Test anxiety -- in kids or adults -- can be neutralized

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

If you're heading back to the classroom, you may also be facing a type of anxiety that arises when it's test time. Lots of kids and adults face test anxiety, but there are some strategies that can help. We'll hear about them from my guest, Mr. John Ringhisen. He's a nurse practitioner of psychiatry and behavioral sciences at Upstate.

Welcome back to "The Informed Patient," Mr. Ringhisen.

John Ringhisen, NP: It's good to be back, Amber. I appreciate you having me.

Host Amber Smith: So how common is test anxiety?

John Ringhisen, NP: It's amazingly common, particularly in my practice, where I handle a lot of the medication management and psychiatry services for Upstate Medical University.

So a great deal of my patients deal with test anxiety, but it's also very common in the community, and not just with people that are going to school or in academic settings.

Host Amber Smith: Is some degree of anxiety about a very important test considered normal?

John Ringhisen, NP: It is. Some level of anxiety is a natural response to going into a situation where you're going to be evaluated.

Whether you have test anxiety really speaks to how impaired or how much being anxious interferes with your ability to successfully perform to your satisfaction on an exam, assuming that you've done the proper studying, and you've prepared yourself for the exam.

Host Amber Smith: So what is the youngest age that it might become apparent?

John Ringhisen, NP: I've heard of cases in the pediatric providers that I work with, that they see kids as young as when they first start going to school all day, kindergartners, first graders, where you don't think of them being tested, but think of it more as performance anxiety. The idea that they need to have the right answer or the idea that they need to behave a certain way starts becoming a very anxious situation for the child.

Host Amber Smith: For someone as young as, like, a kindergartner, what would be the signs and symptoms that would clue a teacher or a parent that something's up?

John Ringhisen, NP: Usually what you start to see is where the child starts to become more and more avoidant of participating in class because they're trying to avoid the anxiety of having to have the right answer right on the spot at home. Parents will find that their children just don't want to go to school, or they're very anxious around school, and school becomes a real burden for them.

Host Amber Smith: Are there physical symptoms? Even as kids get older and

they start recognizing that tests stress them out, do they experience physical symptoms?

John Ringhisen, NP: Some of them can. They'll describe kind of the symptoms that you associate with anxiety that you feel on your body, where your chest might get very tight, you might get short of breath, you might break out into a sweat. Some people's sleep can be really disturbed because they're so worried about being in a testing situation or having to perform at school that they ruminated about things at night and don't sleep very well.

Host Amber Smith: Is there a personality type that is more or less likely to have test anxiety?

John Ringhisen, NP: No, not really. We do see performance anxiety and specifically, test anxiety, across all kinds of personality types. I've even seen some professionals that you would think wouldn't have any trouble speaking in front of a large group or being evaluated for, say, like, a raise or a performance enhancement at work suddenly get very nervous in those situations.

Host Amber Smith: What type of tests are we talking about? Because there's a wide variety, from pop quizzes to these short, little, maybe even daily, tests that some teachers may give, versus, like, a semester exam. Do you see anxiety across the board?

John Ringhisen, NP: I do. I see it more often on what are considered high-value examinations, where there's a large percentage of the grade that's associated with the exam, those midterm semester exams or the final exams for a course, or sometimes, even large papers or large assignments that have a large weight in the class, can become more anxiety provoking than say, a pop quiz or a regular daily test over the knowledge of what they had to read the night before.

Those don't have as much of an impact over their overall evaluation. So with being less valuable, they don't get as anxious about those events.

Host Amber Smith: So do we know what causes anxiety like this?

John Ringhisen, NP: It's really an anxious response to any other stressor that somebody might experience. It just happens to be more acute and more focused in the academic setting, or it comes to people's increased notice in an academic setting because we don't really test ourselves outside of school. When we start working on the job, the idea that you have to sit down and take a written exam where you have to get the right answer, that's not something you typically do with your work. So it's really in the academic setting that we see this kind of performance anxiety where being in an exam situation really manifests itself.

Host Amber Smith: So someone who really struggles with this in school, they can look forward to it ending once they graduate or are they likely to see other types of anxieties crop up?

