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Performance Anxiety Terrence Clark, MD Associate Clinical Professor Dept. of Psychiatry and Behavioral Sciences Grand Rounds, Department of Psychiatry.

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Presentation on theme: "Performance Anxiety Terrence Clark, MD Associate Clinical Professor Dept. of Psychiatry and Behavioral Sciences Grand Rounds, Department of Psychiatry."— Presentation transcript:

1 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

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3 Acute Performance Failure due to Anxiety Suboptimal performance under stress Suboptimal performance under stress

4 Walking the Plank Effortless Effortless Danger invites conscious trying Danger invites conscious trying

5 Types of Performance Anxiety Public Speaking- 20 % excessive fear Public Speaking- 20 % excessive fear Math Anxiety Math Anxiety High Stakes Exams High Stakes Exams Athletics Athletics

6 Anxiety Anxiety Anxiety, “get over it, be strong, face it.” Anxiety, “get over it, be strong, face it.” Fight it Fight it Strength of OCD, panic attacks, performance failure Strength of OCD, panic attacks, performance failure

7 Performance Anxiety Suffering Suffering Impaired functioning Impaired functioning

8 Performance Anxiety Phenomenology Phenomenology Theory Theory Interventions: Interventions: Psychological – emphasis in presentation Psychological – emphasis in presentation Psychopharmological-briefly Psychopharmological-briefly

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10 Emphasis on Athletics Applicable to other settings as well as a game Applicable to other settings as well as a game Games as metaphor Games as metaphor Use of games in therapy, core issues Use of games in therapy, core issues

11 Athletics Infamous examples: Infamous examples: Greg Norman, 1996 Masters Greg Norman, 1996 Masters Jana Novatna Wimbledon, 1993 Jana Novatna Wimbledon, 1993 Foul shot in last seconds of basketball Foul shot in last seconds of basketball Team going flat Team going flat Average athletes, every day Average athletes, every day

12 The Game on the Line George George Foul shots to tie or win Foul shots to tie or win Sweaty palms Sweaty palms Memory of past failure Memory of past failure Self talk, a good try Self talk, a good try

13 The Game on the Line Vision of air-ball Vision of air-ball Thoughts, meaning, doubt, stakes Thoughts, meaning, doubt, stakes Sense of self/identity Sense of self/identity Routine Routine

14 Air-ball Air-ball What happened? What happened? How? How? Why? Why? What could George do differently? What could George do differently?

15 George’s Challenge How does he manage the cognitive and physical aspects that emerge in competition? How does he manage the cognitive and physical aspects that emerge in competition? How does he optimize his chance of successful performance? How does he optimize his chance of successful performance?

16 Components for George to Consider Pre-performance routine Pre-performance routine Managing thoughts Managing thoughts Managing air-ball vision Managing air-ball vision His psychology of competition/life His psychology of competition/life Language, self talk Language, self talk Accessing instinct Accessing instinct

17 Strategies Denial, suppression Denial, suppression Resilient from experience Resilient from experience Acceptance, acknowledge such can happen Acceptance, acknowledge such can happen Multi-faceted sense of self Multi-faceted sense of self Dis-identification with thoughts, actions Dis-identification with thoughts, actions

18 Strategies Strategies Awareness of trying modality Awareness of trying modality Star Wars, Nike Star Wars, Nike Ways of accessing instinct Ways of accessing instinct Self-talk, unc knows no negative Self-talk, unc knows no negative “and” vs. “but” “and” vs. “but” Recall of prior success Recall of prior success

19 Acute Performance Failure There appear to be at least three distinct, There appear to be at least three distinct, yet sometimes overlapping, entities that produce acute performance failure: yet sometimes overlapping, entities that produce acute performance failure: Panicking Panicking Choking Choking “Yips” “Yips”

20 Doubt Doubt High likelihood of impairing performance High likelihood of impairing performance Erodes confidence Erodes confidence Cascades Cascades

21 Two Types of Learning/Memory. Explicit (declarative) memory governs the recollection of facts, events, and associations.. 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 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

22 Explicit Memory Explicit memory appears to be centered in the part of the brain called the hippocampus. 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. 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 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

