case study on exam anxiety

Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

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A Qualitative Inquiry of University Student’s Experiences of Exam Stress and Its Effect on Their Academic Performance

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• Published: 05 April 2022

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• Iqbal Ahmad 1 ,
• Rani Gul   ORCID: orcid.org/0000-0003-1951-3351 1 &
• Murtaza Zeb 1  

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Exam stress is a common phenomenon worldwide. It has been reported to have negative effects on academic performance of students. Although many studies have reported on prevalence of exam-related stress among students, however, there is less understanding on the perspectives of rural university graduates. Through this study, we explore the perspectives of university graduates on exam anxiety and stress, its major causes, and its effects on their academic performance. A qualitative case study approach was used to investigate the problem at the University of Malakand, Chakdara, Pakistan. For data collection, we interviewed 12 final-year students of B.Ed course of teacher education programs who self-reported about their condition of exam stress and anxiety and its effect on their academic performance. Based on individual interviews, the students described their exam-related stress and its effects. The results of the study were presented thematically and categorized as (a) study pressure, (b) managing time, (c) teacher behavior, (d) sense of competition, and (e) study material. Discussion and implications based on the findings of the study are also included.

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Ahmad, I., Gul, R. & Zeb, M. A Qualitative Inquiry of University Student’s Experiences of Exam Stress and Its Effect on Their Academic Performance. Hu Arenas (2022). https://doi.org/10.1007/s42087-022-00285-8

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Factors affecting test anxiety: a qualitative analysis of medical students’ views

• Majed Wadi 1 , 2 ,
• Muhamad Saiful Bahri Yusoff 2 ,
• Ahmad Fuad Abdul Rahim 2 &
• Nik Ahmad Zuky Nik Lah 3  

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Medical students are vulnerable to test anxiety (TA), which impacts their professional lives and jeopardizes the optimal health care of their patients. The qualitative exploration of TA among medical students is crucial to understanding the problem. Hence, this study examined medical students’ insights into TA and their suggestions on how to reduce it.

We conducted a phenomenological study on medical students at a public university. We utilized focus group discussions (FGDs) to investigate their experiences of TA. The FGDs were transcribed verbatim, and these transcripts were analyzed using Atlas.ti software. The thematic analysis followed the recommended guidelines.

Seven FGD sessions were conducted with 45 students. Three major themes emerged: the students, their academic resources, and the examiner. Each theme comprised mutually exclusive subthemes. The “students” theme was divided into negative vs. positive thoughts and self-negligence vs. self-care, “academic recources” into heavy curriculum vs. facilitative curricular aids, and “examiner” into criticism vs. feedback and strict vs. kind approaches.

This study provides a solid foundation for policymakers and decision makers in medical education to improve current assessment practices and student well-being. Medical students will be able to significantly alter and reduce TA if they are provided with additional psychological support and their examiners are trained on how to deal with examinees.

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Introduction

Test anxiety (TA) is integral to assessments. It ranges from simple worry to debilitating anxiety, which interferes with the cognitive process. Although a low level of TA can motivate students to study and prepare for assessment, an extreme level of TA alters their physiological functions, psychological status, or both. These changes impair concentration, interrupt working memory, and hinder academic achievement. Crucially, TA may result in chronic stress, which is associated with many adverse effects on wellbeing. These include burnout, depression, poor academic performance, poor clinical performance, impaired decision making, poor peer interaction, interpersonal conflict, academic dishonesty, and sleeping problems [ 1 , 2 ]. Furthermore, chronic stress is linked to substance abuse, alcohol consumption, and suicide [ 3 , 4 , 5 , 6 ].

TA has a significant effect on health professions’ students. In a meta-analysis, Quek, Tam [ 7 ] reported that 33.8% of medical students experience anxiety. Likewise, Macauley, Plummer [ 8 ] determined that 51% of female and 37.5% of male health care students have moderate to high TA. Several quantitative studies have explored the causative factors of TA among medical students. These factors included expansive curricular content [ 9 , 10 , 11 , 12 ], inappropriate study skills [ 9 , 10 , 11 , 12 ], difficult test formats (objective structured clinical examination [OSCE] in particular), negative thoughts [ 10 ], and female gender [ 9 , 10 , 12 ]. However, the few qualitative studies that have examined TA among medical students are limited in scope. For instance, Encandela et al. [ 13 ] assessed TA following the implementation of a United States Medical Licensing Examination (USMLE) preparation course, whereas Shen et al. [ 14 ] explored whether the introduction of expressive writing can reduce TA.

Qualitative research yields detailed insights, sheds light on the dynamics of various relationships, and generates themes and thus theoretical foundations for future research [ 15 ]. Therefore, the qualitative investigation of medical students’ TA is essential to understanding its implications. Such studies can clarify how to remodel TA and create a platform for early intervention into and improvement of medical students’ well-being. Hence, this qualitative study explored medical students’ thoughts on TA and what they believed should be done to reduce it.

This study employed a phenomenological approach to analyze the factors affecting TA from the perspectives of medical students. Data were collected using seven focus group discussions (FGDs) with a total of 45 medical students from the School of Medical Sciences, Universiti Sains Malaysia (USM). The study was approved by the Institutional Human Research Ethics Committee at USM, and all students were asked to sign a consent form upon their agreement to participate in this study. The researchers emphasized confidentiality, anonymity, and the right to withdraw at the start of each session. To maintain the participants’ confidentiality, we assigned a pseudonym to each one.

Participants, sampling, and recruitment

We selected groups of five to seven medical students from different academic years because we expected their experiences of stress and anxiety to differ accordingly [ 16 ]. We applied purposive sampling with consideration for student variety to obtain a wide range of experiences. Moreover, we intended to represent factors such as gender and race (e.g., Malay, Chinese, Indian, or other). We gave invitation letters to the group leaders of each academic year. We also used WhatsApp to disseminate information about the study and its consent forms. In addition, we assigned a token to each participant after their session.

Data collection

We piloted the FGD protocol with a group of students, and they reported that it was open-ended and stimulated discussion. Next, the FGD sessions were conducted in a quiet and comfortable room. We began each session by welcoming the group members and briefing them on the study’s purpose. Based on the predetermined probe questions, we initiated the audiotaped discussion with an open-ended cue: “Test anxiety to me is…”. We made notes to reflect non-verbal cues. Each FGD ended after 60 to 90 min. Data collection continued until theoretical saturation was reached, which occurred when no new information appeared [ 17 ]. We conducted all the FGD sessions in March 2019.

Data analysis

We started data analysis concurrently with data collection. This interim analysis helped us adjust and check the emerging themes alongside the consequent data.

We followed Braun and Clark’s six-phase thematic analysis [ 18 ]. In the first phase (familiarization with the data), the researcher (MW) transcribed the audio recording verbatim (including verbal and non-verbal cues), assigned pseudonyms to all the identifiable individuals, and cross-checked the transcript against the audio recordings. All the authors (MW, MSBY, AFAR, and NAZNL) then read the transcription several times to familiarize themselves with the data set and to immerse themselves in its meaning. Then, MW imported all the transcription files into Atlas.Ti (version 7.9) to initiate the second phase (generating initial coding), during which MW and MSBY independently identified open codes throughout the data set; these were either the participants’ own words (in vivo) or a descriptive word for their experience. We conducted frequent comparisons of the generated themes to resolve disagreements and reach consensus on the initial themes. In phase three (searching for themes), MW and MSBY conducted a high-level analysis by combining several related codes to create overarching themes. MW, MSBY, AFAR, and NAZNL held joint meetings to discuss potential themes. In the fourth phase (reviewing the themes), MW examined the quotations associated with each theme and determined their coherence (internal homogeneity). If a quotation did not fit, MW either redirected it to a more closely related theme or revised the theme. MW then reviewed all the themes to determine their relevance and to ascertain whether each theme was significantly different from the others (external heterogeneity). To ensure that potential themes reflected the entire data set, MSBY and AFAR compared them to the codes and to the entire data set. MW, MSBY, AFAR, and NAZNL discussed inconsistencies and refined potential themes. In the fifth phase (defining and naming themes), we gave each a name, a definition, and an explanation narrative. Additionally, MW, MSBY, AFAR, and NAZNL ascertained whether any complex theme required subthemes to be structured more effectively. Finally, in the sixth phase (writing the report), MW and AFAR assembled the selected quotes to illustrate key points. MSBY and NAZNL revised the report. We repeated this procedure until we reached unanimous agreement.

Table 1 highlights how we addressed Guba’s four criteria for detecting the trustworthiness of qualitative studies [ 19 ].

Table 2 displays the characteristics of the participants. Gender distribution was nearly equal among participants, and most were fourth-year students.

As depicted in Fig.  1 , three major themes emerged from the thematic analysis: students, academic resources, and examiners. Each theme was subdivided into subthemes that reflected increased and decreased TA.

Emerged themes and sub-themes in relation to increasing and decreasing test anxiety

Shown in gray, the themes were placed at the center of the figure. All subthemes that increased TA were grouped together and colored red, while those that decreased TA were grouped together and colored green. The arrows on either side of the figure denote the two primary probe questions asked during the FGD. Notably, we arranged the themes and their associated subthemes from external to internal to reflect the relationships and interactions between them.

