Open AccessFour reasons why we should screen for dissociation in competitive sportsRalph Erich Schmidt, Andres Ricardo Schneeberger, and Malte Christian ClaussenRalph Erich SchmidtRalph E. Schmidt, PhD, Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse 31, 8032 Zurich, Switzerlandralph.schmidt@pukzh.ch Department of Psychology, University of Geneva, Switzerland Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Switzerland Search for more papers by this author, Andres Ricardo Schneebergerhttps://orcid.org/0000-0001-8176-9126 Department of Psychiatry, University of California San Diego, USA Search for more papers by this author, and Malte Christian Claussenhttps://orcid.org/0000-0002-8415-3076 Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Switzerland Clinic for Depression and Anxiety, PZM Psychiatry Center Münsingen AG, Switzerland Search for more papers by this authorPublished Online:February 09, 2023https://doi.org/10.1024/2674-0052/a000040PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreThis article discusses the current literature on the definition, prevalence, and consequences of dissociation in competitive sports. In light of the available evidence, it is argued that there are four reasons why dissociation deserves particular attention in this context: (i) Dissociation seems to be more prevalent among athletes when compared with the general population; (ii) potentially performance-enhancing aspects of dissociation may contribute to its chronic use; (iii) dysfunctional aspects of dissociation may entail underperformance; (iv) chronic use of dissociation may mask and exacerbate mental disorders, such as Post-traumatic Stress Disorder, and delay recovery from injury. In conclusion, it is advocated that standardized measures of dissociation be included in medical sports examinations.What is dissociation?The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [1] defines dissociation as a disruption, interruption, and/or discontinuity of the normal, subjective integration of behavior, memory, identity, consciousness, emotion, perception, body representation, and motor control.Under the umbrella of this general definition, the DSM-5 distinguishes five different types of dissociative disorders: (i) Dissociative Identity Disorder; (ii) Dissociative Amnesia; (iii) Depersonalization/Derealization Disorder; (iv) Other Specified Dissociative Disorders; (v) Unspecified Dissociative Disorder.However, dissociative symptoms are also included in other DSM-5-defined disorders. For example, the diagnostic criteria for Post-traumatic Stress Disorder (PTSD) explicitly feature a dissociative subtype. Criteria for the dissociative subtype are that reminders of the traumatic stressor (PTSD Criterion A) lead to depersonalization or derealization symptoms. Moreover, dissociative amnesia figures as a possible symptom of Acute Stress Disorder (ASD) and of PTSD.Dissociative symptoms, such as depersonalization or derealization, are experienced by a large percentage of people in response to traumatic events but generally decline over time [2]. Following motor vehicle accidents, for instance, no fewer than 79% of survivors reported at least one symptom of dissociation [3]. The number, intensity, and persistence of peritraumatic dissociative symptoms – including depersonalization, derealization, tunnel vision, confusion, temporal or spatial disorientation, trance-like experiences, and amnesia – have been found to predict the development of PTSD (for a review, see [4]). A possible mediating mechanism is that dissociation leads to inaccessible or fragmented memories of the traumatic experience, thereby precluding integration of the information into the autobiographical memory system [4, 5].Current conceptualizations suggest that dissociation is a psychobiological state or trait that serves a protective function in response to overwhelming and potentially traumatic experiences [6]. Dissociation is thought to mitigate the impact of such experiences by sequestering information about them through activation of altered states of consciousness. As a consequence, dissociation segregates the full meaning and impact of the events from awareness [7]. Several lines of evidence indicate that dissociation might be the human equivalent to the “freeze” or “feigning death” reaction (“thanatosis”) in animals that is elicited when a fight or flight reaction to life-threatening danger has failed or would be more dangerous [7, 8].Athletes may be exposed to potentially traumatic events prior to their sports career (in their childhood), or in the course of their career (during training and competition, or in their private life) [9]. Such events include physical violence, sexual violence, physical injury, and vicarious or witnessed trauma [9, 10]. Numerous studies in general and clinical population samples have revealed a cumulative or dose-dependent effect of traumatic events on dissociative and post-traumatic symptomatology, with particularly strong associations if traumatic events occur early in life [7, 11]. In accord with this general pattern, a study in a sample of elite athletes found that those with a history of multiple