Performance AnxietyPerformance Anxiety

Terrence Clark, MDTerrence Clark, MD

Associate Clinical ProfessorAssociate Clinical Professor

Dept. of Psychiatry and Behavioral SciencesDept. of Psychiatry and Behavioral Sciences

Grand Rounds, Department of Psychiatry Grand Rounds, Department of Psychiatry and Behavioral Sciences, James H. Quillen and Behavioral Sciences, James H. Quillen College of MedicineCollege of Medicine

April 5, 2013April 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 Acute Performance Failure due to Anxietydue to Anxiety

• Suboptimal performance under Suboptimal performance under stress stress

Walking the PlankWalking the Plank

EffortlessEffortless

Danger invites conscious tryingDanger invites conscious trying

Types of Performance Types of Performance AnxietyAnxiety

• Public Speaking- 20 % excessive fearPublic Speaking- 20 % excessive fear

• Math AnxietyMath Anxiety

• High Stakes ExamsHigh Stakes Exams

• AthleticsAthletics

Anxiety Anxiety

•Anxiety, “get over it, be strong, face Anxiety, “get over it, be strong, face it.”it.”

•Fight itFight it

•Strength of OCD, panic attacks, Strength of OCD, panic attacks, performance failureperformance failure

Performance AnxietyPerformance Anxiety

• SufferingSuffering

• Impaired functioningImpaired functioning

Performance AnxietyPerformance Anxiety

• PhenomenologyPhenomenology

• TheoryTheory

• Interventions:Interventions:

Psychological – emphasis in Psychological – emphasis in presentationpresentation

Psychopharmological-brieflyPsychopharmological-briefly

Emphasis on AthleticsEmphasis on Athletics

• Applicable to other settings as well Applicable to other settings as well as a gameas a game

• Games as metaphorGames as metaphor

• Use of games in therapy, core issuesUse of games in therapy, core issues

AthleticsAthletics

• Infamous examples:Infamous examples:

• Greg Norman, 1996 MastersGreg Norman, 1996 Masters

• Jana Novatna Wimbledon, 1993Jana Novatna Wimbledon, 1993

• Foul shot in last seconds of Foul shot in last seconds of basketball basketball

• Team going flat Team going flat

• Average athletes, every day Average athletes, every day

The Game on the LineThe Game on the Line

• GeorgeGeorge

• Foul shots to tie or winFoul shots to tie or win

• Sweaty palmsSweaty palms

• Memory of past failureMemory of past failure

• Self talk, a good try Self talk, a good try

The Game on the LineThe Game on the Line

• Vision of air-ballVision of air-ball

• Thoughts, meaning, doubt, stakesThoughts, meaning, doubt, stakes

• Sense of self/identitySense of self/identity

• RoutineRoutine

Air-ballAir-ball

• What happened?What happened?

• How?How?

• Why?Why?

• What could George do differently?What could George do differently?

George’s ChallengeGeorge’s Challenge

• How does he manage the cognitive How does he manage the cognitive and physical aspects that emerge in and physical aspects that emerge in competition?competition?

• How does he optimize his chance of How does he optimize his chance of successful performance?successful performance?

Components for George to Components for George to ConsiderConsider

• Pre-performance routinePre-performance routine

• Managing thoughtsManaging thoughts

• Managing air-ball visionManaging air-ball vision

• His psychology of competition/lifeHis psychology of competition/life

• Language, self talkLanguage, self talk

• Accessing instinctAccessing instinct

StrategiesStrategies

• Denial, suppressionDenial, suppression

• Resilient from experienceResilient from experience

• Acceptance, acknowledge such can Acceptance, acknowledge such can happenhappen

• Multi-faceted sense of self Multi-faceted sense of self

• Dis-identification with thoughts, Dis-identification with thoughts, actionsactions

StrategiesStrategies

• Awareness of trying modalityAwareness of trying modality

Star Wars, NikeStar Wars, Nike

• Ways of accessing instinctWays of accessing instinct

• Self-talk, unc knows no negativeSelf-talk, unc knows no negative

• “ “and” vs. “but”and” vs. “but”

• Recall of prior successRecall of prior success

Acute Performance FailureAcute Performance Failure

There appear to be at least three distinct,There appear to be at least three distinct, yet sometimes overlapping, entities that yet sometimes overlapping, entities that

produce acute performance failure:produce acute performance failure:

• Panicking Panicking

• ChokingChoking

• ““Yips”Yips”

DoubtDoubt

• High likelihood of impairing High likelihood of impairing performanceperformance

• Erodes confidenceErodes confidence

• CascadesCascades

Two Types of Two Types of Learning/MemoryLearning/Memory• . Explicit (declarative) memory . Explicit (declarative) memory

governs the recollection of governs the recollection of facts, facts, events, and associations.events, and associations.

• Implicit memory deals with Implicit memory deals with proceduralprocedural memory that does not require memory that does not require conscious awareness; for example, one conscious awareness; for example, one is able to recall how to ride a bicycle or is able to recall how to ride a bicycle or play the piano after many years of not play the piano after many years of not performing either function performing either function

Explicit MemoryExplicit Memory

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

• When an individual experiences severe When an individual experiences severe stress, there is secretion of epinephrine and stress, there is secretion of epinephrine and glucocorticoids. glucocorticoids.

