OCD in College Athletes
Publication: American Journal of Psychiatry
To the Editor: Extensive media coverage of the 2016 Summer Olympics in Rio de Janeiro and the emergence of sports medicine as a subspecialty reflect elite athletes’ important societal roles. While the optimization of athletes’ physical performance is a priority, their mental health is largely ignored. Psychiatric studies of competitive athletes are nonexistent in the United States and are limited worldwide, despite risks to athletes that include sleep disruption, travel, low autonomy, and performance demands (1–3). Physicians are biased toward athletes’ mental well-being (3, 4); moreover, athlete help-seeking is stigmatized (4).
Obsessive-compulsive disorder (OCD) is a debilitating, treatable illness affecting 2.3% of adults, with subthreshold obsessive-compulsive symptoms occurring in 28.2% of adults (5). Competitive athletes’ traits, including overresponsibility, perfectionism, and secrecy, mask OCD identification (4, 5). Calorie obsession, body hyperfocus, superstitions, and rituals are normative for athletes (2). We report findings from the first OCD study in collegiate athletes, derived from two data collection waves of a study on college athletic stress at a Division I National Collegiate Athletic Association school.
Method
In year 1, 20.1% (N=54) of 269 athletes representing 13 sports screened positive for OCD on the validated Psychiatric Diagnostic Screening Questionnaire (PDSQ) (6), prompting detailed examination. In year 2, 270 (141 of whom were included in year 1) completed the PDSQ, the Florida Obsessive-Compulsive Inventory (FOCI) (7) (diagnostic score ≥8), and the Obsessive-Compulsive Checklist Patient Rating Scale (8) (detailing symptoms). “All-conference” elite-level athletes were identified. National Comorbidity Survey Replication epidemiologic data were used for comparison (5). Analyses were conducted via SPSS, version 20 (SPSS, Chicago) (significance threshold p<0.05).
Results
All participants denied OCD diagnosis, as confirmed by medical records. Nearly 35% (N=94) of year 2 participants endorsed obsessive-compulsive symptoms, 16.7% (N=45) screened positive for OCD, and 5.2% (N=14) met full OCD criteria. Among OCD-affected athletes, half reported more than five symptom types, with hoarding, ordering, and checking as the most common (Table 1). The mean age at onset was 14.3 years (SD=3.9), 5.3 years (SD=4.8) prior to assessment, which is comparable to OCD findings from the National Comorbidity Survey Replication (5). All-conference athletes reported fewer OCD symptoms (t=2.36, df=119.6, p=0.02) and screened positive less frequently for OCD (χ2=5.68, p=0.017) compared with their peers.
| Item Descriptiona | Obsession/Compulsion Type | Full Sample (N=270) | PDSQ Positive Screen (N=45)b | FOCI Positive Diagnosis (N=14)c | All-Conference Athletes (N=53) | Non-All-Conference Athletes (N=217) | Associated Distress (N=270) | Clinical Distress (score >8) (N=14) | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| N | % | N | % | N | % | N | % | N | % | Mean | SD | Mean | SD | ||
| Any hoarding symptoms | 98 | 37.5 | 21 | 55.8 | 8 | 61.5 | 15 | 29.4 | 83 | 39.5 | |||||
| Fear of losing important information and/or indecision about throwing things out | Hoarding obsessions | 62 | 23.7 | 15 | 34.1 | 6 | 46.2 | 8 | 15.7 | 54 | 25.6 | 3.8 | 2.36 | 6.17 | 1.94 |
| Fear of losing things/“need to know” | Hoarding or need to know | 77 | 29.4 | 20 | 45.5 | 6 | 46.2 | 12 | 23.5 | 65 | 30.8 | 3.99 | 2.40 | 5.50 | 2.67 |
| Hoarding/having clutter | Hoarding compulsions | 7 | 2.7 | 0 | 0.0 | 0 | 0.0 | 2 | 3.9 | 5 | 2.4 | 3.86 | 2.67 | – | |
| Any symmetry symptoms | 80 | 30.8 | 16 | 51.2 | 7 | 58.3 | 10 | 19.6 | 70 | 33.5 | |||||
| Need to engage in ordering | Arranging compulsions | 38 | 14.4 | 16 | 36.4 | 6 | 46.2 | 5 | 9.8 | 33 | 15.6 | 4.72 | 2.96 | 8.50 | 2.07 |
| Reread/rewrite; repeating behaviors | Repeating compulsions | 40 | 15.3 | 12 | 27.9 | 4 | 30.8 | 7 | 13.7 | 33 | 15.7 | 4.18 | 2.86 | 9.25 | 0.96 |
| Symmetry/exactness concerns | Symmetry obsessions | 29 | 11.1 | 7 | 15.9 | 3 | 25.0 | 3 | 5.9 | 26 | 12.4 | 3.59 | 2.57 | 3.67 | 1.53 |
| Counting compulsion | Counting compulsions | 6 | 2.3 | 2 | 4.7 | 1 | 7.7 | 1 | 2.0 | 5 | 2.4 | 3.67 | 1.53 | 10.00 | 0.0 |
| Any forbidden thought symptoms | 84 | 32.8 | 17 | 51.2 | 7 | 58.3 | 13 | 25.5 | 71 | 34.6 | |||||
| Checking about harm to self/others or body condition | Checking compulsions | 36 | 13.8 | 10 | 23.3 | 5 | 38.5 | 8 | 15.7 | 28 | 13.3 | 3.18 | 2.31 | 4.80 | 1.79 |
| Fear of impulsive, harmful behaviors | Aggression obsessions | 12 | 4.6 | 4 | 9.3 | 3 | 25.0 | 1 | 2.0 | 11 | 5.1 | 5.17 | 2.62 | 5.33 | 3.22 |
| Concern about disease | Somatic obsessions | 13 | 5.0 | 4 | 9.1 | 3 | 23.1 | 3 | 5.9 | 10 | 4.7 | 4.92 | 2.33 | 4.67 | 3.51 |
| Praying or having magical thoughts to prevent harm | Praying or mental compulsions | 55 | 21.1 | 13 | 30.2 | 3 | 23.1 | 6 | 11.8 | 49 | 23.3 | 3.92 | 2.86 | 5.33 | 2.08 |
