatment for trauma-related disorders.52 53

    While alpha-blocking agents such as prazosin have often been used off-label to address hyperarousal and nightmares among the general population with PTSD, the evidence for this approach is mixed.52 53 The AHRQ systematic review found a low strength of evidence for alpha-blocking medications in treating PTSD.53 Moreover, when prescribing this class of medications to elite athletes, providers should consider their potential to decrease blood pressure, as elite athletes may have low blood pressure at baseline. Other agents sometimes used to augment PTSD treatment, such as the anticonvulsant topiramate and second-generation antipsychotics olanzapine and risperidone, are considered to have a low strength of evidence for efficacy.53 Moreover, antipsychotics may cause side effects, including sedation and weight gain, that could be particularly problematic for elite athletes.59 60

    Conclusion

    There may be higher rates of PTSD and other trauma-related disorders in elite athletes than in the general population, stemming from traumas that include sport-specific inciting events. Although data are sparse regarding the frequency of screening of athletes for PTSD, relatively high rates of PTSD in this population may warrant routine screening for trauma-related symptomatology. Widespread use of standardised screening for athletes, routinely and/or following traumatic events, could prevent ASD symptoms progressing to PTSD and may ameliorate serious function-interfering PTSD symptoms. Additionally, given the relationship between trauma response and ACEs, a screening protocol to identify at-risk athletes may be helpful in developing targeted interventions within institutions and teams. Some efforts in the field of trauma-related disorders in athletes have moved towards algorithms for screening; however, no validated tool or protocol has risen to the level of standard of care.

    Athletes may consciously or subconsciously mask trauma-related symptoms or avoid presenting for mental health treatment due to stigma, delaying important treatment. The coping styles described in athletes may be amenable to various evidence-based therapies already used to treat PTSD in the general population, with reasonable adaptations based on what we know about athletes’ physiology and psychology.

    What is already known

    • Elite athletes are commonly exposed to sources of physical and emotional trauma, including personal injury/risk of injury, witnessing of injuries in teammates and traumas incurred outside of sports participation.

    • Traumatic experiences may manifest as mental health symptoms or disorders, including acute stress disorder, post-traumatic stress disorder or adjustment disorder.

    • Early detection and treatment of trauma-related mental disorders may reduce the risk of them progressing to chronic conditions.

    What are the new findings

    • Elite athletes may have increased rates of trauma-related symptoms and disorders compared with the general population.

    • Elite athletes commonly develop coping strategies that can be adaptive in the setting of trauma, but may also mask trauma-related symptoms, making trauma-related disorders more difficult to detect.

    • While general guidelines exist for the treatment of trauma-related disorders, treatment and screening protocols specific to elite athletes have not been established.

    Acknowledgments

    The authors thank the other participants in the 2018 IOC Consensus Meeting on Mental Health in Elite Athletes, including David Baron, Antonia Baum, Abhinav Bindra, Richard Budgett, Niccolo Campriani, Joao Mauricio Castaldelli-Maia, Alan Currie, Jeff Derevensky, Lars Engebretsen, Ira Glick, Paul Filip Gorczynski, Vincent Gouttebarge, Michael Grandner, Doug Hyun Han, David McDuff, Margo Mountjoy, Aslihan Polat, Rosemary Purcell, Margot Putukian, Simon M Rice, Allen Sills, Torbjorn Soligard, Todd Stull, Leslie Swartz and Li Jing Zhu for their input on the development and interpretation of this research.

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    Footnotes

    • Contributors All authors have participated in the following: (1) substantial contributions to the conception and design of the work, and the acquisition, analysis and interpretation of data; (2) critical revisions of drafted work for important intellectual content; and (3) final approval of the version published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.