Performance Anxiety
Terrence Clark, MD
Associate Clinical Professor
Dept. of Psychiatry and Behavioral Sciences
Grand Rounds, Department of Psychiatry
and Behavioral Sciences, James H. Quillen
College of Medicine
April 5, 2013
Disclosure Statement of
Financial Interest
• I, Terrence Clark, M.D.
DO Not have a financial
interest/arrangement or affiliation with
one or more organizations that could
be perceived as a real or apparent
conflict of interest in the context of the
subject of this presentation.
Acute Performance Failure due
to Anxiety
• Suboptimal performance under stress
Walking the Plank
Effortless
Danger invites conscious trying
Types of Performance Anxiety
• Public Speaking- 20 % excessive fear
• Math Anxiety
• High Stakes Exams
• Athletics
Anxiety
• Anxiety, “get over it, be strong, face it.”
• Fight it
• Strength of OCD, panic attacks,
performance failure
Performance Anxiety
• Suffering
• Impaired functioning
Performance Anxiety
• Phenomenology
• Theory
• Interventions:
Psychological – emphasis in presentation
Psychopharmological-briefly
Emphasis on Athletics
• Applicable to other settings as well as a
game
• Games as metaphor
• Use of games in therapy, core issues
Athletics
• Infamous examples:
• Greg Norman, 1996 Masters
• Jana Novatna Wimbledon, 1993
• Foul shot in last seconds of basketball
• Team going flat
• Average athletes, every day
The Game on the Line
• George
• Foul shots to tie or win
• Sweaty palms
• Memory of past failure
• Self talk, a good try
The Game on the Line
• Vision of air-ball
• Thoughts, meaning, doubt, stakes
• Sense of self/identity
• Routine
Air-ball
• What happened?
• How?
• Why?
• What could George do differently?
George’s Challenge
• How does he manage the cognitive and
physical aspects that emerge in
competition?
• How does he optimize his chance of
successful performance?
Components for George to
Consider
• Pre-performance routine
• Managing thoughts
• Managing air-ball vision
• His psychology of competition/life
• Language, self talk
• Accessing instinct
Strategies
• Denial, suppression
• Resilient from experience
• Acceptance, acknowledge such can
happen
• Multi-faceted sense of self
• Dis-identification with thoughts, actions
Strategies
• Awareness of trying modality
Star Wars, Nike
• Ways of accessing instinct
• Self-talk, unc knows no negative
• “and” vs. “but”
• Recall of prior success
Acute Performance Failure
There appear to be at least three distinct,
yet sometimes overlapping, entities that
produce acute performance failure:
• Panicking
• Choking
• “Yips”
Doubt
• High likelihood of impairing performance
• Erodes confidence
• Cascades
Two Types of Learning/Memory
• . Explicit (declarative) memory governs
the recollection of facts, events, and
associations.
• Implicit memory deals with procedural
memory that does not require conscious
awareness; for example, one is able to
recall how to ride a bicycle or play the
piano after many years of not performing
either function
Explicit Memory
• Explicit memory appears to be centered in the
•
•
part of the brain called the hippocampus.
When an individual experiences severe stress,
there is secretion of epinephrine and
glucocorticoids.
Severe stress responses can harm and, over
time, produce atrophy of the hippocampus,
preventing consolidation or retrieval of conscious
explicit memory . The individual often
experiences this as going blank
Memory
• Some emotional memories can be
reawakened without requirement of
consciousness
• Conventional or declarative memories,
more conscious, stored in adjacent
hippocampus
Neurological Underpinnings
• Hippocampus – Explicit memory
• Amygdala and associated areas in basal
ganglia – Implicit memory/learning
Theory of Ironic Processes of
Mental Control
• Intentional, counter-intentional results
• Operating process, conc. Promotes the
intended result
• Monitoring process, unc. searches for
unwanted outcomes
• Wegner, Psychological Review,1994 Vol101,No1,34-52
Ironic Process
• Performing what one is trying to avoid
• George wanted to avoid an air-ball
Wegner
Ironic Outcome
• Stress, and decreased cognitive
capacity…monitoring may supersede and
lead to least intended outcome
• Promotes weird outcome
• Performer trying not to miss, misses
The Trying Modality
• Recruiting explicit memory interferes with
implicit function
“aiming” a baseball
“steering” a golf shot
“trying” to knock in a putt
Choking
Did George choke?