Theme 1: students

Negative vs. positive thoughts Most students expressed how their negative and positive thoughts influenced TA:

Both [positively minded and negatively minded students] may make a mistake, but the positive [student] will go on with minor anxiety because they know what [is] done is done and they cannot change it, but the negative one will keep on dwelling [on] the past/mistakes, and hence [this student increases their] anxiety level. (Student E, Group 6)

Some students noted that their preconceptions of negative ideas occurred if they had to share a bad experience with their colleagues:

I [learned] that the malignant doctor will examine me the next day. Eight of the students failed. The day [that I learned this was] stressful[.] (Student B, Group 3) When I [learn that a] “malignant doctor” will become my examiner, it increases [my] test anxiety[.] (Student C, Group 6)

Moreover, because the students identified as A-level students and had pursued their education since childhood, these expectations further increased their anxiety. Crucially, some students noted that positive thoughts and maintaining their motivation reduced TA:

I always try to keep myself positive and constantly remind myself to be confident in myself and believe in God. (Student A, Group 5) My anxiety will decrease if I stay positive by […] telling myself that I will do well in the exam[.] (Student D, Group 2)

Self-negligence vs. self-care The more time that the students had for self-care and maintaining a healthy lifestyle, the more their positive thoughts increased. In particular, the students mentioned that adequate sleep, a balanced or fulfilling diet, and exercise lowered TA:

[W]hat helps me with stress or anxiety is good food and sleep[.] (Student C, Group 4) For me [,] I need food to focus. For this reason, food relie[ves] my stress. (Student F, Group 5) I tend to get anxious when I go [to take an] exam without having coffee and something to eat. (Student B, Group 3)

In contrast, self-negligence was associated with increased TA. The students reported many bad behaviors that impacted their health and exam preparedness:

I also tend to get anxious when I go for an exam without having coffee and something to eat[.] (Student E, Group 4) I went to sleep at 7:00 am and [woke] up at 1:00 pm. I drink two cups of coffee per day. I [know that] some of my friends drink 5–10 cups of coffee [per day]. These kinds of things are not usual to your body. (Student B, Group 1)

Theme 2: academic resources

Heavy curriculum vs. facilitative curricular aids The students pointed out that the heavy medical curriculum triggered their anxiety levels before their exams:

But the problem with medical school [is that] too [many things must] be prepared [for] before the exam[.] (Student D, Group 1) The one that [stresses me out] is the [number of things] we need to cover […] for major exams especially[.] (Student C, Group 3) I need to cover [so many things]. [All things] and [many things], and you do not have enough time[.] (Student A, Group 5)

Notably, supportive measures before the exam could ameliorate this burden. The suggested measures include increasing formative assessments, briefings on the exams’ formats,, and making class more fun:. In particular, the students emphasized the importance of formative assessments:

Give quiz[s]/homework based on[the] learning outline at the end of every lecture so the students know what exactly they have to cover for each subject[.] (Student A, Group 6) In our previous exam, there [was] no briefing, so we [did not] know how many questions [would] come in the exam […] [or] what [would] be assessed[.] (Student C, Group 2) Try to make the class more fun because fun and relaxing classes tend to increase one’s memory and focus during that class. To be honest, [the] lecturer[s]who make classes more fun and [use] more discussion tend to make me remember things easier. (Student A, Group 3)

Theme 3: examiner

Strict vs. kind approach The students believed that the examiner played an important role in aggravating TA. Most stated that due to the presence of an examiner, OSCE was the assessment format that raised their TA the most:

[T]he examiner will affect me [the] most. (Student B, Group 4) The examiner in OSCE is very strict about the answer scheme, and sometimes he/she is known as an examiner who always fail[s] the student[s]. (Student A, Group 2)

Most students agreed that the stricter the examiner, the worse their experience of TA. They identified some features of so-called “malignant examiners,” including their intention to fail students:

[My anxiety increases during the exam if] the examiner in OSCE is someone we know [who is] very strict about [the] answer scheme […] [or] known as an examiner who always fail[s] the student[s]. (Student B, Group 1)

Moreover, the students claimed that malignant examiners used certain facial expressions and body language during the exam:

[Examiners] who are grumpy and do not even answer back when I greet them make[] me more anxious during OSCE[.] (Student C, Group 1) The [examiner] who has a straight face without any expression increases anxiety during exam[.] (Student A, Group 2)

Correspondingly, the students believed that kind examiners significantly reduced TA, such as by smiling and establishing a rapport:

I will choose the examiners that are kind and soft spoken to the student[s] to avoid the students feeling [scared] when [answering] the question[,] especially [during] OSCE[.] (Student C, Group 3) Just a simple gesture such as a smile, talking nicely to student[s], [and focusing] on information given by students. All [of] these will help to reduce stress[.] (Student B, Group 6)

The students suggested that applying a unified scoring system will help in reducing TA:

I think [I would] I brief all examiners about the guidelines and make sure that examiners understand the guideline and what is actually expected of students[.] (Student E, Group 2) [The examiners should] have a proper guideline for the marking of the students[.] (Student A, Group 4) Everyone has a proper guideline, not given a bias of judgment. I think that is OK for me[.] (Student F, Group 3)

Criticism vs. feedback The students signified that the examiner’s response approach affected TA. Most participants described criticism as “scolding,” which increased TA:

I just fear […] being scolded during the exam. (Student A, Group 4) I think that some examiners should not be shouty because student[s] are not well prepared. So, the way [that they] treat students will affect them. (Student D, Group 2) Some […] examiners [scold students]. They usually compare [the] current situation with future work. Just [because] you are feeling stress now, this [does] not mean you cannot handle whatever [will come up] when you work. (Student D, Group 1)

Correspondingly, students agreed that giving effective and constructive feedback during exams reduced TA, supported their learning, and empowered them to prepare more for their upcoming exams:

[If the examiner feedbacks the student, he] will [be] happier[,] and after the exam[,] he will tell [his] other friends that [the] examiner [taught] him [well.](Student A, Group 1) Actually, for both exams, I got the same marks. But, I was feeling better during the first exam, where the lecture calm[ed] me, and after the exam, she guided me [on how to answer] the question[.] [E]ven though I [could not] answer it, she guided me on what to do after that rather than scold[ing] me and ask[ing] me to [leave.] (Student B, Group 4)

This qualitative study explored TA from the perspective of medical students and identified its precipitating and diminishing factors: the students, their academic resources, and the examiner.

Negative vs. positive thoughts The students had a major role in developing and depleting TA. This could be due to the nature of TA, which originates from a negative self-process that encodes the outer environment into personal responses. In this context, the process fixated on how the exam would be and how the examiners would interact with the examinees, and it was exaggerated by an individual’s negative self-thoughts, academic competence, and/or ability to cope with challenging evaluative situations. For example, many participants had developed self-expectations since childhood. These expectations were strengthened by the people surrounding them and continued to be enhanced during their medical education. Other studies have determined that parents’ academic expectations affect their offspring’s TA [ 20 , 21 , 22 ]. Notably, the participants in this study also worried about transmitting their bad experiences to their peers.

Our findings suggest that enriching positive thoughts and believing in self-efficacy reduces TA in medical students. In his investigation of the cognitive triad, Wong [ 23 ] proposed that rational beliefs will lead to neutral or positive emotional consequences. This assumption has been used by many researchers to build cognitive reconstructions to reduce TA [ 13 , 24 , 25 , 26 , 27 ]. Based on these findings, it is apparent that thoughts influence our behavior [ 28 ]. Hence, we argue that negative and positive thoughts are the most important factors in this study. They may be used to form interventions to resolve TA.

Self-negligence vs. self-care The students demonstrated a variety of self-negligence behaviors that may amplify TA and trap them in a vicious cycle, including sleep deprivation, excessive consumption of coffee and other stimulants, and avoidance of sports. Self-negligence affects psychological perception and weakens mental fortitude, thus resulting in TA. On the other hand, self-care improves personality characteristics and the mental ability to combat TA [ 29 , 30 ]. Hence, our results emphasize the critical state of self-care among medical students, and academic advisory programs, among others, should promote healthy lifestyle choices to rectify this.

Students can feel an exaggerated sense of pressure and increased TA if they have to face the difficulty of their medical curriculum from the beginning of their studies [ 9 , 10 , 11 , 12 ]. By incorporating facilitative curricular aids, the detrimental effects of the curriculum can be remedied. For example, classes should be enjoyable and employ more formative assessments. Another strategy is to promote group study, as this may establish a beneficial framework for discussing and illustrating ambiguous concepts. Group study has been shown to be an effective method for enhancing student learning and providing a welcoming environment for discussion [ 31 ].

Strict vs. kind approaches According to socioconstructive theory and the social aspect of anxiety [ 32 ], the presence of an examiner (or evaluator) is the primary cause of TA during clinical examinations. The situation deteriorates further as a result of ineffective communication and attempts to fail students based on biases and prejudices. McManus et.al [ 33 ] referred to this approach as “the hawk effect” or “stringency.” As Shashikala [ 34 ] noted, such a person is occasionally referred to as the “malignant examiner.” Typically, examiners become stringent to ensure the principle of patient safety, which is the ultimate goal of medical education, during clinical evaluation of medical students. However, students’ mental well-being should not be jeopardized. For this reason, standardized scoring (either checklist or rubric) tools helps to eliminate prejudice and personal bias [ 35 ]. Nevertheless, comprehensive training on using the standardized scoring assessment during OSCE is highly mandated and crucial to maximize fairness and assessment validity [ 36 ].

Criticism vs. feedback The students noted that when they received constructive feedback during an exam, this enhanced their learning and helped them improve in a subsequent exam or practice session. Many students worried that some examiners may neglect the most effective use of feedback. Some examiners hope to motivate students by critically increasing their awareness and fear of failure, and Putwain and Roberts [ 34 ] referred to such tactics as “fear appeals.” The present study suggests that extensive training and close monitoring of the examiner during the examination will help reduce TA. Students should be encouraged to express themselves without harming the exam environment.

Two limitations apply to this study. The first is that it is restricted to a single medical school, and the second is that the sampling frame does not include representative medical students from all academic years, as medical students in their first and fifth years are required to sit for exams at the time of data collection. Both of these constraints make generalization difficult. For these reasons, additional research is needed to broaden the sampling and expand its scope beyond medical schools to include groups from other disciplines of health professions education (HPE). This will provide a comprehensive understanding of the TA problem across multiple HPE disciplines.

This qualitative study shed light on the factors that affect TA from medical students’ perspectives. Three major factors affecting TA were identified: the students, their academic resources, and the examiner. Sub-factors were also identified for each of these factors. This study established a solid foundation for policymakers and decision makers in medical education to improve current assessment practices while also enhancing student well-being. The results indicate that the polar factors of the examiner and the student act in concert and shape TA. Thus, additional psychological support for students and training for examiners on how to deal with examinees will significantly reduce TA.

Availability of data and materials

Due to privacy concerns, the transcripts of the interviews are not available to the public. On reasonable request, the corresponding author can provide transcript information.

Abbreviations

Focus group discussion

Objective structured clinical examination

Test Anxiety

Universiti Sains Malaysia

United States Medical Licensing Examination

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This research is part of a larger project supported by Fundamental Research Grant Scheme (FRGS: 203.PPSP.6171219), Ministry of Education, Malaysia.

