The psychological implications of injury

The psychological factors which would render an individual more susceptible to injury have been discussed in . This article is concerned with the psychological problems that can ensue from injury and that could prevent or delay recovery. This is seen as a problem because there are no straightforward relationships existing between the severity of an injury and the intensity of the psychological reactions. Of course many sportsmen have few psychological problems stemming from injury. If the injury is incapacitating, the sportsman convalesces for a while, possibly seeks the help of a physiotherapist or doctor, undergoes therapy and eventually resumes playing without any appreciable psychological side-effects. There are, however, many individuals whose injuries precipitate inappropriate psychological reactions which in turn lead to recurrent injury problems, inadequate recovery period or extended rehabilitation. The intensity of these psychological reactions is governed by several interacting factors.

FACTORS AFFECTING PSYCHOLOGICAL REACTION TO INJURY The individual’s history of injury

If the injury background is extensive then psychologically negative reactions are likely to be more intense; frustration, anger, resignation and despair may be intensely felt, creating an apathetic attitude during the recovery phase. In this kind of psychological state, the recovery phase is likely to be seriously extended and the chances of re-injury enhanced.

The nature of the injury

Other things being equal, the psychological trauma will tend to increase as a function of the severity of the injury, but only to the extent that the individual is aware of the severity. As Stein (1962) has noted, it is often the case that the more grave the injury, the fewer are the emotional complaints. This is partly because of immediate post-trauma shock which can leave a player amnestic and anaesthetised against feelings of pain. When full awareness returns, the process of rationalisation has already begun. Additionally there is a finality about the severe injury which, in a sense, can lessen or eliminate the feelings of anger and irritation which normally accompany the injury. Thus the immediate psychological reactions may be minimal in contrast with the sometimes profound long-term reactions to severe injury. These reactions are influenced by the degree of disability and how apparent it is to others. The sportsman in particular tends to have a sophisticated body image based on an awareness of the beauty and integrity of his body. If he is physically damaged, his body image, an integral part of his ego, may be threatened to an intolerable degree. The psychological implications can be extensive.

The nature of the sport

Few participants in sport fully expect to be injured but it is clear that the likelihood of injury varies markedly across sports. For example, Macintosh et al (1972) found that injury in golf was a rare event, whereas Mongillo (1968) reported Tabrah’s calculation that the risk of disabling injury in high school (American) football was 13666 times higher than in underground mining. It seems reasonable to hypothesise that the psychological trauma associated with particular injury will be a decreasing function of the general level of risk entailed in the sport. All else being equal, a particular sports injury will generate more emotional trauma in a low-injury risk golfer than in the high-injury risk football player. This tendency is enhanced by the stereotyped reactions of peers in the sense that the injured footballer may gain much sympathy and experience heightened feelings of masculinity. The injured male golfer is more likely to have his masculinity under threat.

The nature of the injury interacting with the nature of the sport The interaction is important in that, for example, the psychological effect of a cut eye would be greater for a boxer than, say, for a free-style wrestler. Although both sports here are contact sports in which injury risk is relatively high, the nature of boxing ensures that a cut eye is a particularly devastating injury, encouraging greater psychological repercussions.

The level of competition in which the injury has occurred The casual tennis player who plays a few times every summer and who sprains his wrist is unlikely to find the experience as traumatic as the tournament player who earns his living from the game. The implication of this is that the psychological effects of injury are only worthy of serious study in relation to what might be termed ‘serious’ sport. The holiday skier who fractures his leg may suffer considerable personal trauma but it is of no general significance. Physical fitness is also important; the sportsman who is physically fit, having become adapted to fairly severe physical stresses before injury, can more easily adapt to the demands of a physical rehabilitation programme – he is less likely to ‘acquiesce’ to the disability (Bender et al, 1971).

PERSONALITY AS A FACTOR AFFECTING REACTION TO INJURY Eysenck’s two-factor theory

The importance of personality in reaction to injury can be demonstrated by making reference to the theories of Eysenck who has studied the structure of personality. Eysenck (1957) delineated two major orthogonal dimensions along which the personality of individuals can vary, extroversion-introversion and neuroticism-stability.

