OCD in College Athletes

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.

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.