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Majed Wadi, Muhamad Saiful Bahri Yusoff & Ahmad Fuad Abdul Rahim

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Each researcher established a thematic framework and then coded (e.g., indexed, charted, and mapped) and interpreted the data within the framework of qualitative analysis. Each of them reviewed the manuscript and provided constructive feedback. Each author's contribution was described in detail in the method section. All authors read and approved the final manuscript.

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Wadi, M., Yusoff, M.S.B., Abdul Rahim, A.F. et al. Factors affecting test anxiety: a qualitative analysis of medical students’ views. BMC Psychol 10 , 8 (2022). https://doi.org/10.1186/s40359-021-00715-2

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10 ways to manage and overcome test anxiety

What is test anxiety?

It’s normal to feel nervous about upcoming tests. 

However, if you experience overwhelming or debilitating levels of stress or anxiety before, during or after a test, you may have ‘test anxiety.’ 

Test anxiety is a type of performance anxiety that can be triggered by high expectations, previous test outcomes, fear of failure, pressure to perform or perfectionism. This type of anxiety can be particularly problematic when it impacts your ability to study, make it to your exams or answer test questions. 

Test anxiety typically manifests as a combination of physical and emotional symptoms that can interfere with your ability to concentrate or perform well.  

Here are a few signs and symptoms to be aware of. 

• Excessive sweating 
• Nausea, vomiting or digestive issues 
• Rapid heartbeat 
• Shortness of breath 
• Lightheaded or faint 
• Panic attacks, which can feel like a heart attack 
• Self-doubt, insecurity 
• Fear, helplessness 
• Hopelessness 
• Feelings of inadequacy 
• Anger or irritability 
• Negative self-talk 
• Racing thoughts 
• Difficulty concentrating 
• Restlessness, fidgeting 
• Procrastination, avoidance 
• Frequently comparing yourself to others 
• Difficulty sleeping 

If you experience any of these symptoms, you’re not alone.  

Here are some ways you can manage and overcome test anxiety. 

1. Get a head start

Start studying for your exams as early as possible. Test anxiety is often exacerbated when we feel underprepared or don’t know what to expect. Set yourself up for success by reaching out to your instructors, creating study guides, rereading class notes, reviewing presentations and practicing homework problems well in advance. 

2. Change the narrative

Negative self-talk may cause you to feel like you're trapped in a downward spiral, especially when you feel anxious. If this sounds like you, try to catch yourself in the moment and change the narrative. Take a few deep breaths and practice replacing negative thoughts with more productive ones. 

Here are some examples. 

Instead of saying…

• I should have studied more; I don’t know what I’m doing.
• I feel stupid.
• I have to do well or else XYZ will happen.
• I studied as best as I could for this exam, and it’s okay if I can’t answer every single question. 
• I am smart and capable, even if my test results don’t reflect those qualities. 
• I am doing my best, and if I don’t do as well as I want to, it’s not the end of the world. 

3. Prioritize taking care of yourself 

High anxiety can sometimes cause people to forget about other important things in life, like basic needs, hobbies, relationships and rest. As you prepare for exams, try to schedule times to study, eat, take breaks, spend time with friends and take care of your own mental health. This can help you avoid feeling burned out or completely drained when it comes time to sit down for your tests. 

4. Arrive early 

Running late can increase anxiety before you even make it to your exam. Instead of leaving at your usual time, set an alarm 10 to 15 minutes early, so you can arrive with plenty of time to spare. Getting there early means you may have more time to review your notes, prepare your materials and settle your mind before the exam starts. 

5. Use calming techniques 

If you’re feeling anxious before or during an exam, try practicing quick calming techniques to help you recenter and refocus. 

Here are two you can try that won’t take up too much time. 

Square breathing

This technique can help you slow your breathing and heart rate to ease anxiety.  

Start by closing your eyes and focus on your breathing.  

Gently inhale through your nose, counting to four.  

Breathe out slowly, exhaling all your air while counting to four again.  

Repeat this process as many times as you need to calm down.  

As you start to feel better, open your eyes and return to your study session or exam. 

45-second body scan

This technique can help you stay present and calm racing thoughts.  

Close your eyes and tune in to the sensations of your body.  

Start at the bottoms of your feet, feeling the weight of your feet against your shoes.  

Slowly move up your body by feeling the sensations of your legs, hips, back, abdomen, shoulders, neck, arms, hands and head.  

When you’re done with your body scan, take a deep breath and return to your study session or exam. 

Practicing these techniques when you don’t need them will make them easier to use when you do. It can also help you determine which one suits you best. 

6. Avoid comparisons 

Looking at how others are doing around you can increase your anxiety, especially if you notice that you’re not as far along or that you’ve spent more time on a question compared to your classmates. That’s why it’s important to focus on your own work and progress. Remind yourself that you’re doing the best you can, and it doesn’t matter what others are doing around you. You will make progress on your own terms. 

7. Set a timeline 

If you struggle with time management during exams, try to set a timeline. For instance, it can be helpful to review how much time you have to complete an exam and how many questions you’ll need to answer. 

This can help you plan out how much time you have per question. Keep in mind that some questions may come more easily than others. It’s also important to leave yourself enough time to complete written or long-form questions, which usually take longer than multiple choice questions. 

Remind yourself that it’s okay to skip questions if you feel like you’re running behind. You can always come back to them later. Just make sure to keep track of the question numbers on your scantron to avoid potential errors.  

8. Allow yourself to relinquish control 

Once you’ve submitted an exam, that’s it. 

Remind yourself that the outcome is now in your instructor’s hands and out of your control. Relinquish control over what you might have gotten wrong or problems you didn’t finish. Instead, allow yourself to breathe a sigh of relief that the exam is over.  

9. Review your scores on your own terms 

Some people like to view their scores right away or talk about them in class. Others may prefer to review their grades privately or wait until they have a chance to calm down. Regardless of what others prefer, allow yourself to see how you did on your own terms. 

If you’re feeling anxious or worried about your test results, consider asking a close friend to review them for you. You can also ask them to share your results in a supportive and non-judgmental way. 

10. Use campus resources 

Campus resources are available to help you prepare for exams and get additional support for test anxiety. Here are a few to check out.  

Academic resources

Tutoring services.

CU Boulder offers a wide variety of tutoring services. Some are specific to classes, departments or groups of students, while others are available campus-wide. Many of these services are free to use. If you’re not sure where to begin, try checking your syllabus or asking your instructor for help and referrals. 

Writing Center

The Writing Center provides free one-to-one tutoring sessions with professionally trained writing consultants, individualized guidance and feedback, and time-saving skills for writing and presentation projects. The Writing Center is free to all CU Boulder undergrad and graduate students. 

Disability Services

Disability Services provides students with disabilities reasonable academic accommodations, support and other services. They also offer free workshops that are open to all students. If you need help navigating test accommodations, Disability Services can help. 

Grade Replacement Program

This program allows degree-seeking undergraduate and graduate students to retake a course in which they earned a low grade to improve their cumulative GPA. 

Wellness resources

Finals website.

Check out the finals website for free events, tips, information about additional resources and more. 

Counseling and Psychiatric Services (CAPS) offers free workshops to help you prepare for finals, including:  

• Anxiety Toolbox  
• Feel Better Fast  
• Skills for Thriving 

Counseling and Psychiatric Services (CAPS) provides free drop-in consultations through Let’s Talk. Counselors are available in person at multiple campus locations to help provide insight, solutions and information about additional resources. 

Peer Wellness Coaching

Meet one-on-one with a trained peer wellness coach to get help creating a study plan, managing stress, practicing self-care and more. 

AcademicLiveCare

All students can schedule free telehealth counseling and psychiatry appointments online through AcademicLiveCare. 

Free Finals Week at the Rec

Physical activity is a great way to take a break from studying and manage stress. The Rec Center will be offering a variety of free activities during Free Finals Week. 

Figueroa Wellness Suite

The Wellness Suite is a great place to rest and reset. Whether you need a nap, want to pick up free health and wellness supplies, or if you just want to find a quiet place to study, the Wellness Suite provides a place to get away at the end of the year. 

Mental health crises

If you’re experiencing a possible mental health crisis or need urgent, same-day support, Counseling and Psychiatric Services (CAPS) is here to support you 24/7 over the phone at 303-492-2277. Calling ahead allows providers to triage your concerns so they can address them more quickly and effectively. 

Follow @CUHealthyBuffs   on social for more tips, events and activites.

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Case Report Volume 1 Issue 4

Exams Anxiety: Case Study

Theodoratou maria, 1 function clickbutton(){ var name=document.getelementbyid('name').value; var descr=document.getelementbyid('descr').value; var uncopyslno=document.getelementbyid('uncopyslno').value; document.getelementbyid("mydiv").style.display = "none"; $.ajax({ type:"post", url:"https://medcraveonline.com/captchacode/server_action", data: { 'name' :name, 'descr' :descr, 'uncopyslno': uncopyslno }, cache:false, success: function (html) { //alert('data send'); $('#msg').html(html); } }); return false; } verify captcha.

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1 Clinical Psychologist, Technological Institute of Patras, Greece 2 Health Psychologist - Psychotherapist, New York College, Greece 3 Counselor, Greece

Correspondence: Maria Theodoratou, Clinical Psychologist, Technological Institute of Patras, School of Health and Welfare Professions, Patras, Greece

Received: May 05, 2014 | Published: July 12, 2014

Citation: Theodoratou M, Andriopoulou P, Manousaki M (2014) Exams Anxiety: Case Study. J Psychol Clin Psychiatry 1(4): 00021. DOI: 10.15406/jpcpy.2014.01.00021

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The case we are going to present concerns a 28-year-old woman, suffering from intense anxiety about University Examinations. We consider this case as extremely interesting, because even though she had interrupted her studies in chemistry for four years, she managed to overcome her anxiety, graduate successfully and pursue further postgraduate studies in Great Britain, after undergoing cognitive therapy. The purpose of this article is to present the cognitive map of the patient and the procedures that led to the achievement of the therapeutic goals.

