REVIEW ARTICLE Sports Med 2003; 33 (1): 13-31

0112-1642/03/0001-0013/$30.00/0

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The ‘Yips’ in Golf

A Continuum Between a Focal Dystonia and Choking
Aynsley M. Smith,1 Charles H. Adler,2 Debbie Crews,3 Robert E. Wharen,4
Edward R. Laskowski,1 Kelly Barnes,1 Carolyn Valone Bell,1 Dave Pelz,5 Ruth D. Brennan,1
Jay Smith,1 Matthew C. Sorenson1 and Kenton R. Kaufman6
1 Sports Medicine Center, Mayo Clinic, Rochester, Minnesota, USA
2 Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
3 Department of Exercise Science, Arizona State University, Tempe, Arizona, USA
4 Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
5 Pelz Golf Institute, Austin, Texas, USA
6 Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota, USA

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1. Dystonia, a Neurologic Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2. A Dystonia Perspective on the ‘Yips’ in Golf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3. Choking as a Phenomenon in Sport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4. A Choking Perspective of the ‘Yips’ in Golf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
5. Choking vs Dystonia in Golf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
6. Performance Anxiety in Golfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
7. Neuroscience Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
8. Alcohol and β-Blockers to Reduce Performance Anxiety . . . . . . . . . . . . . . . . . . . . . . . . 21
9. Golfers’ Perceptions of the ‘Yips’: An Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
9.1 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
9.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
9.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
9.4 Limitations and Conclusions of the Present Investigation . . . . . . . . . . . . . . . . . . . . . 28
10. Future Research Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
11. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Abstract The definition of the ‘yips’ has evolved over time. It is defined as a motor
phenomenon of involuntary movements affecting golfers. In this paper, we have
extended the definition to encompass a continuum from the neurologic disorder
of dystonia to the psychologic disorder of choking. In many golfers, the patho-
physiology of the ‘yips’ is believed to be an acquired deterioration in the function
of motor pathways (e.g. those involving the basal ganglia) which are exacerbated
when a threshold of high stress and physiologic arousal is exceeded. In other
golfers, the ‘yips’ seems to result from severe performance anxiety. Physically,
the ‘yips’ is manifested by symptoms of jerks, tremors or freezing in the hands
and forearms. These symptoms can result in: (i) a poor quality of golf performance
(adds 4.9 strokes per 18 holes); (ii) prompt use of alcohol and β-blockers; and
14 Smith et al.

(iii) contribute to attrition in golf. Golfers with the ‘yips’ average 75 rounds per
year, although many ‘yips’-affected golfers decrease their playing time or quit to
avoid exposure to this embarrassing problem. While more investigation is needed
to determine the cause of the ‘yips’, this review article summarises and organises
the available research. A small study included in this paper describes the ‘yips’
phenomenon from the subjective experience of ‘yips’-affected golfers. The sub-
jective experience (n = 72) provides preliminary support for the hypothesis sug-
gesting that the ‘yips’ is on a continuum. Based on the subjective definitions of
72 ‘yips’-affected golfers, the ‘yips’ was differentiated into type I (dystonia) and
type II (choking). A theoretical model provides a guide for future research on
golfers with either type I or type II ‘yips’.

Many golfers, athletes,[1-6] teaching profession-
als,[7-10] sport scientists[11-29] and medical investi-
gators and clinicians[30-35] are confused by the
‘yips’, a putting problem which affects profes-
sional and amateur golfers. The ‘yips’ is defined as
a jerk, tremor or freezing in the distal upper ex-
tremity[18,26,31-34] that interrupts the putting stroke.
Some believe this is the result of choking (a psy-
chologic failure to perform), while others believe
this is due to a focal, task-specific dystonia. One
teaching professional described the ‘yips’ as a
‘fail-safe shutdown’ caused by a deterioration of
confidence rooted in unsound stroke mechanics.[7]
Our group recently described the ‘yips’ as a psy-
choneuromuscular impediment to execution of the
putting stroke in golf.[26] Sachdev[34] called the
‘yips’ an occupational cramp or dystonia. These
definitions of the ‘yips’, albeit confusing, describe
symptoms of both dystonia (a neurologic disorder)
and choking (a psychologic disorder). We believe
that the ‘yips’ should be defined as a motor phe-
nomenon of involuntary movements affecting
golfers, with multiple possible aetiologies, span-
ning a continuum from the neurologic disorder of
dystonia to the psychologic disorder of choking
(table I). The pathophysiology of the ‘yips’ in
many golfers may be an acquired deterioration
in the function of the basal ganglia and a conse-
quence of extreme performance anxiety in others.
Symptoms are exacerbated when a threshold of
high stress and arousal is exceeded. Physically,
the ‘yips’ is manifested by jerks, tremors or freez-
ing that result in a poor motor performance. The
‘yips’ reduces the quality of the golfing experi-
ence and leads to attrition in golf. A review of dys-
tonia,[36-40] choking[10,13,14,28,41-47] and performance
anxiety[29,47-51] contributes to our current under-
standing of the ‘yips’.
Symptoms in golfers with the ‘yips’ are either:
(i) attributable to a specific focal dystonia; (ii)
choking; or (iii) a consequence of the interaction
of features of both which renders the pathophysi-
ology difficult to decipher. Symptoms may also
progress along the continuum just as the ‘yips’ in
the McDaniel[33] study progressed from one hand
to the other within 4 years. For example, some golf-
ers may have symptoms of dystonia and become so
anxious and obsessed about their putting problem
that it is impossible to separate the factors in the
interaction. Conversely, chokers may also exhibit
the ‘double pull’ phenomenon, which mimics the
agonist/antagonist behaviour reported in dystonia,
an intriguing neurologic disorder.
1. Dystonia, a Neurologic Disorder
Dystonia is a neurologic disorder characterised
by involuntary movements resulting in spasms,
twisting and posturing of a body part. The key fac-
tor that differentiates this movement disorder from
others is that there is a sustained posture that occurs
at some time during the movement. It is estimated
that the prevalence of generalised dystonia (multi-
ple body parts affected) is between 0.2–6.7 indi-
viduals per 100 000 while the prevalence of focal
dystonia (one body part affected) is at least 30 in-
dividuals per 100 000.[37] Dystonia may be classi-
fied by the age of onset, the aetiology or the distri-
bution. Dystonia may be focal: involving a single