23 Memory Some emotional memories can be reawakened without requirement of consciousness Some emotional memories can be reawakened without requirement of consciousness Conventional or declarative memories, more conscious, stored in adjacent hippocampus Conventional or declarative memories, more conscious, stored in adjacent hippocampus

24 Neurological Underpinnings Hippocampus – Explicit memory Hippocampus – Explicit memory Amygdala and associated areas in basal ganglia – Implicit memory/learning Amygdala and associated areas in basal ganglia – Implicit memory/learning

25 Theory of Ironic Processes of Mental Control Intentional, counter-intentional results Intentional, counter-intentional results Operating process, conc. Promotes the intended result Operating process, conc. Promotes the intended result Monitoring process, unc. searches for unwanted outcomes Monitoring process, unc. searches for unwanted outcomes Wegner, Psychological Review,1994 Vol101,No1,34-52 Wegner, Psychological Review,1994 Vol101,No1,34-52

26 Ironic Process Performing what one is trying to avoid Performing what one is trying to avoid George wanted to avoid an air-ball George wanted to avoid an air-ball Wegner Wegner

27 Ironic Outcome Stress, and decreased cognitive capacity…monitoring may supersede and lead to least intended outcome Stress, and decreased cognitive capacity…monitoring may supersede and lead to least intended outcome Promotes weird outcome Promotes weird outcome Performer trying not to miss, misses Performer trying not to miss, misses

28 The Trying Modality Recruiting explicit memory interferes with implicit function Recruiting explicit memory interferes with implicit function “aiming” a baseball “aiming” a baseball “steering” a golf shot “steering” a golf shot “trying” to knock in a putt “trying” to knock in a putt

29 Choking Choking Did George choke? Did George choke? Acute performance failure under perceived stress Acute performance failure under perceived stress

30 Choking Reliance on explicit/conscious memory Reliance on explicit/conscious memory Loss of trust in unc. implicit motor functioning Loss of trust in unc. implicit motor functioning “Trying” “Trying” Loss of spontaneity Loss of spontaneity Mechanical Mechanical

31 Did George Panic? Did he stop thinking? Did he stop thinking? Focus on survival? Focus on survival? Example of Jean Van de Velde Example of Jean Van de Velde

32 Panic During Intense Competition Perceptual narrowing-the mind going blank, Perceptual narrowing-the mind going blank, The stress response, with concomitant impairment in explicit memory, may hinder one’s ability to think The stress response, with concomitant impairment in explicit memory, may hinder one’s ability to think Leaving the athlete to rely on instinct alone 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 When an athlete is exposed to excessive autonomic hyper-arousal and panics he turns to “instinct” and may temporarily lose ability to think critically

33 The “Yips”, Famous Examples Scott Hoch Scott Hoch Bernhard Langer Bernhard Langer Chuck Knoblauch, baseball, NY Yankees Chuck Knoblauch, baseball, NY Yankees Bane of the average golfer Bane of the average golfer

34 The YIPS Sudden contraction of a group of muscles interrupting a fluid well coordinated motion Sudden contraction of a group of muscles interrupting a fluid well coordinated motion Looks like a jerking or stabbing motion Looks like a jerking or stabbing motion Very difficult to control Very difficult to control Destroyed careers Destroyed careers Give up the sport Give up the sport

35 Yip Focal dystonia? Focal dystonia? Happens in those who have practiced a great amount Happens in those who have practiced a great amount Mink notes that basal ganglia are organized to facilitate voluntary movement and inhibit competing movements, Mink notes that basal ganglia are organized to facilitate voluntary movement and inhibit competing movements, Unconscious level of functioning Unconscious level of functioning Mink Mink

36 YIPS Stress causes release of glutamate….dopamine…. Disinhibit ion of competing motor programs Stress causes release of glutamate….dopamine…. Disinhibit ion of competing motor programs

37 Components of Pre-performance Routine Readying routine Readying routine Focus Focus Visualize the shot Visualize the shot Might focus on one relevant external cue or thought Might focus on one relevant external cue or thought