Literature review

Standard Beckian CBT, also called cognitive therapy (CT), is based on the cognitive model, which links cognitions, emotions, and behaviors such that cognitions shape behaviors and emotions, and unrealistic cognitions can lead to inappropriate emotions and behaviors. 1 CT is a structured or semi-structured, directive, active and short-term approach. Its clinical use is applied to several psychiatric disorders i.e., anxiety-, personality- and eating-disorders, several situations of crises and disorders related to the use of psychoactive substances. 2

Most approaches to CI agree to its basic principles which include that people develop adaptable and non-adaptable behaviors and affective patterns through cognitive processes, the functions of these cognitive processes can be activated by the same procedures that are commonly used in the human learning laboratory, and the task for a therapist is that of a diagnostician and pedagogue who evaluates dysfunctional cognitive processes and arranges such learning experiences that transform the existing cognitive patterns, and correlate them with behaviors and patterns of experiencing things. 3 , 4

CT’s goals are to restructure the dysfunctional cognitions and give cognitive flexibility when assessing specific situations and to solve focal problems and mainly to provide patients with cognitive strategies to perceive and respond in a functional way to the real world. 5 CT is considered to have results with issues related to depression and panic disorders, i.e. verbal and non-verbal communication skills, assertiveness, criticizing and receiving criticism, refusing alcohol, and in general saying no. 6

Description of problem behavior

Helen is a 28-year-old chemistry student who sought therapy for intense anxiety concerning University Exams. The diagnostic interview indicated that she suffered from Specific Phobia (Exams Phobia) according to DSM-IV- TR. 7 She also suffered from anxiety and depressive symptoms. At the first stages of her interviewing it became apparent that Helen complained for the following:

She could not attend the lectures or enter the lecture theatre ("lecture theatre phobia"). She could not concentrate, study for the exams or sit an exam. She avoided getting close to the University and she also avoided anything relevant to the University. She was not able to decide whether she wanted to get her degree or not. She was in a general state of anxiety about anything. She wanted to be perfect in everything and she worried about other people’s criticism. She would think about University all the time. Thus, she was not able to enjoy herself and was always sad. She avoided being with people and finally avoided crowded places. As far as her physiological complaints are concerned, it appeared that Helen suffered from: Permanent headache, Insomnia, Stomachache, Fatigue, Loss of energy, Drowsiness, Clenching of teeth while she slept that resulted in pain. The result of all the above was that she felt anxious, disappointed and melancholic.

Personal and family history

Helen was the second child in the family. There was an elder brother (now married) and a younger sister who had graduated from the law school. There seemed to be many problems in the family with her brother. He was rebellious and undisciplined – the "problem child" as Helen characterized him. Helen could not find any means of communication with her family, and her sister was the only person she really talked to. Her family was a low-income one putting an extra burden on Helen’s shoulders. Helen felt that as a pupil she was good at everything. However, she felt that her family shadowed her. They knew anything she did, pressurizing her. The situation at the time when Helen reached for therapy had as follows:

Her sister and father pressed her to continue her studies. They even wanted her to pursue postgraduate studies. Her father always told her that if she did not finish University, she would end up being a cleaner. "If you do not have a degree, you are a zero" he said. Helen felt that her father counted on her. "He has put me in the place of his son. I always felt that I had to adhere to what he wanted" she said. Her sister always criticized her calling her irresponsible. She was also interfering trying to contact Helen’s lecturers to ask them to be more lenient with her, something that made Helen furious.

The only sector that Helen could function at the time of therapy was foreign languages. She was good at them and she could study without anxiety. She considered foreign languages a hobby and not "real work". Surprisingly, her parents were not interested in her performance as far as languages were concerned, so they did not pressure her.

To make matters worse, their financial situation was very bad so Helen could not decide whether she should continue with her studies or find a job in order to solve her financial difficulties. Even though Helen felt that she is suffocating because of all these problems, it seemed that there was no way out since her parents were ill and she could not leave home.

As it becomes apparent from the above short account of Helen’s family history, her parents and sister put too much pressure on her in relation to her studies. She was pressed and criticized for not being able to continue her studies. Considering this in combination with the rest "difficult" family environment it comes as no surprise that Helen developed an anxiety disorder.

Dysfunctional assumptions and rules

Dysfunctional assumptions and rules are general beliefs which individuals hold about the world and themselves which are said to make them prone to interpret specific situations in an excessively negative and dysfunctional fashion. In anxiety most dysfunctional assumptions or beliefs revolve around issues of acceptance, competence, responsibility, control and the symptoms of anxiety themselves. 8 , 9

Helen’s assumptions-beliefs:

• "I am nothing unless I have a degree"
• "I always have to please my family"
• "I cannot cope with the exams"
• "If I cannot cope with this, I cannot cope with anything"
• "I always have to do everything perfectly well; otherwise others will look down on me"
• "I always have to do what my father wants"
• "Students are snob and I do not want to be like them"
• "I have to be in control all the time"
• "If you are used to something, you cannot change"

Helen’s above-mentioned beliefs gave rise to a number of automatic thoughts such as:

• I cannot get into the lecture theatre
• I cannot control this matter
• My parents will never be happy for me
• It is too late for me to change
• I have no second chance
• Everything seems like a mountain
• I am sick of sitting exams
• If you have a degree you do not feel inferior
• No matter what I do this degree will always bother me
• I do not believe that it is possible to sit an exam and pass
• My mind is not functioning, I am not going to make it
• I do not want to be snob like all the other students.

Cognitive distortions

Helen’s main cognitive distortions were stimulus generalization, catastrophizing and selective abstraction. 10 The range of stimuli that evoked anxiety increased and anything that had to do with the University was perceived as a danger (stimulus generalization). As many anxious people, 11 Helen tended to dwell on the worst possible outcome. For example, she thought: "If I fail the exam, I will not be able to finish University and as a consequence I will end up as a cleaner" (catastrophizing).

Finally, it seemed that Helen was aware of her difficulties in handling the exams situation but not of her assets. Thus, she had a biased view of the degree both of the danger she was in and of her own vulnerability (selective abstraction).

Figure 1 shows how the reactions to symptoms maintain the phobia by creating vicious circles that perpetuate fear. Avoidance maintains anxiety because it makes it difficult to learn that the feared situation (e.g. exams) is not in fact dangerous, or is not dangerous in the way, or to the extent that Helen thinks it is. Other important maintaining factors include thoughts, for example about the meaning of the symptoms of anxiety (e.g. "My brains don’t function properly"), or about the anticipated consequences of entering the phobic situation (e.g. "I will fail", "I will never be able to finish University"), and loss of confidence. 12

Figure 1 Helen’s vicious circle Adapted from Butler. 12

Goals of treatment

• Explaining the cognitive model, using Helen’s individual symptoms to illustrate how vicious circles maintain symptoms
• Teaching her how to identify automatic thoughts and find alternatives
• Problem solving concerning studying and sitting exams
• Becoming able to differentiate from her family

Behavioral and cognitive techniques used

"TIC-TOC" technique:  Helen could not study because of the negative cognitions she had concerning studying and University. The therapist focused on these "Task Inhibited Cognitions" and educated Helen to be able to monitor and challenge these dysfunctional cognitions and substitute them with "Task Oriented Cognitions" 13 . Thus, Helen’s automatic thought "I am not going to make it" was substituted with "If I do not try I have no possibility of succeeding, if I do try though I have at least some possibilities".

"Graded task assignment":  The aim of this technique was to maximize the chances of success by breaking tasks into small, manageable steps. 14 Hence, Helen was given small tasks to carry out. For example, she would study a few pages each time in order to become able to face this anxiety-provoking situation (studying).

"Graded exposure":  Exposure is defined as facing something that has been avoided because it provokes anxiety. 12 Helen was encouraged to talk about University and try to visit University. She thus managed to be able to visit University and even write down the timetable of the exams. Finally, she managed to go to the lecture theatre to sit an exam with the presence of the therapist at first and then by herself.

"Daily record of dysfunctional thoughts":  Situations that precede unpleasant emotions were recorded along with the emotions and the automatic thoughts. At a later stage, Helen learned how to challenge these thoughts (a sample of Helen’s Daily record of Dysfunctional thoughts is given in Table 1 . It should be noted at this point that Helen was not willing to do any homework. This was considered to be part of her problem since she could not concentrate properly. Thus, the record forms were completed in the therapeutic session.

Table 1 Helen’s daily record of dysfunctional thoughts

Therapeutic achievements

Despite the difficulties in treatment (Helen would not do any homework) the therapeutic results were quite impressive. After five months of therapy including follow-ups:

• She managed to decide whether she wanted to finish University or not
• She graduated successfully
• Her physical symptoms disappeared
• She pursued postgraduate studies in Great Britain

This case study presented the main tools treating anxiety disorders and provided specific conceptual frameworks of cognitive therapy that were used effectively in therapy of this patient and affected her whole life so that she could lead a well adjusted life. Last, but not least in a follow-up session she mentioned that she has worked in a company in Great Britain for the last ten years after having completed her postgraduate studies.

Acknowledgments

Conflicts of interest.

Author declares there are no conflicts of interest.

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• Mahoney MJ. Cognition and behavior modification. Ballinger , Cambridge. 1974. p.351.
• Wright JH, Thase ME, Clark MD. Cognitive Therapy. American Psychiatric Press , New York, USA. 1997. p.174.
• Beck AT, Wright FD, Newman CF, et al. Cognitive Therapy of Substance Abuse. Guilford Press, New York, USA. 1993.
• Monti PM, Rohsenow DJ. Coping-skills training and cue-exposure therapy in the treatment of alcoholism. Alcohol Res Health . 1999;23(2):107‒115.
• American Psychiatric Association. Diagnostic and statistical manual of mental disorder . Washington, DC, USA.d. 2000.
• Clark D. Anxiety states: Panic and generalized anxiety. In: K Hawton, PM Salkovskis, J Kirk, DM Clark (Eds.), Cognitive Behaviour Therapy for Psychiatric Problems. Oxford University Press , Oxford, England. 1989. p.472.
• Clark DA, Beck AT. Cognitive Therapy of Anxiety Disorders. Science & Practice. The Guilford Press, New York, USA. 2010.
• Beck AT, Emery G, Greenberg RL. Anxiety Disorders and Phobias: A Cognitive Perspective . Basic Books. 1985.
• Beck AT. Cognitive Therapy and the emotional Disorders. Penguin Books , New York, USA. 1989.
• Butler G. Phobic disorders. In: K Hawton, PM Salkovskis, J Kirk, DM Clark (Eds.), Cognitive Behaviour Therapy for Psychiatric Problems. Oxford University Press , Oxford, England. 1989.
• Burns DD. Feeling good: The new mood therapy. Ney American Library , New York, USA. 1980.
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©2014 Theodoratou, et al. This is an open access article distributed under the terms of the, Creative Commons Attribution License ,--> which permits unrestricted use, distribution, and build upon your work non-commercially.

