Mental distress and disorders in sports can manifest as both sport-specific and non-sport-specific disorders. These conditions may impair performance and increase the risk of physical injury. If unrecognized or inadequately treated, mental health disorders can lead to severe long-term consequences for athletes. In certain sports, the prevalence of mental disorders even exceeds that of the general population. However, competitive athletes are significantly underrepresented in psychiatric healthcare due to systemic barriers, including fear of failure, career-related anxieties, and a culture that often subordinates personal needs to athletic demands. Consequently, athletes typically seek help only when mental distress impairs performance. To address this, proactive intervention during subclinical phases is essential for maintaining both mental health and elite success. Accordingly, a structured, multi-stage sports-psychiatric diagnostic framework in competitive sports is required to enable the detection of mental disorders using established examination and screening methods before a decline in performance occurs. Established assessment methods as well as those currently under development are presented. These include structured, categorical, multi-stage procedures, baseline assessments, and dimensional methods. It is demonstrated that the prevention of mental disorders and subsequent performance drops is best achieved through continuous sports-psychiatric support within the sports system. In this context, operationalized psychodynamic diagnostics proves to be a valuable dimensional tool that also enables performance-related intrapsychic potential analyses and supports the early identification of even subclinical psychological pathologies.

• Sports

• Psychiatric Diagnostics

• Mental distress

• Mental disorders

• Psychological pathologies

Schorb A, Moser AC (2026) Sports Psychiatric Diagnostics in Competitive Sports. Ann Psychiatry Ment Health 14(2): 1216.

Competitive athletes access psychiatric treatment less frequently than other patient populations [1-3]. This discrepancy is often precipitated by profound anxieties surrounding the initiation of treatment, which is widely conceptualized as a personal failure [1]. Furthermore, concerns regarding career longevity and external pressure from the athletic environment may compound these difficulties [4]. In some instances, deeply ingrained behavioral patterns that prioritize performance over personal needs further inhibit help-seeking behavior [3]. Additionally, sports psychologists and mental coaches are regularly entangled in role conflicts, balancing the optimization of performance with athletic or institutional interests [3]. Consequently, athletes often disclose psychological distress to their support staff only when psychiatric symptoms demonstrably impair athletic performance [4].

While recreational sports serve as an effective stress buffer, competitive sports inherently lack this protective capacity [5], being governed by institutionalized demands for success and performance maximization within national and international competitions [6]. While recreational sports are integrated into everyday life as a leisure activity, competitive sports form an independent social system. This structural isolation offers athletes limited opportunities to develop an identity outside of their athletic role [6]. As the careers of elite athletes generally begin in childhood or adolescence, individuals are exposed to performance pressure and expectations of success from an early age. They are continuously evaluated, compared, and selected based on their athletic performance [6].Within this system, competitive success confers social status and plays a significant role in shaping an athlete’s self-esteem [6]. Due to early specialization and the strong identification with the athletic role, combined with a lack of alternative identity sources, sporting performance frequently becomes the primary basis for self-esteem [7]. Consequently, self-esteem and identity are largely derived from performance and, in particular, from success. Athletic failure may therefore be experienced as personal failure. Overall, athletic performance plays a central role in stabilizing both self-esteem and identity [6,8]. However, athletic success and mental health must not be mutually exclusive. Ideally, athletes should be educated and empowered to advocate for both their physical and psychological well-being in the sense of an informed consent. The unique demands of competitive sports necessitate a reliable assessment of psychological burdens and risks, as well as precise diagnostics, treatment, and aftercare – even for subclinical psychological disorders. This approach must comprehensively integrate both elite sports-specific constraints and physiological sports science factors [9].

The specific aspects of competitive sports, along with certain sport-specific phenotypes of mental disorders, frequently extend beyond the scope of classical psychiatric perspectives [3]. Developmental aspects in sports, performance pressure, time zone and climate shifts, loneliness during travel, monotony, sport-specific demands and overloads, impaired performance, injuries, and potential overtraining syndromes must be considered during diagnosis and treatment planning [3,10,11].

