The phenomenon of sudden neurotic breakdown in men devoted to physical fitness was first revealed to me many years ago when working with Sir Martin Roth in Newcasrleupon-Tyne, but it was only subsequently, in Leeds as a consultant psychiatrist, that I was able to embark on a systematic study of the problem. The clinical team in Leeds received around 400 new psychiatric referrals each year,1 and so we encountered in considerable numbers some of the disorder complexes that are not often seen in other clinical settings.
Over a period of three years 44 patients came under our care who had what we called "athlete's neurosis." All were men. Other characteristics they shared were (1) an excessive and often exclusive preoccupation with physical fitness, (2) a sudden breakdown occurring at about the age of 40 years, when their physical powers were beginning to wane, and (3) the fact that their breakdown had followed almost immediately some threat to their physical well-being.
In most instances the ensuing neurotic illness of these men was characterized by anxiety and neurotic depressive features. A minority recovered fairly quickly. The majority proceeded to an intractable chronic neurotic state extremely resistant to psychological and physical therapies.
In making inquiries into the previous life experiences, relationships, and personality traits of these men we discovered an unexpected theoretic aspect of this disorder. Both their personal histories and the impressions these men created when one saw them indicated they were well-adjusted, sociable people who had experienced excellent health and happy relations with other members of their families and with their peers - not only in their adult years, but also in childhood. Most had made satisfactory marriages and enjoyed their work and the company of their fellows. Until the immediate crisis they had no idea of what "nerves" meant. That such people should suddenly develop crippling neuroses seemed inconsistent with received ideas on the etiology of neuroses, as summarized by Schneider's dictum, "There are no neuroses, only neurotics."2
Relatives were interviewed to see if there might be some discrepancy, but their accounts matched those of the patients. In discussing this paradox colleagues would emphasize that a first psychiatric illness of sudden onset in a person on the threshold of middle age who had previously been of sound personality was most likely to be a psychosis, probably an atypical endogenous depression (syn. manic depressive psychosis, depressed type, International Classification of Disorders 296.2). But, try as we might, we could not project the manifestations of other than neurotic disorders on these patients. The revealed pattern of causality of "athletic neurosis" in these men thus was an exception to the general rule that neurotic illness develops only in personalities with many of the traditionally accepted neurotic markers in the life history - a finding we realize may be unacceptable in some quarters.
The general run of neurotic men we treated in Leeds proved to be significantly different in many respects from those with the athletic neurosis. Unlike the athletes, the ordinary neurotics had had a lifelong lack of interest in physical prowess and well-being. Their life stories were characterized by childhood ill health and disturbed interpersonal relations. In these men the immediate precipitant was quite often a reactivated crisis in relationships, almost never a threat to their physical well-being, as was the case with the athletic neurotics. They differed from the athletic group of men with essentially similar neurotic symptomatology in many other ways - e.g., they were younger when referred for treatment, had immature bone structure, and had low sociability, and lower extraversion and higher neuroticism scores on the Maudsley Personality Inventory (MPI). They also had a more favorable prognosis, in most cases.
The findings and conclusions were submitted for a doctoral thesis,3 but we continued our investigation. We wanted to find whether members of both groups - athletic men and nonathletic men with neurotic illness - differed in their premorbid characteristics from men of similar age who were not suffering from neurotic illness. So a search for normal controls was launched.
We did this by contacting the general practitioners who had referred patients in our original study. In the National Health Service more than 95 per cent of the people are registered with a general practitioner. Dr. T. A. Kerr and I contacted each physician who had referred one or more of the 44 patients in our study. We located each patient's case record in the alphabetically stacked files and selected arbitrarily as a normal control the next following male who had been born in the same year as the patient.
The general practitioner then went with us either in the evening or on a Saturday morning to the home of this normal "control," introduced us to his patient, and left us to carry on with the interview, psychological tests, and anthropometry.
After a decade and a half in hospital-based psychiatry I found it most salutory to encounter healthy people in their homes. And I think the controls also appreciated our visits. We were well received nearly everywhere we went, offered refreshment in two-thirds of the homes that we visited, and usually found that both husband and wife told us much more of an intimate nature than was required by our study. Perhaps one reason for this is that it is a rare opportunity in life to be able to sit down for an hour with a trusted stranger and be invited to talk freely about oneself.