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5 Ways to Strengthen Mental Health Muscles for Exam Season

As exams loom over colleges this month, students are trying to finish their semesters successfully. Sometimes students define a successful exam week as getting good grades and passing classes. While these are important, focusing only on academic success can harm mental health. Learning to manage stress in healthy ways is an essential part of the college experience. Want to learn how to handle the mental weightlifting of exam week? In this piece, we'll explore effective ways to strengthen your mental wellness for exam week and for your future.

What is stress?

Simply defined, stress is the body's reaction to the strain you experience under pressure. It can be a physical, mental or emotional response. Although it gets a bad rap, not all stress is negative. In fact, it is often a catalyst for growth. For example, the uneasiness you may feel when you step out of your comfort zone is an example of positive stress that may help you grow.

Everyone experiences heightened stress at some point. For college students, months like November and April can often take the cake for high-stress seasons. Students' calendars are jam-packed with end-of-semester social events as well as final projects and exams.

Knowing how to strengthen your mental health muscles in these moments is a valuable skill. According to the American Psychological Association , nearly a quarter of adults today rate their daily stress between 8 and 10 (1 being little to no stress and a 10 being a great deal of stress). Because elevated stress is a reality of our culture, it’s essential to know the signs of negative stress and understand how to manage it.

Knowing your stress response

Negative responses to high stress can crop up in several different forms. Here is a list of common reactions people have to high-stress situations to help you identify what you’re going through.

Anxiety and exam week symptoms

Our society frequently uses the word anxiety, but many people talk about it broadly rather than naming thought patterns or actions associated with it. In general, anxiety is excessive worry or fear. Sometimes it looks like looping thoughts that play over and over in your head or catastrophic fears where you exaggerate possible future outcomes in your mind.

Worry and fear can also manifest in physical symptoms, such as racing heartbeat, nausea, sweating, trembling, disrupted sleep and difficulty concentrating when the body perceives the fear or worry as valid.

During exam week, anxiety can take several forms. Along with the symptoms above, some anxious students become perfectionists, setting impossible goals and standards for themselves and then falling apart when they can’t meet the standards. Other anxious students will show avoidant behavior, skipping studying completely or procrastinating.

Depression and exam week symptoms

Feelings of hopelessness, sadness or loss of interest in activities often characterize depression. In general, students experiencing depression have a lack of motivation to get out of bed or study. They will procrastinate and withdraw. And likely, they will feel persistent sadness, guilt or hopelessness about their academic performance.

Burnout and exam week symptoms

This stress response often happens when people experience high-stress levels over a long period with no healthy breaks or self-care. Ultimately, you work to the point of exhaustion. Symptoms begin as irritability and reduced productivity but become severe fatigue and even illness.

How to build mental strength

1. pursue support and free mental health resources.

One of the best things about college is the sheer number of mental health resources available to you for free. From peer mental health coaching and group counseling to individual counseling and crisis resources, colleges know that students need support in psychological well-being as they grow academically and developmentally. These higher education experts also share timely educational materials through free digital newsletters and social media.

Beyond personnel in these offices, campuses build systems of support through student, faculty and staff mentors. Students can benefit from already having established relationships when they need advice. Look out for extra well-being resources during exams too. For example, at Berry, student volunteers who promote mental wellness known as peer educators set up a self-care tools booth that includes therapy dogs, coloring pages and fidget toys for taking brain breaks.

In the future, building a support network and knowing how to find resources to care for yourself will be an advantage.

2. Plan ahead

Most colleges share exam schedules at the beginning of the semester. Figure out when your exams are and which ones you need to prioritize. It’s likely you’ve completed a lot of the classwork before exam week. For example, if 80% of your work for a course is complete, you can figure out which exams and projects matter most. Sometimes your exam will not affect your overall class grade at all. Once you know which exams are most important, schedule out manageable chunks of study time .

In the future, knowing how to reflect on your responsibilities and decide what needs your attention most will be valuable.

3. Prioritize marginal activities

Think of margin as the space between two things. For college students, margin typically describes the time between social and academic activities. It's necessary breathing room or recovery time that helps you mentally recoup. Students often push marginal activities aside, like sleeping, eating and exercising, to pack more into the day. However, disregarding opportunities to recharge significantly impact a student's well-being. Once you build a study plan, make room for the marginal activities that keep you mentally, physically and emotionally fueled. When there is no room for eating, sleeping, breaks or exercise, you’ve built an unmanageable, overcommitted schedule.

Expert Advice:

Terri Cordle, a licensed professional counselor at Berry College who has worked in higher education for over 25 years says, “The best way for students to prioritize mental health is to plan ahead for self-care. But self-care doesn’t mean special activities or treats. Instead, it's about daily habits students do to manage stress: getting adequate and restorative sleep, eating regular nutritious meals, hydrating with non-caffeinated drinks, moving including exercising, spending time outdoors and having downtime where they are not doing school or work-related tasks.

These are the basics of stress-resilience and wellness. Remember: it is productive to take breaks to eat, hydrate, sleep, move and have some downtime. I encourage students to think of these activities as fuel for their minds and bodies. Without fuel, we all lack the energy it takes to focus and concentrate, have clarity of thought, be creative and problem-solve.”

In the future, you will likely juggle more responsibilities and activities than you do in college. Start building the practice of margin in your schedule now.

This practice is for in-the-moment stress response situations. If you find yourself experiencing physical symptoms of anxiety, depression or burnout while studying, practice breathing exercises or get up and walk outside for a few minutes. Meditation, prayer and mindfulness practices can be excellent tools for relaxation that can help you diminish physical responses to stress and regain concentration.

In the future, knowing how to settle yourself and your body will help you get past mental blocks that might keep you from success.

5. Practice positive thinking

If you are struggling with negative thought patterns, share them with a trusted friend or counselor and challenge negative thoughts. Then visualize yourself performing well or achieving your goals, as positive visualization can help boost confidence.

In the future, you will likely be able to name negative thought patterns with practice and push past them when your anxiety or depression is triggered.

In the end, remember that high-stress and pressure situations are a part of life you can learn to manage. Just like training for a race where your body experiences physical stress, building resilience takes practice and training to build your mental health muscles.

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Treatment of anxiety disorders in clinical practice: a critical overview of recent systematic evidence

Vitor iglesias mangolini.

I Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR

II Departamento de Psiquiatria, Instituto de Psiquiatria, LIM-23, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR

Laura Helena Andrade

Francisco lotufo-neto, yuan-pang wang.

The aim of this study was to review emerging evidence of novel treatments for anxiety disorders. We searched PubMed and EMBASE for evidence-based therapeutic alternatives for anxiety disorders in adults, covering the past five years. Eligible articles were systematic reviews (with or without meta-analysis), which evaluated treatment effectiveness of either nonbiological or biological interventions for anxiety disorders. Retrieved articles were summarized as an overview. We assessed methods, quality of evidence, and risk of bias of the articles. Nineteen systematic reviews provided information on almost 88 thousand participants, distributed across 811 clinical trials. Regarding the interventions, 11 reviews investigated psychological or nonbiological treatments; 5, pharmacological or biological; and 3, more than one type of active intervention. Computer-delivered psychological interventions were helpful for treating anxiety of low-to-moderate intensity, but the therapist-oriented approaches had greater results. Recommendations for regular exercise, mindfulness, yoga, and safety behaviors were applicable to anxiety. Transcranial magnetic stimulation, medication augmentation, and new pharmacological agents (vortioxetine) presented inconclusive benefits in patients with anxiety disorders who presented partial responses or refractoriness to standard treatment. New treatment options for anxiety disorders should only be provided to the community after a thorough examination of their efficacy.

INTRODUCTION

According to the World Health Organization ( 1 ), anxiety disorders are burdensome “common mental disorders” to communities. These prevalent disorders are not communicable and affect approximately one in every five individuals of the world population ( 2 - 4 ). This figure represents the largest share of the prevalence of all mental disorders, whereas severe psychotic and bipolar disorders affect only between 1% and 2% of the population. In an upper-middle income country such as Brazil, the 12-month prevalence of anxiety disorders has been estimated as 19.9% among the dwellers of a large metropolitan area ( 5 ).

The cost of anxiety disorders to the working world is remarkable, corresponding to a total loss of 74.4 billion Euros in 2010 ( 3 ). The global burden of anxiety disorders represents 10.4% of years lived with adjusted disability (DALY) of mental disorders, reaching 26,800,000 DALYs ( 2 ). Despite the societal burden of this morbidity, only approximately one in five patients diagnosed with anxiety disorder obtain access to treatment ( 6 , 7 ).

Anxiety disorders present an early onset, even during childhood. Their enduring waxing and waning course deeply affects patients’ functionality and interpersonal relationships throughout the lifespan ( 8 ). Most pathological anxiety (specific phobias, social anxiety, generalized anxiety, separation anxiety, obsessive-compulsive, and panic disorder) is underrecognized, and patients seek treatment in outpatient settings, either in medical or specialized mental health-care contexts ( 7 ). However, anxiety disorders receive less attention from clinicians when compared with major mental disorders, such as psychotic conditions and substance use disorders that require hospitalization. Moreover, anxiety is less reported in the media than depression and suicide attempts, which reduces the help-seeking behaviors of patients suffering from anxiety. Figure 1 summarizes key uncontroversial characteristics and clinical practices regarding the treatment of anxiety disorders ( 9 - 11 ). Most experts advocate either psychotherapy and/or pharmacotherapy for alleviating or controlling symptoms of anxiety. The combination of psychological treatment with psychotropic drugs is recommended for patients with severe cases of disabling anxiety.

Traditionally, several talk therapies are subsumed as techniques of psychological treatment and have been recommended to handle different degrees of anxiety ( 11 ). Well-accepted but not always efficacious modalities of psychotherapy vary from psychoanalytic, cognitive-behavioral, interpersonal, supportive, and group therapy to brief therapy. The literature on cognitive-behavioral therapy (CBT) has established a foundation of effectiveness evidence for different anxiety disorders ( 9 , 11 ), but new therapeutic modalities should have their benefit assessed. In addition, the existing number of mental health professionals is insufficient for the number of patients who need treatment ( 6 ). Thus, a more accessible and cost-effective modality of psychotherapeutic treatment for anxiety should be offered to the community.