• Severe stress responses can harm and, over Severe stress responses can harm and, over time, produce atrophy of the hippocampus, time, produce atrophy of the hippocampus, preventing consolidation or retrieval of preventing consolidation or retrieval of conscious explicit memory . The individual conscious explicit memory . The individual often experiences this as going blankoften experiences this as going blank

MemoryMemory

• Some emotional memories can be Some emotional memories can be reawakened without requirement of reawakened without requirement of consciousnessconsciousness

• Conventional or declarative Conventional or declarative memories, more conscious, stored in memories, more conscious, stored in adjacent hippocampusadjacent hippocampus

Neurological UnderpinningsNeurological Underpinnings

• Hippocampus – Explicit memoryHippocampus – Explicit memory

• Amygdala and associated areas in Amygdala and associated areas in basal ganglia – Implicit basal ganglia – Implicit memory/learningmemory/learning

Theory of Ironic Processes Theory of Ironic Processes of Mental Controlof Mental Control• Intentional, counter-intentional resultsIntentional, counter-intentional results

• Operating process, conc. Promotes the Operating process, conc. Promotes the intended resultintended result

• Monitoring process, unc. searches for Monitoring process, unc. searches for unwanted outcomesunwanted outcomes

• Wegner, Psychological Review,1994 Vol101,No1,34-52Wegner, Psychological Review,1994 Vol101,No1,34-52

Ironic ProcessIronic Process

• Performing what one is trying to Performing what one is trying to avoid avoid

• George wanted to avoid an air-ballGeorge wanted to avoid an air-ball

WegnerWegner

Ironic OutcomeIronic Outcome

• Stress, and decreased cognitive Stress, and decreased cognitive capacity…monitoring may supersede capacity…monitoring may supersede and lead to least intended outcomeand lead to least intended outcome

• Promotes weird outcomePromotes weird outcome

• Performer trying not to miss, missesPerformer trying not to miss, misses

The Trying ModalityThe Trying Modality

• Recruiting explicit memory interferes Recruiting explicit memory interferes with implicit function with implicit function

“ “aiming” a baseballaiming” a baseball

“ “steering” a golf shotsteering” a golf shot

“ “trying” to knock in a putttrying” to knock in a putt

ChokingChoking

Did George choke?Did George choke?

Acute performance failure under Acute performance failure under perceived stress perceived stress

ChokingChoking

• Reliance on explicit/conscious Reliance on explicit/conscious memorymemory

• Loss of trust in unc. implicit motor Loss of trust in unc. implicit motor functioningfunctioning

• ““Trying”Trying”

• Loss of spontaneityLoss of spontaneity

• Mechanical Mechanical

Did George Panic?Did George Panic?

• Did he stop thinking?Did he stop thinking?

• Focus on survival?Focus on survival?

• Example of Jean Van de VeldeExample of Jean Van de Velde

Panic During Panic During Intense CompetitionIntense Competition

• Perceptual narrowing-the mind going blank, Perceptual narrowing-the mind going blank,

• The stress response, with concomitant The stress response, with concomitant impairment in explicit memory, may hinder impairment in explicit memory, may hinder one’s ability to thinkone’s ability to think

• Leaving the athlete to rely on instinct aloneLeaving the athlete to rely on instinct alone

• When an athlete is exposed to excessive When an athlete is exposed to excessive autonomic hyper-arousal and panics he autonomic hyper-arousal and panics he turns to “instinct” and may temporarily turns to “instinct” and may temporarily lose ability to think criticallylose ability to think critically

The “Yips”, Famous The “Yips”, Famous ExamplesExamples• Scott HochScott Hoch

• Bernhard LangerBernhard Langer

• Chuck Knoblauch, baseball, NY YankeesChuck Knoblauch, baseball, NY Yankees

• Bane of the average golferBane of the average golfer

The YIPSThe YIPS

• Sudden contraction of a group of Sudden contraction of a group of muscles interrupting a fluid well muscles interrupting a fluid well coordinated motioncoordinated motion

• Looks like a jerking or stabbing motionLooks like a jerking or stabbing motion

• Very difficult to controlVery difficult to control

• Destroyed careersDestroyed careers

• Give up the sportGive up the sport

YipYip

• Focal dystonia?Focal dystonia?