© Adis International Limited. All rights reserved. Sports Med 2003; 33 (1)
 ‘Yips’ in Golf
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Table I. Summary of comparison across ‘yips’ studies
‘Yips’ study Study design Definition of ‘yips’ Aetiology Recruitment and Eligibility Golf experience Putts most Conclusions
sample (y)/hcp troublesome
McDaniel et al.[33] Questionnaire Motor Increased Mailed to 1050 99% onset of ‘Yips’ (35.6); non- 0.3–2.4m (1–8 Anxiety
phenomenon of workload, 77% PGA, USGA and S&S during ‘yips’ (31.0) feet) from cup in exacerbates
involuntary performance LPGA golfers: tournaments, tournaments ‘yips’, but not
movements anxiety, basal 42% (n = 441) acquired S&S sole cause
affecting golfers ganglia, subcortical returned, of after 20 years
biochemical whom 93 golfers of golf
changes due to reported having
aging the ‘yips’
Sachdev[34] Psychometrics, Occupational From 19–20th Recruited from Golfers ‘Yips’ (35.1)/10.7. Tournaments Anxiety
medical cramp in golf. century ‘yips’ Australian golf acquired Added 4.7 strokes exacerbates
histories, neuro Term did not review: organic clubs, 20 golfers symptoms ‘yips’, but not
exam/RT appear until disorders, physical with ‘yips’, 20 affecting short sole cause
1977 causes, anxiety, golfers without game, normal
psychological ‘yips’, played neuro and
causes, idiopathic competitive golf muscle testing,
dystonia for 5 years at golfers had
high level ‘trick strategies’
Smith et al.[26] Phase I Psychoneuromotor Psychological 1042 returned Golfers ‘Yips’ (30.4)/4.45; 0.3–1.5m (1–5 The ‘yips’ is on a
questionnaire, impediment to (anxiety), questionnaires, requested to non-‘yips’ (30.8)/ feet) from cup in continuum of
phase II pilot execution of the neurological 461 ‘yips’ participate if 4.53 tournaments choking (anxiety)
study putting stroke in (dystonia) and retained they had been and focal dystonia
golf repetitive motor golfing a long
movements time and had a
(evidenced by hcp of under
acquired ‘yips’) 12. This was
done to ensure
the problem
was ‘acquired’
Present study Phase III a A motor Deterioration in the Recruited via Golfers ‘Yips’ hcp = 6.6 Tournaments Provides initial
questionnaire phenomenon of function of motor ‘yips’ website, requested to support for ‘yips’
involuntary pathways (e.g. direct mailings participate if continuum with
movements those involving the and flyers posted they had been anchors of focal
affecting golfers basal ganglia), in golf locker golfing a long dystonia and
that includes a exacerbated by rooms. Sample time and had a choking
continuum of those high arousal in was the analysis hcp of under
with dystonia and golfers with of questionnaires 12. This was
Sports Med 2003; 33 (1)

those who are dystonia; from 72 ‘yips’- done to ensure

chokers. The ‘yips’ symptoms affected golfers the problem
is manifested by attributed to severe who were invited was ‘acquired’
jerks, tremors and performance to participate
freezing anxiety in chokers
hcp = handicap; LPGA = Ladies Professional Golf Association; PGA = Professional Golf Association; RT = reaction time; S&S = signs and syptoms; USGA = United States Golf
Association.

