Performance anxiety is defined as an unpleasant psychological state in response to a perceived threat concerning the performance of a task or event, under pressure (Cheng et al. 2009). Additionally, performance anxiety may involve the concern of being perceived and evaluated negatively by others (Hook et al. 2013). This construct shows different dimensions, such as a social dimension (e.g., social judgment), a cognitive dimension (e.g., worry, self-focused attention), a physiological dimension (e.g., autonomous arousal, somatic tension), and a regulatory dimension (e.g., perceived control) (Cheng et al. 2009).
In an alternative perspective, performance anxiety consists of behavioral, cognitive, and physiological symptoms and signs that may precede or accompany a performance and that seem out of proportion to the specific situation. Some degree of performance anxiety is common, if not universal, but disabling symptoms may indicate the need of professional intervention (Lederman 1999).
Performance anxiety is one form of anxiety and shows an impact on different domains of functioning, including cognitive, social, motor, and sexual performance (Koeck 2018). A systematic literature review indicated that the prevalence of anxiety disorders ranges from 1.2% to 28%, in older samples (Bryant et al. 2008). Although data is scarce, performance anxiety is a common condition, affecting up to 70% of the population worldwide (Bourne 2011). Performance anxiety may be experienced by older adults in social situations, in their quality of life and show implications, such as difficulties in carrying daily routine tasks and maintaining significant social relations (National Collaborating Center for Mental Health 2013).
Key Research Findings
Recent literature indicated a positive relationship between Performance anxiety and cognitive decline (Eysenck et al. 2007). Aging may imply neurodegenerative cognitive conditions and deficits in social cognition, complex cognition, executive functions, episodic memory performance, immediate- and short-delay recall, and long-delay recall (de Vito et al. 2017). Functional decline may be a result of increased fragility, which exacerbates restricted mobility. Aging also leads to difficulties in spatial navigation and mobility difficulties, which may lead to performance anxiety in old age (Sheardova et al. 2015). Physical frailty and dependence on others may cause performance anxiety while performing activity tasks (Mehta et al. 2007). In a different perspective, anxiety and depression also showed a serious impact on the physical performance of older adults (Mehta et al. 2007).
Performance anxiety may be related to the fear of failure and a loss of sexual self-confidence. In this context, performance anxiety is related to the behavior of spectatoring (Kirana and Porst 2013), which means that during sexual contact the man’s focus is on mentally monitoring his performance (or lack of) rather than on pleasure and sexual cues: this detracts attention from the pleasurable aspects of sexual activity, making it difficult to achieve and maintain arousal. From a physiological perspective, anxiety or stress can stimulate the production of norepinephrine/epinephrine, which has an inhibitory impact on sexual arousal (Minhas and Mulhall 2017). Sexual performance anxiety is reported by older adults, mainly due to sexual complications, such as erectile dysfunctions or diminished sexual satisfaction. Indeed, sexual performance is greatly influenced by psychological factors, such as performance anxiety, with a high impact on older adults’ well-being (Laumann and Waite 2008). Performance anxiety is negatively correlated with flow, since older individuals have the ability to lose feelings of self-consciousness during a state of flow. Additionally, it was found that there was a moderately strong positive correlation between neuroticism and performance anxiety in old age (Hook et al. 2013).
Brutto and his colleagues (2015) studied the relationship between cognitive status and performance anxiety of older adults. The study evaluated self-reported symptoms of depression, anxiety, and stress of older adults living in an underserved rural South American population. Community-dwelling Atahualpa older adults were evaluated with the Depression Anxiety Stress Scale-21 (DASS-21) and the Montreal Cognitive Assessment (MoCA). MoCA scores were significantly lower for depressed than for not depressed individuals. Depressed older participants had significantly lower total and domain-specific MoCA scores for abstraction, short-term memory and orientation. Anxiety was related to significantly lower total MoCA scores but not to differences in domain-specific MoCA scores. Stress was not associated with significant differences in MoCA scores. The present study suggests that depression and anxiety are associated with poorer performance in older residents living in rural areas of developing countries (Brutto et al. 2015).