- Categorical Multistage Psychiatric Diagnostics

For psychiatric screening in Olympic sports, the Sport Mental Health Assessment Tool 2 (SMHAT-2) is currently utilized [12]. The SMHAT-2 is an internationally standardized screening instrument designed for the early detection of mental health symptoms in competitive and elite athletes. Developed by an expert consensus group convened by the International Olympic Committee (IOC), the original tool was published in 2021 as SMHAT-1 [13], whereas the revised version was released as SMHAT-2 in 2026 [12]. It is specifically tailored for sports medicine physicians, psychologists, and trained medical professionals to identify mental health symptoms and disorders in elite athletes aged 16 and older.

The SMHAT-2 utilizes a refined three-step approach to optimize early detection and clinical support. Step 1: Universal (Mandatory) Screening – It serves as a comprehensive universal screening administered to all athletes, utilizing five validated disorder-specific screening questionnaires and two single questions to facilitate the early detection of a broad spectrum of potential mental health symptoms.

• Anxiety: Generalized Anxiety Disorder-7 (GAD-7)

• Depression: Patient Health Questionnaire-9 (PHQ 9)

• Cannabis use

• Nicotine / Tobacco use

• Sleep Disturbance: Athlete Sleep Screening Questionnaire (ASSQ)

• Disordered Eating: Eating Disorder Examination Questionnaire Short Form (EDE-QS)

• Alcohol Misuse: Alcohol Use Disorders Identification Test (AUDIT)

Furthermore, Step 1 utilizes a single-item trigger from the PHQ-9 (Question 9) to ensure the immediate detection of suicidal ideation. Elevated scores on GAD-7 ≥ 10 or PHQ 9 ≥ 10 mandate follow-up evaluation via the PC-PTSD-5 in Step 2, whereas a positive substance use history activates the CAGE protocol. Severe domain-specific scores – defined as ASSQ ≥ 8 (sleep), EDE-QS ≥ 15 (disordered eating), or AUDIT ≥ 8 (alcohol misuse) – serve as immediate triage markers that bypass Step 2 to directly initiate formal clinical management in Step 3 (Clinical Assessment and Treatment). This stage involves a comprehensive clinical evaluation and management protocol conducted strictly by sports medicine physicians or registered mental health professionals to establish formal diagnoses and treatment pathways.

The SMHAT-2 is certainly a state-of-the-art advancement that has propelled comprehensive mental health assessment in sports. However, studies evaluating the predecessor tool, SMHAT-1, revealed multiple implementation barriers capable of restricting its practical utility [14-16]. Although it ensures a comprehensive psychometric evaluation of athletes, the predictive validity of its triage component varies across different mental health domains, yielding between 5% and 60% false-negative results [14,16]. In the unrevised version (SMHAT-1), however, the Athlete Psychological Strain Questionnaire (APSQ) was deployed as a non-specific screening tool for initial triage; moreover, the practical implementation of the complete algorithm required substantial time, thereby limiting its feasibility for routine screening [17]. To address this, a shorter, more economical alternative derived from the unrevised SMHAT-1 items was validated within the Polish Olympic sports context as the Athlete Mental Health Screener-18 (AMHS-18) [17]. The AMHS-18 serves as a time-efficient instrument for athlete mental health evaluations, offering a practical alternative, particularly when time and resources are constrained or when more frequent screenings are warranted. In Poland, the AMHS-18 is integrated into the ATHLETE MENTAL HEALTH SCREENING AND SUPPORT SYSTEM [18], which comprises four distinct stages: 1. Initial Meeting, 2. Questionnaire Administration, 3. Brief Clinical Intake Interview, and 4. Post-Interview Feedback and Mental Health Recommendations.