15
16
body part; segmental: involving adjacent body
parts (face and neck); hemi: involving multiple
unilateral parts; multifocal: involving multiple ad-
jacent or non-adjacent parts; and generalised: in-
volving the legs as well as other body parts.
Generalised dystonias are usually hereditary or
drug-induced, while focal and multifocal dystonias
are more often sporadic. Most adults afflicted with
dystonia have a focal or segmental dystonia. Task-
specific dystonias may affect writing (writer’s
cramp), as well as activities performed by dentists,
musicians[38] and stenographers.[32] Individuals
with writer’s cramp often can use their hands nor-
mally for most activities except writing. When they
begin to write, they will often describe an involun-
tary jerk or pull resulting in flexion or extension of
one or more fingers or the wrist. Musicians may
develop a similar involuntary flexion or extension
of the fingers or wrist that interferes with playing
wind instruments, string instruments or using
drumsticks. Other professionals, including dentists
and surgeons, have developed an involuntary
movement that interferes with the fine movements
of the fingers or hands that most often occurs with
specific motions or tasks. When the dystonia in-
volves multiple activities, it is called a generic limb
dystonia.
The ‘yips’ also appears in many golfers to be a
task-specific dystonia.[37] The incidence of dysto-
nia in professionals who are required to perform
skilled, repetitive hand movements is about one in
3400. Dystonia affects between one in 200 and one
in 500 musicians.[38] The aetiology of dystonia
may be primary, idiopathic, hereditary, sporadic or
secondary;[39] yet, the actual pathophysiology is
not understood. Symptoms include a repetitive
twisting, turning and posturing that can be phasic
or tonic and, to date, there is no known, effective
treatment.
The Scientific Advisory Board of the Dystonia
Medical Research Foundation, in 1984, agreed to
define dystonia as a “syndrome of sustained mus-
cle contractions, frequently causing twisting or re-
petitive movements, or abnormal postures.”[52] In
1995, the definition specific to limb dystonia was
© Adis International Limited. All rights reserved.
Smith et al.
expanded upon by Uitti[52] who suggested that ac-
tion dystonia implies an involuntary posturing
(dystonia) superimposed on a voluntary move-
ment. Task-specific limb dystonia, a subset of ac-
tion dystonia, occurs primarily when a specific task
is performed. The upper limb is most often in-
volved. Tasks affected require either: (i) highly re-
petitive movements; (ii) extreme motor precision
and an interplay between conscious, or at least
feedback-related modulation; and (iii) a repeti-
tively executed motor plan. Putting meets these cri-
teria.
The underlying pathophysiology of dystonia re-
mains unclear. Some investigators have implicated
an abnormality in the dopaminergic system in the
basal ganglia, but neuropathologic studies have
been inconclusive. Secondary, or symptomatic,
dystonias may be caused by medications (espe-
cially the dopamine blocking drugs), metabolic
diseases, head injury and stroke.
2. A Dystonia Perspective on the ‘Yips’
in Golf
In 1989, 42% of 1050 professional and amateur
male golfers responded to a 69-item question-
naire,[33] 28% experienced the ‘yips’. Respondents
averaged 36 years of age, 21 years of golf experi-
ence prior to symptoms, and 60% reported freezing
on short putts. Symptoms in the ‘yips’-affected
progressed from one hand to the other in 60% of
respondents in 1 year. Symptoms were most prob-
lematic during tournaments (99%), and a tendency
toward obsessional thinking was reported.
In a comprehensive study in 1992 of 20 Austra-
lian ‘yips’-affected golfers and their matched con-
trols, no psychopathology was detected in the
‘yips’-affected golfers.[34] Neuropsychologic tests
of mental and motor speed and visual motor coor-
dination did not differ between groups, and golfers
with ‘yips’ reported less alcohol use. A slightly
higher tendency towards obsessional thinking and
self-reported anxiety in the golfers with ‘yips’ was
interpreted to be a consequence of the ‘yips’, not
the cause.[33,34] Both studies[33,34] concluded the
‘yips’ may be a focal dystonia exacerbated by, but
Sports Med 2003; 33 (1)
‘Yips’ in Golf
not caused by, anxiety (table I). The ‘yips’ in golf
has been attributed to mechanisms such as: (i) bio-
chemical changes in the brain that accompany
aging; (ii) excessive use or overuse of involved
muscles; (iii) intense coordination and concentra-
tion demands; (iv) focal dystonia of the limb; and
(v) stress and obsessive thoughts.[32-34] In addition,
electrophysiologic analysis of limb dystonia re-
veals co-contractions of agonist and antagonist
muscles of the forearm which supports the notion
of a focal dystonia of the limb.[40]
In the first phase of a third study, a multidisci-
plinary team of investigators met with golf profes-
sionals in 1997 to discuss the ‘yips’.[26] A ques-
tionnaire incorporating the opinions of teaching
professionals and the investigative team was
mailed to 2630 golfers with a handicap (hcp) of
less than 12. To ensure the 1031 (39%) respon-
dents were good golfers who had acquired the
‘yips’ and not just bad putters, only males with a
10 and under hcp (453 ‘yips’ and 393 non-‘yips’)
and females under 12 hcp (23 ‘yips’ and 20 non-
‘yips’) were included in the analysis (n = 889).
Golfers with and without ‘yips’ were similar in
age, health status, average games played per sea-
son, playing experience and hcp.[26] Inclusion cri-
teria of golfers with ‘yips’ ensured that only golf-
ers who had been good putters prior to their
episodic symptoms (average of 6 years’ duration)
were retained in the study. The fact that they were
good golfers was supported by their average hcp
of 4.5. Symptoms were most apparent when put-
ting in tournaments at distances under 1.5m (5 feet)
from the cup. Fast, downhill, left-to-right breaking
putts, playing in and/or leading a tournament, dif-
ficult putts, specific competitors and easy putts
also precipitated symptoms.
In a second phase of our research,[26] physical,
physiologic and performance differences in golf-
ers with and without ‘yips’ were measured.[18,23,26]
Heart rate (HR), grip force (GF) and electromyo-
gram (EMG)[23] were recorded while ‘yips’ (n = 4)
and non-‘yips’ golfers (n = 3) putted difficult sce-
narios. During putting, golfers with ‘yips’ had in-
creased HR and GF compared with non-affected
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17
golfers. All golfers used an instrumented standard-
length putter, a standard grip (thumbs forward) and
a non-compensated stance. HR, GF and EMG ac-
tivity in the wrist flexors and extensors were all
greater in ‘yips’-affected golfers.
Putting performance in golfers with and without
‘yips’[26] during specific scenarios difficult for the
‘yips’-affected, demonstrated that golfers with
‘yips’ had greater error (distance ball ended up
from the cup), made fewer first putts and averaged
five of ten compared with nine of ten consecutive
putts made by golfers without ‘yips’. Whether
these golfers experienced dystonia, were chokers
or experienced symptoms of both was not clear.
3. Choking as a Phenomenon in Sport
Because of the role of anxiety in sport and eval-
uative performances, researchers have sought to
understand the arousal and performance relation-
ship.[43-51,53] The cognitive appraisal model (figure
1) depicts some of the events that occur when a
golfer chokes. For example, factors such as sup-
portive audiences may negatively impact on per-
formance by causing athletes or performers to fo-
cus attention on themselves instead of on their
task.[43,44,53] Choking, an extreme manifestation of
performance anxiety, is a suboptimal performance
that results from self-focused or distracted atten-
tion.[14] The golfer may focus inappropriately on
biomechanics, the score or on his or her self image.
Regardless of what the golfer focuses on, most im-
portant is that self-attention may harm skilled per-
formance. Although choking[10,13,14,41-43,53] can
occur in any sport or task when an individual wants
to perform well, it has been studied comprehen-
sively in golf during putting.
4. A Choking Perspective of the ‘Yips’
in Golf
Choking in golf is a phenomenon recently re-
ceiving research attention.[10,53] Several studies[8-
10,13,14,28,53] on choking in golf have attempted to
identify learning styles and situations that might
precipitate choking. Two mechanisms have been
proposed to account for choking: (i) distraction (cog-
Sports Med 2003; 33 (1)
18
The athlete
• Personality factors
• Skill
• Fitness
• Personal experience
The sport Cognitive
situation appraisal
• Task difficulty • Of demands
• Demands • Of resources
• Of consequences
and their meaning
• Of bodily reactions
Fig. 1. Factors that affect the arousal-performance relationship (reprinted from Williams,[54] with permission from The McGraw-Hill
Companies).
nitive load), which occurs when pressure distracts
golfers from the task at hand; and (ii) self-focus,
when attention shifts inward to self-presentational
concerns,[43] thereby disrupting performance. To
differentiate between these competing mecha-
nisms 112 novice male golfers were divided into
two groups.[13] The first group learned to putt under
an increased cognitive load (i.e., counting back-
wards from 100 by two’s) and the other group
learned under the condition of increased self-
awareness (i.e., being videotaped) until they reached
a specified criterion of accuracy. Both the distrac-
tion group and the video group performed well
under a high-pressure condition and did not
choke.[14] Conversely, when a group was tested
who had not adapted to increased self-focused at-
tention or distraction, high pressure adversely af-
fected performance. Learning how to putt during
distraction and videotaping helped to recruit
thoughts away from self and task from self-focus
and distracting influences in order to focus on the
task at hand.[10,13]
To learn more about who chokes and when, ten
average golfers putted 20, 1.5m baseline putts, in-
doors, while being videotaped with hidden cam-
eras.[13] These golfers next putted on television
(NBC Dateline), with the opportunity to win
$US300[10,13] if they matched or improved. They
would lose $US100 if their objectives were not
met. Five golfers were successful and five choked.
© Adis International Limited. All rights reserved.
Smith et al.
Emotional or
physiological Behaviour
response
• Heart rate • Motor performance
• Muscle tension • Decision making
• Brain waves • Perception
• Skin conduction • Retention of
learned material
One golfer made eight fewer putts than at baseline,
one made ten more putts thus, earning $US300, and
anxiety failed to predict poor performance.[13]
The strongest predictor of poor performance
was the self-reported average golf score. Unsuc-
cessful putters (chokers) reported anticipated
scores of less than 90. Conversely, those who suc-
ceeded reported anticipated scores over 90. Golf-
ers reporting lower anticipated scores may have
closely monitored their performances,[13] which re-
sulted in increased self-awareness and choking.
Putters who were successful[13] were not burdened
by such high expectations.
Unsuccessful putting performance was asso-
ciated with increased frontal theta, left hemi-
sphere alpha, and beta electroencephalogram
(EEG) activity[10] that relate to increased anxiety
and arousal.[10,27,55] These EEG patterns were rep-
licated when European tour players were studied
while performing poorly.[8] If observed during the
‘yips’ behaviour, such EEG activity would support
