Chapter 33
Athlete Mental Health
Andrew T. Wolanin and Donald R. Marks
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Mental health issues and concerns have become
an increased focus of attention in the media, pro-
fessional literature, and administrative policies in
recent years. In particular, in 2016 the National
Collegiate Athletic Association (NCAA) Sport
Science Institute released the Mental Health Best
Practices manual that detailed a set of guidelines
for providing screening and mental health services
for athletes who participate in university athletic
departments (NCAA, 2016). This manual acknowl-
edges various forms of psychopathology in athletes
and recognizes the need for mental health services
for athletes. In addition, Division 47 of the American
Psychological Association indicated in the president’s
address that there has been an increased focus on
developing guidelines for applied professional work
with athletes (Kontos, 2015).
The media and the scientific community have
reported on case studies in which athletes have experi-
enced various forms of psychopathology in the context
of sport competition. In addition, there are case studies
involving tragic instances of the athlete withdraw-
ing from sports and, in extreme cases, entertaining
thoughts of suicide or, in rare instances, committing
suicide. Although administrative bodies and the
media are cognizant of mental health issues occurring
among athletes, the literature on psychopathology in
sport is relatively sparse. The lack of clear preva-
lence data generally results in a lack of understand-
ing as to why certain psychopathology may exist for
http://dx.doi.org/10.1037/0000123-033
APA Handbook of Sport and Exercise Psychology: Vol. 1. Sport Psychology, M. H. Anshel (Editor-in-Chief)
Copyright © 2019 by the American Psychological Association. All rights reserved.
APA Handbook of Sport and Exercise Psychology, Volume 1: Sport Psychology,
edited by M. H. Anshel, T. A. Petrie, and J. A. Steinfeldt
Copyright © 2019 American Psychological Association. All rights reserved.
certain types of athletes at various points in their
athletic development, which in turn results in a lack
of well-controlled trials of interventions to treat the
mental health issues that are occurring. The authors
contend that athletes are an underserved population
when it comes to mental health issues, which have
a direct effect on individual well-being, athletic
performance, and healthy human development
across the lifespan.
In this chapter, we explore the literature relevant
to various forms of psychopathology in athletes,
provide a conceptualization of how these mental
health conditions may be uniquely manifested in an
athlete population and environment, and discuss how
athletes may experience functional impairments. In
addition, we provide an overview of evidence-based
practice with potential adaptations or limitations
with athlete populations. Finally, considering the
paucity of research in some of the areas of focus in
this chapter, we provide directions and recommen-
dations for evidence-based treatments and future
research on this important topic.
DEPRESSIVE DISORDERS
Mood-related problems are widely occurring forms
of psychological distress, characterizing many of
the most routinely diagnosed psychiatric conditions.
The Diagnostic and Statistical Manual of Mental
Disorders, fifth edition (DSM–5; American Psychiatric
653
 Wolanin and Marks
Association, 2013), identifies numerous symptoms
associated with mood, including behavioral, physical,
and cognitive changes. Given the variety of poten-
tially mood-related symptoms, the epidemiology of
depressive disorders has been a challenging area of
investigation.
Major Depressive Disorder
Of significant importance to the general population
and athletes, major depressive disorder (MDD)
has been the most widely studied across an array
of diverse contexts (Ritschel, Gillespie, Arnarson,
& Craighead, 2013). The primary symptoms of
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MDD are intense and frequent negative mood and
loss of interest in, or capacity to derive pleasure from,
life activities. One of these two symptoms is required
to meet the criteria for an MDD diagnosis. Other
symptoms include significant changes in weight (i.e.,
5% weight gain or loss), insomnia or hypersomnia,
psychomotor agitation or slowing, fatigue, feelings of
worthlessness or guilt, diminished concentration, and
thoughts of death or suicidal ideation (American Psy-
chiatric Association, 2013). To receive the MDD diag-
nosis, an athlete must experience at least five of these
symptoms for 2 weeks or more. Because of the variety
of possible symptoms, there are more than 225 differ-
ent ways an athlete could meet criteria for an MDD
diagnosis (Zimmerman, Ellison, Young, Chelminski,
& Dalrymple, 2015).
The National Comorbidity Survey Replication
(N = 9,090) study estimated the 12-month preva-
lence rate for MDD at 6.6% and the lifetime preva-
lence rate at 16.2% (Kessler et al., 2003; Kessler,
Chiu, Demler, Merikangas, & Walters, 2005). There
are, however, significant demographic variations
in prevalence, with adolescents (ages 12–17 years)
approximately twice as likely as the general popula-
tion to meet criteria for MDD (Center for Behavioral
Health Statistics and Quality, 2016). Also, prevalence
rates among women run roughly twice as high as
those found among men (Kessler et al., 2003).
Prevalence estimates for MDD among athletes
have varied. A recent study (Wolanin, Hong, Marks,
Panchoo, & Gross, 2016) involving 465 college
athletes and using the Center for Epidemiological
Studies Depression Scale (CES-D; Radloff, 1977)
revealed that 23.7% of athletes endorsed at least mild
654
depressive symptoms, and 6.3% endorsed moderate
to severe symptoms likely to meet criteria for MDD.
Female athletes in this study were 1.84 times more
likely to experience clinically relevant depressive
symptoms than male athletes. These findings resem-
bled rates found by Yang et al. (2007), who also used
the CES-D in a survey of 257 college student athletes.
Those authors found that 21% endorsed at least mild
depressive symptoms, and 6.2% endorsed moderate
to severe symptoms; again, female student athletes
were more likely (1.32 times) than male student
athletes to report significant depressive symptoms.
By contrast, a study of 162 German elite and amateur
athletes also using the CES-D (Nixdorf, Frank,
Hautzinger, & Beckmann, 2013) found that 19%
endorsed symptoms consistent with a diagnosis
of MDD (CES-D score of 22 or higher) with no
significant differences between male and female
athletes’ rates of depression. Nixdorf et al. (2013)
also found that only 15% of elite athletes endorsed
significant depressive symptoms compared with
29% of amateur athletes.
Researchers have discovered lower rates of clini-
cally relevant depressive symptoms in athletes than
in nonathletes. Proctor and Boan-Lenzo (2010), for
example, found that only 15.6% of college student
athletes reported at least mild depressive symptoms
on the CES-D, which was approximately half the rate
found among nonathlete students. Armstrong and
Oomen-Early (2009), in a study of NCAA Division I
collegiate athletes (n = 104) and student nonathletes
(n = 123), found significantly lower levels of depres-
sive symptoms among athletes. Notably, however,
athlete status was not a significant predictor of
depressive symptoms when other factors examined
in the study were taken into account, including
gender, self-esteem, social connectedness, and sleep.
Findings from these studies differ from those of
Storch, Storch, Killiany, and Roberti (2005), who
found a prevalence rate of 7.1% for clinically rel-
evant depressive symptoms in a sample of 98 ath-
letes, with female athletes roughly twice as likely
as male athletes to experience significant symptoms.
It should be noted, however, that Storch et al. used
a personality battery that may have lower sensitivity
than measures used in epidemiological research,
such as the CES-D.

Taken together, it appears that the prevalence esti-
mates for depression among athletes vary substantially
across samples. It is clear, however, that clinically
relevant depressive symptoms are common among
athletes at all levels of sport competition and that
female athletes are at greater risk than male athletes.
