Вы находитесь на странице: 1из 12


discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/46425791

Sport-related Performance Anxiety in Young

Female Athletes

Article in Journal of pediatric and adolescent gynecology December 2010

DOI: 10.1016/j.jpag.2010.04.004 Source: PubMed


18 712

3 authors, including:

Hatim Omar
University of Kentucky


All in-text references underlined in blue are linked to publications on ResearchGate, Available from: Hatim Omar
letting you access and read them immediately. Retrieved on: 15 November 2016
J Pediatr Adolesc Gynecol (2010) 23:325e335


Sport-related Performance Anxiety in Young Female Athletes

Dilip R. Patel, MD1, Hatim Omar, MD2, and Marisa Terry, BS1
Michigan State University College of Human Medicine, Kalamazoo Center for Medical Studies, Kalamazoo, Michigan; 2University of
Kentucky School of Medicine, Lexington, Kentucky, USA

Abstract. The prevalence of anxiety disorders in adoles- is reported to be no more stressful than many other ac-
cents range from 6% to 20%, and it is much higher for anx- tivities of daily student or work life in general where
iety symptoms not meeting criteria for a specific anxiety competition is involved and performance is measured.
disorder. The prevalence is much higher in females. Some level of sport related performance anxiety is
Athletes participating in sports experience different levels
considered to be normal and healthy; however, ex-
of stress from competitive sports. For most young athletes
(generally 13 to 24 years old, i.e., high-school and college
treme anxiety in athletes can be detrimental in these
age group) sport participation is reported to be no more performance situations. A number of factors may con-
stressful than many other activities of daily student or work tribute to the development, severity, and persistence
life in general where competition is involved and perfor- of performance anxiety related to sport participation.
mance is measured. Some level of sport related perfor- This article reviews the definitions, theories, clinical
mance anxiety is considered to be normal and healthy; presentation, evaluation, and management principles
however, extreme anxiety in athletes can be detrimental of performance anxiety symptoms in young athletes.
in these performance situations. A number of factors may
contribute to the development, severity, and persistence of
performance anxiety related to sport participation. This ar- Definitions
ticle reviews the definitions, theories, clinical presentation, In the context of sport participation competitive anx-
evaluation, and management principles of performance iety is defined as a tendency to perceive competitive
anxiety symptoms in young athletes.
situations as threatening and to respond to these situ-
ations with feelings of apprehension and tension. 1
Anxiety symptoms are related to the stress of partici-
Key Words. Performance anxietyArousalCogni- pation in sports. Stress results from an imbalance be-
tive behavior therapyCompetitive state anxiety tween perceived environmental demands and the
Competitive trait anxietySport anxiety scale perceived response capability of the athlete.1 Anxiety
Sport competitive anxiety test is an apprehensive anticipation or fear by the individ-
ual of some dangerous occurrence in the future.2 Anx-
iety is usually accompanied by unpleasant feelings,
stress or tension, and somatic symptoms and signs.
Introduction Sport related anxiety symptoms may or may not be in-
dicative of an anxiety disorder. The Diagnostic and
The prevalence of anxiety disorders in adolescents Statistical Manual of Mental Disorders, 4th edition,
range from 6% to 20%, and it is much higher for anx- Text revision (DSM-IV-TR), defines anxiety disorder
iety symptoms not meeting criteria for a specific anx- as persistent fear or worry that causes significant dis-
iety disorder. The prevalence is much higher in tress and impairment of age-appropriate functioning
females. such as school work, play, occupation, and interper-
Athletes participating in sports experience different sonal relations.2 The symptoms in anxiety disorder
levels of stress from competitive sports. For most take up a significant amount of daily time of the indi-
young athletes (generally 13 to 24 years old, i.e., vidual and can last over a period of several months,
high-school and college age group) sport participation typically 6 or more months. Types of specific anxiety
disorders as classified in the DSM-IV-TR are listed in
Address correspondence to: Dilip R. Patel, MD, 1000 Oakland Table 1.2 Various types of sport-related anxiety are
Drive, Kalamazoo, MI 49008; E-mail: patel@kcms.msu.edu summarized in Table 2.1,3e10
2010 North American Society for Pediatric and Adolescent Gynecology 1083-3188/$36.00
Published by Elsevier Inc. doi:10.1016/j.jpag.2010.04.004
326 Patel et al: Performance Anxiety in Young Female Athletes