- Psychiatric Basic Assessment

Within the D-A-CH region (Germany, Austria, and Switzerland), a model for structured, multi-tiered psychiatric diagnostics in competitive sports is currently under development. This model incorporates a Psychiatric Basic Assessment (PBA) embedded within annual or biannual sports medicine evaluations (Table 1) [19]. It is designed to implement a three-stage diagnostic approach: the first stage quantifies the extent of functional impairments, psychological functioning, general self efficacy, and resilience; the second stage consists of a structured interview focusing on psychiatric symptoms; and the third stage involves symptom- and disorder specific diagnostics. Included in the primary stage are defined clinical ‘red flags’ that indicate an immediate need for further medical or psychological investigation. The PBA is conducted by professionals with formal training in psychiatry, psychotherapy, or clinical psychology.

Table 1: Components of the PBA [19]

Limitations of Existing Screening Instruments

As previously noted, evaluations using the SMHAT-1 - and likely its short form, the AMHS-18 - carry the risk of overlooking highly adapted athletes or those presenting with atypical symptoms, particularly because a psychiatric basic assessment in the stricter sense is not integrated [19]. The screening relies exclusively on self-report questionnaires, which are susceptible to false-negative outcomes driven by underreporting [20]. Furthermore, the administration of psychiatric and psychological diagnostics by individuals lacking formal psychiatric psychotherapeutic, or clinical psychological training warrants critical examination [19].

- Mental Health Care Concepts Incorporating Early Psychiatric Diagnostics in Competitive Sports

In any case, the safe and effective management of psychiatric disorders necessitates specialized clinical expertise [21]. Current practices regarding sports psychiatric and psychotherapeutic care remain highly heterogeneous. It is recommended that sports psychiatric resources be provisioned at both the club and federation levels [3]. These resources can be integrated into specialized care concepts that explicitly account for performance related factors [4]. Fundamentally, psychiatry should not merely be utilized for disorder treatment, but proactively engaged for preventive and differential diagnostic interventions, thereby allowing athletes to be continuously supported within the sports system [22]. Not infrequently, due to a lack of specialized knowledge within this system, psychiatric conditions are identified and treated only at an advanced stage [22].

- Psychiatric Assessment During Career Transition and Retirement

At the end of an athletic career, the prevalence of psychiatric symptoms and disorders among elite athletes is significantly elevated [23]. Consequently, it is vital for elite athletes to prepare for life after sports well in advance [24]. Early planning for a dual career (combining sports and education) is considered the most critical protective factor for a successful transition. Organizations such as KADA [25], in Austria or Swiss Olympic [26], provide specialized mentoring and counseling programs to facilitate and support this process.

When vocational, financial, social, or psychological resources are lacking, the transition can culminate in a ‘crisis transition’ that necessitates professional intervention [23]. Fundamentally, a standard of care is recommended that ensures access to support and, if required, clinical treatment at the end of an athletic career. Upon career termination, an ‘Exit Health Examination’ (EHE) is strongly advised [23,27]. Furthermore, alternative studies advocate for ‘After-Career Consultations’ (ACC) as a critical framework for safeguarding the mental health of retired athletes [23,28].

- The Integrated Risk Model and Athlete Risk Assessment Matrix

The Integrated Risk Model (IRM) and the Athlete Risk Assessment Matrix (ARAM) represent state-of-the-art clinical frameworks [29]. They are designed to systematically evaluate and longitudinally monitor the psychological safety and competitive readiness of competitive athletes regarding their participation in training, competitions, or travel. Together, they constitute the first formal risk assessment model in sports psychiatry that avoids viewing the athlete in isolation, instead encompassing their entire athletic and personal ecosystem.

The IRM is predicated on the recognition that mental health in competitive sports is highly complex and cannot be captured solely by counting symptoms [29]. Instead, it interconnects two core dimensions, beginning with a symptom-based risk stratification along a continuum. Within this framework, psychological distress is not merely classified as ‘sick’ or ‘healthy’ in a categorical manner; rather, it is conceptualized as a fluid continuum based on symptom severity. The second dimension encompasses the socio-ecological ecosystem, wherein the model examines the reciprocal influences between the athlete and their environment across three distinct levels. At the closest proximity is the microsystem, which represents the immediate environment including coaches, teammates, roommates, staff, friends, partners, and family. This layer is embedded within the exosystem, which comprises the broader sport, organizational structures, regulations, and the respective governing body. Finally, the macrosystem accounts for overarching influences, specifically the high performance sport environment as well as public and social media.