Chronic Depression
Persistent depressive disorder (PDD) was first intro-
duced in DSM–5 (American Psychiatric Association,
2013), which merged the categories of dysthymic
disorder and chronic major depressive disorder. PDD
is characterized by depressed mood for a period of
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2 years (1 year in children and adolescents). During
this period, the individual must have experienced
two of the following: poor appetite or overeating,
insomnia or hypersomnia, fatigue, poor self-esteem,
difficulty concentrating or making decisions, or feel-
ings of hopelessness. The prevalence rate for this
new diagnostic category has yet to be determined,
and no prevalence estimates for athletes are available.
It is reasonable to surmise, however, that the chronic
stressors confronting athletes at all levels of competi-
tion could contribute to development of PDD.
Depression Risk Factors for Athletes:
Sport, Injury, and Loss
Potential risk factors for depression are numerous,
but sport type, injury, and loss have been targets of
sustained research. Researchers have noted signifi-
cant differences in depressive symptoms by sport
type. Wolanin et al. (2016) found that the highest
risk for clinically relevant depressive symptoms
could be found among track and field athletes, with
35.4% reporting at least mild depression and 8.5%
endorsing symptoms that were moderate to severe.
The lowest risk of depression was found among
lacrosse players, of whom 11.6% reported at least
mild symptoms and only 1.4% reported symptoms
that were moderate to severe. In a recent study of
199 German junior athletes, Nixdorf, Frank, and
Beckmann (2016) similarly found that athletes
participating in individual sports reported higher
levels of depression than athletes in team sports.
Injury status is another factor contributing to
the prevalence of depressive symptoms in sport. As
Wolanin, Gross, and Hong (2015) noted, multiple
Athlete Mental Health
studies (Appaneal, Levine, Perna, & Roh, 2009;
Brewer & Petrie, 1995; Petrie, Brewer, & Buntrock,
1997) identified differences in depression prevalence
between athletes with recent injuries and those with-
out an injury history. In a study by Leddy, Lambert,
and Ogles (1994), injured collegiate athletes were at
significantly greater risk than noninjured controls for
endorsing depressive symptoms. Fully 51% of 175
injured athletes in that study obtained scores indicat-
ing at least mild depressive symptoms. Manuel et al.
(2002), in a study of adolescent athletes (N = 48),
found that 27% of injured athletes endorsed moder-
ate or severe depressive symptoms at injury onset.
There have been exceptions to these findings.
One specific form of sport injury, concussion or
mild traumatic brain injury (MTBI), has been linked
with depression (Hutchison, Mainwaring, Comper,
Richards, & Bisschop, 2009; Wolanin et al., 2015).
Acute mood changes following concussion have
been shown to contribute to higher endorsement of
depressive symptoms within 14 days of injury in high
school and college athletes (Kontos, Covassin, Elbin,
& Parker, 2012). In a large study (N = 672) of youth
hockey players, Mrazik, Brooks, Jubinville, Meeuwisse,
and Emery (2016) also found a significant association
between acute head injury and elevated depressive
symptoms. See also Chapter 38, this volume.
The relationship between MTBI and vulnerability
to depression appears to be sustained over time. In
a study of 1,044 retired National Football League
(NFL) players, athletes with histories of concussion
demonstrated significantly elevated risk for depres-
sion diagnosis for 9 years following retirement (Kerr,
Marshall, Harding, & Guskiewicz, 2012). Of athletes
reporting no concussions, only 3% endorsed clinically
significant levels of depression, compared with 26.8%
of athletes who reported 10 or more concussions
during their playing careers. In another study of NFL
athletes (N = 2,552), Guskiewicz et al. (2007) found
that players reporting one or two concussions were
1.5 times more likely than athletes without a concus-
sion history to be diagnosed with depression. Athletes
with three or more concussions were three times
more likely to be diagnosed. Neuroimaging studies
involving retired NFL athletes (Hart et al., 2013;
Strain et al., 2013) also revealed patterns of brain
activity that correlate with elevations on measures of
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 Wolanin and Marks
depression. Didehbani, Munro Cullum, Mansinghani,
Conover, and Hart (2013) examined 30 retired NFL
athletes and found a significant relationship between
reported lifetime concussions and current depressive
symptoms.
Although MTBI may yield sustained neurological
changes, it is not clear whether these postinjury
changes contribute to depressive symptoms. Find-
ings from functional magnetic resonance imaging
(fMRI) studies of depressed nonathletes suggest
similar patterns of neurological responding to those
of depressed athletes with histories of concussion
(Chandrasekhar Pammi et al., 2015; Herwig et al.,
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2010). In a study of 84 collegiate athletes with
histories of concussion and 42 healthy controls,
Vargas, Rabinowitz, Meyer, and Arnett (2015) found
that several factors contributed more to depressive
symptoms than number of concussions, including
higher preinjury depressive symptoms, lower full-
scale IQ, older age at first participation in sport,
non-White ethnicity, and fewer numbers of games
missed. Finally, it is difficult to separate the effects
of MTBI from musculoskeletal injuries in general.
Mrazik et al. (2016) found similar rates of depres-
sive symptoms among athletes with concussions and
competitors who endured another type of injury.
Mainwaring, Hutchison, Bisschop, Comper, and
Richards (2010) found that athletes with anterior
cruciate ligament (ACL) injuries endorsed higher
levels of depression for longer periods than those
with concussions.
In addition to gender and injury status, experi-
ences of loss also have been associated with depres-
sive symptoms. Examples include career termination
(Stephan, Bilard, Ninot, & Delignieres, 2003) and
significant defeat or deterioration of performance
(Hammond, Gialloreto, Kubas, & Davis, 2013).
Research concerning depression risk at career termi-
nation has examined differences between voluntary
(e.g., retirement) and involuntary (e.g., graduation,
career-ending injury, termination for performance)
departure from sport. Loss of athletic participation
brings about changes in social networks, daily activ-
ity schedules, and life priorities, which can be abrupt
and even traumatic (Wippert & Wippert, 2008,
2010). The frame of reference for life engagement
shifts as one transitions from a focus on practice and
656
competition in sport to other domains of life activity
(see Grove, Lavallee, & Gordon, 1997).
Hammond et al. (2013) found that loss of status
relative to other athletes also contributed to depres-
sive symptoms. In a study of 50 varsity swimmers,
these researchers found a significant relationship
between depressive symptoms and changes in perfor-
mance among the top 25 competitors, with athletes
whose performance was poorer reporting higher
levels of depression. Although 68% of the sample
in this study endorsed having met criteria for major
depressive disorder in the past 3 years, performance
changes proved to be a better predictor of depressive
symptoms than a history of depression. A recent qual-
itative study (Doherty, Hannigan, & Campbell, 2016)
regarding the experience of depression among male
Olympic athletes shed light on the processes poten-
tially underlying associations between performance
degradation and depression. Extreme athletic iden-
tity (e.g., exclusive, all-consuming focus on sport),
external locus of evaluation (obsessive drive to win,
playing to prove self-worth), and perceived inability
to manage stressors (loss of performance skills, unac-
ceptable performance results) all featured in athletes’
accounts of how their depression developed.
Depression in Athletes: Etiology
and Conceptualization
Researchers examining the etiology of depression
have typically advanced theory-specific conceptual-
izations, with cognitive behavioral and biomedical
approaches receiving the greatest research attention
(Ritschel et al., 2013).
