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When I let my enormous chimp out, I start thinking like a pessimist. I have a tremendous sense of foreboding, wondering about the what ifs, about crashes and mistakes.

Chris Hoy, six-time Olympic track cycling gold medallist, in a 2009 BBC interview

High-level sporting competition comes with high levels of pressure for athletes and their support staff. Anxiety in athletes carries both performance enhancing benefits and the potential to see athletes ‘choke’ under the pressure of the big race or event. It has affected top athletes across the whole spectrum of sport, from David Beckham (soccer—obsessive compulsive disorder) to Missy Franklin (Olympic gold medal swimmer—panic attacks).

Direct financial incentives and sponsorship deals, the media obsession with winners and losers, peer and family pressure, and a host of other social pressures all come together in modern-day sport at the top level. Sporting organisations often portray the ability to deal with this pressure as part of displaying the mental toughness required to compete, and this can predispose athletes, especially those yet to establish themselves, to say they are coping.1 This may internalise concerns and lead to mental health disorders such as anxiety and depression (Chapter 21). These can also manifest in physical forms such as conditions affecting the gastrointestinal, respiratory or cardiovascular systems (Chapters 1012).

This chapter discusses the range of anxiety disorders most often seen in both recreational and elite athletes. We outline the principles of clinical management for athletes suffering from anxiety disorders.


The Anxiety and Depression Association of America (ADAA) states that as of 2018 anxiety disorders are the most common mental health complaint affecting US citizens, with 18.1% of the population affected each year.2 Risk factors can include, but are not limited to, genetic predisposition, brain chemical imbalance, life events and personality. More specific to athletes, there is an inherent risk that participating in elite sport can predispose them to factors or situations that may negatively impact upon their mental health (Table 22.1).

Table 22.1Elite sport participation risks contributing to possible mental health concerns

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