The ARAM serves as the practical, clinical tool that builds directly upon the foundational principles of the IRM [29]. This assessment grid places a primary focus on risk modifiers, specifically directing clinical attention toward factors that can either buffer the overall psychological risk, such as protective factors like resilience and social support, or heavily exacerbate it through variables like severe injury, squad pressure, or interpersonal violence. Furthermore, the matrix is designed for longitudinal monitoring, enabling clinicians to utilize the system to generate a systematic inventory of all relevant risk factors. Consequently, this approach allows for the precise tracking of positive developments, clinical deterioration, or overarching trends in an athlete’s mental state over months or entire competitive seasons. Traditional screening protocols frequently rely purely on standardized self-report questionnaires. The IRM and ARAM crucially expand this perspective by enabling individualized risk analyses. They assist federations and medical professionals in making evidence-based decisions regarding whether an athlete is mentally stable enough for competitive sports, or if acute intervention is required within the athlete’s environment.

- Operationalized Psychodynamic Diagnosis in Sports

Intrapsychic processes play a crucial role in sports, influencing both health and performance, with these two factors maintaining a reciprocal relationship [4,22]. It appears valuable to capture and reflect upon the underlying dynamic processes of relevant factors such as subjective experiences, demands, pressure, resources, resilience, interpersonal relations, dysfunctional relationship patterns, intrapsychic conflicts, personality functioning, structural integration, self-esteem, energy, body experience, overload, performance, and mental health symptoms [4,11,22,30]. In particular, the foundations of dynamic intrapsychic processes can be assessed using Operationalized Psychodynamic Diagnosis (OPD) [31]. The OPD-3 Module Sports/Competitive Sports was specifically developed for athletes [22]. It serves to capture psychodynamic approaches, allowing for the assessment and processing of differentiated dimensional processes within sports. This applies to psychodynamic profiling, potential analyses, and psychodynamic performance-related aspects. Furthermore, it enables the provision of coaching and counselling for individuals and institutions, as well as the prevention of mental disorders, the identification of (sub)clinical pathologies alongside suitable treatment options, crisis management, and differentiated dimensional diagnostics with integrated treatment planning and clinical management of mental and psychosomatic disorders. The module can also be seamlessly integrated into frameworks of mental healthcare and prevention [3,4,22].

Athletes are exposed to specific risks that increase the probability of developing a mental disorder [1,2,3]. Furthermore, empirical evidence suggests that they seek psychiatric and psychotherapeutic treatment less frequently and at a later stage compared to the general population [1,3]. Consequently, regular psychiatric and psychotherapeutic examinations for athletes are highly warranted [3,12,19]. For this purpose, structured categorical and dimensional assessment methods, as well as baseline assessments and risk assessment models, are either currently available or under development.

Psychological diagnostics in competitive sports is also essential because adequate performance and mental health are inextricably linked [4]. In high-performance sports, purely sport-psychological coaching, such as mental training, is often insufficient as it fails to capture deeper, unconscious blockages or clinical symptoms [3,22]. In this context, a well-founded assessment initially makes a significant contribution to resolving performance blockages by systematically investigating phenomena such as choking under pressure [22]. Instead of merely addressing symptoms, it uncovers underlying unconscious conflicts – for instance, in the domains of self-esteem or autonomy – and differentiates between situational fluctuations in performance and structural deficits in self-regulation. Furthermore, such a diagnostic approach enables the early detection and prevention of clinical disorders by rendering subclinical pathologies visible, particularly before they become chronic or lead to a premature career end [22]. Based on these insights, tailored and integrated treatment planning can be realized, serving as a critical interface: it initiates targeted clinical psychotherapeutic interventions when necessary and seamlessly networks the athletes’ sporting environment with the medical healthcare system. Ultimately, such diagnostics can also provide the foundation for sustainable potential analysis and personality development, as it not only highlights deficits but also decodes the athlete’s individual psychological resources and resilience, thereby providing coaches and support staff with a scientifically sound basis for customized leadership, workloads, and communication [22].