John Ringhisen, NP: They could see other types of anxieties crop up, where if they're not addressing the underlying thought or the underlying belief of being evaluated, that causes that really big spike in their anxiety that makes performing on a test very difficult for them if they run into a similar situation.

Some of the ones that I listed before were like, say an employer wants to evaluate you for a raise, or you're going into an interview situation where you feel like you're going to be judged and evaluated as to whether you're appropriate for a position or not.

I've seen people that struggled with test anxiety during childhood struggle in similar ways in those situations where they're being judged and evaluated.

Host Amber Smith: So test anxiety can crop up later in life in stressful situations.

John Ringhisen, NP: Yeah, that's what I was kind of talking about where sometimes you see it crop up in people once they get out of school. Where I see it the most is job interviews. They go into an interview where they don't interview very well because they're so anxious about being just the focus of the conversation and the focus of being judged or evaluated as to whether you're going to be appropriate for a job.

That's probably the most common area where I see a carryover later into life, where people who struggle and come to me as adults saying, "I can never interview," or "I can never stand up in front of people, and I'm very bad at public speaking, and that's becoming more part of my job as you move up in management, you're expected to talk to and communicate with your coworkers. I'm very bad at that."

When I have a discussion with them, one of the questions I ask is, is this something that's persisted or is this something that you struggled with a lot as a kid? Did you have a lot of test anxiety or did you struggle on group projects or speaking in front of the class or anything like that?

And a lot of times those individuals say, "Yeah, I had a really hard time testing as a kid."

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with nurse practitioner John Ringhisen from psychiatry and behavioral sciences at Upstate, and we're talking about test anxiety.

I'm curious if this is something that should be diagnosed and treated.

John Ringhisen, NP: It should be diagnosed and treated as part of an overall anxiety disorder. We don't have a specific diagnosis for test anxiety. It's usually more contained with the idea of being socially anxious and a social anxiety disorder, or being generally anxious and as part of a generalized anxiety disorder.

Host Amber Smith: So you would assess somebody overall. Might there be medications involved?

John Ringhisen, NP: There could be. We typically try to start with behavioral interventions, where test-taking skills, studying skills, things that will make somebody more confident in their academic performance and their academic capabilities so that the idea of being evaluated on those skills is not as much of a stressful situation for them.

I have prescribed as-needed medication so that that way you're not taking something every day. Just a few minutes before you go into a really difficult exam or a situation where you know you're going to be anxious, you take something, like an antihistamine. One I use, very common, is called Vistaril, or hydroxyzine. It's kind of like a non-drowsy Benadryl. And the idea is that that calms your body enough so that by you not having such a strong response in how you feel, you're not sweating, your heart rate hasn't really kicked up, you're not feeling really anxious, hopefully, because you're more comfortable going through the exam experience.

And it's important with those as-needed medications to kind of pre-medicate. It's kind of like chasing pain in the hospital. You'll hear about people having surgery, and the physical therapist comes in, and before the physical therapist comes in to do any kind of range-of-motion exercises, your nurse gives you something for your pain so that you can be a better participant in your physical therapy.

It's the same idea of anxiety. It's much easier and much more successful with an as-needed medication to get ahead of the anxiety rather than try to chase it after you're already starting to really freak out in an exam situation.

Host Amber Smith: What happens if somebody has severe test anxiety, but they don't get treatment?

They go unrecognized, they fall through the cracks or whatever. Does it tend to get worse?

John Ringhisen, NP: The test anxiety itself usually doesn't get worse, but what we see is the anxiety starts to bleed over into other areas of life. They start becoming increasingly socially anxious, and they become avoidant of social situations where they're feeling judged and evaluated.

They might become more critical of themselves. And when that starts to happen, you start to see people get really down on themselves, and you might see symptoms of depression and sadness start to crop up because the anxiety is limiting or making them more critical of themselves because they're not performing well in those testing situations.

Host Amber Smith: So it sounds like it is important to recognize this.

John Ringhisen, NP: It is. It's important that if you feel like you are putting extra effort, extra time and extra energy into just being able to sit comfortably through an exam or evaluation, consider the idea that there might be something going on outside of school. Or inside the context of what you're trying to accomplish with your academics that you need to speak with somebody about.