Acute performance failure under perceived
stress
Choking
• Reliance on explicit/conscious memory
• Loss of trust in unc. implicit motor
functioning
• “Trying”
• Loss of spontaneity
• Mechanical
Did George Panic?
• Did he stop thinking?
• Focus on survival?
• Example of Jean Van de Velde
Panic During
Intense Competition
• Perceptual narrowing-the mind going blank,
• The stress response, with concomitant
•
•
impairment in explicit memory, may hinder one’s
ability to think
Leaving the athlete to rely on instinct alone
When an athlete is exposed to excessive
autonomic hyper-arousal and panics he turns to
“instinct” and may temporarily lose ability to
think critically
The “Yips”, Famous Examples
• Scott Hoch
• Bernhard Langer
• Chuck Knoblauch, baseball, NY Yankees
• Bane of the average golfer
The YIPS
• Sudden contraction of a group of muscles
interrupting a fluid well coordinated
motion
• Looks like a jerking or stabbing motion
• Very difficult to control
• Destroyed careers
• Give up the sport
Yip
• Focal dystonia?
• Happens in those who have practiced a
great amount
• Mink notes that basal ganglia are
organized to facilitate voluntary movement
and inhibit competing movements,
• Unconscious level of functioning
Mink
YIPS
• Stress causes release of
glutamate….dopamine…. Disinhibit ion of
competing motor programs
Components of Pre-performance
Routine
• Readying routine
• Focus
• Visualize the shot
• Might focus on one relevant external cue
or thought
Self Paced Sports
• Free throws, golf, target shooting
• Dealing with down time,
• Pre-shot routine is necessary
High Level
Competitive Athletes
• Most play to win
• Survey of Olympic Athletes, Sports
Illustrated
• Androgen use
Philosophy of Competition
• Playing to win
• Investment, meaning to the individual
• Playing for ego purposes (a game within a
game)
Walker
Instinct
• Trusting implicit unconsciously known
motor skills
• Bobby Jones
• Ben Hogan
Flow
• During a task-orientated activity
• Loss of self-consciousness
• In the moment
• Altered perception of time
• Sense of absorption
• Sense of control and unity
Csikszentmiahalyi
George, Office Appointment
• Listen
• Adequate time
• Explore the event and past events
George, Office Visit
• Explore sense of self
• What worked before
• Suggest when receptive
• Hope
• End
Resilient Athlete
• Positive Cognition
• Reliance on implicitly known skills
• Good use of imagery
• Sound Psychology of competition
• Plays to win
• Confidence
Preparation for The Event
• Rested
• Do what has worked before
• Be prepared
Dealing with Distractions
• Internal distractions
• External distractions
• In the bubble
Treatment
• Cognitive Behavioral Therapy
• Action Commitment Therapy
• Pharmacotherapy
Action Commitment Therapy
• Mindfulness
• Acceptance
• Disidentification with thoughts, emotions
• Reinforcing a sense of self separate from
momentary thoughts and feelings
Hayes,S. Folette,V. Linehan,M.
Mindfulness
• A process of moving towards a state in
which one is fully observant of external
and internal stimuli, in present moment,
open to accepting, exposure to previously
avoided stimuli, inc. self observation
Mindfulness
• Awareness
• Non-judgmental observation
• Beginners mind
• In the moment
• Accept/let go
Decentering
• Mindfulness Based Cognitive Therapy
• I am not my thoughts
• Thoughts are not facts
• Segal,Teasdale,Williams from Mindfulness and Acceptance, Edited
by Hayes, Follette, Linehan
Metacognitive Awareness
• A cognitive set in which neg thoughts and
feelings are experienced as mental events
rather than self
• This may decrease automatic responses
• A desensitization process, promotes
exposure, tolerance
Acceptance Based Therapies
• Internal events are transient responses,
rather than threatening and to be avoided
• Function of the problematic cognitions are
most relevant
• Layers of function,
• Present moment includes the past,
present and future (Blink)
Pharmacotherapy
• SSRI’s
• Beta adrenergic blockers
• Benzodiazepines
Summary
• Performance Anxiety
• Acute Performance Failure
• Theories: conscious/unc. Memory/motor
• Psychology of competition
• Language, e.g. “try”, “but”
• Mechanical/instinct