Moreover, anxiety, namely performance anxiety and depression are both important correlates of cognitive function among older adults. However, longitudinal studies investigating how they covary with cognition within the same individual are scarce. Laukka and his colleagues (2018) aimed to simultaneously estimate associations of between-person differences and within-person variability in anxiety and depression with cognitive performance in a sample of non-demented older people. For performance anxiety, between-person differences were more influential; people who scored higher on anxiety relative to other same-aged individuals demonstrated poorer cognitive performance on average. The results from this study highlighted the importance of addressing both between- and within-person effects of negative mood and suggest that anxiety and depression affect cognitive function in different ways among older adults (Laukka et al. 2018).
Furthermore older adults with performance anxiety or depression experience additional memory dysfunctions beyond that of the normal aging process. However, few studies have examined test bias in memory assessments due to anxiety performance or depressive symptoms. Williams and his colleagues (2017) studied the impact of self-reported symptoms of anxiety performance and depression on the measurement equivalence of memory tests in older adults.
Anxious but not depressive symptoms introduce test bias into the measurement of memory in older adults. This indicates that memory models for research and clinical purposes should account for the direct relationship between anxiety performance symptoms and memory tests (Williams et al. 2017).
In a study by Lukasik and his colleagues (2019), results indicated that working memory performance can be sensitive to stress- or anxiety-related interference. These effects have been studied in clinical and older adult populations. However, less is known about the effects of stress and anxiety on working memory in non-depressed adult populations. This lack of research is relevant, given the increasing prevalence of stress in a working age population (Dowker et al. 2016; Wiegner et al. 2015). Experiencing stress and feelings of anxiety are common in healthy populations, but we know very little about how these mental states are associated with cognitive performance. Previous studies are also hampered by the fact that they have used only single working memory measures (e.g., Moran 2016). The results of this study showed a trend toward a negative association between transient anxiety and working memory performance. Hence, working memory performance seems to be rather robust against normal variation in everyday stress and anxiety (Lukasik et al. 2019).
Previously literature has shown that motor performance following perceptual-training strategies that encourage explicit processing (compared to guided-discovery approaches that do not) is more susceptible to negative effects of performance anxiety among older populations (Masters and Maxwell (2008). Conversely, it is argued that phylogenic skills (e.g., controlling posture) have been learned early in childhood in the relative absence of explicit declarative information. As such, with phylogenic skills, it is not possible to revert back to earlier cognitive stages of learning. Therefore, when describing anxiety-related alterations in attempts to consciously control these movements, it is perhaps inappropriate to refer to the concept of reinvestment, but rather as an internal focus of attention (Young and Williams 2015).
Medical treatment is aimed primarily at the physiological manifestations of performance anxiety, which represent increased sympathetic nervous system activity. While many approaches have been utilized with older adults, beta-adrenergic blocking agents are very effective in counteracting the often debilitating tachycardia, sweating, and tremor that may accompany this disorder. A number of studies have demonstrated the effectiveness of this approach as well as its relative safety. The medication should be prescribed by a professional after an adequate assessment and discussion of potential risks and benefits (Lederman 1999). Beta-blockers relieve the autonomic symptoms of performance anxiety among older adults and may be beneficial in performance anxiety, but knowledge on related psychiatric outcomes is unknown (Butt et al. 2017). Beta-blockers inhibit the binding of catecholamines (e.g., epinephrine) to beta-adrenergic receptors. Propranolol or atenolol, among others, has been prescribed off-label for decades to suppress the cardiovascular symptoms of acute anxiety, for instance, tachycardia and palpitations in performance anxiety. However, a beta-blocker alone does not address the CNS and other non-cardiovascular symptoms (Thomas et al. 2017). Moreover, atenolol has been shown to be beneficial in performance anxiety, alcohol withdrawal, and flight phobia (Gottlieb et al. 1994), and scopolamine has been known for producing a calming effect in psychiatric older patients (Thomas et al. 2017; Witkin et al. 2014).
Future Research Directions
In previous studies with Individual Cognitive Therapy (ICT) among older adults, results indicated significantly lower frequencies of safety behaviors and negative social thoughts. It was concluded that ICT could be an effective course of treatment for older adults with performance anxiety. Further research and therapy interventions are necessary in old age (Clason et al. 2015).
The combination of medication and psychotherapy has proved to be effective in the treatment of performance anxiety symptoms (Hyer 2013). A review of the evidence-based therapy for anxiety symptoms, indicated four types of therapies effective concerning performance anxiety, including relaxation training, cognitive behavioral therapy, supportive therapy, and cognitive therapy (Ayers et al. 2007). Literature has also demonstrated that antidepressants are highly efficacious in the treatment of performance anxiety (Crocco et al. 2017). Additionally, the challenge of identifying older individuals who experience performance anxiety is relevant for implementing adequate interventions aimed on reducing performance anxiety (Hook et al. 2013).