Extroversion (E) is a commonly observed trait among sportsmen, and the typical extrovert is sociable, outgoing, carefree, changeable, assertive, physically active and optimistic. The typical introvert is hesitating, cautious, reflective, and pessimistic.

Those high on neuroticism tend to be nervous, anxious, depressive, moody and emotionally volatile. They are liable to neurotic breakdown under stress. Stable individuals, on the contrary, are even-tempered, calm and emotionally stable.

Eysenck’s inhibition hypothesis associated with extroversion-introversion is of particular relevance -cortical inhibition is higher in extroverts, making them less sensitive and less able to tolerate tasks of a routine nature. Inhibition accumulates to a greater extent in the central nervous system (CNS). The relative insensitivity means that they have strong nervous systems and the effort to reduce cortical inhibition makes them crave for excitement. Eysenck (1967) reported that extroverts have higher pain thresholds and Lynn and Eysenck (1961) found a highly significant correlation between extroversion and pain tolerance.

A picture is emerging then of two extreme personality types which would produce quite different reactions to similar injuries. On the one hand there is the impulsive, optimistic, changeable extrovert. His general insensitivity to pain and need for excitement make him impatient to return to competition. Consequently, he is likely to under-react to the injury in the immediate post-trauma phase. Subsequently he may be unable to accept the routine and discipline of the treatment phase. Therefore, the need for caution must be impressed upon him by those interested in his full recovery. On the other hand, there is the hesitating, restrained, pessimistic introvert for whom the physical trauma has more psychological impact. He has low tolerance for pain and will have a tendency to overreact, making an injury appear more serious than it really is. This individual will need encouragement and reassurance during rehabilitation.

The difference between these extremes is well illustrated by the kind of question they might ask after severe sports injury. The extrovert asks, ‘when can I play again?’ In contrast the introvert asks ‘can I play again?’

The tendencies outlined in relation to extroversion-introversion could be reinforced or diminished depending upon the degree of neuroticism of the individual. The individual’s weightings on E and N will determine the kind and degree of psychological handicap he suffers . Obviously both the stable extrovert and stable introvert will be least problematical, unless of course they suffer severe physical trauma associated with discouraging prognosis. In such circumstances even the most stable of individuals can develop severe psychological problems.

With reference to the interaction between E and N, Eysenck (1963) has suggested that phobias, anxiety states and similar phenomena are more likely to develop in the introvert, who seems to turn his neurosis in on himself. He is beset by psychological conflicts on which his anxiety feeds (Sanderson, 1977). Hence the trauma of sports injury is likely to be most severe in the neurotic introvert. Not only is it likely that his psychological state will have the effect of delaying his recovery – loss of function could partly be a result of anxiety- but on return to competition, apprehension is likely to remain. He may distort reality to the extent of being irrational about the possibilities of re-injury, e.g. the soccer player injured in a 50/50 tackle who subsequently avoids such situations at all costs. The irony is that the behaviour adopted to avoid anticipated injury could well lead to a greater probability of the player being injured again, as suggested by Reilly’s (1975) findings. In the light of this, perhaps it is as well that evidence suggests that introverts, particularly neurotic introverts, constitute only a small minority of competitive sportsmen.

Self-concept or self-esteem is high in the extrovert and when he tends towards instability, the self-concept neurotic breakdown in individuals with so-called ‘athletic’ personalities. In his examination of patients with neurotic illness, he noticed that they could all be reliably categorised in terms of their athleticism (Table 1). He compared the distribution of athleticism in his male neurotic patients with that of a control group of ‘normals’ and found marked significant differences between them, I.e. a much greater tendency for neurotic males to be either extremely non-athletic or extremely athletic. He found clear aetiological differences between these extremes. The athletic neurotic was much more likely to have had his breakdown generated by a threat to his physical well-being, often in the form of injury. It was found that those with athletic personalities developed neurotic symptoms in their mid-thirties compared with the late-twenties for the other group. It appears that the ‘athletes’ became particularly vulnerable at a time when their overvalued physical abilities were declining. They were found to be relatively insensitive to other kinds of stressor. Several other points emerged from this study:

Table 1 Athleticism (After Little, 1969)

Grade +2 Grades + 1,0,-1 Grade –

Extremely athletic attitudes and practices ’Normal’ athletic attitudes and practices Completely non-athletic attitudes and practices may be perceived as being threatened. The self-concept may be highly dependent on both physical appearance and physical function – and both may be impaired by injury, resulting in emotional stress associated with loss of self-esteem.