the contention that the ‘yips’ is exacerbated by
anxiety.[26,32-34] To date, there are no studies doc-
umenting EEG activity in ‘yips’-affected golfers
during unsuccessful putting. In summary, it seems
that distraction from the golfer’s optimal psycho-
logic and physiologic state potentially leads to a
choking performance. The combination of in-
creased arousal and distracted attention preceded
the poor performance often defined as choking. As
Sports Med 2003; 33 (1)
‘Yips’ in Golf
depicted, the interaction between cognitive ap-
praisal and physiologic response can negatively ef-
fect motor performance, decision making, percep-
tion of the situation and recall or memory, if the
athlete appraises the situation as stressful (figure
1).
5. Choking vs Dystonia in Golf
Golfers who choke and golfers with a dystonia
differ on the aetiology, age of acquisition, docu-
mentation of EEG activity to date, strokes affected
and the treatment interventions likely to be suc-
cessful (table II). While dystonia and choking dif-
fer in many respects, performance anxiety is expe-
rienced by both groups (figure 2). For golfers with
dystonia, performance anxiety contributes to and
exacerbates the ‘yips’ symptoms. For chokers, per-
formance anxiety such as trait and high-state anx-
iety probably combine with self-focused attention
and over-analysis to cause the ‘yips’.
6. Performance Anxiety in Golfers
Although it is understood that performance anx-
iety exacerbates both choking and dystonia, it is
important to consider both the cognitive and phys-
iological perspectives. The term ‘yips’ has been
applied to both golfers who experience a focal dys-
tonia and those who choke. Although no differ-
ences in state and trait anxiety were detected be-
tween the golfers with and without ‘yips’, studies
Table II. A comparison of the aetiology, documentation of electroencephalogram (EEG), type of stroke affected and the type of treatment
appropriate in dystonia and choking in ‘yips’-affected golfers
Dystonia
Aetiology Prolonged abnormal posture; fine motor skills affected
Age Most golfers reporting the ‘yips’ are approximately 45 years Most golfers studied to test choking are between
of age
Acquired Only affects low handicap (mean 4.5) golfers after 20–30
years of golf experience
EEG No EEG studies reported to date during putting and
dystonia
Stroke Most often affects putting; fine motor skills
Treatment Responds initially to new grip, long putter or stance, which
requires golfer to form a new template
© Adis International Limited. All rights reserved.
19
thus far that have examined the ‘yips’ phenomenon
have all reported that the ‘yips’ is worsened by
anxiety.[26,33,34] It should be noted that anxiety and
stress worsens involuntary movements in many
neurologic disorders, such as Parkinson’s disease,
essential tremor and Tourette’s syndrome.
In addition to the presumed influence of person-
ality variables such as trait anxiety, obsessiveness
and confidence on the ‘yips’ putting behaviour, so-
ciological and sport-specific situational factors
also play a role and interact with emotional factors
to increase state anxiety. Of 435 ‘yips’-affected
golfers (mean hcp 4.5), most anxiety provoking
situations were: (i) leading tournaments; (ii) tricky
putts (those putts with difficult lies or more than
one change in inclination); (iii) specific competi-
tors; and (iv) the need to make easy putts.[26] These
situations may interact with personality, cognitive
appraisal factors and golf-specific situations to
precipitate high arousal which, depending on the
individual, may facilitate or cause a deterioration
in optimal performance (figure 2).[23,45-48]
Although psychometric measures of anxiety
were not administered in the second phase of our
‘yips’ research,[26] ‘yips’-affected golfers (n = 4)
experienced faster HR, greater GF and EMG activ-
ity in the wrist flexors and extensors, and putted
less well than the non-‘yips’ affected controls (n =
3). These measures may be physiologic and phys-
ical markers that are a consequence of perfor-
mance anxiety. Alternatively, it is also possible
Choking
Self-focused awareness; may cause generalised
muscle tension
20–30 years of age
Not acquired as it can affect a golfer early, in the
middle of, or late in career
Left brain activity last second before putting supports
choking
May affect any stroke; studied most in golfers when
putting
Will not respond to physical changes; may benefit from
β-blockers, sport psychology, etc.
Sports Med 2003; 33 (1)
20
Performance anxiety
Dystonia (type I)
• Acquired
• Affects low hcp
• Golfers
n = 40
Fig. 2. A model illustrating a continuum on which choking and dystonia anchor opposite ends. Of the 72 ‘yips’ golfers in the study
only the responses of 70 could be interpreted. Definitions seem to cluster along the continuum. Performance anxiety exacerbates
both types of ‘yips’. hcp = handicap.
that increased GF, EMG activity and HR may
cause high anxiety and a poor putting performance
(figure 1).
When performance anxiety is severe, it can lead
to choking, which may result in the ‘yips’. Al-
though some golfers with high performance anxi-
ety choke or develop a dystonia (table II), others
execute their putts competently without ‘yip-
ping’.[10] Conversely, it is unlikely that either the
dystonia or choking symptoms of the ‘yips’ during
putting occurs in the absence of performance anx-
iety.
To date, investigators interested in the ‘yips’
have only acknowledged superficially that state
and trait anxiety (closely akin to fear) exacerbate
symptoms during putting. There has been little ac-
knowledgement of the potential contributions of
neuroscience, and especially the limbic system, to
our understanding of cognitions and emotions such
as fear.
7. Neuroscience Considerations
Although much of the neuroscience research to
date has examined the function of the amygdala
and hippocampus in animals,[55] some of these
findings may improve our understanding of the
© Adis International Limited. All rights reserved.
Smith et al.
Non-categorised Choking (type II)
• Self focused
• Not acquired
• Psychologic
n = 14 n = 16
Yips
‘yips’. For example, McNaughton and Gray[55]
suggested that defensive avoidance, specifically
fear, is controlled by the amygdala. These authors
suggest that in approach-avoidance situations, as-
sessment of the conflict is controlled by the hippo-
campus. McNaughton and Gray[55] studied the role
of theta waves seen on EEG in the presence of high
arousal. They attribute a link between arousal and
theta waves to the hippocampus reaction, and they
concluded that in animals, anxiolytic drugs have a
mild effect on memory while reducing the percep-
tion of threat. Davis,[56] in a review article, sug-
gested that fear activates the amygdala, the hypo-
thalamus and brain stem, which result in an
elevated corticosteroid response. He also postu-
lated that opiate and benzodiazepine receptors lo-
cated in specific areas of the amygdala explain the
fear- and anxiety-reducing effects of various drugs
when given systemically.
Recent research being conducted in humans, ex-
amining meditation and neuroimaging, is complex
but is likely to evolve to further our understanding
of brain and behaviour.[57] For example, the meas-
urement of regional blood flow during meditation
has been examined using single proton emission
computed tomography (SPECT). Regional cere-
bral blood flow, which correlates with cerebral ac-
Sports Med 2003; 33 (1)
‘Yips’ in Golf
tivity, was measured during meditation sessions
where practitioners increased their intensity of fo-
cus on a visualised image.[57] During meditation,
significantly increased cerebral blood flow was
observed in the cingulate gyrus (the limbic sys-
tem). Interpretations of these findings are not yet
clear, however it seems likely that eventually they
may be extrapolated to alternative hypotheses. For
example, opposite responses to meditation will
likely be found when golfers are studied in this
manner, during feared ‘yips’-provoking situations.
Newberg et al.[58] have suggested that in the
limbic system the amygdala serves as our emo-
tional ‘watchdog’, the hippocampus is the ‘diplo-
mat’ and the hypothalamus is the ‘master control-
ler’. While more empirical data are needed to
support these statements, this oversimplified de-
scription serves as a useful interpretation of a com-
plex neurophysiologic interaction. Fear, a primary
factor in ‘yips’-affected golfers, accompanied by
activation of the amygdala, plays a role in the cor-
ticosteroid release that often occurs during high
arousal.[59] The qualitative assessment of fear of
failure beliefs provided by Davis et al.[59] is en-
lightening and their integrated psychophysiologic
model shows the role of negative affect, anxiety
and fear which may partially explain the experi-
ence of ‘yips’-affected golfers.
To date, our attempt to understand the ‘yips’
phenomenon using a generic testing of anxiety[34]
has been too superficial to decipher which emo-
tions (i.e. fear or frustration) are triggering the per-
formance anxiety experienced. We have also been
unable to clearly identify the areas of the limbic
system responsible for the performance anxiety
experienced. We have also failed to clearly iden-
tify the areas of the limbic system responsible
for the performance anxiety experienced by ‘yips’-
affected golfers.
Therefore, future research based on the model
(figure 3), must integrate the golfer’s subjective
ratings of fear with objective physiologic data on
the sympathoadrenomedullary axis (HR), the hy-
pothalamus-pituitary axis (salivary cortisol and
testosterone) and EEG (waves and documentation
© Adis International Limited. All rights reserved.
21
of hemisphere dominance) during putting under
conditions of stress. Although determining the
benefits of pharmacologic manipulation must be
done in randomised, controlled trials; in the mean-
time, many ‘yips’-affected golfers seek relief from
the ‘yips’ using their own pharmacologic reme-
dies.
8. Alcohol and β-Blockers to Reduce
Performance Anxiety
Little is known about how ‘yips’-affected golf-
ers treat their symptoms. Reducing performance
anxiety[35,60-69] may be achieved through the use of
alcohol and pharmacologic agents, such as β-
blockers.[35,66-69] Musicians and athletes, includ-
ing golfers, deal with performance anxiety through
either or both of these means.
For example, 28% of musicians surveyed be-
lieved that music majors had a problem with chem-
ical use, such as marijuana.[60] In a study of orches-
tra members and music students, 34% admitted
taking sedatives or alcohol to cope with music
performance anxiety.[62] In a different study,[63]
20% of musicians were concerned about their
substance use. It was also reported that 23% of
musicians used β-blockers,[64] and in another study
of 2122 sophisticated musicians, 27% were using
β-blockers.[65]
Physiologic symptoms of performance anxiety
include tremors, shaking, palpitations and tachy-
cardia. In several studies,[66-68] β-blockers inhib-
ited the increase in heart rate during performance
and reduced tremors and shaking compared with
the placebo groups. For example, a review of eight
studies[68] showed that most musicians reduced
their tremors with β-blockers compared with pla-
cebo controls.[68] On the other hand, although
tremors were reduced, musicians reported drowsi-
ness.[68] β-Blockers are also used by individuals
experiencing various forms of performance anxi-
ety as well as by those with essential or hereditary
tremors.[70-74]
Although β-blockers decrease performance
anxiety[69,71-74] by blocking β-adrenergic recep-
tors,[74] they are minimally effective in treating fo-
Sports Med 2003; 33 (1)
22 Smith et al.