Over a period of several months we accumulated information on 33 normal men.4 These normals, in their attitude toward athletics and athletic prowess, occupied a position midway between the fanaticism of the athletic male neurotics and the indifference of the nonathletic male neurotics. The only other difference between the normals and the athletic neurotics was that the athletic neurotics were even more sociable than the normals. Sociability is a characteristic of those who participate in sports, and the social interaction adds greatly to the fun and pleasure.5 The nonathletic men who had presented with neurotic disorders, on the other hand, were quite different from the normal controls, for they possessed many features that conformed to our accepted model of the neurosis-prone subject.6
The athletic men who fared badly under treatment not only were fanatically devoted to physical prowess, expressed either in sports or in their work, but obtained their satisfaction in life, outside the family, from an exclusive devotion to physical activities - an overvaluation that intensified their vulnerability as they began to lose speed, coordination, and strength on the threshold of middle age. At this Ufe stage a threat, in the form of illness or injury, can turn such a person into a chronic neurotic wreck, despite a report that in general neurotically ill males with low neuroticism and high extraversion scores on the MPI have a favorable prognosis.7
The relevance of the immediate precipitant to these athletic neurotics' breakdown makes psychological sense only when one understands the valuation system of such a person. Similar breakdowns occur in men exclusively devoted to work when they are forced to retire. Such crises create not so much neuroses of conflict as neuroses of deprivation.8 Each is a bereavement reaction to loss of part of one's self, necessitating, in Lindemann's words, "readjustments which do not belong to the arsenal of habitual adjustive responses."9
The athlete's crisis is but one of several that can be experienced on the threshold of middle age in males. Jacques10 not only discovered a sudden jump in the death rate in men of creative genius when they entered the 35-39 age bracket but also gave many examples of various sorts of decline in men reaching the late 30s. Some of these subjects, after living through an unproductive postcrisis phase, eventually broke through to a less feverish "sculpted creativity" in their 40s or 50s. He found that those who did not confront and overcome the violent upheaval of this period of their lives either declined or died.
Jacques compares the situation to that described by Dante at the beginning of The Divine Comedy: "In the middle of the journey of life, I came to myself within a dark wood, where the straight way was lost . . . that wood, savage and harsh and dense, the thought of which renews my fear."11 Dante eventually emerged from the inferno, found his way through purgatory, and arrived at paradise. But what possible athletic paradise awaits the worn-out fitness fanatic once he has reached the middle of his journey of life? Those who have pursued athleticism in parallel with other, less physically demanding enthusiasms may well come through the dark wood, especially if these alternatives can be appropriately pursued into and beyond middle age. A similar disorder confronts many women who have overvalued key family relationships; they are creating a vulnerability that only awaits activation, for their work in mothering cannot be needed forever, and - a second deprivation - their own parents will not live forever.
A major characteristic that emerged as a result of this study was that the man with an athletic neurosis had no need for a manifestly neurotic predisposition to precede the onset of neurotic breakdown. One single overvalued aspect of life can create the preneurotic vulnerability (although it is doubtful that a symptom-free overvaluation could be considered a neurosis until the point of overt breakdown was reached). People in such a state of specific vulnerability are relatively resistant to nonrelevant Stressors but collapse into serious maladjustment when the appropriate Stressor arrives - as it must, almost inevitably. Few athletes can expect to excel in strenuous physical activities indefinitely - though it must be admitted that the best long-distance Finnish skiers are juxta-geriatric! The breakdown might be averted if the athlete made a sensible changeover to gentler exercises as he reached midlife, but once into the overt neurosis few athletic neurotics will consider such a solution.
Extreme male athleticism is to be observed in two main forms. The first is the "body beautiful." The more feminine type of woman, it has been reported,12 finds the man who has the tapering "V" physique to be the most attractive. Such a woman, of course, may be in for a big disappointment, since some of the narcissistic muscle builders and devotees of health food shops, while eager to display that body beautiful, are fearful lest the love object be damaged or weakened - for example, by sexual activity. The hero of Muscle Beach13 is an example. I have yet to see such a "Mr. Atlas" present as a psychiatric casualty.
It is the second form of extreme male athleticism that we found among our patients at Leeds: the athletes who we found had become suddenly and neurotically disabled were those who had been preoccupied with the body in action as an aspect of male competitiveness. The impression given by these men is that they are constitutionally predisposed to seek their satisfactions through physical channels and that they lack abilities in other directions.
It is hard to link their overvaluation of athletics to any distortion in their upbringing. We simply found no evidence of this.
The psychological motives in sport are complex and fluctuating.14 Many authors emphasize the aggressive component in sports, and it is not surprising to find that aggression, when turned in on the self, aggravates the depression and anxiety associated with the experience of deprivation.
Prospects for the prevention of athletic neurosis are no more encouraging than the prospects for treatment. One might hope that these fanatical fitness enthusiasts might be identified in advance, warned of the hazards ahead, and encouraged to modify their attitudes and behavior in time to prevent mental illness. But it is my experience that these lemmings do not want to know. If pressed, they become angry and scornful. In correspondence with sports- feature journalists and sports-medicine physicians I have come to believe that the psychological defenses of these enthusiasts are virtually unassailable: the very notion of a neurotic athlete is taboo.