If the injury is not severe, such an individual may ‘play through it’ rather than suffer the indignity of succumbing to it. He represses the unwanted facts about the injury, using the Freudian defence mechanism of denial. If the injury is incapacitating, his neurotic recklessness may be exhibited in unwillingness to accept treatment and returning too early to competition. He lays the groundwork for re-injury maybe of a more serious nature and increases the likelihood of the development of chronic injury-proneness.

Injury and neurotic breakdown

Little (1969) found a relationship between injury and

Inter-observer reliability, r=0. 1. Neurotic symptoms developed in the great majority of cases almost immediately following injury and often on the same day. 2. The trauma was generally mild, which encouraged the conclusion that level of vulnerability rather than severity of injury was the major factor precipitating neurotic breakdown. 3. The athletic neurotics did not have histories of neurotic illness and tended to be highly extroverted and of previous sound health.

Little concluded: ‘Like exclusive and excessive emotional dependence on work, on key family relationship bonds, intellectual pursuits, physical beauty, sexual prowess or any other over-valued attribute or activity, athleticism can place the subject in a vulnerable pre-neurotic state leading to manifest neurotic illness in the event of an appropriate threat, or actual enforced deprivation, especially if abrupt and unexpected.’

Individual differences in reaction to pain

As mentioned earlier, personality is also an important factor in the perception of and tolerance to pain . Historically, a stimulus-response (s-R) model of injury and pain was accepted, I.e. the behaviouristic idea of a linear relationship between severity of injury and intensity of pain . But modern psychology postulates an s-o-R model which recognises that many variables other than severity of injury determine the reaction to pain .

S-o-R

For instance, there are cultural and ethnic differences in the reaction to pain; peoples of Mediterranean origin tend to complain and seek sympathy more readily for a level of pain to which North Europeans would register no reaction.

The ‘meaning of the situation’ is also an important factor, as evidenced by Beecher’s (1959) observation that wounded soldiers requested morphine much less frequently than similarly wounded civilians. Far from experiencing pain, the soldiers’ reaction might well be that of relief at being removed from the arena of battle. In sport, the athlete who wishes to compete because of the potential glory but who finds the competitive situation anxiety-inducing, may well experience immediate psychological relief. Those in attendance immediately post-trauma, risk being misled as to the seriousness of the injury. Treatment of such an athlete may be made more difficult because of this feeling of relief; indeed, recovery might be delayed because of his, maybe unconscious, vested interest in maintaining his injured state. Anxiety at the prospect of recovery and return to the conflict situation can be converted into unconsciously sustained muscle tension, which delays the recovery.

Another example of reaction to injury being influenced by the meaning of the situation concerns the documented reaction of a Football League goalkeeper. In gathering a ball, a dog collided with him, damaging his cruciate ligaments so badly that he had to retire. However, he continued with the game, determined not to suffer the indignity of being removed from the game by a dog (Harris and Varney, 1977)! We can assume that his insistence on continuing the game affected the judgement of those tending his injury.

The amount of attention concentrated on stimuli contributes to the intensity of pain experience. The soccer player, for example, may well be unaware of a severe kick on the shin during the excitement of the contest. Melzack (1973) noted that many stimuli outside the focus of attention would be unnoticed, ‘including wounds that would cause considerable suffering under normal circumstances’.

Even if the injury requires immediate treatment, there may often be sufficient reverberating central nervous system (CNS) activity to mask pain perception. Superficial observation of a player’s psychological reactions might encourage the view that the injury is not severe and that the player can continue.