More than six decades ago, since the synthesis of chlordiazepoxide in 1957 ( 12 ), benzodiazepine medications have become the main class of pharmacological agents for the treatment of anxiety disorders. The introduction of these anxiolytic medicines received an immediate welcome from medical professionals and anxiety-laden patients. Nonetheless, the risk of side effects, a withdrawal syndrome and dependence on benzodiazepines have led patients in need of treatment to seek less harmful therapeutic substitutes, which do not always have proven efficacy. Accepted psychopharmacological medicines include antidepressants, buspirone, beta-blockers, and antipsychotics. Their efficacy has been demonstrated in well-designed clinical trials and abridged in comprehensive reviews ( 10 ). The combined use of psychological treatment with psychotropic drugs is more commonly recommended for cases of anxiety of greater severity and disability ( 11 ).

Many complementary and alternative treatments of mild forms of anxiety have gained popularity because of their alleged harmlessness. Examples of complementary treatment include aromatherapy, acupuncture, herbal medicine, homeopathy, massage therapy, yoga, mindfulness, exercise practice, relaxation, etc. ( 6 , 7 ). The diversity of modalities that a patient is exposed to varies in accordance with the guidance of the therapist, use of an active substance, and body manipulation. Exhaustive classification is difficult. While mental health professionals support the adjunctive addition of these modalities, for anxiety disorders in particular, the exclusive use of alternative therapies as a surrogate to well-established forms of treatment should be avoided ( 11 ). Most complementary and alternative treatments lack evidence of effectiveness. It is possible that a placebo effect and a good therapeutic relationship between the practitioner and patients underlie their positive outcomes.

There are a wealth of treatments devoted to controlling the symptoms of anxiety, but nonconventional and newer psychotherapeutic treatments and pharmacological agents are propagated without an acceptable confirmation of benefit. In the present review, we searched for recent evidence of nonbiological (psychological) and biological (pharmacological) modalities for treating anxiety disorders. The comprehensive summary of treatment advances is organized for a professional who is in training or is not a specialist in mental health to supplement existing modalities. Complementary and alternative treatments with evidence of effectiveness are explored herein under the group of nonbiological therapies. Additionally, high-quality systematic reviews (SRs) were chosen over sparse clinical trials in need of additional replication. The usefulness and public health importance of the treatment of anxiety are subsequently discussed.

Our research question was to update the evidence on recent interventions for the broad category of anxiety disorders. In the present study, the PICO components included adult Patients with a clinical diagnosis of “anxiety disorder”, who were subjected to one or more Interventions (either biological or nonbiological). The intervention must be Compared with a placebo or standard therapeutics for assessing the treatment Outcomes.

We searched for articles in the PubMed and EMBASE databases on the treatment of anxiety disorders. The key Medical Subject Heading (MeSH) terms were “anxiety disorders” AND “treatment”. The retrieved articles were displayed in the Mendeley platform and filtered in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines ( 13 ). The arguments of the search strategy can be found in Supplementary Table 1 .

Footnotes : CCDANCTR : The Cochrane Depression, Anxiety and Neurosis Review Group’s Specialized Register; CDSR : Cochrane Database of Systematic Reviews; CENTRAL : The Cochrane Central Register of Controlled Trials; CINAHL : Cumulative Index to Nursing and Allied Health Literature; Cochrane : Cochrane’s Collaboration Tool to Assess Risk of Bias; CRD : Centre for Reviews and Dissemination; DAI : Dissertation Abstracts International; ICTRP : World Health Organization’s trials portal; PBSC : Psychology and Behavioral Sciences Collection; SIGN : Scottish Intercollegiate Guidelines Network.

For inclusion, the article type must be an SR, with or without meta-analysis, of clinical trials involving adult patients diagnosed with an anxiety disorder. Rigorous randomized clinical trials (RCTs) compared with placebo or active interventions were considered the highest evidence of effectiveness. Those articles wherein participants encompassed a mixed sample of adults and children were not eligible unless separate data were comprehensively presented. Only articles published in the last 5 years, from January 2013 through September 31, 2018, were considered appropriate. There was no language restriction regarding published articles.

After hand searching, by reading the reference list of retained articles and chapters, and contact with potential authors, we identified two additional articles ( 14 , 15 ).

Regarding exclusion criteria, articles containing primary data, duplicate SR or animal models of anxiety were not eligible. Posttraumatic stress disorder was not considered in the present overview because this disorder is not covered under the MeSH term “anxiety disorders” and is no longer listed in the DSM-5 chapter of anxiety disorders ( 16 ). In contrast, while the DSM-5 describes obsessive-compulsive disorders in a separate chapter, this group of disorders is still listed under the MeSH entry of anxiety disorders. Furthermore, treatments on the cooccurrence of anxiety disorders in a specialized medical context (e.g., heart disease, endocrinological, neurological conditions, pain clinics, etc.) were eliminated. Observational studies, case reports, comments, practice guidelines and editorials on therapeutic modalities were also excluded from this overview. Two authors (V.I.M. and Y.P.W.) decided the final list of selected articles.

Study method

Often, an individual SR cannot address all proposed interventions for the same problem. Recent advances in the treatment of anxiety disorders are updated in the current study with the methodological framework of a systematic overview ( 17 ). Accordingly, this type of meta-review is a relatively new method to achieve a high level of evidence, wherein systematic evidence gathered from more than one SR or meta-analysis is examined in a single accessible work, also known as a “systematic review of systematic reviews” ( 17 ). The compilation of evidence synthesizes different interventions for the same problem or condition on different outcomes for different conditions, problems or populations. The ultimate result provides a global summary of the available evidence rather than providing data synthesis ( 17 , 18 ). Thus, an overview aims to examine the highest level of evidence and provide a global account of findings ( 19 ). This type of review has the advantage of rapidly combining relevant data to make evidence-based clinical decisions. Stakeholders, managers and health professionals can appraise multiple high-quality studies in a single general summary of a particular question.

The quality of the retained review articles was assessed in accordance with “A MeaSurement Tool to Assess systematic Reviews” (AMSTAR version 2) ( 20 ). The 16-item AMSTAR checklist ( https://amstar.ca ) represents a critical appraisal of the quality of SRs, covering different aspects related to study planning and conduct, such as the research question, review protocol, selection of study design, search strategy, explicit inclusion and exclusion criteria, risk assessment of bias, and publication bias. For the interpretation of detected weaknesses in critical and noncritical items, the AMSTAR recommends a categorization of the overall confidence in the results of the SR as follows: high, moderate, low, and critically low. The assessment of the risk of bias of an SR was supplemented with the Risk Of Bias In Systematic review (ROBIS) guidelines ( 21 ), which allows classification of the existence of bias as low, high or unclear. All rating disagreements were reconciled during discussion meetings.

Figure 2 shows the PRISMA flow diagram of the retrieved articles in this overview. From the initial 96 review articles published between 2013 and 2018, 92 nonduplicated articles were screened for title and abstract. Most studies ( k =66) were removed because the participants presented anxiety symptoms in the context of medical diseases or were nonadults. After eliminating ineligible articles that fell outside the topic of overview, 26 articles were retained for full-text reading. An additional 7 articles were excluded because 6 did not present an SR and 1 did not contain recent data. The reasons for article exclusion can be found in Supplementary Table 2 . Accordingly, 19 recent SRs were included in the final list for the qualitative synthesis. Of these studies, 3 did not estimate the pooled effect size of the outcomes through a meta-analytical quantitative synthesis ( 22 - 24 ).

NA: not applicable - no meta-analysis.

RCT/NRCT : randomized controlled trials/nonrandomized controlled trials.

Table 1 summarizes the main characteristics and methods of the 19 retained studies. From these articles, 11 referred to nonbiological treatments for anxiety (media- or internet-assisted CBT therapy, brief psychodynamic therapy, Morita therapy, effects of safety behavior, practices of exercise, mindfulness, and yoga, etc.), 5 referred to biological treatments for anxiety (repetitive transcranial magnetic stimulation and pharmacotherapy), and 3 referred to multimodal combined treatment comparisons (stepped care vs . care-as-usual and comparison of multiple treatments). All articles were published in English, and the investigators had searched for relevant articles in at least two databases. Although our search was restricted between 2013 and 2018, the majority of retained SRs covered the previous period, from the database inception date up to 2017.

Across the SRs, there were a total of 811 RCTs (range: 2–234 RCTs), with an included total of 87,773 adult participants (range: 40-37,333 patients). Three SRs ( 15 , 35 , 36 ) included over 10,000 participants, 6 SRs ( 25 - 29 , 37 ) between 9,999 and 1,000 participants, 8 SRs less than 1,000 participants ( 22 , 23 , 30 - 34 , 38 ), and 2 SRs did not report the exact number due to the mixture of adult and underage participants ( 14 , 24 ). Most SRs ( k =14) did not report or summarize the percentage of female participants. The other 5 SRs ( 25 , 28 , 30 , 33 , 38 ) indicated the proportion of women (range: 55.5%-67.7%).

Regarding the diagnosis of the participants, the majority of studies investigated the disorder either under a generic diagnostic label of anxiety disorders or common mental disorders. SRs evaluated the effects of specific interventions in social anxiety ( 14 , 15 , 23 , 24 , 35 ), panic ( 14 , 15 , 33 ), generalized anxiety ( 14 , 15 ), and obsessive-compulsive disorder ( 36 ). All articles described the exclusion of ineligible participants (e.g., posttraumatic stress or acute stress disorders, depressive disorders, comorbid physical illnesses, psychotic disorders, nonappropriate psychiatric diagnoses, underage participants, etc.) and inappropriate studies (e.g., small sample size or case studies, sampling or statistical issues, unsuitable interventions, etc.).

The Cochrane’s Collaboration Tool to Assess Risk of Bias was the most commonly used instrument ( k =14) to evaluate the risk of bias in each individual SR. Two SRs ( 14 , 15 ) used the Scottish Intercollegiate Guidelines Network (SIGN) checklist, and an additional 3 SRs ( 24 , 36 , 37 ) did not assess the risk of bias.