adverse childhood experiences (ACE) – including physical, sexual, and emotional violence, physical and emotional neglect, domestic violence, and parental substance use – had an increased risk for somatization disorders, problematic alcohol use, and prescription medication use [12].How prevalent is dissociation?Dissociative disorders are prevalent in a wide variety of people and can occur at any point in life. In industrialized countries the prevalence of dissociative disorders varies between estimates of 2.4% [13] in the general population and 11.4% in college students samples [14]. The disorders need to be differentiated from dissociative symptoms that can occur in up to 75% of healthy adults [15]. Dissociative disorders often develop in the context of traumatic life events with a special focus on adverse childhood experiences (ACE) [16]. A recent meta-analysis estimated the prevalence of the dissociative subtype of PTSD at 38.1% across all samples [17].While the literature on dissociative disorders in athletes continues to be sparse, there is clearer evidence that PTSD is increased in this population. Thomson and Jaque [18] demonstrated that 13.3% of all athletes met the diagnostic criteria of PTSD with some specific subgroups (dancers) reaching prevalence rates of 25.4%. Adverse childhood experiences are also prevalent in athlete populations: 30.8% endorse at least one ACE, and the average ACE score among athletes is 2.1 (SD=1.5) [12].As mentioned, there is a paucity of studies focusing specifically on dissociative disorders in athletes. A comparison between rhythmic gymnasts and female dancers showed high levels of non-pathological and pathological dissociation within both groups of athletes [19]. In athletes, dissociation can be an adaptive mental skill used to enhance performance in high-stress situations [9]. However, there is an inherent risk in ignoring symptoms of dissociation in athletes because the possible presence of psychiatric symptoms and disorders might be overlooked. The current culture in sports supports athletes’ inclination to downplay and underreport symptoms of dissociation because of fear of stigma and discrimination. In a population of athletes that presents with high levels of preexisting trauma, additional stress is likely to lead to additional numbing, avoidance and dissociation. The combination of these symptoms and the athletes’ tendency to minimize them, may preclude an accurate assessment of mental health disorders.Why is dissociation particularly important in sports?Two factors may contribute to the presumably higher prevalence of dissociation in competitive sports. First, dissociation may be used as a partly adaptive mental skill to enhance performance [19]. And second, the available evidence suggests that athletes are more frequently exposed to interpersonal violence – including sexual violence, physical violence, and psychological violence – than the general population (for a review, see [10]).Athletic performanceTo achieve optimal performance, athletes need to be able to fully focus their attention on task-relevant information and to ignore personal, situational, and organizational distractors and stressors [20]. In the literature of sport psychology, two attentional strategies have been described in this context: associative strategies, where athletes focus on bodily sensations (e.g., breath, muscle tension) and performance-related cues (e.g., stroke rate in rowing), and dissociative strategies, where athletes focus on task-unrelated contents (e.g., daydreams, music, landscape) to distract themselves from pain, fatigue, and negative affect [21].Research has shown that experienced and elite athletes are able to voluntarily shift toward associative strategies as task demands intensify [19, 22, 23], whereas less experienced and well performing athletes tend to adopt and maintain dissociative strategies to manage stressful tasks [24].Mental health and trauma-related disordersAs mentioned, dissociation may be an adaptive coping response to stressful and potentially traumatic events in the short run [7, 25]. However, especially among athletes with histories of childhood abuse, dissociative reactions may overgeneralize to any stressful situation in competitive settings, thereby potentially impeding performance [19, 26].Independently of exposure to adverse childhood experiences, the use of dissociative strategies may be very common among athletes and often reach pathological levels as a study with female dancers and rhythmic gymnasts suggests [19]. When compared with a control group, the dancers obtained significantly higher scores on an item of the Dissociative Experience Scale-II [27] that assesses depersonalization (“Some people have the experience of feeling that their body does not seem to belong to them.”) and the rhythmic gymnasts’ score was close to that of the dancers. The gymnasts scored significantly higher on the item assessing the ability to ignore pain (“Some people find that they sometimes are able to ignore pain.”) and the dancers’ scores were also comparatively higher than were those of the controls. Of note, the duration of professional practice