Up to date, few studies have applied massive multiplayer online role-playing games (MMORPGs) to provide psychological and behavioral help. However, performance anxiety, intimacy anxiety, and observation anxiety significantly decreased quality of life in old age. Older participants showed less anxiety and improved social relationships after moderately playing MMORPGs; hence more research is needed in this area (Ho et al. 2015).
Further computerized cognitive interventions have been increasingly used in order to allow for an individualized experience and for a focus on areas that need further improvement (Kueider et al. 2012). Literature suggests that anxiety does affect the performance of older adults in multiple aspects, thus impairing the overall functionality and social support of these individuals. Supporting literature is scarce and this condition needs to be explored in depth. Further research is needed to support these findings along with effective interventions among older adults (de Vito et al. 2017).
- Bourne EJ (2011) The anxiety and phobia workbook. New Harbinger Publications, OaklandGoogle Scholar
- Clason J, Johansson F, Mörtberg E (2015) Individual cognitive therapy for professional actors with performance anxiety. Ann Depress Anxiety 2(6). http://www.diva-portal.org/smash/record.jsf?pid=diva2%3A882766&dswid=-4546. Accessed 1 Jan 2019
- Del Brutto OH, Mera RM, Del Brutto VJ et al (2015) Influence of depression, anxiety and stress on cognitive performance in community-dwelling older adults living in rural Ecuador: results of the Atahualpa Project. Geriatr Gerontol Int 15(4):508–514. https://doi.org/10.1111/ggi.12305CrossRefGoogle Scholar
- Hyer L (2013) Psychological treatment of older adults: a holistic model. Springer Publishing Company, New YorkGoogle Scholar
- Kirana PS, Porst H (2013) Erectile dysfunction. In: Kirana PS, Tripoldi R, Reisman Y, Porst H (eds) The EFs e ESSM syllabus of clinical sexolagy, Amsterdam, pp Medix 596–Medix 635. https://www.essm.org/filestore/Bilder/user_upload/pdf/syllabus/ECPS_Syllabus_-_Index.pdf. Accessed 1 Jan 2019
- Koeck P (2018) Performance anxiety. https://www.15minutes4me.com/anxiety/performance-anxiety/. Accessed 1 Jan 2019
- Lederman RJ (1999) Medical treatment of performance anxiety. Anxiety 1(2). https://www.sciandmed.com/mppa/journalviewer.aspx?issue=1095&article=1047. Accessed 1 Jan 2019
- Lukasik KM, Waris O, Soveri A et al (2019) The relationship of anxiety and stress with working memory performance in a large non-depressed sample. Front Psychol 10. https://doi.org/10.3389/fpsyg.2019.00004
- Mehta RL, Kellum JA, Shah SV et al. (2007) Acute kidney injury network: Report of an initiative to improve outcomes in acute kidney injury. Crit Care 11(2):R31. https://doi.org/10.1186/cc571310.1186/cc5713
- National Collaborating Centre for Mental Health (2013) Social anxiety disorder: recognition, assessment and treatment. British Psychological Society, LeicesterGoogle Scholar
- Thomas T, Benjamin AB, Dooley TP (2017) Treatment of acute anxiety episodes in patients using a fast-acting beta blocker–scopolamine combination drug. Ann Depress Anxiety 4(2):1088. https://www.researchgate.net/profile/Thomas_Dooley/publication/321197778_Treatment_of_Acute_Anxiety_Episodes_in_Patients_Using_a_Fast-Acting_Beta_Blocker_-_Scopolamine_Combination_Drug/links/5a1485a70f7e9b925cd51297/Treatment-of-Acute-Anxiety-Episodes-in-Patients-Using-a-Fast-Acting-Beta-Blocker-Scopolamine-Combination-Drug.pdf. Accessed 1 Jan 2019Google Scholar
- Wiegner L, Hange D, Björkelund C et al (2015) Prevalence of perceived stress and associations to symptoms of exhaustion, depression and anxiety in a working age population seeking primary care-an observational study. BMC Fam Pract 16:38. https://doi.org/10.1186/s12875-015-0252-7CrossRefGoogle Scholar