Cognitive behavioral approaches.   From a behav-
ioral perspective, Lewinsohn (1974) ascribed
depressive symptoms to reduced rates of response-
contingent positive reinforcement. In this model,
an initial alteration in opportunities for reinforce-
ment contributes over time to social withdrawal,
loss of interest in activities once enjoyed, decreased
estimates of self-worth, agitation, hopelessness, and
even suicidality as a potential escape from a vicious
downward spiral. Following Lewinsohn’s theory,
certain sentinel events in an athlete’s life (e.g., injury,
relationship changes) could prove likely contribu-
tors to reduced opportunities for reinforcement and
the formation of depressive symptoms. Lewinsohn

also noted the importance of social skills in respond-
ing to these environmental changes. Interpersonal
skills deficits, he contended, would render it difficult
for the individual to navigate to new contexts in
which alternative reinforcement opportunities might
be found.
Cognitive theories of depression emphasize the
relationship between depressive symptoms and par-
ticular cognitions. To explain the development of the
hopelessness and pessimism so often accompanying
depressive symptoms, Seligman (1975) formulated
the theory of learned helplessness. Elaborations on
Seligman’s work have explored the role of explana-
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tory style (Ritschel et al., 2013) and the ways that
the depressed individual’s account of his or her
helplessness in a given situation contributed to the
development of hopelessness. Abramson, Metalsky,
and Alloy (1989) described “hopeless depression” as
resulting from the belief that pervasive deficits make
desirable outcomes unobtainable. Beck (1963, 1987)
observed that individuals experiencing psycho­
logical distress typically espoused thoughts and
perspectives that led to faulty information process-
ing and, ultimately, to emotional distress, passivity,
and hopelessness. Beck, Rush, Shaw, and Emery
(1979) identified these perspectives as “cognitive
distortions,” noting that distortions about the self,
world, and future characterized depression.
Recent developments in the cognitive behav-
ioral tradition have focused on conceptualizing
certain forms of verbal thought (e.g., rumination)
as a distractor from present moment experience
(Zettle, 2007). Mindfulness- and acceptance-based
therapies (Hayes, Strosahl, & Wilson, 2011; Segal,
Williams, & Teasdale, 2012) suggest that preoccu-
pation with mental activity and overidentification
with the content of particular thoughts contributes
to reduced engagement in life, which, in turn, may
contribute to formation of depressive symptoms.
Rumination concerning unwanted experiences or
particular stories about oneself could contribute to
further disengagement from potentially reinforcing
environmental contingencies.
Biomedical approaches.   Proponents of biological
theories of depression emphasize the role of genetics
and heritability. Nevertheless, no clear candidates for
genetic markers of mood disorders have been found
Athlete Mental Health
(Joseph, 2015; Ritschel et al., 2013). Neurotransmitter
hypotheses regarding depressive symptoms also have
received considerable research attention, especially
following the success of serotonergic medications. Yet
no differences between depressed patients and healthy
controls in the availability of neurotransmitters has
been found (Moncrieff, 2008; Stahl, 2013). Recently
psychiatrists have considered the role of brain-derived
neurotrophic factor (BDNF) in depression. BDNF may
be more effectively produced and regulated as a result
of antidepressant treatment, and it may contribute to
more resilient stress responding (Gonul et al., 2005;
Ritschel et al., 2013; Stahl, 2013).
Other biological approaches to depression have
emphasized neuroendocrinology, suggesting that
stress hormone dysfunction creates a susceptibility
for mood disorders. Proponents of these approaches
contend that a biological predisposition to excessive
hypothalamic-pituitary-adrenal (HPA) axis reactivity
contributes to difficulties in responding effectively
to stress challenges in life (e.g., loss, change, failure),
which in turn contribute to the development of
depressive symptoms (Ritschel et al., 2013). From the
standpoint of clinicians working with athletes, it may
be most useful to know that there are sex differences
in HPA responding (Goel, Workman, Lee, Innala,
& Viau, 2014). These differences may contribute to
the discrepancies in depression prevalence between
male and female athletes. In addition, considerable
research has examined the role of the HPA axis and
associated brain areas in responding to pain or other
forms of discomfort (Greenspan et al., 2007), which
may be a potential factor in the relationship between
injury and depressive symptoms in athletes.
Depression-Related Impairment
for Athletes
The most serious form of impairment associated with
depression is suicidality. A. M. Smith and Milliner
(1994) identified factors common to athletes in their
own sports medicine practice who had attempted
suicide. These included experiencing a serious injury
requiring surgical intervention, extended absence
from sport because of injury rehabilitation, erosion
of athletic skills because of absence from play, and
replacement on their team or at their position in sport.
Suicide is the 10th leading cause of death among the
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 Wolanin and Marks
general population and the second leading cause of
death among individuals 15 to 34 years of age (Centers
for Disease Control and Prevention, 2013), the age
group in which most athletes fall. Suicide risk is asso-
ciated with prior suicide attempts, mood disorder
diagnosis, substance use, and access to lethal means
of self-harm (Suicide Prevention Resource Center &
Rodgers, 2011). It is recommended that all clinical
sport psychologists and behavioral health profession-
als obtain thorough training in the prevention and
management of suicidal crises (see Kleespies, 2014).
Other problems associated with depressive dis-
orders among athletes include lack of engagement
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in training and competition or nonadherence to
injury rehabilitation regimens. Loss of enthusiasm
and enjoyment related to depressive anhedonia and
psychomotor slowing could contribute to significant
changes in team dynamics, situational responsive-
ness, and coach–athlete relationships (K. D. Cogan,
2000; Gardner & Moore, 2006). These behavioral
changes could be misinterpreted as a function of
an athlete’s misguided approach or an “attitude
problem,” but they are likely to be unresponsive to
simple instructions or urgings to “think differently.”
In addition, athletes with depressive symptoms
may experience significant problems with sleep
deprivation, leading to performance deficiencies in
sport and other domains of life, such as academic
or social activities. Similarly, hypersomnia and
fatigue in depression can lead to missed practices
and disrupted training schedules, as well as failure
to engage in important remedial or rehabilitation
programs. Loss of appetite in depression may lower
energy and diminish performance, and weight gain
associated with depression may pose problems for
athletes in sports with narrow weight classifications.
The diminished concentration associated with
depression can be a source of significant impair-
ment. When concentration problems arise for ath-
letes without histories of attentional difficulties,
it is useful to consider mood-related symptoms.
Often, concentration problems relate to engagement
in depressive rumination regarding the causes for
distress (e.g., why do I feel so bad?). Ruminative
self-questioning is likely to contribute to cognitive
fusion (Hayes, 1987; Hayes et al., 2011; Zettle,
2007), in which the athlete clings inflexibly to
658
particular explanations for his or her distress.
Athletes who have made an error or lost a key match,
for example, may expend considerable mental effort
reviewing “what went wrong,” perhaps assigning
blame to themselves or others for the unsatisfactory
performance outcome. While engaging in this type
of retrospective scrutiny, athletes may miss oppor-
tunities to engage in alternative responses. Athletes
engaging in “reason giving” rumination (Zettle,
2007, p. 44) may demonstrate psychological inflex-
ibility, insisting that the perceived causes of their
distress (e.g., injury, performance decrement, change
in ranking, character flaw) must change before their
mood symptoms can improve.
Finally, avoidance of unwanted experiences
while experiencing depressive symptoms can also
maintain social withdrawal. For example, if athletes
must face a judgmental or aversive peer or coach,
they may choose instead to minimize interaction
or even miss a practice or event. The result of this
experiential avoidance could be increased aversive
consequences, leading to further interpersonal diffi-
culties and potentially even to lost opportunities for
engagement in sport.
BIPOLAR AND RELATED DISORDERS
Three diagnostic categories are included in the
DSM–5 (American Psychiatric Association, 2013)
section on bipolar disorders: (a) bipolar I disorder,
(b) bipolar II disorder, and (c) cyclothymic disorder.