Dystonia (type I) Choking (type II)

• Patient history, • Sensation of stress
physical and Performance • Increased self-awareness
neurological exam anxiety • Increased EEG activity
• Acquired left brain last second
• Is this really a dystonia? prior to putt

Type I study – test
β-blockers,
antileptics, BoNT
• Changes in stance,
grip force, putter
during putting
• Test EEG while
putting
• Patient history
• Genetic influence
of dystonia
• Role of cortisol and
testosterone
Expected outcomes:
• β-blockers will have
no effect
• BoNT and antileptics
may help
• Changes in stance,
etc., will have initial
effect, but not lasting
• EEG, not sure what
to anticipate
Yips behaviour
Psychoneurologic
impediment primarily to
putting stroke in golf
Characterised by:
• Jerk, twitch, tremor,
or freezing
• Anxiety, fear of failure
• Poor performance
Differentiate fear:
• Excitement/approach
• Avoidance/flight
• Relate to objective data
Type II study – test
β-blockers effect on:
• Psychology
Anxiety – social
desirability (SD),
interaction obsessive-
compulsiveness
• Physiologic
HR, salivary cortisol
and testosterone, EEG
• Physical
EMG, grip force
Expected outcomes:
• Benefit from β-blockers
• Rank high on SD
• Changes in stance
not effective
• EEG activity in left
brain greatest just
before ball contact

Fig. 3. A model based on the notion that there are at least two types of ‘yips’ (type I and type II) and suggesting logical directions for
future testing of both types. BoNT = botulinum toxin; EEG = electroencephalogram; EMG = electromyogram; HR = heart rate.

cal dystonia.[36,70] For example, when musicians
are anxious, the anxiolytic property of β-blockers
reduces symptoms caused by high adrenaline lev-
els.[74]
Symptoms of performance anxiety (choking)
and dystonia described by musicians are compara-
ble to the ‘yips’ phenomenon experienced by golf-
ers. For example:
• to achieve excellence, both musicians and golf-
ers assume an abnormal posture and perform
repeated fine muscle movements over many
years prior to onset of symptoms
• both groups perform intricate movements be-
fore large evaluative audiences
• the errors of both groups are immediately appar-
ent to observers (e.g. audience, media and lis-
teners)
• both groups have much to gain or lose based on
the quality of their performance
• a study in 1978[75] reported high pre-performance
state anxiety in single-sport athletes and solo
musical performers (in middle school children)
prior to sport or music participation. Single-
sport athletes and solo musical performers ex-

© Adis International Limited. All rights reserved. Sports Med 2003; 33 (1)
‘Yips’ in Golf
perienced higher state anxiety than team sport
athletes
• both groups tend to over-practice
• approximately 30% of both groups have tried
β-blockers and/or alcohol to decrease symp-
toms of performance anxiety.
Dystonia in musicians affects the particular
muscles being overused. For example, focal dys-
tonia affects cheek muscles in musicians who play
wind instruments and finger muscles in guitarists.
On the other hand, it affects the wrist flexor and
extensor muscles in most golfers.
Since β-blockers decrease the physical and psy-
chologic symptoms of performance anxiety, sev-
eral sports (i.e. archery and shooting) have banned
their use during competition. To date, professional
golf organisations have not banned β-blocker use
in North America[35,69] even though players have
discussed the positive effects of β-blockers on
their symptoms.[69] The use of β-blockers or other
performance-enhancing agents in tournaments in
the United Kingdom, such as the British Open, is
forbidden.[35] Although, collectively, empirical
data about the ‘yips’ are accruing, there are only
occasional anecdotes that describe the subjective
experience of the ‘yips’-affected.
9. Golfers’ Perceptions of the ‘Yips’:
An Investigation
Interpretations of the ‘yips’ by non-‘yips’ af-
fected physicians, teaching professionals and sport
scientists are respected; yet, rarely, are the ‘yips’-
affected golfers asked to subjectively describe
their symptoms. Self-perception is the subjective
way in which we see and evaluate ourselves.[76]
Perception influences individual beliefs, which
may influence the golfer’s decision about the type
of treatment to seek. For example, golfers with
‘yips’ who believe their wrist jerk is an acquired
movement disorder, such as a dystonia, may seek
medical advice, whereas golfers who attribute
their wrist jerk to poor putting technique will con-
tact a teaching professional. Self-perception influ-
ences the golfer’s willingness to accept a diagno-
sis, adhere to treatment and change behaviour.
© Adis International Limited. All rights reserved.
23
The purpose of the small study described in de-
tail below was to quantify and qualify the self-
perceptions of ‘yips’-affected golfers concerning
their putting problem. This study addressed: (i) if
perceptions of ‘yips’-affected golfers support a
theory (figure 2) in which dystonia (type I) and
choking (type II) are on a ‘yips’ continuum; (ii) do
type I and type II ‘yips’ have different causes; and
(iii) are both types influenced by performance anx-
iety?
9.1 Methods
A preliminary golf questionnaire was devel-
oped and posted on the Mayo Clinic website
(www.mayo.edu/research/yips/). Fliers were also
mailed to several golf-teaching professionals iden-
tified from the United States Golf Association ros-
ter. Recipients were asked to post the question-
naires in their golf club locker rooms. Website
visitors interested in participating in this project
downloaded the questionnaire, those who phoned
were mailed questionnaires, and all completed
questionnaires were returned via US ground mail.
The questionnaire was completed by low hcp
golfers (n = 72) in the US and Canada in the first
quarter of 2001. The questionnaire obtained de-
mographics, a ‘yips’ history and the golfer’s
subjective perception or definition of the ‘yips’.
The golfer’s perceptions were analysed qualita-
tively[77-79] and quantitatively. Three investigators
conducted the preliminary analysis. Golfer’s per-
ceptions were triaged into themes and were
categorised as representing physical symptoms
(dystonia: type I), psychosocial symptoms (chok-
ing: type II), or a combination of both (non-
categorised). The preliminary analysis was then
mailed to three physician co-investigators who
were specialists in movement disorders and golf.
The few definitions in each category which did not
have 100% agreement were assigned to the classi-
fication that received agreement by two of three
physicians. This triangulation process validated
the analysis and utilised the knowledge of the in-
vestigators,[26] sources of data on perceptions and
Sports Med 2003; 33 (1)
24 Smith et al.

