Simone Biles pulled out of the all-around competition for gymnastics on Wednesday, citing the mental health issues that made her drop out of team competition on Tuesday night. U.S. Gymnastics said the 24-year-old gymnast opted not to compete. 

"I truly do feel like I have the weight of the world on my shoulders at times," Biles wrote on Instagram. "I know I brush it off and make it seem like pressure doesn't affect me but damn sometimes it's hard."

Biles isn't the first Olympics great to face mental health struggles — Michael Phelps, now a commentator for NBC, said he had thoughts of suicide and dealt with depression after the 2012 Olympics. Biles, arguably the greatest gymnast of all time, joined a growing list of athletes who have openly discussed mental health issues.

Earlier this year, Naomi Osaka, who just lit the Olympic cauldron on Friday night, withdrew from tennis's French Open and never went to Wimbledon due to her own focus on mental health. She recently exited Olympic competition early. Sha'Carri Richardson lost out on a chance to compete in Olympic track and field events due to her own battles with mental health and Tom Dumoulin, a Dutch cyclist who won silver on Wednesday in individual men's time trials, left training in January citing that it was "very difficult for me to know how to find my way as Tom Dumoulin the cyclist" before resuming his training in May.

Biles also faced understandable pressures.

"The pressure to perform, the worry of failure, representing your country, your family and yourself," said Dr. Marcel Yoder, faculty athletics representative with the University of Illinois at Springfield. "There's the fear of failure to realize the goals you've set for yourself, which can be a major anxiety."

Yoder, an associate professor of psychology and exercise science, earned his doctorate in sports psychology from the University of Louisville and specializes in sports psychology, mindfulness and sports performance enhancement. He says that Biles may have avoided disaster by focusing on her mental health. 

"The worst thing is she could get hurt," Yoder said. "When we are under anxiety and pressure it causes us to think differently and specifically our attentional focus narrows and it’s like tunnel vision."

"If I’m in an event that requires me to have a very broad focus and I get that tunnel vision, that affects my performance and I may not adjust to environmental cues to, at the minimum, keep myself from getting injured," he continued. "It can also increase muscle tension as our muscles get stiff when we’re worried and that affects coordination. That can lead to impaired performance and potential injury."

Social media can also increase the pressure, Yoder said. Outside pressure can come from judgments not only from oneself, coaches and family, but from people athletes don't know as they face a 24/7 "virtual spotlight," which adds additional stress. That adds external and internal pressures, including expectations from others and the self-imposed pressure to make your training pay off, Yoder said. 

"Getting a payoff for all the blood, sweat and tears you put in, you've got one chance to show it and this is it and there isn't a second chance for many Olympic athletes," Yoder said. "That expectation to perform on that day the best you can, that can be overwhelming." 

This year's Olympics are unlike any other, which may add additional pressure. Yoder said there are some unique things going on with athletes with the lack of fans, as some of them are unused to the notable absence. There are unusual circumstances contributing to pressures and expectations of fans and others to perform, as fans may have adapted faster than athletes to a lack of crowds at sports events thanks to sports like basketball and football competing with smaller crowds. At the U.S. Olympic Qualifiers in St. Louis, there were fans in attendance as Biles came in first in the all-around competition, although they were more spread out than most years.

The mental side of athletic competition is also something that goes without attention, Yoder said. That mental side of health is not only often ignored in athletics but it can be stigmatized in other aspects of public life as well. There's also a temptation to hide the pressure one may be under because of that stigmatization. 

"Think of all of the words people use when discussing mental illness, words like crazy, nuts, there’s stigmatization," Deborah Humphrey, the executive director of the Madison County Mental Health Board. "When you’ve got a physical illness like cancer, people support you, when you talk mental illness, people are afraid because they don’t understand it, they react differently, because of what they may think of mental illness, there’s a stigma attached, there’s a fear there because they don’t understand it."

People from all aspects of life may have experienced different pressures than normal the past year-plus because of the pandemic. 

"The numbers are increasing in terms of suicides, people are starting to show more in terms of anxiety and depression," Humphrey said. "During the first year or so people maintained or did okay, as we went towards the end of the year, as people were getting the vaccine, people had a realization of what we just went through and other issues come into play. Employment issues, workforce is diminished, it’s been very difficult. Places are short-staffed, their clientele is coming in and can’t get food as quickly, those kinds of things that are lingering are impacting people in different places in different ways than we would have suspected in the past."

Humphrey said that athletes like Biles, Osaka and Phelps coming forward in terms of mental health helps to prove that mental health doesn't respect income or age or race, and that it can affect anybody. It also helps to destigmatize mental health when someone like Biles steps forward and deals with it. 

"When it’s a celebrity or someone in the know when people can identify with, it destigmatizes mental health," Humphrey said.

For athletes who are not in the right head space before a competition or game, Yoder said the simplest thing to do is to breathe. 

"The simplest and easiest thing to do is control your breathing," Yoder said. "If you get anxious you’re thinking about a past event, you’re thinking about the past or the future, what happens if I don’t nail this vault for example. Bringing yourself to the present, which is the only moment you have to control, bringing yourself to the present is key to performing your best. One of the best ways to be present is focusing on your breathing, deep controlled breaths at a slower pace than normal."

"When we’re anxious, our breathing becomes shallow and faster, and we can use that to our advantage when we breathe slowly and deeply," he continued.

If you're feeling pressure and stress, Humphrey said there are varying levels of help that are available. 

"There are different levels of care, it depends on where you’re at," Humphrey said. "If someone is feeling down and depressed and they’re not in a situation where they need hospitalization, there are counselors, if things are more complicated and depression is more intense, feeling very distraught, there are crisis services to engage with, if it’s a serious, serious issue and the person feels like harming themselves and have stopped eating or doing necessary things, that might require inpatient services. It depends on where that person is and what kind of need they need to reach out for."

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