Bipolar I disorder features experience of a severe
“manic episode,” which the DSM–5 describes as
“a distinct period of abnormally and persistently
elevated, expansive, or irritable mood” (American
Psychiatric Association, 2013, p. 124), coupled with a
similarly abnormal and persistent increase in activity
or energy. The distinct period in this case is defined
as either 1 week or any duration if hospitalization
is needed. Bipolar II disorder involves both a hypo-
manic episode (lasting 4 days or more but not leading
to hospitalization) and a major depressive episode.
Manic and hypomanic symptoms, as specified in the
DSM–5, include (a) inflated self-esteem or grandiosity,
(b) decreased need for sleep, (c) talkativeness or
pressured speech, (d) flight of ideas, (e) distractibility,
(f) increased goal-directed activity, and (g) excessive

risk-taking. Cyclothymic disorder is a rare condition
involving a chronic pattern of both hypomanic symp-
toms insufficient to meet criteria for a hypomanic
episode and depressive symptoms insufficient to meet
criteria for a major depressive episode.
According to data from the World Mental Health
Survey Initiative (Merikangas et al., 2007), global life-
time prevalence for the bipolar disorders as a whole
is 2.4%, with a 12-month prevalence of 1.5%. Of
the 11 nations included in the World Mental Health
Survey, the United States reported the highest rates
of the bipolar disorders, with lifetime prevalence of
4.4% and 12-month prevalence of 2.8%.
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Bipolar Disorder: Etiology and
Conceptualization
As with the depressive disorders, there are bio-
medical and cognitive behavioral explanations
for the development and maintenance of bipolar
disorder symptoms.
Biomedical approaches.   Bipolar disorder has typi-
cally been presumed to have a genetic basis. Critics,
however, have found genetic evidence less than con-
vincing (Joseph, 2004, 2006), and efforts to identify
particular genetic loci associated with bipolar disorder
have yielded largely inconclusive results (Jones &
Bentall, 2006; Willicutt & McQueen, 2010). Given the
widespread acceptance of high heritability estimates in
the literature, however, few researchers would rule out
genetic contributors to bipolar symptoms (Miklowitz
& Johnson, 2013).
Biomedical approaches have emphasized the role
of particular neurotransmitters in bipolar symptoms,
including glutamate, gamma amino-butyric acid
(GABA), dopamine, serotonin, and norepinephrine
(Stahl, 2013). Anticonvulsant medications used
to control manic symptoms (e.g., valproic acid,
lamotrigine), for example, influence the glutamate
and GABA systems. Lithium appears to influence
GABA, as well as dopamine, serotonin, and norepi-
nephrine, which have been associated with depres-
sion (Stahl, 2014). Because medications can reduce
bipolar symptoms, researchers have assumed that
development of the disorder is related to dysfunction
in the neurotransmitter systems the medications
target (Moncrieff, 2008).
Athlete Mental Health
Cognitive behavioral approaches.  Behavioral con-
tributors to bipolar symptoms have been more widely
studied in recent decades. According to Miklowitz
and Johnson (2013), two areas of concern have been
associated with the onset of both manic and depres-
sive symptoms: (a) life events and (b) social support.
Life events include stressors and relational challenges
that bring about changes in an athlete’s routines and
functional context. These events could include losses,
traumas, relationship changes, and disruptive events,
all of which have been associated with depressive
symptoms. Yet, life events have also been associated
with manic symptoms, particularly events involving
goal attainment and sleep disruption.
According to S. L. Johnson, Eisner, and Fingerhut
(2007), individuals who have experienced manic
symptoms may have heightened sensitivity to
reward and increased positive affect in response to
success. These individuals also appear to be more
responsive to incentive cues and more inclined to
choose difficult future goals after achieving a
success. Athletes with histories of mania may be
more sensitive to changes in sleeping patterns and
life schedules, with sleep and circadian rhythm dis-
ruption associated with the onset of mania (see Melo
et al., 2016). Finally, competitors at risk for bipolar
symptoms may be more vulnerable to loss of social
supports or increases in negative expressed emotion
(McMurrich & Johnson, 2009; Miklowitz, 2007).
Bipolar Disorder and Impairment
for Athletes
Considering these psychosocial contributors in the
context of sport activity, it quickly becomes apparent
that athletes with vulnerability to bipolar symptoms
face unique challenges and risks. Goal attainment is
a central feature of an athlete’s life, with continual
renewal of performance objectives and reorientation
of one’s aspirations toward new benchmarks (e.g.,
entrance to an elite level, securing a league or class
championship). Moreover, sport achievement at
many levels can be associated with a varied and
often disruptive schedule. Student athletes, for
example, often juggle complicated schedules to
complete academic requirements while maintain-
ing participation in their sport (Cosh & Tully,
2015). Sleep deprivation, or at least alteration of
659
 Wolanin and Marks
sleep schedules, particularly prior to athletic com-
petition, is well documented and in some instances
may become the norm (Fullagar et al., 2015; Juliff,
Halson, & Peiffer, 2015). Additionally, athletes at
all levels may lack adequate social supports or face
critical, unsupportive relationships with coaches,
fellow athletes, family members, or others in their
life who are disappointed with their choices or
behavior (Kassing & Infante, 1999; Ritvo & Glick,
2005). Each of these factors can contribute to behav-
ioral health problems and reduced quality of life for
athletes, but they may prove especially detrimental
for athletes with histories of the mood symptoms
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associated with bipolar depression and mania (Glick,
Stillman, Reardon, & Ritvo, 2012). Ideally, unwanted
outcomes related to mania or hypomania can be
successfully avoided through proper treatment,
informed coaching support, and crisis prevention.
Symptom distress and behavioral problems
associated with bipolar and related disorders can
be significantly debilitating for athletes. As with
other mood-related problems, suicidality is a
primary concern among individuals with bipolar
symptoms. According to Jamison (2000), 25% to 50%
of individuals with a diagnosis of bipolar disorder
attempt suicide at least once in their lives, and their
attempts are more likely to be lethal. It is imperative,
therefore, to treat suicidality among athletes with
bipolar diagnoses or associated patterns of distress
with responsiveness and sensitivity, as well as an
appropriate sense of urgency.
Depressive symptoms associated with bipolar
disorder contribute to impairment in ways resem-
bling MDD and PDD (Miklowitz & Johnson, 2013).
Manic symptoms, however, can also be a significant
source of impairment. At elite levels of sport partici-
pation, in particular, frequent or intense emotional
disruptions are likely to take a toll on all of an ath-
lete’s relationships. Aggression, including belligerent
on-field behavior as well as problems with violence
off the field, also can be associated with manic or
mixed states (Baum, 2003). Florid manic symptoms
can lead to hospitalization or arrest, which in turn
can contribute to unreliability and disengagement,
potentially leading to loss of eligibility or even ter-
mination of an athlete’s career. Hypomanic symp-
toms, by contrast, may go unobserved (Andersen,
660
Denson, Brewer, & Van Raalte, 1994) and contrib-
ute either to minimal impairment or even perceived
improvements in engagement or performance
(Gardner & Moore, 2006).
