Athlete Collapses – Paying The Price For a Rampant Id Or An Incomplete Ego

A few days ago, I read of a veteran athlete who collapsed and died during an endurance event. Last weekend I watched the highlights of an epic six day off-road cycle event around the beautiful Cape Town countryside, and noted that a number of competitors were ‘veteran’ folk whose best athletic days were perhaps past, but were still pushing their physical limits to their utmost as part of the event. These got me thinking of why athletes push themselves to the point of collapse, and occasionally past it to the point where they die during the sporting event they are participating in. I was reminded of some theoretical and research work I did a while ago with some great work collaborators – Professors Kevin Thompson, Carl Foster, Jos De Koning, Jack Raglin, Dom Micklewright and Bill Roberts, with whom we developed an ‘alternate’ theory of the reasons why athlete collapse, during a wonderful ‘brainstorming’ session where we all got together at Vrije University in Amsterdam to work on the theory as a team a few years ago.

Our bodies and minds have some exquisite protective mechanisms that usually prevent us from pushing ourselves to fast and collapsing / damaging ourselves when playing sport – an obvious example being the inner voices we hear when ‘pushing it hard’ urging us to slow down, and warning us that there may be negative consequences of continuing performing the exercise bout too long or too hard. But athletes and folk exercising, particularly during competitive events, often ‘resist’ these cautionary ‘voices’ and processes, and usually push themselves as hard as they possibly can in order to perform the best they can during their chosen competitive event. So there is a competition between homeostatic protective mechanisms and psychological drives to achieve success that are in a continuous ‘negotiation’ during any exercise bout or competitive event.

There are a number of reasons why folks competing in an event collapse, often related to heart dysfunction, such as heart attacks, arrhythmias (faulty electric rhythms in the heart), and cardiomyopathies (an enlarged heart), but also potentially due to a host of other non-cardiac reasons, such as exercise-induced bronchospasm (asthma), low blood sugar, exertional heat illness (when one’s body becomes too hot), hypothermia (when one’s body becomes too cold), and exercise induced postural hypotension (low blood pressure) amongst other causes. It’s interesting that the majority of folk collapse close to the finish line or just afterwards, or close to the cut-off times for medals or race closure times, which clearly indicate that athletes collapse and die usually when trying to complete or reach a particular set ‘target’ for the competitive event they are performing. An athlete that collapses during an exercise bout without feeling any symptoms of any of these disorders is understandable and unfortunate – they just collapse without knowing they have anything wrong with themselves, and there is not much that can or could be done for folk like this. There is perhaps an element of ‘bad luck’ in folk who collapse such – while numerous studies of performing exercise on a regular basis indicate that it is healthy to do so, and enhances longevity, numerous studies have also shown that during an exercise bout itself, the risk of sudden death increases significantly, so there is a ‘play off’ always between the long term benefits of habitual exercise and the increased risk of dying each time one does exercise. Therefore, in folks who collapse without symptoms, in effect the risk ratio / chance has simply worked against them, from a statistical and ‘luck’ perspective.