Table III. Definitions of the peceptions of the ‘yips’ (classified as dystonia [type I]), as defined by 40 of 72 ‘yips’-affected golfers
Uncontrollable movement on short putts with hands/wrist producing jerking motion/stabbing of putt vs a smooth stroke
Last second jerk of the club and turn of face of the putter
Complete inability to make a proper stroke with the putter. Inability to keep the wrists from snapping, the shorter the putt, the worse the
problem
Freezing on short putts or twitching/jerking on short putts
Involuntary movement of body/arms/hands not in coordination with desired movement
Involuntary spasm or nerve reaction
Involuntary motion of the hands during a stroke
Inability to make a smooth stroke on putts (especially short putts)
Neurologically generated problem that disrupts communication between nerves/muscle and brain
‘Freeze’ over the ball and often make spastic jerky putts
Involuntary aberration in usual putting stroke, especially on short putts
Uncontrollable movement in the hands that causes the putter blade to turn
‘Flinch’ or ‘jerk’ that occurs at or just prior to impact on an actual golf shot
Involuntary twitch in the right wrist that destroys both distance and direction in short game shots
Involuntary jerking of hands when putting
Jerky, uncontrollable swing with the putter
Flinching on impact
Failure to control club face at contact
When you can’t take the putter back; or when you finally get it to move, you take it back short and then putt the ball going forward
While in the process of stroking the ball, there is a sudden jerk or movement that alters the normally expected swing pattern. It is
involuntary
Inability to bring the club back and/or jabbing-type blow at the ball
Your brain will not let you control your hands
Tendency to jerk putter or freeze over shortish putts and chips
Twitch of the hands at a putt
When putting, just before contacting the ball, having a spasm causing the player to miss the putt
Involuntary motion or freeze up while putting
When at the point of contact with the ball, your muscles explode uncontrollably
Involuntary flinching of the nerves that you can’t control
Uncontrolled flinch at impact causing you to miss a shot that you would normally make
Total loss of control when trying to perform a stroke
Involuntary movement of the wrist only when the ball is in play
An involuntary twitching of the right hand on every putt
Sudden unexpected movement
Uncontrollable flinch
Hands take on a mind of their own and refuse to complete stroke or chip. Jerk out or across the ball; at worst, can’t even bring putter back
Nervous twitch or jerk which inexplicably occurs during the putting stroke
Loss of control of my right wrist during putting
Inability to draw putter back on a 1-footer. Uncontrollable muscle spasm in short putting stroke and chipping
Uncontrolled movement of the arms/hands just before making contact with the ball. The movement is like a twitch or jerk
An involuntary flinching during a short motion

the opinions of expert colleagues (R Wharen, per-
sonal communication).[70,79]
9.2 Results
Subjective descriptions of the ‘yips’ were an-
alysed from the questionnaires returned by the first
72 interested golfers. Sixty-nine ‘yips’-affected
male golfers (mean hcp of 6.7, ranging between
0–16) and three ‘yips’-affected female golfers
(mean hcp of 13.1, ranging between 7–17) com-
pleted questionnaires to assess ‘yips’ symptoms.
Of these 72 ‘yips’-affected golfers, 62 (85%) had
hcps of 10 and under. Most had achieved a high
level of golf proficiency (e.g. were on golf schol-
arships, etc.) before acquiring the ‘yips’.[34]
The mean age of the 72 golfers was 52 years,
mean golf experience was 36 years and golfers av-
eraged 75 rounds of golf per year. Golfers with

© Adis International Limited. All rights reserved. Sports Med 2003; 33 (1)
‘Yips’ in Golf 25

Table IV. Definitions of the ‘yips’ (classified as choking [type II]), as defined by 16 of 72 ‘yips’-affected golfers
Inability to make simple short putts when you need to, as if paralysed
Inability to commence the putting stroke finally followed by a ‘herky-jerky’ putting stroke. The entire predicament is probably caused by
negative feelings; wondering how you will miss the putt rather than the feeling of making the putt
The feeling that you cannot make a putt regardless of how easy it is. Nervousness, tension and jumpiness
Can’t make short putts and lose confidence and then get nervous over them
Nervousness over short range putts. Sometimes making it difficult to draw the putter back. Causes loss of confidence
Involuntary mental response in putting that you feel overrides technique and ability
Not being able to make the same stroke when competing or just playing that you can make when practising
Can’t start the golf swing
Inability to repeat swing or stroke that would be made with no pressure
Lack of confidence, particularly short putts
When the adrenaline gets going and nervousness sets in at certain times
Inability to consistently make a 3–4 foot putt while putting under pressure
Your mind tells you that you can’t make short putts, thus you either push or pull the putt
Inability to think in a relaxed, positive, quiet manner, and the inability to execute during period of slightest pressure
Nervousness and tight feeling in the body prior and during the putt
Mental freeze up that does not allow your muscles to freely work

‘yips’ averaged 20 years of club tournament expe-
rience with 66 (90.4%) playing in local and 19
(26%) in national tournaments. ‘Yips’ symptoms
were episodic in 54% and affected putting only in
53.4%.
When ‘yips’-affected golfers defined the ‘yips’,
it was assumed they were describing the ‘yips’
symptoms they experienced. Three primary inves-
tigators reduced the definitions into the two themes
of dystonia (n = 40) and choking (n = 16) [see table
III and table IV]. Fourteen had symptoms of both
themes and were determined to be non-categorical
(see table V). Two golfers described the ‘yips’ in
a manner that failed to describe their symptoms at
all.
In the dystonia category (type I), definitions fo-
cused on physical characteristics of the ‘yips’ such
as “an involuntary spasm or nerve reaction” (table
III). Within this category, golfers mentioned a jerk
(n = 28), freezing (n = 10) and a tremor (n = 6).
Type I golfers tried to treat their symptoms by a
change in either grip (n = 17), stance (n = 8), putter
length (n = 14) or swing (n = 2). Sixteen golfers
(40%) self-medicated with alcohol, four (10%)
self-referred to a sport psychologist and seven
(17.5%) tried relaxation (n = 3), music (n = 2),

Table V. Non-categorised definitions of the ‘yips’, as defined by 14 of 72 ‘yips’-affected golfers

A physical reaction to a mental/physical condition which causes a jerky motion at impact causing the putt to be pulled/pushed off line
Tighten up and your stroke gets short and choppy. Sometimes you flinch
Inability to make a normal smooth stroke under pressure with a standard-size putter
Involuntary collapse during a putting stroke
Muscles tighten up and the mind shuts down
Anything that interferes with the natural free flow of the putting stroke (tightness, freezing over putt)
Flinching at impact. The desire to make a smooth, complete motion at the golf ball and the inability to do so. Lack of confidence in ability,
especially under pressure
Uncontrollable nervosa, mini panic attacks, like a lightning rod of hypertension right in the middle of the stroke
Physical reaction to performance anxiety
When your nerves affect your putting stroke, preventing you from obtaining a smooth stroke
Nervous reaction of the wrist as you are about to hit the ball
Loss of ability to putt, caused by a lack of ‘feeling’ in your hands, as a result of fear of missing putts
Medically: a psychoneuromuscular reaction experienced during short putts. Socially: a horrifying affliction prompting avoidance behaviour
in others. A ‘career killer’
Inability to putt the ball. Look over it, but feel you can’t pull the trigger, in a freeze mode