Excessive risk-taking and impulsivity, which
are often associated with manic states, also pose
potential problems for athletes exhibiting symptoms
of bipolar disorder (Dudek et al., 2016). Athletes
who engage in excessive exuberance or poorly con-
sidered risk-taking during sport performance may
be more prone to injuring themselves or others,
including teammates (Junge, 2000; Sluis et al., 2017;
Zeren & Oztekin, 2005). In addition, poor decision
making could contribute to lack of individual or
team success, which in turn could foster personal
or interpersonal distress. Risky sexual behavior
also is associated with manic states (Dvorak, Wray,
Kuvaas, & Kilwein, 2013), and sexual risk-taking
among athletes has been associated with a variety
of negative outcomes, including significant career
disruption (Reel, Joy, & Hellstrom, 2012; Wetherill
& Fromme, 2007). Similarly, grandiosity and exag-
gerated self-importance could promote unrealistic
expectations on the part of the athlete and others in
his or her support system, as well as interpersonal
conflict when and if unrealistic claims or assump-
tions are challenged (Newman, Leahy, Beck, Reilly-
Harrington, & Gyulai, 2002).
ANXIETY AND RELATED DISORDERS
Anxiety-related problems are prevalent forms of
psychological dysfunction and commonly diag-
nosed psychiatric conditions. The DSM–5 (American
Psychiatric Association, 2013) identifies numerous
symptoms associated with anxiety including behav-
ioral, physical, and cognitive changes. Among the
most relevant anxiety and related disorders specified
in DSM–5 are panic disorder, generalized anxiety
disorder, and social anxiety disorder; identified as
related disorders are posttraumatic stress disorder
(PTSD) and obsessive-compulsive disorder (OCD).
Panic disorder is a behavioral health issue that may
be of significance for athletes related to high demand
situations or environments that threaten mental or
physical well-being. The primary diagnostic criterion
for panic disorder, according to the DSM–5, is recurrent

unexpected panic attacks, which are experiences of
an “abrupt surge of intense fear or intense discomfort
that reaches a peak within minutes” (American
Psychiatric Association, 2013, p. 208). To be diag-
nosed with panic disorder, athletes must experience
persistent worry about having another panic attack
and increased frequency of behaviors to avoid trig-
gers associated with the panic attack. The avoidance
may lead to agoraphobia, and avoidance of situations
from which the person believes that escape may be
difficult if a panic attack begins to occur. Generalized
anxiety disorder (GAD) is primarily characterized by
chronic excessive and pervasive worry that causes
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functional impairment across multiple settings. The
worry is uncontrollable and results in symptoms of
physical and mental fatigue, poor concentration, irri-
tability, muscle tension, sleep disturbance, and feeling
on edge. Social anxiety disorder, which is also known
as social phobia, is a behavioral health problem with
significant relevance for athletes, particularly athletes
in sports that involve performance in the presence of
spectators, coaches, or judges/arbiters. The primary
diagnostic criterion involves persistent (6 months
or more) fear in social situations “involving possible
scrutiny by others” (American Psychiatric Association,
2013, p. 202). Specifically, the individual fears that
he or she will display anxiety to others or otherwise
behave in a manner that others evaluate negatively.
Forms of distress include fear of embarrassment or
humiliation, as well as fear of rejection by others or
causing offense to others. The DSM–5 also includes
a “performance only” specifier for social anxiety dis-
order, which pertains to those who only experience
distress in the context of public speaking or other
performance situations.
The 12-month prevalence of panic disorder is 2.7%
in the adult populations (Kessler et al., 2005) and has
a typical age of onset in early adulthood. Research on
the prevalence of panic disorder in athletes is limited.
Schaal et al. (2011) found a lifetime prevalence
of panic disorder in 2.8% of an elite French ath-
lete population, which is similar to the 12-month
prevalence of panic disorder in the general popula-
tions of the United States. In addition, Gulliver,
Griffiths, Mackinnon, Batterham, and Stanimirovic
(2015) found that 4.5% of an elite Australian athlete
population had clinically significant panic disorder
Athlete Mental Health
symptoms (not diagnostic). There are also case studies
and anecdotal evidence of athletes experiencing panic
attacks during competition (Eichner, 2011, 2014).
The occurrence of panic attacks prior to competition
should be viewed as a situation-specific panic attack,
social anxiety, or a specific phobia rather than panic
disorder and the presence of unexpected panic attacks.
GAD occurs in approximately 3.1% of the general
population in a given year (Kessler et al., 2005) and
has an age of onset from late adolescence into early
adulthood. Gulliver et al. (2015) conducted a study
of 224 elite Australian athletes and measured GAD
symptoms with the Generalized Anxiety Disorder
7 scale (GAD-7) and found that 7.1% of the sample
population had a GAD-7 score above 11, indicating
clinically significant symptoms of GAD. This finding
was consistent with Schaal et al. (2011), who found
6% of elite French athletes had clinically significant
levels of GAD symptoms.
The lifetime prevalence rate for social anxiety dis-
order in the United States is estimated at 13% (Kessler,
Petukhova, Sampson, Zaslavsky, & Wittchen, 2012).
Estimates of those meeting criteria for a social anxi-
ety diagnosis, who experience only fears relating to
performance as opposed to generalized social anxiety,
range from 0.7% in a survey of adolescents (Burstein
et al., 2011) to 8.7% in a community sample (Stein,
Torgrud, & Walker, 2000). There are no systematic
prevalence studies of social anxiety disorder occur-
rence in athlete populations.
Posttraumatic Stress Disorder
DSM–5 (American Psychiatric Association, 2013)
defines PTSD as “exposure to actual or threatened
death, serious injury, or sexual violence . . .” (p. 271)
and a stress reaction after the exposure. The stress
reaction involves symptoms of reexperiencing the
event (flashbacks, nightmares, distress to cues),
avoidance of internal stimuli (thoughts, emotions,
memories) and/or external stimuli (people, loca-
tions, actions, objects, situations) associated with
the trauma, mood disturbance, and hyperarousal
or reactivity. PTSD has a lifetime prevalence of 6.8%
(Kessler et al., 2005), and risk may increase pro-
gressing through adulthood because of exposure to
more potentially traumatic events. Empirical data
regarding the experience or prevalence of PTSD in
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 Wolanin and Marks
athletes are minimal. Shearer, Mellalieu, and Shearer
(2011) conducted a case study of an elite rifle shooter
who developed PTSD following a bicycle accident
and discussed treatment from a cognitive behav-
ioral perspective, and Hammermeister, Pickering,
McGraw, and Ohlson (2012) discussed conceptual
links between psychological skills and PTSD symp-
toms in military personnel. Despite the lack of cur-
rent data on PTSD in athletes, it has been noted in
clinical practice by the authors and collaborators in
sports medicine practices.
Case studies of PTSD in athletes postinjury
(Appaneal, Perna, & Larkin, 2007; McArdle, 2010)
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have provided insight into the nature of PTSD in
athletes postinjury. Shuer and Dietrich (1997)
identified a relationship between athletic injury and
intrusive thoughts and avoidance behaviors of the
athlete, but they did not provide data regarding the
occurrence of PTSD symptoms.
Obsessive-Compulsive Disorder
DSM–5 (American Psychiatric Association, 2013)
presents diagnostic criteria of OCD as having obses-
sions, compulsions, or both. Obsessions are recur-
rent, intrusive, and unwanted thoughts, images, or
urges that cause distress, which the person tries to
suppress or neutralize. Compulsions are repetitive
behaviors or mental processes that the person feels
compelled to perform in response to an obsession;
these behaviors and processes are meant to reduce the
anxiety of distressing obsessions but are unrealisti-
cally connected to the obsessive content. OCD has a
lifetime prevalence of 1.6% (Kessler et al., 2005) and
has typical onset in late adolescence or early adult-
hood. There is a dearth of prevalence data of OCD
occurrence in athlete populations. Schaal et al. (2011)
reported a 1.7% lifetime prevalence of OCD in elite
French athletes, which is consistent with prevalence in
the general population. OCD is likely a low-occurrence
disorder in athlete populations, as it is in the general
population, but nonetheless a disorder of clinical
significance that will likely be observed and expe-
rienced in athletic settings. Cromer, Kaier, Davis,
Stunk, and Stewart (2017) reported that 5.2% of
a sample of 269 college athletes across sports met
diagnostic criteria of OCD based on self-report of
symptoms. Of note in this study, 0% of the athlete in
662
the sample reported being diagnosed with OCD or
were diagnosed with OCD in their medical record.
