Performance Anxiety

What is performance anxiety?

Performance anxiety is a specific type of social anxiety that occurs in relation to specific events. Exam-related anxiety, public speaking (glossophobia) and stage fright are all types of performance anxiety. Social anxiety disorder can be limited to performance anxiety, or in its most severe form, it can cause a person to feel anxious any time they are around others.

Is performance anxiety normal?

Most people will experience some level of social anxiety from time to time. This is perfectly normal when working outside your comfort zone. However, some people experience intense feelings of anxiety, which can interfere with their ability to function in stressful situations. This can then lead to avoidance, which can have negative consequences professionally, socially, and in terms of mental health. For people who experience symptoms related to performance anxiety, medications such as Propranolol, and psychotherapies like CBT (cognitive behavioral therapy) can be helpful to get the anxiety under control. 

Is performance anxiety common?

Performance anxiety is very common. Many people will feel nervous before going on stage, making a speech, or taking an exam. This is a natural human response to high-stress situations. Some people may experience severe symptoms of anxiety including panic attacks. This is less common, and medications or psychotherapies may benefit people in this group. 

Is social anxiety disorder a mental illness?

While anxiety can be a normal response to a stressful situation, it rises to the level of a clinical disorder when it is severe enough to interfere with activities of daily living.  People with social anxiety disorder may experience panic attacks and other physical symptoms of anxiety such as a rapid heart rate, profuse sweating, tremors, shaking, and nausea.  

How does social anxiety occur?

Social anxiety is caused by the body’s fight or flight response. When the fight or flight response kicks in, the body releases adrenaline. Evolutionarily, this may have occurred to help early humans fight off or escape from predators. Sometimes the body responds to other stressful situations, such as public speaking in the same way as it would to a life-threatening situation. The increased levels of adrenaline can cause shaking, a rapid heart rate, nausea, and profuse sweating, symptoms which are commonly associated with situational anxiety. 

What triggers social anxiety?

The triggers of social anxiety can vary from person-to-person. Common triggers include:

• Public speaking (glossophobia)
• Performing (stage fright) - this may include dancing, music or drama
• Exams or tests
• Job interviews
• Social events
• Being away from home
• Dealing with conflict
• Unfamiliar situations
• Sexual experiences

Who is most likely to experience performance anxiety?

It is not known why some people experience severe anxiety and others do not. However, there are are several factors that may be involved:

• Personality - People who are more introverted may be more likely to experience situational anxiety.
• Perfectionism - People who aim for perfection are likely to place greater pressure on themselves and their performance. This can make them feel that the risks of making a mistake are much greater than they actually are. 
• Parental pressure - Concerns about disappointing one’s parents may increase anxiety in certain situations such as exams or performing in front of parents. 
• Peer pressure - Peer pressure can come in different forms. Sometimes it can be related to a desire to ‘fit-in’, but it can also be related to concerns about disappointing one’s peers or not meeting their expectations. 
• Low self-esteem - Individuals with low self-esteem may be more likely to believe that they will not perform well in a certain situation. This can increase their anxiety levels. 
• Catastrophizing - People who catastrophize a situation, often feel that the situation is far worse than it actually is, or that an outcome will be much worse than is likely.  This increases the pressure on them to perform correctly in certain situations, which can influence their anxiety levels. 
• Difficulty processing stress - Some people seem better able to cope with stressful situations than others. People who have difficulty processing stressful emotions may be more likely to experience panic attacks as part of an anxiety disorder. 

What are the symptoms of performance anxiety?

Psychological symptoms may include:

• Nervousness
• Low-self esteem
• Worry or concern
• Irritability

Physical symptoms may include:

• Shaking or tremors
• Sweating
• Shaky voice
• Pounding heartbeat
• Rapid breathing
• Blushing
• Nausea

The physical symptoms of performance anxiety can exacerbate the psychological symptoms. Many people find that once the physical symptoms have been treated, they are better able to manage the psychological aspect. 
 

How is performance anxiety diagnosed?