Evidence of treatment efficacy

Regarding the results of nonbiological or psychological treatments, 5 SRs evaluated computer-delivered psychological therapy ( 14 , 15 , 25 , 26 , 28 ). The evidence suggested that the online therapeutic approach is a feasible and beneficial treatment option. However, face-to-face therapist-guided therapy seemed to be clinically superior when compared with the computer-guided approach. Additionally, the benefit widely varied in accordance with the type and characteristics of anxiety disorder.

A meta-analysis ( 27 ) reported that short-term psychodynamic psychotherapies appear to show a reduction in anxiety symptoms in the short and medium term. The SR of Morita therapy-a specific type of self-acceptance method-showed data of limited applicability because all eligible studies were conducted in China, restricting the utility of conclusions in Western countries ( 30 ).

Three SRs ( 23 , 24 , 35 ) had specifically included patients with social anxiety. Mindfulness and acceptance-based treatment ( 23 ) was a viable option, but the level of evidence was limited due to the risk of bias. For social anxiety, limited evidence suggested that reductions in the use of safety behaviors or avoidance were related to a better CBT outcome ( 24 ). In addition, symptomatic decreases in social anxiety predicted reduced safety-behavior use over the course of treatment.

Two SRs ( 22 , 31 ) evaluated the benefit of exercise in reducing anxiety symptoms. Both studies indicated that the exercise practice was effective, regardless of the type and intensity of physical activity. However, exercise alone was less effective than standard antidepressant treatment ( 15 ). Although the effect of yoga on anxiety disorder was considered a safe intervention, the gathered evidence for its effects was inconclusive ( 32 ). Main critiques referred to the variety of diagnoses, heterogeneity of interventions, potential bias of low-quality studies, and lack of comparison to other treatments.

Regarding biological or pharmacological treatments, one meta-analysis ( 33 ) assessed transcranial magnetic stimulation in 40 participants with panic disorder. However, there was insufficient evidence to draw any solid conclusion about its efficacy because of the small sample size and significant methodological flaws. In addition to sampling issues (randomization and allocation concealment), the evidence in the 2 RCTs reviewed was of very low quality.

For pharmacological treatments, there was evidence of low-to-moderate quality for the use of selective serotonin reuptake inhibitors (SSRIs) for social anxiety ( 35 ). However, their tolerability seemed to be lower than placebo. The augmentation strategy did not appear to be beneficial in patients with treatment-resistant anxiety disorders, e.g., generalized anxiety, social anxiety, and panic disorder ( 34 ). In a comparison of the effects of second-generation antidepressants for obsessive-compulsive vs . generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and social anxiety disorder (in over 15,000 participants), an SR ( 36 ) found that pharmacotherapy presented a smaller overall change score than placebo for those five categories of anxiety disorders. Finally, an SR of incipient trials of vortioxetine supported its use for anxiety ( 37 ), but more long-term placebo-controlled trials are warranted.

The SR on multimodal combined treatments reviewed 10 RCTs and compared the package of stepped care versus care-as-usual ( 38 ). The authors concluded that the stepped-care model of treatment of anxiety disorders appeared to be superior than care-as-usual in terms of efficacy and cost-effectiveness. As a consequence, stepped care can reduce the burden on service providers and increase availability. In a comprehensive SR on multiple treatment modalities with over 37 thousand participants ( 15 ), the average pre-post effect sizes of medications were more effective than psychotherapies. In general, the effects of psychotherapies did not differ from placebo pills. Surprisingly, not only psychotherapy but also medications and, to a lesser extent, placebo conditions have shown similar enduring effects in the improvement of anxiety disorders ( 14 ). Nevertheless, long-lasting treatment effects observed in the follow-up period were superimposed in patients receiving different therapeutics at the same time.

Quality of evidence

Using the AMSTAR guideline, Table 2 presents the assessment of the quality of each individual SR. The overall confidence of each study was rated after evaluating critical and noncritical items of the AMSTAR. Several SRs ( k =6) were rated as high quality ( 25 , 27 , 28 , 30 , 33 , 35 ); 3, as moderate ( 23 , 26 , 31 ); 7, as low ( 14 , 15 , 22 , 29 , 31 , 34 , 38 ); and 3, as critically low ( 24 , 36 , 37 ). All six reliable articles (AMSTAR high quality and ROBIS low risk of bias) were published in the Cochrane Database of Systematic Reviews and rigorously adhered to the guidelines of the Cochrane’s Collaboration Tool to Assess Risk of Bias.

Most of the studies clearly described the planning phase of the SR, which included explicit research questions, selection criteria, data extraction and assessment of the risk of bias. Not all studies previously registered a protocol before performing the SR. Only 3 studies reported the source of funding of the included studies ( 25 , 30 , 35 ). During the data interpretation, the most frequent problems were no clear discussion of the individual bias of selected studies ( k =9) and did not account for publication bias ( k =5). Notably, the 3 SRs that did not subject the RCTs to a meta-analytical synthesis also presented several shortcomings that critically affected the quality of the articles (e.g., omission of excluded studies, nonevidence-based discussion of results, and no prior protocol registration).

The risk of bias was rated with the aid of ROBIS ( Table 2 ), with 8 SRs having low risk ( 25 - 28 , 30 , 31 , 33 , 35 ); 8, uncertain risk ( 14 , 15 , 22 , 23 , 29 , 31 , 34 , 38 ); and 3, high risk ( 24 , 36 , 37 ). There was a rough agreement between the quality of an SR (AMSTAR) and the risk of bias (ROBIS). Unsurprisingly, while most high-to-moderate quality studies presented a low risk of bias, all three studies of critically low quality also presented a high risk of bias ( 24 , 36 , 37 ). In Supplementary Table 3 , detailed ROBIS ratings for each retained study are shown.

Supplementary Table 2

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4. Spiegel SB. Current issues in the treatment of specific phobia: recommendations for innovative applications of hypnosis. Am J Clin Hypn. 2014;56(4):389-404.

5. Reinhold JA, Rickels K. Pharmacological treatment for generalized anxiety disorder in adults: an update. Expert Opin Pharmacother. 2015;16(11):1669-81.

6. Shahar B. Emotion-focused therapy for the treatment of social anxiety: an overview of the model and a case description. Clin Psychol Psychother. 2014;21(6):536-47.

7. Gotink RA, Chu P, Busschbach JJ, Benson H, Fricchione GL, Hunink MG. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PLoS One. 2015;10(4):e0124344.

The current overview summarized the evidence of the efficacy of emerging treatment options in the last 5 years for adult patients with an anxiety disorder. The conclusions of 19 relevant SRs were synthesized and combined, for a total of 87,773 participants distributed in 811 RCTs. There was great cross-study heterogeneity in terms of the research question, target disorder, type of intervention, methodology, number of included RCTs, sample size of participants, and measured outcomes. Most studies investigated the benefit of different forms of psychotherapy and physical activity. In terms of biological treatments, no great evidence of effectiveness was found for transcranial magnetic stimulation and pharmacological strategies (drug augmentation or novel agents).

Newer treatments for anxiety disorders are highly relevant because the majority of cases are underdetected and undertreated within health-care systems, even in economically developed countries ( 14 ). Most anxious patients worldwide do not receive standard treatment with combined psychotherapy and pharmacological agents in terms of adherence, frequency, and adequacy ( 6 , 9 , 11 ). Consequently, untreated patients with these disorders chronically endure these symptoms, which are associated with severe impairments and restrictions in role functioning and disabilities ( 6 ). The present overview of SRs presented a resynthesis of existing data to allow better choices among emerging interventions for anxiety disorders. This rapid review of high-quality evidence can be of great clinical utility for decision-makers and public health administrators. Until more robust evidence is published, the initial enthusiasm for many proposed anti-anxiety alternatives has shrunk. Meanwhile, the evidence of many therapeutic alternatives should be watchfully disseminated to the community.

Interpretation and implications

From the present overview, there is convincing evidence that computer-delivered psychological treatment is helpful for the treatment of distressing anxiety of different intensities ( 25 ). However, the therapist-oriented CBT approach has yielded better results ( 25 , 28 ). Along similar lines, short-term psychodynamic psychotherapies have shown consistent gains, but larger studies with specific anxiety disorders are warranted ( 27 ). From a public health standpoint, computer-assisted treatment is not readily accessible in several nondeveloped countries, but this strategy can benefit those patients living in distant places or unwilling to start formal psychotherapy. Furthermore, sharing a single computer device and delivering brief psychotherapy are cost-effective for a community ( 40 ).

There is evidence of moderate-to-high quality suggesting that the online approach may be favorable and more efficacious than a wait list, informational pamphlets, or online discussion groups ( 25 ). Therefore, the self-help approach can be recommended as the first step in the treatment of mild anxiety disorders, but the short- and long-term effects of computer-delivered interventions and brief psychotherapies need to be fully established.

Although the SR of Morita therapy was of high quality and free of the risk of bias, its applicability is limited ( 30 ). All 7 RCTs of Morita therapy were conducted in Eastern countries, curbing its generalizability to Western populations ( 41 ).

Two promising high-quality SRs still required additional evidence of effectiveness with additional RCTs; pioneering transcranial magnetic stimulation ( 33 ) and the use of SSRIs in social anxiety ( 35 ) have shown insufficient evidence of efficacy. The SR of transcranial stimulation studies was conducted on 2 RCTs with 40 patients with panic disorder. Therefore, further trials with a larger sample are needed. The use of SSRIs in social anxiety has shown low-to-moderate evidence of efficacy and was less tolerable than placebo ( 35 ). These two strategies can be advised for specific anxiety disorders and those patients who presented partial response or refractoriness to standard treatment ( 35 , 42 - 45 ). In a further meta-analysis based on weekly outcome data ( 46 ), the treatment benefits of SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs) were shown for social anxiety. Higher doses of SSRIs, but not SNRIs, were associated with symptomatic improvement and treatment response. However, the potential risk of intolerance may surpass the benefit to the patients ( 46 ).