Etiology and Conceptualization of Anxiety
and Related Disorders
The etiology of anxiety and related disorders usually
considers the influence of physiological, behavioral,
and cognitive factors. Physiological or biological
factors include individual differences in sensitivity
to interoceptive or contextual cues associated with
threat detection (Barlow, 2004). Neurotransmitter
activity (Stahl, 2013) may contribute to these differ-
ences. Sensitivity of particular brain regions, includ-
ing the amygdala and hippocampus, may also play a
part (Stein, Goldin, Sareen, Zorrilla, & Brown, 2002).
More broadly, physiological differences in inhibition
or neuroticism, which are typically associated with
temperament, may result from genetic variation and
contribute to vulnerability to social anxiety and
other anxiety problems (Ledley, Erwin, Morrison, &
Heimberg, 2013; Stein & Gelernter, 2010).
From a behavioral perspective, individuals with
anxiety-related disorders typically endeavor to avoid
feared stimuli (e.g., places where a panic attack has
occurred, situations in which evaluation could occur,
trauma, obsessive thoughts). This avoidance may be
maintained through negative reinforcement as the
feared stimulus is successfully evaded, providing an
experience of relief (Hofmann, 2012). Behaviors asso-
ciated with anxiety symptoms may include focus on
negative self-perceptions along with efforts to conceal
the anxiety reaction. The physiological symptoms
can, in turn, become a focus of introspective atten-
tion. Athletes with panic disorder symptoms may
scan their inner experience for sensations associated
with a panic attack (e.g., racing heart, sweating,
butterflies in the stomach), many of which are asso-
ciated with various aspects of physical exertion and
sport performance. Athletes with social anxiety may
focus attention on their anxiety-related physio­
logical sensations and fear that these experiences
are visible (and unacceptable) to others.
There are a number of cognitive behavioral models
of anxiety, particularly GAD. The metacognitive model
of pathological worry (Wells, 2006) indicates that
people may have both positive and negative beliefs
about worrying, and that people engage in “meta-

worry,” or beliefs about the effectiveness of worrying
or need to worry. For example, athletes with GAD
may think, “If I worry about all of the possible forma-
tions of the opponent, I can avoid failure.” Athletes
also engage in efforts to reassure themselves (exces-
sive review of video) or avoiding situations that are
perceived to be uncontrollable. People eventually
view worry as uncontrollable but also necessary to
cope with life demands. Intolerance of uncertainty
(Koerner & Dugas, 2006) and avoidance of anxiety
(Sibrava & Borkovec, 2006) are additional empirically
established models of GAD in which people use worry
as a method of regulating their fears and uncertainty
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about situations. A similarity of these referenced mod-
els of GAD is that worry serves as a method of coping
with situations that eventually becomes dysfunctional
and hinders athletes’ ability to regulate themselves
and make adaptive decisions in stressful situations.
Anxiety and Related Disorders and
Impairment for Athletes
Anxiety contributes in various ways to athletic per-
formance and impairment. As the Yerkes-Dodson
law (Yerkes & Dodson, 1908) suggests, a moderate
level of anxious arousal has the potential to enhance
performance. As an athlete’s focus on anxious arousal
increases, however, capacity for concentration on
performance may decline. Efforts to avoid or sup-
press anxious responding may paradoxically exac-
erbate distress. As the athlete struggles to eradicate
contextually relevant thoughts, feelings, and body
sensations (e.g., increased heart rate or respiration
rate associated with athletic performance), the task of
controlling anxiety may interfere with sport engage-
ment. The result can be a vicious cycle in which
performance suffers and distress escalates. Specific
implications of these problems often vary according
to the forms of anxiety (e.g., panic, worry) that the
athlete experiences.
Panic disorder.   The occurrence of unexpected
panic attacks will likely result in functional impair-
ment for them across multiple domains of their life.
Because of the self-evaluative nature of panic disorder,
athletes with the disorder will be hypersensitive to
their own physiological sensations and increases in
physiological responses (e.g., heart rate) that may
Athlete Mental Health
be necessary for athletic engagement and competi-
tion. In addition, their thoughts may focus on their
bodily sensations rather than the athletic task at
hand. Avoidance of a situation in which one may
have difficulty being able to escape will be particu-
larly dysfunctional for athletes. Athletes may avoid
competition or practice in which there may not be
an opportunity to “escape” once the activity com-
mences. Athletes may also avoid social interactions,
such as team meetings, meals with teammates, or
services in the athletic training room due to irratio-
nal fear of having other people see them lose their
emotional control or “freak out” and feel embar-
rassed from their irrational behavior. As a result of
both a shift of cognitive focus and avoidance of situ-
ations, athletes’ performance will likely deteriorate,
and they risk withdrawal from sport because of addi-
tional mental health concerns.
Of concern with panic disorder is the potential
occurrence of a panic attack while participating in
a water-based athletic event. Anecdotal stories from
the swim portions of triathlons (Eichner, 2011, 2014)
have suggested that a panic attack may increase the
risk of hyperventilating and drowning. Although the
link between panic attacks and fatalities has not been
established, it does raise awareness of the conse-
quences of panic attacks in high-risk sports.
Generalized anxiety disorder.   Athletes may be
at risk for GAD as worry and perfectionism may be
useful at various points in athletic preparation and
development, and anticipation and worry about
problems may even enhance performance in some
situations. In diagnosable GAD, however, athletes
have difficulty controlling their worry, spending time
and exerting mental effort to control their fears and
engaging in avoidance or reassurance strategies to
minimize their distress. Athletes meeting criteria
for GAD may experience worry about the athletic
environment (e.g., performance, teammates, travel,
coaches), but they will also experience worry about
other domains of their life.
The root of dysfunction from GAD is in the
inability to be cognitively present or mindful of the
moment at hand, which results in impairment for
athletes in many ways. Athletes with GAD are likely
to have performance difficulties or fail to perform
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 Wolanin and Marks
to their potential because of continued worry and
increased non–task related cognitive activity that
may hinder a state of flow or the ability to engage
effectively over the course of a performance task.
Athletes’ worry may also result in overpreparation of
nonessential tasks related to a performance, exces-
sive planning for future events or contingencies, and
focus on performance details that are inconsequen-
tial or misguided. In addition, excessive worry may
also result in interpersonal difficulties with coaches,
teammates, and family; athletes may engage in
repeated questioning on strategy, purpose, or tech-
nique that may be perceived by others as pestering
Copyright American Psychological Association. Not for further distribution.
or annoying. The athlete may also be perceived to
be zoning out or not listening in teammate inter­
action or team meetings, but in reality the athlete is
mentally worrying about a future scenario. Taken
together, the impairment related to GAD for athletes
is likely to be mild and chronic anxiety that becomes
exacerbated in particular situations, rather than an
acute severe clinical issue.
Social anxiety.   Social anxiety can have debilitating
consequences for athletes and athletic performance.