While diagnostic criteria for social anxiety disorder can be found in the diagnostic and statistical manual, there are no official diagnostic criteria for performance anxiety.  If you experience moderate to severe anxiety with related symptoms, in response to a stressful situation, then you have performance anxiety and may benefit from treatment. 

Social anxiety vs general anxiety disorder

It is important to distinguish social anxiety from general anxiety as this affects treatment.  An individual with general anxiety disorder (GAD) is unlikely to benefit from treatment with Propranolol in the long term. The two conditions can certainly overlap, however, in the case of general anxiety disorder, treatment is normally handled by a mental health specialist.  An easy way to determine if you have general anxiety disorder, is by using a scale known as the GAD-7. If you score a 10 or higher on this scale, you should seek consultation with a mental health specialist and would likely benefit from a daily, long-acting medication. 

Social anxiety and panic attacks

Situational anxiety commonly leads to panic attacks. During a panic attack people often experience:

• A rapid or pounding heartbeat
• Sweating
• Nausea
• Chest pain
• Shortness of breath
• Hyperventilation (rapid breathing)
• Lightheadedness
• Tremors

These symptoms lead some people to believe that they are experiencing a heart attack or other illness, which can further exacerbate the symptoms. Not everyone who has situational anxiety will also have panic attacks. 
 

Social anxiety and depression

Both depression and anxiety commonly occur together and can be triggered by stressful life events. Anxiety can be a symptom of major depression and depression may occur as a result of an anxiety disorder. Therefore, similar treatments can be effective for both depression and anxiety. Antidepressants such as Sertraline and Citalopram may be prescribed alongside beta-blockers to help with situational anxiety and depression. Regular exercise, stress-reduction, and psychotherapies, such as cognitive behavioral therapy (CBT) can also be beneficial for both conditions. If you experience both situational anxiety and depression, you should let the prescribing doctor know so they can advise you on the most appropriate treatment. 

What is sexual performance anxiety?

The term ‘performance anxiety’ is sometimes used to refer to concerns surrounding sexual performance. This can be a factor in conditions such as premature ejaculation and erectile dysfunction (ED). The anxiety may be related to worries about pregnancy, sexual health, satisfying a partner, or simply maintaining an erection. 

One of the main challenges of sexual performance anxiety is that it can often create a negative cycle: The anxiety can affect sexual performance, which increases the anxiety levels for the next sexual encounter. Psychotherapy, sex therapy, or medications such as sildenafil for erectile dysfunction or sertraline for premature ejaculation, may be beneficial in this case.  Propranolol is in a class of medications known as beta blockers which can cause transient erectile dysfunction  It is therefore not prescribed for sexual performance anxiety. 
 

Performance anxiety treatment

Beta blockers are often prescribed to treat the physical symptoms of anxiety, such as a rapid or pounding heart rate, nausea and shaking. Reducing the physical symptoms of anxiety can help to reduce anxiety to more manageable levels.

How to manage social anxiety without medication

There are several ways to reduce anxiety without medication. These include:

• Exercise - Regular exercise has been proven to benefit people with anxiety. When you exercise, your body releases feel-good chemicals known as endorphins, which can help to reduce anxiety.
• CBT -  Cognitive behavioral therapy (CBT) is a popular type of psychotherapy. It works by giving you techniques to modify your behavior and thought patterns. Making these changes can influence your thoughts and feelings and reduce your anxiety. 
• Mindfulness - Mindfulness is a psychological exercise in which you focus on being present in the moment. This can help people with social anxiety as it helps you avoid worrying about the future and allows you to direct your attention towards your current situation instead. 

Other psychotherapies and techniques can also be beneficial, but it may take some time to find out what works well for you. 

Will social anxiety go away?

Social anxiety can vary from person-to-person. Some people find that social anxiety goes away as they get used to a situation. Medications such as Propranolol can help this process. Alternatively, some people find social anxiety can be more persistent, for example, they may always feel nervous during exams. In both cases, medications and psychotherapy can be effective treatment methods.