• Happens in those who have practiced a Happens in those who have practiced a great amountgreat amount

• Mink notes that basal ganglia are Mink notes that basal ganglia are organized to facilitate voluntary movement organized to facilitate voluntary movement and inhibit competing movements, and inhibit competing movements,

• Unconscious level of functioningUnconscious level of functioning

MinkMink

YIPSYIPS

• Stress causes release of Stress causes release of glutamate….dopamine…. Disinhibit glutamate….dopamine…. Disinhibit ion of competing motor programsion of competing motor programs

Components of Pre-Components of Pre-performance Routineperformance Routine

• Readying routineReadying routine

• FocusFocus

• Visualize the shotVisualize the shot

• Might focus on one relevant external Might focus on one relevant external cue or thought cue or thought

Self Paced SportsSelf Paced Sports

• Free throws, golf, target shootingFree throws, golf, target shooting

• Dealing with down time, Dealing with down time,

• Pre-shot routine is necessaryPre-shot routine is necessary

High Level High Level Competitive AthletesCompetitive Athletes

• Most play to winMost play to win

• Survey of Olympic Athletes, Sports Survey of Olympic Athletes, Sports IllustratedIllustrated

• Androgen useAndrogen use

Philosophy of CompetitionPhilosophy of Competition

• Playing to winPlaying to win

• Investment, meaning to the individualInvestment, meaning to the individual

• Playing for ego purposes (a game Playing for ego purposes (a game within a game)within a game)

Walker Walker

InstinctInstinct

• Trusting implicit unconsciously Trusting implicit unconsciously known motor skillsknown motor skills

• Bobby Jones Bobby Jones

• Ben HoganBen Hogan

FlowFlow

• During a task-orientated activity During a task-orientated activity

• Loss of self-consciousnessLoss of self-consciousness

• In the momentIn the moment

• Altered perception of time Altered perception of time

• Sense of absorptionSense of absorption

• Sense of control and unitySense of control and unity

Csikszentmiahalyi Csikszentmiahalyi

George, Office AppointmentGeorge, Office Appointment

• ListenListen

• Adequate timeAdequate time

• Explore the event and past eventsExplore the event and past events

George, Office VisitGeorge, Office Visit

• Explore sense of selfExplore sense of self

• What worked beforeWhat worked before

• Suggest when receptiveSuggest when receptive

• HopeHope

• EndEnd

Resilient AthleteResilient Athlete

• Positive CognitionPositive Cognition

• Reliance on implicitly known skillsReliance on implicitly known skills

• Good use of imageryGood use of imagery

• Sound Psychology of competitionSound Psychology of competition

• Plays to win Plays to win

• ConfidenceConfidence

Preparation for The EventPreparation for The Event

• RestedRested

• Do what has worked beforeDo what has worked before

• Be preparedBe prepared

Dealing with DistractionsDealing with Distractions

• Internal distractionsInternal distractions

• External distractionsExternal distractions

• In the bubbleIn the bubble

TreatmentTreatment

• Cognitive Behavioral TherapyCognitive Behavioral Therapy

• Action Commitment TherapyAction Commitment Therapy

• PharmacotherapyPharmacotherapy

Action Commitment Action Commitment TherapyTherapy• MindfulnessMindfulness

• AcceptanceAcceptance

• Disidentification with thoughts, emotionsDisidentification with thoughts, emotions

• Reinforcing a sense of self separate from Reinforcing a sense of self separate from momentary thoughts and feelings momentary thoughts and feelings

Hayes,S. Folette,V. Linehan,M. Hayes,S. Folette,V. Linehan,M.

MindfulnessMindfulness

• A process of moving towards a state A process of moving towards a state in which one is fully observant of in which one is fully observant of external and internal stimuli, in external and internal stimuli, in present moment, open to accepting, present moment, open to accepting, exposure to previously avoided exposure to previously avoided stimuli, inc. self observationstimuli, inc. self observation

MindfulnessMindfulness

• AwarenessAwareness

• Non-judgmental observationNon-judgmental observation

• Beginners mindBeginners mind

• In the momentIn the moment

• Accept/let goAccept/let go

DecenteringDecentering

• Mindfulness Based Cognitive Therapy Mindfulness Based Cognitive Therapy

• I am not my thoughtsI am not my thoughts

• Thoughts are not factsThoughts are not facts

• Segal,Teasdale,Williams from Mindfulness and Acceptance, Segal,Teasdale,Williams from Mindfulness and Acceptance, Edited by Hayes, Follette, LinehanEdited by Hayes, Follette, Linehan

Metacognitive AwarenessMetacognitive Awareness

• A cognitive set in which neg thoughts A cognitive set in which neg thoughts and feelings are experienced as and feelings are experienced as mental events rather than selfmental events rather than self

• This may decrease automatic This may decrease automatic responsesresponses

• A desensitization process, promotes A desensitization process, promotes exposure, toleranceexposure, tolerance

Acceptance Based Acceptance Based TherapiesTherapies• Internal events are transient Internal events are transient

responses, rather than threatening responses, rather than threatening and to be avoidedand to be avoided

• Function of the problematic cognitions Function of the problematic cognitions are most relevantare most relevant

• Layers of function, Layers of function,

• Present moment includes the past, Present moment includes the past, present and future (Blink)present and future (Blink)

PharmacotherapyPharmacotherapy

• SSRI’sSSRI’s

• Beta adrenergic blockersBeta adrenergic blockers

• BenzodiazepinesBenzodiazepines

SummarySummary

• Performance AnxietyPerformance Anxiety

• Acute Performance FailureAcute Performance Failure

• Theories: conscious/unc. Theories: conscious/unc. Memory/motorMemory/motor

• Psychology of competitionPsychology of competition

• Language, e.g. “try”, “but”Language, e.g. “try”, “but”

• Mechanical/instinctMechanical/instinct