Fears of scrutiny by teammates, coaches, the media,
and spectators, as well as unrealistic expectations
regarding acceptable performance, can lead athletes
to avoid attending important activities (Gardner &
Moore, 2006). These generalized social fears can
also lead to attentional difficulty as individuals focus
on attempting to control or manage anxiety rather
than on the task at hand. In addition, athletes grap-
pling with anxiety about being present at social or
interpersonal situations may engage in limited social
interaction, reducing eye contact and supportive
communication with team members and others.
The relief associated with avoiding feared situations
often contributes to a vicious cycle of avoidance,
with once successful athletes gradually paring back
engagement in sport-related activity in an effort to
control or minimize unwanted anxiety (R. E. Smith
& Smoll, 1990). In addition, athletes with social
anxiety may exaggerate the competitive aspects
of interpersonal situations, while minimizing the
potential for support and cooperation from others.
Their responses in these situations may be mis­
interpreted by others as critical or aloof, which may
664
in turn contribute to others forming the very negative
evaluations that the socially anxious individual fears
(Hofmann, 2012; Ledley et al., 2013).
Athletes experiencing more focused “performance
only” forms of anxiety can also experience significant
impairment (R. E. Smith & Smoll, 1990). Sport psy-
chologists and consultants will be familiar with many
terms athletes have devised over the years and across
sports to describe the crippling effects of performance
anxiety. These include “yips,” “choking,” and “free
throw anxiety.” As Gardner and Moore (2006) noted,
the role of the “audience effect” in these situations
is of particular importance as fears of humiliation or
harsh evaluation change the stimulus properties of
tasks that were once performed with ease. As a result
of evaluation fears, a situation or task that the athlete
and others had viewed as a routine aspect of perfor-
mance can become a high-stress situation in which
substandard performance is viewed as evidence of
incompetence, weakness, or professional inadequacy.
According to R. E. Smith and Smoll (1990), as
many as 50% of high school student-athletes who
withdraw from sport participation do so because of
performance anxiety or related concerns. In younger
athletes, they noted, these percentages may be higher.
In addition, R. E. Smith and Smoll summarized sport
medicine findings indicating that athletes experienc-
ing performance anxiety report other health-related
problems including headache, stomachache, and
stress-related injuries such as reflex sympathetic dys-
trophy, a form of complex regional pain syndrome.
Posttraumatic stress disorder.   PTSD, or subclinical
PTSD, is most likely to be noted in an athletic environ-
ment after an injury to an athlete or a serious injury to
another person during an athletic event. Newcomer
and Perna (2003) found that athletes with a recent
injury experienced increased intrusive thoughts
and avoidance behaviors compared with noninjured
athletes. The speed and force associated with today’s
athletic play has the potential to result in athletic
experiences that may be perceived as life-threatening.
For example, a 100-mph fastball thrown near your
head, catching a football over the middle of the field,
or skiing down a hill at 80 mph may all result in actual
life-threatening experiences. Consequently, many
athletes may not only experience life-threatening

situations during the contest but also witness team-
mates and opponents in such situations. Outside of
athletic play, athletes may experience other traumas
such as physical or sexual assault, car/bus accidents,
and terrorism—not unlike the general population. For
example, Schaal et al. (2011) found that 4.1% of elite
French athletes reported being the victim of physical
or sexual assault. The impairment of PTSD for athletes
will likely be related to the physiological symptoms
of PTSD, but also the avoidance of athletic situations
or triggers that are associated with the trauma experi-
ence. For instance, a baseball player may avoid facing
certain pitchers, a football player may avoid complet-
Copyright American Psychological Association. Not for further distribution.
ing a certain pass pattern in which they were earlier
the victim of a violent hit (e.g., a receiver attempting
to catch a thrown ball moving through the opponent’s
secondary), or a skier may retire from the sport after
a skiing crash and experiencing a serious injury.
The physiological symptoms of PTSD may result in
increased muscle tension, hypervigilance, increased
startle or fear response, and negative mood symptoms
that may lead to performance decline and potentially
increased risk for injury.
Obsessive-compulsive disorder.  Obsessive-
compulsive symptoms may mimic functional athletic
routines and at times be difficult to determine if
they are impairing or helping athlete performances.
Many athletes use routines and repetitive behavioral
patterns to regulate their anxiety prior to or during
performances and may even at times appear to be
rigid in their “need” to perform a particular routine.
The distinction of OCD regarding athletes is that
they will have extreme difficulty in stopping or
completing the routine to engage in the actual
performance. Athletes with OCD may also engage
in mental obsessions and compulsions that are
unobservable to others while they are performing.
These mental routines may occupy their attention
so that they disregard or ignore instructions from
coaches, which will lead to performance impair-
ment. OCD will also likely cause significant impair-
ment for athletes in other domains of their life that
result in academic, occupational, or interpersonal
dysfunction. An example is an athlete who develops
compulsive behaviors connected to athletic perfor-
mance but is unable to minimize the compulsive
behaviors when on vacation with her family.
Athlete Mental Health
PERSONALITY DISORDERS
DSM–5 (American Psychiatric Association, 2013)
describes a personality disorder as a persistent and
inflexible pattern of inner experience and behavior
characterized by significant deviation from cultural
expectations. Domains of functioning affected by
personality disorder include (a) cognition (percep-
tions, interpretations of self and others), (b) emotions
(intensity, lability, appropriateness), (c) interpersonal
relationships, and (d) impulsivity. To meet criteria
for a personality disorder, athletes must experience
difficulties in at least two of these four areas. DSM–5
identifies 10 specific personality disorders grouped
into three categories, or clusters. Cluster A includes
disorders associated with odd or eccentric behavior
(e.g., paranoia or unusual beliefs); Cluster B encom-
passes disorders that involve dramatic, erratic, and
volatile behavior (e.g., self-harm, exploitation of
others, emotional outbursts); and Cluster C features
disorders characterized by anxiety and fearfulness
(e.g., isolation).
Epidemiological research has indicated that among
U.S. adults, prevalence rates for any personality dis-
order range from 9.1% (Grant et al., 2004) to 14.8%
(Lenzenweger, Lane, Loranger, & Kessler, 2007).
Prevalence varies significantly by cluster, with
Cluster A disorders affecting 5.7% of the population,
Cluster B affecting 1.5%, and Cluster C affecting 6%
(Lenzenweger et al., 2007). The most widely occurring
form of personality disorder is obsessive-compulsive
personality disorder (OCPD), with a lifetime preva-
lence nearly 8%; the least frequently occurring is
dependent personality disorder at less than 0.5%
(Grant et al., 2004).
Epidemiological studies have found significant
gender differences in the prevalence of some person-
ality disorders. Some studies have found that women
account for approximately 75% of cases of borderline
personality disorder, and men account for 75% of
antisocial personality diagnoses (Alegria et al., 2013;
D. M. Johnson et al., 2003). Other studies, however,
have not found these gender differences. Grant et al.
(2008), for example, found a prevalence rate of 6%
for borderline personality disorder, with no signifi-
cant differences in prevalence for men (5.6%) and
women (6.2%). Risk factors for personality disorders
in general have included being of Native American or
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 Wolanin and Marks
African American cultural identity; the young adult
age range; poverty and low socioeconomic status;
low educational attainment; and separation, divorce,
or loss of spouse (Grant et al., 2004, 2008). Appar-
ently, no epidemiological research has appeared
to date regarding prevalence rates for personality
dis­orders among athletes. As Gardner and Moore
(2006) observed, however, there is no reason to
expect that athletes are free of these disorders.