Because I've also seen situations where, there's a very stressful situation at home. I have a lot of adult learners, and if there's upset in the home or just the idea of going back to school, the test anxiety doesn't have to be directly related to you doing poorly or being worried about your academics. It could be anxiety from outside of the classroom following you into the testing room.

Host Amber Smith: People might be aware of test anxiety from a common but unpleasant dream called the examination dream. People can have one of these years after they've left school. They dream that they're in a classroom again, a test is being passed out, and they're totally unprepared for it, and they panic.

John Ringhisen, NP: It's interesting that you bring up dreams because the thought and the idea behind how we dream and why we dream is something that I look at a lot in my work because I look more at the emotional context of what's happening in the dream, less so than the narrative context of what's happening.

So in what you talked about there where somebody's feeling very anxious at work, maybe it's not even related to being tested or anything like that, just they're stressed right now. The brain is going to cast a wide net over your entire life experience, and it's kind of like doing a Google search for "afraid." you get a couple trillion hits on "afraid," but your brain kind of pulls the top ones that kind of relate to how you're feeling in the moment and decides to play the best virtual reality scene for you to try to keep you asleep. because that's what dreams really are. They're the guardians and protectors of sleep. That's a very Freudian thing.

So what your brain's trying to do is keep you asleep while you're anxious to preserve and protect your sleep and also give you an opportunity to try to come to resolution with the idea of feeling and being anxious. I'll use myself as an example. When I start to get really anxious, or I know I'm really worried about something, my dreams start to take on the West Point context because four years of West Point was a very anxious experience for me. But I made it through. I successfully graduated. I did fine, but that's what my brain does to me, and I think that's the experience that my brain is trying to give me. Here's a situation where you felt a lot like what you do right now, but you got through it, you were able to navigate it. So it's trying to normalize or kind of remodel the experience that I'm having right now, subconsciously while I'm dreaming, so that that way when I wake up, maybe I feel a little better.

Host Amber Smith: Well, let's talk about if there are some preventive strategies. You mentioned sitting comfortably. Does that have an impact?

John Ringhisen, NP: Sitting comfortably does. And what I mean by sitting comfortably, one of the behavioral interventions that I recommend often to people that struggle with test anxiety is really around the test-taking skills that a lot of the learning centers teach our students here at Upstate and how they approach an exam. Making sure that you've used the restroom before you go into the room, making sure if you are going to use a medication that you've taken it before you go into the room, making sure that all the other stressors, of what am I going to wear? Do I need to pack a lunch? Do I have enough water? Try to take care of much of that stuff ahead of time. So it's less to worry about as you walk into the exam. And then make sure that your environment is comfortable. And some people, I even recommend practicing in a similar environment to the test taking environment that you're going to be in.

Sometimes they give tests here at Upstate that are in some of the larger lecture halls. So just being in such a big open space makes people feel very anxious while they're sitting during their exam, so I encourage them to try to study in places like that. So it's like a level of exposure therapy where as you get used to being in large spaces like that, doing your academic work, maybe that translates over to feeling less anxious in the testing environment.

Host Amber Smith: Is there anything that loved ones can do, parents or teachers, or not do that would help kids who have test anxiety?

John Ringhisen, NP: I think I would rather focus on what I would encourage people to do in this situation because each individual situation is going to be so unique to the individual and the relationship that they have with the person that's trying to be supportive in this case.

The biggest and most important thing that I think teachers and parents and loved ones can do to support somebody who's struggling with this is to try to be validating in the language that you use when you're talking with them. What I mean by that is recognizing that it's a real thing, that it's not just something that is wrong with the individual or something that they just need to suck it up or be more resilient about it. Recognize that this struggle is real to the person that's experiencing it, and that it is a real problem that needs to be addressed and that seeking help is something that is worthwhile and going to help them be better in what they're trying to achieve.

Host Amber Smith: Well, thank you. I appreciate you making time for this interview, Mr. Ringhisen.

John Ringhisen, NP: I greatly appreciate you having me back, Amber.

Host Amber Smith: My guest has been Mr. John Ringhisen. He's a nurse practitioner of psychiatry and behavioral sciences at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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