statistically predicted the ability to ignore pain among gymnasts, suggesting that the use or “success” of dissociative strategies may increase in the course of a sports career [19].In a similar vein, a study among college athletes found that those with chronic injuries scored on the intrusion subscale of the Impact of Event Scale [28] in the range of people who had experienced natural disasters, but scored even higher on the avoidance/denial subscale [29]. This subscale includes items assessing cognitive and behavioral avoidance, emotional numbing and dissociation (“I felt as if it hadn’t happened or wasn’t real.”). Regarding gender, it was found that chronically injured female athletes scored higher on the avoidance/denial scale than did their male counterparts [29], in agreement with a previous investigation into the use of associative and dissociative strategies among male and female athletes [30].What are the consequences of dissociation?As detailed earlier, dissociation may be an adaptive coping response to stressful situations or potentially traumatic situations in the short run [7, 25]. However, chronic and inflexible use of dissociation has been associated with a number of negative consequences, including underperformance, underdiagnosis and undertreatment of trauma-related disorders, increased rates of self-injury and suicidality, and delayed recovery from injury [7, 9]. The risk of overuse of dissociation is particularly high for athletes who endured interpersonal violence in childhood [26], were exposed to interpersonal violence during the sports career [10], suffered traumatic injury [29], or experienced any combination of the previous factors in the sense of cumulative or complex trauma [11].Regarding sports performance, dissociative strategies may undermine performance if they are used too frequently or too rigidly, thereby impairing flexible adaptation to task demands [19]. This may me gathered from research showing that elite athletes are able to voluntarily shift toward associative strategies as task demands intensify [22, 23], whereas less well performing athletes tend to adopt and maintain dissociative strategies to manage stressful tasks [24]. Athletes may not necessarily recognize dissociation as dysfunctional, and so not report it during a clinical encounter [19]. And even if they do realize dysfunctional aspects of dissociation, they may hide them because – as mentioned earlier – psychological problems are often stigmatized in high-performance settings and any sign of vulnerability may jeopardize a sports career [9, 19, 31].Be it consciously or not, the use of dissociation may in this way mask the presence of trauma-related disorders [9]. If the latter remain undetected, undiagnosed, and untreated, there is an increased risk of progression toward a chronic or complex trauma-related disorder [9, 11]. Independently of potential undertreatment, acute and prolonged use of dissociation is a risk factor for later development of PTSD [4]. Moreover, chronic use of dissociation may increase the risks of self-injury [32, 33], suicidality [32, 34], and delayed recovery from injuries [9, 35]. In addition, habitual use of dissociation may entail numbing that renders individuals blind to dangerous future situations, thereby heightening the risk of revictimization or retraumatization [29, 36].ConclusionAlthough normal dissociation in the context of athletic performance must in principle be distinguished from pathological dissociation as a symptom of trauma-related disorders and experienced violence and abuse, the two types of dissociation overlap in terms of processes and functions. For instance, pathological forms of dissociation may be self-induced by way of deliberate self-injury [37, 38], and there is preliminary evidence suggesting that athletes may also resort to such dysfunctional forms of “emotion regulation” [39].In view of the wide array of potentially negative consequences of chronic dissociation, including underperformance, underdiagnosis and undertreatment of trauma-related disorders, increased rates of self-injury and suicidality, and delayed recovery from injury, we advocate that screening for dissociation be included in routine sports psychiatric examinations [40]. The latter should be conducted by qualified mental health care professionals – psychiatrists and psychotherapists – with trauma- and dissociation-specific training and expertise.Sports physicians, sports psychologists, and other sports professionals should be sensitized and enabled to recognize dissociative reactions associated with mental disorders and refer affected athletes to qualified mental health care professionals. Early detection of trauma-, training- or competition-related overuse of dissociation is paramount to prevent progression toward towards (complex) PTSD and retraumatization [9].References1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Washington, DC: American Psychiatric Press; 2013. First citation in articleGoogle Scholar2 Cardeña E, Spiegel D. Dissociative reactions to the Bay Area earthquake. Am J Psychiatry. 1993;150:474–78. 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