A more ‘interesting’ group of folk who collapse during performing exercise, from an academic and research perspective, are those who feel warning symptoms of impending collapse or medical catastrophe, such as chest pains from a heart disorder, or dizziness due to either heart disorder or decreasing blood sugar for example, and yet still continue exercising. There is clearly an issue in these folk, who must feel that completing the event and achieving their set goal is more important than the chance of collapsing and dying, and who try and do so with obvious ‘warning signs’ such as these physical symptoms that disaster for them is impending. With my colleagues I mentioned above, we had a long think about this, and came to the conclusion that social factors must be associated with either winning or completing an event to the individual that does this, that are important to a greater degree than they would be to most ‘normal folk’ who don’t feel the need to compete in athletic events, or who stop when they feel the development of such symptoms and go to their doctors to be assessed as a matter of urgency. These ‘needs’ may include the need to appear fit and healthy and perhaps therefore more desirable to prospective sexual partners, or to increase one’s perceived esteem in one’s social circle, or to simply ‘prove’ to oneself’ that one can complete a challenging event, for example. They also may be indicative of overt psychopathology, such as an addiction to the sport being performed. Several studies have shown that habitual exercisers get depressed when they cannot perform their routine exercise or are unable to challenge themselves by competing routinely, due to illness or other reasons. A neat study performed by some excellent graduate students and colleagues of mine examined this concept of social need in the sporting context, in a study on male runners who ran three times on a treadmill at the same speed. The first time they ran alone, in the second an attractive female ‘actor’ came into the room halfway into the trial and spoke to them while they were running, and in the third, a muscular male ‘actor’ did likewise. They were asked to rate how tired they felt, and with the introduction of the attractive female, the male runners told the experimenter, who was present at the room at the same time, that they felt significantly less tired when in the presence of the attractive female as compared to when running alone (though they did not realize they had rated it differently at the time). In contrast, when a muscular male spoke to them, they reported feeling significantly more tired after the male actor interacted with them, despite the pace being the same in all three trials. This study shows that there are social factors at work during any exercise bout, and a large ‘ego’ involvement occurring during exercise performance, and this study perhaps gives us some clues on why folk push themselves during competitive activity, even in the presence of warning symptoms of impending physical catastrophe – the psychological need to do so is greater even than the need to keep oneself alive, and in these folk, who continue exercising even in the presence of warning physical symptoms, is surely evidence of some psychological issues that have not been resolved, and are in need of attention.

So coming back to the point raised above on the number of veterans competing in testing endurance athletic events, which seems to be increasing, one has to consider what is ‘at play’ in the minds of these folk. I have to be honest and say in my youth I exercised and competed to extremes on a regular basis, and collapsed twice during competitive athletic events, once from hypoglycaemia and once I think from hyponatremia (low blood sodium) and had to be revived in the medical tents on both occasions, so I know myself the ‘feeling’ of pushing oneself beyond one’s limits to a state of unconscious. But after a decade or so of doing competitive sport, I came to realize that I was doing it to ‘prove’ something to myself. Somehow, perhaps by doing so for a long period of time, and / or perhaps eventually understanding after some self-reflection that a ‘need’ underpinned this extreme level of activity I was performing in my early twenties, made it no longer a ‘need’, and sport took its ‘rightful’ place in my life since then of being something to do for enjoyment and to keep as fit as best possible within the constraints of a busy career and family life, but not as a key factor of my daily activity (psychology folk like Jung would perhaps say my ‘ego’ had been requited and I had achieved ‘wholeness’ eventually – at least in this sporting realm). So when watching the older folk competing in such epic events such the multi-day cycle race, one admires them for being ‘up for’ such challenges, and part of one wishes that one could still be doing such events that look to be such fun. But one also wonders if there is some unfulfilled need in such folk / an ego not yet complete / a midlife crisis being acted out – and a dangerous one at that, given that the risk of heart dysfunction increases significantly with increasing age. And if some of these veteran (and indeed all) competitors are feeling such symptoms and still keep on going, we need to understand why such individuals feel the need to complete such competitive athletic events, that in the ‘grand scheme of things’ are almost completely unimportant, in the face of impending physical catastrophe, which may be life threatening. As Freud suggested more than a hundred years ago, one’s ‘muscles are the conduit through which the ego imposes its will upon the world’, and folk who feel the need to compete against others, or perhaps more importantly with oneself, particularly at an older age, need to think carefully what are the issues and causes of such ‘needs’ that induce one to do so. There’s a lot to be said for a relaxing cycle on a Sunday morning with one’s mates and / or family. But there is also a lot to be said for sitting quietly with a cup of tea admiring the roses – particularly as we move closer to the end stages of our allotted ‘three score years and ten’, if we are to perhaps give ourselves the best chance of seeing out our allotted time on earth!

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About Alan (Zig) St Clair Gibson

Professor Alan (Zig) St Clair Gibson MBChB PhD MD - Associate Dean (Research), Faculty of Health and Science, , University of Essex, United Kingdom View all posts by Alan (Zig) St Clair Gibson

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