Pain therefore should be seen as a complex reaction to a wide range of interacting variables. Extreme reactions to injury in terms of pain perception and tolerance are as much a function of the psychological state of the person as they are of severity of injury. Those tending to the injured athlete must err on the side of caution and are not likely to ignore manifestations of extreme pain. However, a lack of such overt symptoms cannot automatically be interpreted as a sign of only mild trauma.

REACTION TO CONCUSSION

One physical reason for the absence of pain experience is concussion, a common injury in contact sports. The reactions which accompany concussion have implications for immediate post-trauma treatment. Yarnell and Lynch (1970, 1973), in documenting reactions to concussion in American football players, noticed that retrograde amnesia was a common phenomenon. Specifically, they found individuals who had intact memory of the pre-trauma play and the impact itself for several minutes post-trauma. As little as three minutes later, when retested, they had developed irretrievable memory loss of the impact and its antecedent events. They suggested that the concussive injury prevents short-term memory consolidation with consequent rapid decay of information. An obvious implication is that speedy examination and assessment is necessary in order to utilise information from the victim on what happened, how it feels, and so on, while he is still in possession of all his faculties. This is especially important if concussion is accompanied by other injuries.

In the conditions just described, the psychological trauma resulting from injury vary markedly. The common element is that emotional factors outweigh cognitive or intellectual factors.

Those attending to the needs of the injured athlete should be aware that his personality make-up may be a major factor in his behavioural reactions to the situation. Hence, general perceptiveness and, ideally, specific knowledge of the individual’s psychological profile would be desirable. The efficacy of the treatment is likely to be enhanced if there is an awareness of the physiological and psychological determinants of pain. Treatment can then be based on a more precise assessment of the specific interaction of personality, pain, and injury.

During the rehabilitation phase, the sportsman should be given a realistic appreciation of the prognosis of the injury in order that the development or persistence of counter-productive emotions can be inhibited. In the more extreme cases, it would be an obvious advantage to the injured sportsman if all those with a vested interest in his complete recovery cooperated and pooled information in order to make the treatment phase more effective. At the least, this will be to the long-term benefit of the reckless and the over-cautious sportsman.

REFERENCES

Beecher, H. K. (1959). Measurement of subjective responses. Oxford University Press.

Bender, J. A., Renzaglia, G. A. and Kaplan, H. M. (1971). Reaction to injury. In L. A. Larson (ed). Encyclopedia of sports sciences and medicine. Macmil-lan, New York.

Eysenck, H. J. (1957). The dynamics of anxiety and hysteria. Routledge and Kegan Paul, London.

Eysenck, H. J. (1963). Experiments with drugs. Perga-mon, New York.

Eysenck, H. J. (1967). The biological basis of personality. C. C. Thomas, Springfield, Illinois.

Harris, H. and Varney, M. (1977). The treatment of football injuries. MacDonald James, London.

Little, J. C. (1969). The athletes neurosis – a deprivation crisis. Acta Psychiatrica Scandinavica, 45, 187-197.

Lynn, R. and Eysenck, H. J. (1961). Tolerance for pain, extroversion, and neuroticism. Perceptual and Motor Skills, 12, 161-162.

Macintosh, D. L., Skrien, I. and Shephard, R. J. (1972). Physical activity and injury: a study of sports injuries at the University of Toronto. 1951-1968. Journal of Sports Medicine and Physical Fitness, 12, 224-237.

Melzack, R. (1973). The puzzle of pain. Penguin, Har-monds worth.

Mongillo, B. B. (1968). Psychological aspects in sports and psychosomatic problems in the athlete. Rhode Island Medical Journal, 51, 339-343.

Reilly, T. (1975). An ergonomic evaluation of occupational stress in professional football. Unpublished Doctoral Thesis, Liverpool Polytechnic.

Sanderson, F. H. (1977). The psychology of the injury-prone athlete. British Journal of Sports Medicine, 11, 56-57.

Stein, C. (1962). Psychological implications of personal injuries. Medical Trial Technique Quarterly, 17-28.

Yarnell, P. R. and Lynch, S. (1970). Retrograde memory immediately after concussion. Lancet, April 25, 863-864.

Yarnell, P. R. and Lynch, S. (1973). The ‘ding’: amnestic states in football trauma. Neurology, 23, 196-197.

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