38 Self Paced Sports Free throws, golf, target shooting Free throws, golf, target shooting Dealing with down time, Dealing with down time, Pre-shot routine is necessary Pre-shot routine is necessary

39 High Level Competitive Athletes Most play to win Most play to win Survey of Olympic Athletes, Sports Illustrated Survey of Olympic Athletes, Sports Illustrated Androgen use Androgen use

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41 Philosophy of Competition Playing to win Playing to win Investment, meaning to the individual Investment, meaning to the individual Playing for ego purposes (a game within a game) Playing for ego purposes (a game within a game) Walker Walker

42 Instinct Trusting implicit unconsciously known motor skills Trusting implicit unconsciously known motor skills Bobby Jones Bobby Jones Ben Hogan Ben Hogan

43 Flow During a task-orientated activity During a task-orientated activity Loss of self-consciousness Loss of self-consciousness In the moment In the moment Altered perception of time Altered perception of time Sense of absorption Sense of absorption Sense of control and unity Sense of control and unity Csikszentmiahalyi Csikszentmiahalyi

44 George, Office Appointment Listen Listen Adequate time Adequate time Explore the event and past events Explore the event and past events

45 George, Office Visit Explore sense of self Explore sense of self What worked before What worked before Suggest when receptive Suggest when receptive Hope Hope End End

46 Resilient Athlete Resilient Athlete Positive Cognition Positive Cognition Reliance on implicitly known skills Reliance on implicitly known skills Good use of imagery Good use of imagery Sound Psychology of competition Sound Psychology of competition Plays to win Plays to win Confidence Confidence

47 Preparation for The Event Rested Rested Do what has worked before Do what has worked before Be prepared Be prepared

48 Dealing with Distractions Internal distractions Internal distractions External distractions External distractions In the bubble In the bubble

49 Treatment Cognitive Behavioral Therapy Cognitive Behavioral Therapy Action Commitment Therapy Action Commitment Therapy Pharmacotherapy Pharmacotherapy

50 Action Commitment Therapy Mindfulness Mindfulness Acceptance Acceptance Disidentification with thoughts, emotions Disidentification with thoughts, emotions Reinforcing a sense of self separate from momentary thoughts and feelings Reinforcing a sense of self separate from momentary thoughts and feelings Hayes,S. Folette,V. Linehan,M.

51 Mindfulness 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 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

52 Mindfulness Awareness Awareness Non-judgmental observation Non-judgmental observation Beginners mind Beginners mind In the moment In the moment Accept/let go Accept/let go

53 Decentering Mindfulness Based Cognitive Therapy Mindfulness Based Cognitive Therapy I am not my thoughts I am not my thoughts Thoughts are not facts Thoughts are not facts Segal,Teasdale,Williams from Mindfulness and Acceptance, Edited by Hayes, Follette, Linehan Segal,Teasdale,Williams from Mindfulness and Acceptance, Edited by Hayes, Follette, Linehan

54 Metacognitive Awareness A cognitive set in which neg thoughts and feelings are experienced as mental events rather than self A cognitive set in which neg thoughts and feelings are experienced as mental events rather than self This may decrease automatic responses This may decrease automatic responses A desensitization process, promotes exposure, tolerance A desensitization process, promotes exposure, tolerance

55 Acceptance Based Therapies Internal events are transient responses, rather than threatening and to be avoided Internal events are transient responses, rather than threatening and to be avoided Function of the problematic cognitions are most relevant Function of the problematic cognitions are most relevant Layers of function, Layers of function, Present moment includes the past, present and future (Blink) Present moment includes the past, present and future (Blink)

56 Pharmacotherapy SSRI’s SSRI’s Beta adrenergic blockers Beta adrenergic blockers Benzodiazepines Benzodiazepines

57 Summary Summary Performance Anxiety Performance Anxiety Acute Performance Failure Acute Performance Failure Theories: conscious/unc. Memory/motor Theories: conscious/unc. Memory/motor Psychology of competition Psychology of competition Language, e.g. “try”, “but” Language, e.g. “try”, “but” Mechanical/instinct Mechanical/instinct


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