© Adis International Limited. All rights reserved. Sports Med 2003; 33 (1)
26
medications (n = 1) or exercise (n = 1). Although
some improvement may have occurred, it is note-
worthy that these golfers still registered for the
‘yips’ investigation, so their symptoms had not
completely resolved as a result of the aforemen-
tioned interventions.
The choking category (n = 16) included defini-
tions of psychologic distress such as “inability to
make simple short putts when you need to, as if
paralysed” (table IV). Non-categorised definitions
(n = 14) which contained characteristics of both
dystonia and choking such as “muscles tighten up
and the mind shuts down” were included in table
V. Definitions (n = 2) such as “a nasty monster”
and the “inability to make a proper putting stroke
under any number of conditions” were too vague
to be interpreted and were not included in the anal-
ysis.
From the standpoint of performance, the 40 type
I dystonia golfers had a mean hcp of 6.6, compared
with a hcp of 6.2 for the type II golfers classified
as chokers. The choking group experienced less
range in their hcps (table VI).
9.3 Discussion
It is evident that a golfer’s perception of what is
happening in the mind, body or both can help in-
vestigators determine the aetiology and sub-
sequently the appropriate treatment for the ‘yips’.
In this study, the ‘yips’ descriptors ranged on a
continuum from symptoms of dystonia (55%) to
choking (22%). Nineteen percent (19.4%) of the 72
golfers provided definitions that contained symp-
toms of both dystonia and choking (table V) and as
such were not included in either category (figure
2). Perhaps as more empirical data are obtained,
the non-categorised group (symptoms of both cat-
Table VI. Summary of handicaps for type I and type II ‘yips’-affected
golfers
Type of ‘yips’ Mean Standard
deviation
Type I: dystonia 6.8 4.6
Type II: choking 6.2 3.2
Mean 6.5 3.9
© Adis International Limited. All rights reserved.
Smith et al.
egories) will be positioned in the centre of the con-
tinuum depicted on the theoretical model (figure
2).
These results support research reported earlier
by these investigators[26] on criteria qualifying
most cases of the ‘yips’ as a dystonia. Criteria of
the ‘yips’ were that golfers should have been good
putters and thus have acquired the ‘yips’ problem.
The ‘yips’ symptoms should be episodic, prompt-
ing golfers to alter their grip, putter length or
stance, changes that most often result in temporary
improvement.
Of 200 golfers[26] examined retrospectively for
these criteria in a previously reported study, 136
(68%) met three or four criteria of dystonia and 64
(32%) met two or fewer. In the present study, 38
of 40 (95%) type I dystonia golfers described them-
selves as good putters prior to their ‘yips’ symp-
toms supporting the notion that the symptoms were
acquired. Eighteen of the 40 (42.9%) said their
symptoms were episodic and all (100%) had
changed their grip, stance, putter length or swing.
Using a qualitative analysis of the definitions[77-79]
provided by these ‘yips’-affected golfers, 40 (55%)
were classified as dystonia, compared with 136
(68%) who met the criteria reported earlier.[26]
The high incidence of ‘yips’-affected golfers
who meet the inclusion criteria used to categorise
a dystonia is surprising. This incidence is higher
than expected when one considers that the inci-
dence of focal dystonia (30/100 000) reported in
the general population is fairly low.[37] Even the
increased incidence of dystonia reported by musi-
cians (1 in 200 to 1 in 500)[38] is likely less than
what we are reporting in these competitive low hcp
golfers (we do not have a denominator necessary
to accurately calculate true incidence).
Musicians, like golfers, repetitively perform
fine motor skills under conditions of high arousal,
experience intense concentration demands and fear
not performing well. Supporting the high preva-
Mode Range
lence of dystonia-like symptoms in golfers is the
7 0–17.4 fact that accomplished pianists and guitarists, who
8 2–8 perform repetitive hand movements, experience
7.5 0–17.4 dystonia more often than other musicians. The
Sports Med 2003; 33 (1)
‘Yips’ in Golf
‘yips’-affected were good golfers (mean hcp
4.5[26] and 6.6 in the present study). Golfers with
‘yips’ who have had 20–30 years’ experience re-
petitively practice putting while maintaining the
prolonged abnormal hand and wrist posture in-
herent in the putting grip, a factor believed requi-
site to the onset of dystonia symptoms.
A possible explanation for why the majority of
golfers affected describe symptoms of dystonia
might be that the ‘yips’-affected prefer to interpret
their signs and symptoms as a physical and not a
psychologic impediment. Alternatively, the ‘yips’-
affected are likely to experience a transitory task-
specific dystonia in high-pressure situations (i.e.
golf tournaments). Therefore, symptoms of dysto-
nia may not affect execution of tasks in their daily
lives. As a consequence, ‘yips’-affected golfers
may not seek medical attention. Thus, by avoiding
a neurologic diagnosis, they are not included in the
epidemiology reports on focal dystonia.
The taxonomy differentiating the ‘yips’ into
dystonia (type I) and choking (type II) has appeal.
Self-perceptions of the ‘yips’-affected provide ini-
tial empirical support for the model (figure 2) and
may reduce the lay public’s confusion about the
‘yips’. Figure 3 provides structure for future re-
search testing of both the aetiology and the effec-
tiveness of interventions specific to the ‘type’ of
‘yips’ experienced.
While some ‘yips’ behaviour results from chok-
ing, not all choking results in the ‘yips’. Putts that
fail to go in the cup attributed to high anxiety may
not involve a tremor, jerk, twitch or freezing. The
ball may fail to drop due to mild performance anx-
iety or a slight error in judgement, but the golfer
may not have truly ‘yipped’.
The ‘yips’ type I resembles focal dystonia, the
possible aetiological explanations of which were
listed earlier in the paper. It is said that dystonias
affect the same muscles individuals use to make a
living. The more one practices golf, the more
rounds played per year, the more clinics, years ex-
perience, intensity, concentration and tension, the
more likely it is that the golfer will acquire the
‘yips’ type I. Once started, the ‘yips’ is accompa-
© Adis International Limited. All rights reserved.
27
nied by performance anxiety, by the fear of recur-
rence and by a loss of confidence. In the ‘yips’ type
I, it may be that a nerve conduction pathway, pre-
viously highly functional, wears out (R Wharen,
personal communication). To date, golfers with
the ‘yips’ (type I) do not recover, but re-train them-
selves, with the help of a teaching professional, to
acquire expertise on a long putter, a new grip or
stance. If ‘yips’ type I golfers return to their pre-
vious putting style, the ‘yips’ symptoms usually
return.
The ‘yips’ type II golfers experience choking,
a consequence of self-focused attention,[8,13,14,43,
44,53,76] performance anxiety and possibly over-
analysis.[10,27] Preliminary EEG studies by Crews
et al.[8,27,28] on choking suggest that both success-
ful and non-successful golfers experienced anxi-
ety, but successful golfers may have stopped an-
alysing and balanced the EEG activity of both
hemispheres just before the putt (in the last 3 sec-
onds).[8] Although provocative, this work needs
replication. Interventions suggested to relieve
choking range from cognitive strategies,[19] use
of mental imagery[80-83] and a visualisation pro-
gramme specific to activating the right hemisphere
of the brain.[10] The latter may move the focus of
attention away from left brain analysis to promote
automaticity. The effectiveness of these interven-
tions on choking, at levels of performance anxiety