| Excessive moral concerns | Religious obsessions | 15 | 5.8 | 7 | 16.3 | 2 | 15.4 | 2 | 3.9 | 13 | 6.2 | 3.92 | 2.86 | 5.33 | 2.08 |
| Sexual obsession | Sexual obsessions | 12 | 4.6 | 4 | 9.3 | 0 | 0.0 | 2 | 3.9 | 10 | 4.8 | 4.33 | 3.42 | – | |
| Any miscellaneous symptoms | 45 | 17.2 | 9 | 20.5 | 5 | 38.5 | 6 | 11.8 | 39 | 18.5 | |||||
| Touch/tap/blink; confession | Miscellaneous compulsions | 29 | 11.1 | 9 | 18.2 | 5 | 38.5 | 4 | 7.8 | 25 | 11.8 | 4.25 | 3.16 | 7.20 | 2.59 |
| Superstitious, colors/numbers | Superstitious obsessions | 27 | 10.3 | 4 | 9.1 | 2 | 15.4 | 6 | 11.8 | 21 | 10.0 | 4.05 | 3.24 | 7.50 | 3.54 |
| Any cleaning or contamination symptoms | 30 | 11.7 | 2 | 23.8 | 4 | 33.3 | 8 | 15.7 | 22 | 10.7 | |||||
| Fear and disgust of contamination | Contamination obsessions | 21 | 8.1 | 6 | 14.0 | 3 | 25.0 | 5 | 9.8 | 16 | 7.7 | 3.05 | 2.37 | 5.67 | 4.16 |
| Excessive self-cleaning | Cleaning compulsions | 17 | 6.5 | 8 | 18.6 | 3 | 23.1 | 4 | 7.8 | 13 | 6.2 | 4.97 | 2.95 | 6.33 | 2.31 |
| Any of the above | 156 | 61.4 | 32 | 78.0 | 8 | 72.7 | 26 | 51.0 | 130 | 64.0 | |||||
a
Items are from the Obsessive-Compulsive Checklist Patient Rating Scale, a measure used clinically and in previous investigations of OCD symptom severity (8). This scale is a 17-item questionnaire inquiring about the presence of common obsessions and compulsions. In the present sample, the scale documented adequate internal consistency (alpha=0.78) and good convergent validity with the Florida Obsessive-Compulsive Inventory (FOCI) as well as with the Psychiatric Diagnostic Screening Questionnaire (PDSQ).
b
The PDSQ is a validated measure commonly used in clinical settings for psychiatric symptom screening (6). The number of OCD symptoms endorsed was summed to determine a score between 0 and 7, with a cutoff of 1 indicating the need for further clinical assessment (e.g., a “positive screen”).
c
The FOCI comprises 20 “yes” or “no” items and five symptom severity items and is rated on a 5-point Likert scale (7). The FOCI yields two subscales (i.e., symptom presence and symptom severity). A symptom presence is indicated from a checklist score that ranges between 0 and 20, with a score of 20 indicating the greatest number of symptoms. The symptom severity score is calculated by summing the five severity questions. Athletes were considered clinical on the FOCI if the symptom severity score was 8 or higher (unpublished 1994 data from W.K. Goodman).
Discussion
Self-report on the FOCI suggests that OCD may be as common as 5.2% among college athletes, more than doubling expected rates (2.3%). Symptoms caused moderate to severe distress. Despite self-reported symptoms lasting more than half a decade, no athletes who screened positive for OCD had been diagnosed, and few received psychological treatment. All-conference athletes had lower OCD and obsessive-compulsive symptom rates compared with other college athletes, suggesting a negative association with performance. Although interviews confirming diagnoses were unavailable, the validity of this study’s findings is supported via comparability with expected population rates of obsessive-compulsive symptoms, OCD onset, and symptom types. Physicians should remain vigilant for OCD in athletes given its association with distress and its treatment potential.
References
1.
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2.
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Reardon CL, Factor RM: Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med 2010; 40:961–980
5.
Ruscio AM, Stein DJ, Chiu WT, et al: The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry 2010; 15:53–63
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Zimmerman M, Mattia JI: A self-report scale to help make psychiatric diagnoses: the Psychiatric Diagnostic Screening Questionnaire. Arch Gen Psychiatry 2001; 58:787–794
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Storch EA, Kaufman DA, Bagner D, et al: Florida Obsessive-Compulsive Inventory: development, reliability, and validity. J Clin Psychol 2007; 63:851–859
8.
Stewart SE, Stack DE, Wilhelm S: Severe obsessive-compulsive disorder with and without body dysmorphic disorder: clinical correlates and implications. Ann Clin Psychiatry 2008; 20:33–38
Information & Authors
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History
Accepted: January 2017
Published online: 1 June 2017
Published in print: June 01, 2017
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Funding Information
Dr. Stewart has received research support from the Canadian Institutes of Health Research, the Michael Smith Foundation for Health Research, the British Columbia Provincial Health Services Authority, the International OCD Foundation, the American Academy of Child and Adolescent Psychiatry, and the Anxiety and Depression Association of America. The other authors report no financial relationships with commercial interests.
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