Etiology and Conceptualization
of Personality Disorders
Given the heterogeneity of the personality disorders,
Copyright American Psychological Association. Not for further distribution.
it is unlikely that a single etiological framework could
adequately account for them. Genetic differences con-
tributing to temperament have been cited as important
influences on character development (Livesley, Jang,
& Vernon, 1998; Newton-Howes, Clark, & Chanen,
2015; Svrakic et al., 2002). Beck, Davis, and Freeman
(2015) observed that the personality disorders feature
symptom clusters resembling the broad strategies
organisms use when under threat—avoidance, attack,
and freeze—with genetic predispositions potentially
leading individuals to prefer one strategy over others.
Many researchers (e.g., Bierer et al., 2003; J. G.
Johnson, Smailes, Cohen, Brown, & Bernstein, 2000;
Tyrka, Wyche, Kelly, Price, & Carpenter, 2009),
however, have found that early aversive experiences,
including neglect, physical abuse, and sexual trauma,
are significant contributors to personality disorder
symptoms. Disruptions of the attachment relationship
associated with these adverse childhood experiences
appear to contribute to the development of ineffective
strategies for managing emotional distress and inter-
personal relationships (Chiesa, Cirasola, Williams,
Nassisi, & Fonagy, 2017; Dozier, Stovall-McClough,
& Albus, 2008).
Personality Disorders and Impairment
for Athletes
Impairment associated with personality disorder
symptoms can take many forms. Athletes exhibiting
OCPD, for example, may exhibit rigid adherence to
practice routines and attempt to hold others to per-
fectionistic standards (Owen, 2016). Sports with an
emphasis on individual performance (e.g., track and
field, wrestling) may accommodate these personality
666
characteristics to a greater degree than team sports,
which rely on collaboration. In any athletic setting,
however, inflexible interaction with coaches,
trainers, and fellow athletes is likely to yield
potentially career-disrupting difficulties.
Antisocial and narcissistic personality charac-
teristics in athletes, for example, present significant
problems. Few teammates can safely collaborate with
an athlete who lacks consideration for the welfare of
others or defiantly disregards rules. Problems associ-
ated with drug use, violation of doping rules, and
aggressive and dangerous off-the-field behavior (e.g.,
domestic violence, fights) all may have their origins
in antisocial characteristics (Andersen et al., 1994;
Kavussanu, 2016). Narcissism can be corrosive in
a different way as athletes attempt to maintain an
inflated sense of their own importance. Teammates
and coaches have value only insofar as they reflect
the athlete’s grandiose self-concept (Andersen et al.,
1994). These athletes may respond to the success of
others with hostility or criticism, perceiving another’s
accomplishments as threats to their self-esteem. The
narcissistic athlete’s belief that “it’s all about me,” if
not addressed and modulated, can lead to a culture of
“every man for himself.” Narcissism among coaches
also poses significant risks for athletes, with narcis-
sism in coaches predicting favorable attitudes toward
doping and rule violation among athletes (Matosic,
Ntoumanis, Boardley, Stenling, & Sedikides, 2016).
Borderline personality disorder presents behavioral
and interpersonal problems that include self-injury,
suicidality, emotional vulnerability, unrelenting crises,
and unstable relationships (Linehan, 1993). Intense
interpersonal volatility can be especially troubling as
athletes alternate between idealization and devalua-
tion of others (see Gregory, 2007). A coach, teammate,
or significant other can quickly shift from angel
to demon in the athlete’s estimation, leaving that
person bewildered and frustrated. Sport psycholo-
gists encountering this pattern should conduct a
thorough evaluation, asking specifically, but not
accusingly, about self-harm behaviors and thoughts
concerning harm to others. One might suspect that
individuals exhibiting sufficient symptoms to meet
criteria for this disorder would have difficulty man-
aging the day-to-day rigors of elite athletic competi-
tion, but the recent high-profile disclosures of NFL

wide receiver Brandon Marshall suggests that gifted
athletes can succeed despite significant emotion dys-
regulation and interpersonal volatility (M. Cogan,
2014; O’Keefe, 2015).
CONCLUSION AND FUTURE DIRECTIONS
An increased focus on mental health issues in athletes
is warranted as research and anecdotal stories confirm
the presence of significant mental health concerns
in athlete populations. Mental health concerns in
athletes result in impairment for the athletes in sports
and life domains and require screening and treatment
Copyright American Psychological Association. Not for further distribution.
from psychologists and medical providers.
As may be gleaned from the prevalence data that
were presented in the body of this chapter, future
research regarding the epidemiology of mental health
issues in athletes is clearly warranted. In addition to
prevalence of particular disorders, information about
risk factors and mechanisms specific to athletes
is needed to guide intervention development and
research. This research is needed; however, it comes
with challenges that are due to stigma of mental health
issues in athletic environments and impression
management of athletes who are subjects of the
research (Gross, Wolanin, Pess, & Hong, 2017).
The prevalence and specific nature of mental
health disorders in athletes have been minimally
identified and understood compared with the gen-
eral and other specific populations. Consequently,
evidence-based psychological treatments for athletes
are, to date, underdeveloped, untested, and not
available for systematic implementation with athletes.
Evidence-based interventions are, however, identi-
fied for the diagnostic categories (Chambless &
Hollon, 1998; Chambless & Ollendick, 2001) that
have been discussed in this chapter and may serve to
guide practitioners in regard to the type of interven-
tion for an athlete that will have the best likelihood
for a beneficial outcome. Despite empirically sup-
ported treatments being a significant advancement for
the field of clinical psychology, there is still a notable
theoretical debate about which treatments meet
guidelines, and there are considerable challenges
in disseminating empirically supported treatments
to providers and the public (Forman, Gaudiano,
& Herbert, 2016).
Athlete Mental Health
To date, there are no specific evidence-based
treatments specifically for athletes and certainly no
evidence-based treatments for subsets of athletes
(e.g., gender, sport). Consequently, the profes-
sional who is providing services for an athlete
with a mental health concern should consider
empirically supported treatment for the general
population that has the most appropriate fit for the
needs of the particular athlete. In addition, pro-
viders should conceptualize mental health for the
athlete’s treatment plan through empirically based
principles of change based on the nature of the
athlete’s dysfunction and the appropriate training
of the provider.
In addition to providing athletes with an empiri-
cally supported treatment for their specific mental
health issue, the provider must also balance athletes’
athletic performance demands. Because of the rela-
tionship between an athlete’s performance and mental
health concerns, the provider should consider both
the mechanisms of the particular mental health issues
as well as the psychological mechanisms of perfor-
mance and make efforts to provide an intervention
that is beneficial (and not counterproductive) to
both mental health and athletic performance. In an
effort to achieve this, practitioners should consider
psychological interventions that have an evidence
base in clinical psychology as well as sport psychol-
ogy when possible. For example, acceptance and
commitment therapy is an empirically supported
treatment for a number of mental health concerns
(Hayes et al., 2011), but it also has interventions
designed for athletic performance that may increase
receptivity of the athlete and result in improving
outcomes (Gardner & Moore, 2007; Gross et al.,
2018). Traditional cognitive behavioral approaches
also share mechanisms between clinical psychol-
ogy and sport psychology and may be combined to
provide efficacious treatment—for example, behav-
ioral activation that may serve as a component of
treatment for an athlete with depression while also
providing a sport psychology link to performance
through goal setting.
Understanding and providing screening and treat-
ment for mental health issues in athletes is necessary
to maintain individual and team performance as well
as quality of life. More important, attention to mental
667
 Wolanin and Marks
health related to athletic engagement has the potential
to positively impact athletes’ lives and long-term devel-
opment as healthy individuals.
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