sufficient to elicit the ‘yips’, await empirical test-
ing.
The pathophysiology and aetiologies of the
‘yips’ type I and type II are incomplete. Other ex-
planations postulated to cause the ‘yips’ have been
suggested. Explanations include a psychiatric
block which impedes retrieval of a normal, stored
motor engram for putting.[30] Alternatively, the re-
trieval process may occur normally but yield a
faulty, motor engram characteristic of the
‘yips’.[21] It is also possible that golfers who are
‘yips’-affected have a genetic predisposition to
dystonia or choking not yet identifiable.
A provocative, unsubstantiated psychophysio-
logic hypothesis that merits research attention in-
volves the role of testosterone in contributing to
Sports Med 2003; 33 (1)
28
the ‘yips’ of both types. In college tennis players,
salivary testosterone was significantly higher in
winners than losers.[84] Testosterone remained
high while players continued winning, which led
investigators to conclude that elevated testosterone
was associated with confidence. ‘Yips’ symptoms,
reported most often in men, occur at 45–55 years
of age,[85,86] when testosterone may decline. Lower
levels of testosterone, associated with decreased
confidence, might exacerbate the putting problem,
a premise to be tested in subsequent research.[20]
Another explanation for the ‘yips’ type II has a
psychosocial foundation. Golfers at middle age,
with the expertise necessary to have a low hcp, may
have their self-identity highly invested in golf.
Such a scenario would predispose competent
golfers to ‘acquire’ the type II ‘yips’ which also
has a mean age of onset in the late 40s or early
50s.[26,33,34]
Finally, Dave Pelz,[7] a teaching professional at
the Pelz Golf Institute, has observed that golfers
who become ‘yips’-affected are very intelligent
and committed to their sport. Future research needs
to be done to substantiate his observation. It also
may be that golfers with ‘yips’ are compulsive,
over practice, overanalyse and/or take themselves
too seriously. These interpretations remain conjec-
ture until empirical data are obtained. Perhaps in
the future, a ‘yips’ personality profile will identify
those at risk for developing this frustrating prob-
lem and strategies can be identified to prevent the
onset of symptoms.
Golfer’s self-perceptions provide insight into
what is experienced when the ‘yips’ occurs. Describ-
ing the ‘yips’ as a “horrifying affliction prompt-
ing avoidance behaviour” or a “career killer” con-
veys the distress experienced by golfers who
are ‘yips’-affected. It is worrying when golfers
treat their ‘yips’ symptoms with alcohol or self-
medication. The incidence of reported alcohol
use to treat ‘yips’ symptoms ranged from those
categorised as dystonia (type I: 39%) to those in
the choking group (type II: 33%), percentages
which are similar to the numbers of musicians who
© Adis International Limited. All rights reserved.
Smith et al.
use alcohol and β-blockers to reduce performance
anxiety.
9.4 Limitations and Conclusions of the
Present Investigation
• This present investigation is the first reported
analysis of the golfer’s perception of their ‘yips’
symptoms. These data provide initial support
for the proposed model (figure 2). The results
of this study support previous investigations
that lean toward the diagnosis of a focal dysto-
nia for the majority of ‘yips’-affected golf-
ers.[26,33,34] The ‘yips’ taxonomy (type I and
type II) provides organisation for what, to date,
has been a disorganised picture of the ‘yips’.
Future research will hopefully progress in ac-
cordance with the guidelines provided in figure
3.
• A strength and a limitation of this research is
that it was based upon the golfer’s perception of
the ‘yips’ behaviour. Ideally, a neurologist
would clinically confirm the ‘yips’ classifica-
tion. The questionnaires were returned from all
across the US and Canada so that was not pos-
sible. As with our earlier study[26] on the ‘yips’,
the ‘yips’ respondents were primarily male,
which limits the applicability of the results to
females.
• It is likely that psychosocial influences of peers
and the media have skewed the subjective re-
porting of symptoms and the ‘yips’ experience.
Care must be taken to distinguish between the
type of ‘yips’ reported, and to relate both sub-
jective and objective findings.
10. Future Research Directions
• Subsequent studies should ensure that ‘yips’-
affected golfers are examined clinically to de-
termine the congruity between the golfer’s
perception of the ‘yips’ and the ‘yips’ classifi-
cation assigned by the neurologist. Future stud-
ies will compare the psychometrics, stress
hormones, HR, GF, EMG and EEG relative to
the performance of ‘yips’-affected golfers dur-
ing baseline, placebo and β-blocker conditions
Sports Med 2003; 33 (1)
‘Yips’ in Golf
(figure 3). Golfers experiencing type II ‘yips’
may show greater symptom reduction after re-
ceiving a β-blocker, whereas those with type I
‘yips’ are less likely to find symptom relief.
• It should be noted that because dystonia symp-
toms are greatly exacerbated by anxiety, even
those ‘yips’-affected golfers classified as hav-
ing a dystonia may benefit from a β-blocker, if
it sufficiently reduces anxiety. ‘Yips’-affected
golfers with symptoms of dystonia should be
studied during putting to determine EEG activ-
ity in the right and left hemisphere. Such results
can be compared with the EEG data obtained
from successful and unsuccessful putters (chok-
ers).
• Future studies must delineate the behavi-
our produced by a differentiation of fear and
anxiety. Fear-related measures of avoidance
(flight), excitement (approach) and freezing
may predominate in type II golfers rather than
in dystonia type I golfers. Type II chokers may
exhibit anxiety manifested by stimuli from a
conflict between threat and curiosity.[55] Partic-
ipating in a ‘yips’ putting tournament may ide-
ally stimulate the conflict of interest. Such a
research emphasis will help translate the exten-
sive body of research on animals[55] to an in-
creased understanding of human behaviour
under pressure. Outcomes could then be inter-
preted in light of the psychophysiology research
on adaptation to stress by Dienstbier.[87]
11. Conclusion
Although this paper has advanced our under-
standing of the ‘yips’ beyond work reported ear-
lier,[26] the two categories of ‘yips’, type I and type
II, are not yet adequately described. Interventions
must next be evaluated for effectiveness.
The golfer’s perception of the ‘yips’ will deter-
mine the type of care the golfer seeks for relief of
symptoms. The nomenclature discussed in this pa-
per, once disseminated to golfers, physicians and
teaching professionals, will result in a more
prompt recognition of the ‘yips’ symptoms. Golf-
ers may be triaged promptly into the correct diag-
© Adis International Limited. All rights reserved.
29
nostic category. Those golfers who receive appro-
priate treatment expediently will be less likely to
abuse alcohol or non-prescription medications.
The proposed model provides an organisation
for future research. Results of subsequent investi-
gations on the effectiveness of treatment will not
only help relieve the distress experienced by com-
petent golfers but will also be applicable to musi-
cians,[52] dentists and other similarly affected pop-
ulations and professions.
Acknowledgements
These authors would like to acknowledge the Johannson-
Gund Endowment Fund, Lila Burnett, and Joseph Roberts
for their assistance with this paper. The authors have no
conflicts of interest directly relevant to the contents of this
review.
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Correspondence and offprints: Aynsley M. Smith, Desk L-C,
Sports Medicine Center, Mayo Clinic, Rochester, MN
55905, USA.
E-mail: smith.aynsley@mayo.edu
Sports Med 2003; 33 (1)