Performance Anxiety Performance Anxiety Terrence Clark, MD Terrence Clark, MD Associate Clinical Professor Associate Clinical Professor Dept. of Psychiatry and Behavioral Dept. of Psychiatry and Behavioral Sciences Sciences Grand Rounds, Department of Psychiatry Grand Rounds, Department of Psychiatry and Behavioral Sciences, James H. and Behavioral Sciences, James H. Quillen College of Medicine Quillen College of Medicine April 5, 2013 April 5, 2013
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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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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
• 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
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
• 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
• 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
• 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
• 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)