When affected, athletes with mental illnesses require therapeutic support that is as rapid and effective as possible [4]. Developing and deriving a focused treatment priority using OPD appears to be a helpful option [22]. In competitive sports, an implicitly or explicitly echoing pressure to restore function and performance as quickly as possible poses a particular challenge. Treatments under these conditions may differ from conventional psychotherapeutic processes, where a certain and temporary destabilization with long-term reorientation is a necessary and integral component [3,4]. Within OPD, considerations regarding the potential functionality of intrapsychic dysfunctions are particularly relevant, suggesting that a perceived deficit in the dynamic interaction with other dimensions in sports may indeed appear functional and purposeful [4,22].

1. Claussen MC, Seifritz E (Hrsg.). Lehrbuch der Sportpsychiatrie und -psychotherapie. Psychische Gesundheit und Erkrankungen im Leistungssport. Hogrefe 1. Auflage 2022
2. Reardon CL, Hainline B, Aron CM, Baron D, Baum AL, Bindra A, et al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). Br J Sports Med. 2019; 53: 667-699.
3. Schorb A, Friedrich F, van der Kallen F, Hammer-Weber U, Trost-Schrems J, Pennwieser W, et al. Sportpsychiatrie und Sportpsychotherapie in Österreich. Journal für Neurologie, Neurochirurgie und Psychiatrie. 2026; 27
4. Schorb A, Häfelinger U, Pesicka M, Kohl S, Karus, Kaiser A, et al. Promoting mental health care to reach optimal performance in sports. Sports Psychiatry. 2025; 1-6.
5. Gerber M, Holsboer-Trachsler E, Pühse U, Brand S. Elite sport is not an additional source of distress for adolescents with high stress levels. Percept Mot Skills. 2011; 112: 581-599.
6. Halioua R, Wyssen A, Karrer Y, Matter Brügger S, Milos G, Munsch S. Psychische Erkrankungen im Leistungssport: Gestörtes Essverhalten und Essstörungen. In Claussen MC, Seifritz E (Hrsg.). Lehrbuch der Sportpsychiatrie und -psychotherapie. Psychische Gesundheit und Erkrankungen im Leistungssport. Hogrefe 1.
7. Gugutzer R. Sport. In: Gugutzer R, Klein G, Meuser M, Hrsg. Handbuch Körpersoziologie. Band 2, Forschungsfelder und Methodische Zugänge. Wiesbaden: Springer Fachmedien; 2017; 303-317.
8. Devi G, Kumar S. Sports Performance and Mental health of Athletes.Sports Science & Health Advances. 2023; 1: 46-49.
9. Claussen MC, Gonzalez Hofmann C, Imboden C, Seifritz E, Hemmeter U. Positionspapier–Psychische Gesundheit im Leistungssport. Swiss Archives of Neurology, Psychiatry and Psychotherapy. 2020; 171: w03103.
10. Schorb A, Aichhorn J, Schiepek G, Aichhorn W. Burnout in adolescent elite athletes. Sports Psychiatry: J Sports and Exercise Psychiatry. 2023; 1-6
11. Schorb A, Niebauer J, Aichhorn W, Schiepek G, Scherr J, Claussen MC. Overtraining from a sports psychiatry perspective. Dtsch Z Sportmed. 2021; 72: 271-279.
12. Gouttebarge V, Bindra A, Blauwet C. International Olympic Committee Sport Mental Health Assessment Tool 2 (IOC SMHAT2): development, content validity and feasibility. Br J Sports Med. 2026.
13.     Gouttebarge V, Bindra A, Blauwet C, Campriani N, Currie A, Engebretsen L, et al. International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes’ mental health. Br J Sports Med. 2021; 55: 30-37.
14. Anderson T, Adams WM, Bartley JD. Analysis of the Sport Mental Health Assessment Tool 1 (SMHAT-1) in Team USA athletes. Br J Sports Med. 2023; 57: 1187-1194.
15. Taylor DJ, Huskey A, Kim KN. Internal consistency reliability of mental health questionnaires in college student athletes. Br J Sports Med. 2023; 57: 595-601.
16. Waleria?czyk W, Krzywa?ski J, Gorgol J. Diagnostic effectiveness of the Sport Mental Health Assessment Tool 1 supplemented with a brief clinical intake interview in a cohort of Polish elite Olympic athletes. Br J Sports Med. 2025; 59: 56-63.
17. Waleria?czyk W, Wójcik K, Konopka K, Lisek G, Iwaszkiewicz E, Krysztofiak H. Shorter, faster, but still accurate: using ant colony 