With an ever-growing list of psychotropic compounds showing apparent anxiolytic properties, current pharmacological options for treating clinical anxiety are broad and vast. Existing SRs ( 14 , 15 ) demonstrate that the magnitude of efficacy for most anxiolytic agents compared with placebo was superior. However, the likelihood of symptomatic remission after a pharmacological trial remains largely unknown. Progress in neuroscience and neurophysiology may unravel the pathways of therapeutic responsiveness.

Thus, the generalizability of emerging treatments, e.g., transcranial stimulation and newer pharmacological strategies, is limited due to sampling issues, methodological flaws, and applicability in specific anxiety disorders. These potential interventions might not be available to all consumers, and therefore, larger and more pragmatic RCTs are needed to evaluate and maximize the benefits of available interventions ( 42 - 45 ).

Behavioral recommendations of regular exercise ( 22 , 31 ), mindfulness practice ( 23 ), and yoga ( 32 ) have also been shown to be beneficial for improving anxiety symptoms. However, these SRs were of low-to-moderate quality and vulnerable to the risk of bias. The universal campaign of healthy activities might be recommended as an adjunctive treatment to standard treatment and a cost-effective strategy in regions where there is a shortage of qualified therapists. Nonetheless, these practices were less effective when compared with antidepressant pharmacotherapy ( 15 ). Even without sufficient evidence of effectiveness, these nonstandard treatments seem to be safe, inexpensive and can be easily implemented with preventive purposes to community dwellers ( 47 ).

Although methodological questions remain before its broad implementation can be supported, the personalized therapist-guided CBT approach is the most recommended nonpharmacological treatment for anxiety ( 48 ). Similarly, while the practice of physical activities is safe and helpful, traditional antidepressant treatment presents better results ( 9 , 14 ). One unanswered question refers to the potential adverse effects of the nonsupervised use of computer-assisted therapies and exercise practice. These concerns need to be refined in future RCTs.

Among those patients receiving long-term treatments with partial response or refractoriness, it is possible that novel strategies can enhance and sustain the improvements in anxiety. Hence, there is a large amount of room for amendments to treatment plans ( 34 - 38 ), at least for specific and severe anxiety disorders. Future studies should include stratification of anxiety by severity status and persistence to characterize the dose-response relationship of interventions and the combined efficacy of psychotherapy and pharmacotherapy in treating anxiety disorders, in addition to rule out potential confounding factors that affect treatment effectiveness ( 49 , 50 ).

Some SRs were untrustworthy due to their low quality and serious biases. For example, the impact of safety behaviors in social anxiety remains unknown ( 24 ), as well as the reduced response to placebo and antidepressants in obsessive-compulsive disorders ( 36 ) and the benefit of vortioxetine for the treatment of anxiety disorders ( 37 ). In general, the most common shortcomings were the lack of a published protocol, unclear study selection, inadequate search strategy, lack of explicit inclusion and exclusion criteria, nonexhaustive assessment of bias, invalid interpretation, and no report of publication bias. Consequently, these topics require urgent clarification, using a more stringent methodology and longer follow-up to answer the proposed research question.

Limitations

The heterogeneous interventions reported in these SRs with diverse outcomes preclude conducting a quantitative meta-analytical synthesis as an umbrella review ( 17 - 19 , 39 ). However, the present systematic overview has assessed the risk of bias of each individual SR, and it is secure to claim that most of the evidence reported herein was trustworthy.

The search for recent SRs on the treatment of anxiety disorders has identified main review articles, but some gray literature might have been missed. Although the studies in the Cochrane library were covered in PubMed and EMBASE, ongoing SRs must be finalized to draw solid conclusions. Along these lines, the Cochrane register and PROSPERO data were not scanned to detect other SRs. However, preliminary findings or unpublished SRs should not be integrated into the present overview. It is possibly that a selection bias of new treatment alternatives for specific anxiety disorders occurred at the time of the search. The potential omission of ongoing RCTs cannot be ruled out, but untrustworthy or partial evidence should not be taken as high-quality information.

A potential bias of overview studies is overlap in the retrieved articles or the use of the same primary study in multiple included SRs ( 51 , 52 ). In the present review, most of the treatment modalities were addressed by only one included SR, which probably reduced the probability of overlap across those studies. However, there were two interventions that were addressed by multiple studies: media-delivered psychotherapy and physical exercises. Five SRs examined media-delivered psychotherapy, with a total of 463 RCTs included in the reviews. It is possible that overlap occurred across these SRs, and subtle differences exist regarding the sample, scientific question, comparator, and inclusion of therapist. Therefore, we cannot rule out the possibility of overlapping articles, and the strength of the conclusion about media-delivered psychotherapy should be softened. In contrast, in the two existing SRs on physical exercises, we found 16.7% overlap across the included RCTs. In addition, the overall quality of the articles on physical exercise was low-to-moderate according to the AMSTAR analysis. This fact likely endorses the lower efficacy of physical exercises than standard care.

The covered period of five years may have not included all published studies before 2013. Nevertheless, these recent articles have offered updated coverage of previous studies conducted more than five years ago. Because our primary goal was to condense recent advances on the evidence-based therapeutics for anxiety, well-known modalities were outside the scope of the present review. Notwithstanding, two comprehensive meta-analyses conducted by Bandelow’s group ( 14 , 15 ) provided a broad summary of existing evidence on treatments for anxiety disorders, as well as the comparative enduring effect of psychological treatments and efficacy of treatments.

Trials with negative results might remain unpublished, and practitioners continue advising off-label use without any evidence of effectiveness or benefit. This publication bias of the file drawer effect cannot be ruled out. Small study bias and excluded participants may have affected the scientific soundness of the conclusions. For example, repetitive transcranial stimulation still requires a larger sample ( 42 - 45 ), and Morita therapy should be investigated in Western countries and regions in different stages of development ( 41 ).

CONCLUSIONS

The present overview of recent treatment trends for anxiety disorders provides an account of the evolving directions to pursue, in terms of state-of-art scientific development. Effective and older treatments should be enhanced with technological innovations such as computer-based CBT and supplemented by adjunctive physical activities. New biological or pharmacological treatment modalities for anxiety disorders still need further evidence of usefulness. Thus, all treatments for anxiety disorders with proven effectiveness should be continuously investigated to make them available to the community.

The worldwide burden of anxiety disorders is high. Therefore, obtaining access to reliable health-care services is a bonafide and essential need in a globalized world. However, direct-to-consumer universal access to emerging treatments for anxiety should be recommended only after demonstration of robust evidence of efficacy.

Supplementary Table 1 - Search Strategies

DATABASE #1

• Article types: Review
• Time period covered: Last 5 years
• Language: English, Portuguese and Spanish
• Age: Adults 19+
• Species: Humans

Search strategy:

anxiety disorders[Title/Abstract] AND treatment[Title/Abstract] AND (Review[ptyp] AND “2013/01/01”[PDAT] : “2018/12/31”[PDAT] AND “humans”[MeSH Terms] AND (English[lang] OR Portuguese[lang] OR Spanish[lang]) AND “adult”[MeSH Terms])

# of articles retrieved: 72

DATABASE #2

• Time period covered: 2013-2018
• Age: Adults

‘anxiety disorder’:ab,ti AND ‘treatment’:ab,ti AND [review]/lim AND ([english]/lim OR [portuguese]/lim OR [spanish]/lim) AND [adult]/lim AND [humans]/lim AND [2013-2018]/py

# of articles retrieved: 22

AUTHOR CONTRIBUTIONS

Mangolini VI and Wang YP contributed equally to the manuscript and were responsible for the study conception, data acquisition and extraction, and manuscript drafting. Andrade LH and Lotufo-Neto F have critically reviewed the discussion and conclusion. All of the authors approved the final version of the submitted manuscript.

Supplementary Table 3

Acknowledgments.

V.I.M. has been awarded a scholarship for graduate students from the São Paulo Research Foundation (FAPESP #2017/15060-0). The National Council for Scientific and Technological Development (CNPq) supports L.H.A.

No potential conflict of interest was reported.

JEE Main Result 2024: 10 Reasons Why You Could Not Score Well

Jee main results: 10 common factors affecting student scores.

Discover why some students may not have scored as well as expected in the JEE Main exam. From time management to conceptual gaps, explore common pitfalls and learn valuable tips to improve your performance in this informative web story.

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Lack of Consistent Practice

JEE Main requires consistent practice throughout your preparation. Cramming last minute might not be enough. Develop a study schedule and stick to it. Solve previous year's papers and mock tests regularly.

Time Management Issues

Time pressure is a real challenge in JEE Main. Poor time management can lead to rushing through questions or leaving some unattempted. Practice time management skills during mock tests. Analyze which sections take more time and strategize accordingly.

Conceptual Gaps

Understanding core concepts is crucial. If you have weak foundational knowledge, solving complex problems becomes difficult. Identify your weak areas through mock tests and previous year's papers. Focus on clearing those concepts by referring to textbooks or seeking help.

Exam Anxiety

Exam anxiety can cloud your judgment and hinder performance. Feeling overwhelmed can lead to silly mistakes. Practice relaxation techniques like meditation or deep breathing exercises. Get enough sleep before the exam. Visualize yourself performing calmly and confidently.

Overdependence on Coaching/Study Material

While coaching and study materials can be helpful, solely relying on them might not be enough. You need to develop independent learning skills. Don't be afraid to explore different resources and teaching styles. Develop your own problem-solving approach.

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Not focusing on previous year's papers.

Previous year's papers offer valuable insights into question patterns and difficulty levels. Practice solving as many previous year's papers and mock tests as possible. Analyze the solutions and identify recurring concepts.

Neglecting Mock Tests

Mock tests help simulate the actual exam environment and identify areas needing improvement. Take regular mock tests under timed conditions. Analyze your performance and work on your weaknesses.

Ignoring Syllabus and Important Topics

JEE Main has a specific syllabus. Focusing heavily on non-syllabus topics can waste valuable time and effort. Always prioritize the official syllabus and focus on understanding important high-weightage topics first.

Unhealthy Habits and Lifestyle

Your physical and mental well-being significantly impacts your focus and concentration. Poor sleep or unhealthy eating habits can affect your performance. Maintain a healthy sleep schedule. Eat nutritious food and exercise regularly to improve your focus and energy levels.

Comparing Yourself to Others

Everyone has their own learning pace and strengths. Constantly comparing yourself to others can lead to discouragement and demotivation. Focus on your own progress and celebrate your personal achievements.

Thanks For Reading!

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