Interest in sports is ever on the increase, even if participation is not. In fact, it has become the "pabulum of the masses."15 In contemporary Britain many cry for equality, and elitism, for them, is a sin - yet they choose not to see that in an educational system where none must excel academically lest the losers be made to feel inferior, the members of the sports teams are chosen on merit. They see no inconsistency in the fact that, while financial inequality in every other field of endeavor is decried, the most highly skilled sports heroes earn fabulous rewards in money and acclaim. The sports heroes, if wise, retire while in their 30s and retreat into ownership of profitable sports shops. If unwise, their raison d'être having gone with their youth, many are unable to face social oblivion and break down. Some find final oblivion in suicide, a tragic phenomenon most sports doctors and journalists are reluctant to discuss.
The athlete's neurosis is no rare disorder. It accounted for one out of 11 of all new male referrals to a comprehensive psychiatric service based in a general hospital during the 1960s.1 I can give no figures for the 1970s, since my clinical commitment has been selectively restricted and the hospital's records give no guide on incidence (the etiologic complex of "athlete's neurosis," if recognized, has not been recorded as such in the diagnosisoriented system). But former trainee psychiatrists who worked in the team at Leeds, and who are now in senior posts, assure me that they continue to see many such cases and find them still as difficult to treat.
The contemporary craze for jogging and similar exercises must raise questions about the mental-health implications of this phenomenon. I have no knowledge of any jogger's being referred with an unexplained sudden-onset neurotic illness, and I can find no reference to such an event. Among those who jog there will inevitably be some identifiable fitness fanatics, but the psychiatrist with a widespread practice will undoubtedly find that most joggers are so engaged as part of a commonsense response to health-education programs.
A new life style has been deliberately adopted by the American male since the post-World War II era, and it has altered him from the flabby, obese, cigarette- smoking, mechanically mobile figure of that era who was seemingly hell-bent on early self-destruction. The new style entails dieting, exercise, and reduction or cessation of tobacco smoke intake. Just which of these variables has brought about the change in middle-age mortality in the United States is not entirely clear, but the demonstrable positive advantages of the whole "protective packet" far outweigh any speculated psychiatric morbidity from the physical -exercise component (which, if present, is yet to be demonstrated).
In Britain, where regular exercise and other preventive measures are not yet taken seriously, the price is still being paid. To my rnind, regular physical exercise to avert or postpone disaster ahead is a far cry from the fanatical pursuit of physical prowess as an exclusive way of life, and I doubt that any significant psychiatric morbidity would ensue.
1. Little, J. C-, Kear-Colweli, J. ]., and Lloyd, A. T. Psychiatry in a General Hospital. London: Butterworths & Co. 1974.
2. Schneider, K. Psychopathic Personalities, Ninth Edition. Vienna: Franz Deuticke, 1950.
3. Little, J. C. Physical Prowess and Neurosis. M.D. Thesis, University of Bristol, 1965.
4. Little, J. C., and Kerr, T. A. Some differences between published norms and data from matched controls as a basis for comparison with psychiatrically disturbed groups. Br. . Psychiatry 214 (1968}, 883-890.
5. Snyder, E. E., and Spreitzer, E. A. Involvement in sports and psychological well-being. Int. ]. Sport Psychal. 5 (Rome) (1974), 28.
6- Little, J. C, The athlete's neurosis - a deprivation crisis. AcIa Psychiatr. Scand. 45 (1969), 187.
7. Ken·, T. A., et al. The relationship between the Maudsley Personality Inventory and the course of affective disorders. Br. }. Psychiatry 116 (1970), 11-19.
8. Hill, D. In Tanner, J. M. (ed.)Sfrfiss and Psychiatric Disorders. Oxford: William Blackwell & Sons, 1969, pp. 121-129.
9. Lindemann, E. Symptomatology and management of acute grief. Am. i. Psychiatry 101 (1944), HI-148.
10. Jacques, E. Work, Creativity, Social Justice. London: William Heinemann Medical Publishers, 1970.
11. Alighieri, Dante. The Divine Comedy, in Moore, E. (ed.). The Oxford Dante. Oxford: Oxford University Press, 1924, Inferno, Canto I, 1-6.
12. Lavrakas, P. J. Female preference for male physiques. /. Res. Personal. 9 (September 4, 1975), 324.
13. Wallach, Ira. Muscle Beach. New York: Dell Publishing Company, 1960.
14. Czerwenka-Wenkstetten, H. Psychologic and psychopathological motivation in sport. Z. Nervenheilk 27 (Vienna) (February 27, 1969), 162.
15. Young, M. The Rise of the Meritocracy. London: Thames & Hudson, 1958.