    optimisation to develop and validate the Athlete Mental Health Screener-18 (AMHS-18) as a brief alternative to Sport Mental Health Assessment Tool 1 (SMHAT-1). Br J Sports Med. 2026; 11: bjsports-2025-110881.

18. Waleria?czyk W, Lisek G, Wójcik K, Konopka K, Iwaszkiewicz E, Krzywa?ski J, et al. Taking the best from the two worlds: the benefits of combining athlete mental health screening with brief clinical intake interviews. Br J Sports Med. 2026: bjsports-2025-111155.
19. Gonzalez Hofmann C, Wyssen A, Schorb A, Allroggen M, Dallmann P, Schmidt RE, et al. Sports psychiatric examination in competitive sports. Dtsch Z Sportmed. 2021; 72: 307-315.
20. Heuchert JP, McNair DM. Profile of Mood States 2nd Edition, Multi-Health Systems Inc. Toronto, 2012.
21. Claussen MC, Gonzalez Hofmann C, Schneeberger AR, Seifritz E, Schorb A, Allroggen M, et al. Position paper: sports psychiatric care provision in competitive sports. Dtsch Z Sportmed. 2021; 72.
22. Schorb A. Conference report: 3rd International Conference on Sports Psychiatry, Salzburg, Austria, October 17-18, 2025. Sports Psychiatry. 2025; 4: 215-225
23. Schorb A, Edwards C, Aichhorn W, Schiepek G. Case Report: Overload of a cross-country skier in elite sports, somatoform autonomic disorder, and end-of-career support. Front. Psychol. 2026; 17: 1767962.
24. Gouttebarge V, Castaldelli-Maia JM, Gorczynski P, Hainline B,Hitchcock ME, Kerkhoffs GM, et al. Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis. British J Sports Med. 2019; 53: 700-706.
25. KADA-Sport mit Perspektive.
26. Swiss Olympic.
27. Carmody S, Jones C, Malhotra A. Put out to pasture: what is our duty of care to the retiring professional footballer? Promoting the concept of the ’exit health examination’ (EHE). Br J Sports Med. 2019; 24.
28. Gouttebarge V, Goedhart E, Kerkhoffs G. Empowering the health of retired professional footballers: the systematic development of an after career consultation and Its feasibility. BMJ Open Sport Exerc Med. 2018; 4: e000466.
29. Edwards CD, Weatherbee P. Advancing Mental Health-Related Safety in Sport: The Integrated Risk Model and Athlete Risk Assessment Matrix. Adv Psychiatry and Behavioral Health. 2026.
30. Schiepek G, Schorb A, Schöller H, Aichhorn W, Schiepek G, Schorb A. Prediction of Sports Injuries by Psychological Process Monitoring. Sports Psychiatry. 2023; 1-8.
31. Lackmann V, Sell C, Henkel M, Kozik C, Benecke C. Interrater Reliability of Operationalized Psychodynamic Diagnosis 3 (OPD-3). Zeitschrift für Psychosomatische Medizin und Psychotherapie. 2023; 69: 108-122.ces