Table 1. Classification of Anxiety Disorders* Table 2. Terms Used to Describe Types of Sport-related Anxiety
Panic disorder without agoraphobia
Agoraphobia without history of panic disorder Competitive Anxiety induced by a specific
Specific phobia State Anxiety competitive situation such as
Social phobia a team game that requires
Obsessive-compulsive disorder performance. May encompass
Posttraumatic stress disorder worry about failure, others
Acute stress disorder expectations, social critique, and
Generalized anxiety disorder parental pressure.
Anxiety disorder due to a general medical condition Competitive Anxiety that is an enduring
Substance-induced anxiety disorder Trait Anxiety characteristic of a persons
Anxiety disorder not otherwise specified personality which influences ones
Separation anxiety disorder perception of a competitive
*Partly based on data from DSM-IV-TR.
Somatic Anxiety Physiological expression of anxiety
(e.g., sweat, tremor, tachycardia).
Methods Cognitive Anxiety Psychological expression of anxiety
(e.g., negative thoughts about
Our main aim is to review the definitions, theories, performance, worry, inability to
presentation and management of performance anxiety concentrate, and inattention).
Behavioral Anxiety Behavioral expression of anxiety
symptoms in young athletes, with special consider- (e.g., body language,
ation to female athletes. A PubMed search was done communication patterns,
using key terms anxiety, sports, and athletes, psycho- restlessness).
pharmacology and anxiety, of English language liter- Performance Anxiety Anxiety or fear which negatively
ature; all types of articles were included. Relevant affects the attempted activity, also
known as Stage Fright.
articles, including reviews, were selected. Relevant Facilitative Anxiety Anxiety that results in improved
chapters of the most recent editions of standard text performance.
books were reviewed. A secondary search of bibliog- Debilitative Anxiety Anxiety that results in worsened
raphies of the articles and chapters was done to obtain performance.
additional key articles. Precompetition Anxiety prior to the onset of
Anxiety competition which is reflective of
the objective and perceived
Epidemiology requirements of the individual or
The exact prevalence of sport-related anxiety symp- team to participate in the contest.
toms is difficult to ascertain because of difference in May be influenced by the type of
sport, importance of the contest,
severity, definitions, and assessment tools applied. amount of time before the
Numerous studies report a range of sport related per- competition starts, and personality
formance anxiety symptoms in team and individual of the athlete.
sports; however, large scale epidemiological data are Competition Anxiety Anxiety that occurs during a
not available.8,11e32 Many factors have been identi- competition. May be influenced by
the importance of the contest,
fied that influence the development, severity, and currentsituation, previous
persistence of sport-related performance anxiety.33e65 performance, and personality of the
See Table 3. athlete.
Prevalence of anxiety disorders that meet the Postcompetition Anxiety after the completion of the
DSM-IV-TR criteria in adolescents is estimated to Anxiety competition. May be influenced by
perceived performance, win or loss,
be 6e20%; however a higher percentage may have and sense of enjoyment during the
anxiety symptoms that do not meet the criteria for competition.
a specific disorder.2,3,8 An estimated 2% of individ-
uals are affected by debilitating performance anxi-
ety.22 Worry about performing poorly in sports is
reported to be greater in female athletes and older ath-
letes, whereas male athletes report higher levels of Development of anxiety and how it affects sport
concentration disruption in competitive sport situa- performance has been studied extensively. In the con-
tions.22 Vardar et al investigated the prevalence rate text of sport participation, arousal refers to a continu-
of disordered eating behaviors in young female ath- ous scale of mental and physical attentiveness,
letes and compared the anxiety levels of the athletes ranging from heavy sleep to intense excitement.1
with or without disordered eating behaviors; athletes The main theories of arousal, related anxiety symp-
with disordered eating behaviors were found to have toms, and their relationship to sport performance are
higher state and trait anxiety scores.29 summarized in Table 4.66e77
Patel et al: Performance Anxiety in Young Female Athletes 327

Table 3. Factors that Influence Development, Severity and Anxiety symptoms may occur before, during, or af-
Persistence of Anxiety Symptoms ter the event and include cognitive, behavioral and
Achievement goals
physiological symptoms and signs.4,8,18,19,79 Cogni-
Career maturity tive signs and symptoms include indecision, a sense
Clarity of completion goal of confusion, negative thoughts, poor concentration,
Coaching behaviors and style irritability, fear, forgetfulness, a lack of confidence,
Commitment to sport images of failure, negative self-talk, feeling weak, in-
Coping skills
Difficulty of sport routine
ability to follow instructions, and thoughts of avoiding
Expectations of performance participation. Somatic signs and symptoms include in-
Experience creased blood pressure, racing heart, fast breathing,
Fear of failure sweating, cold and clammy hands and feet, butterflies
Game location in the stomach, dry mouth, need to urinate, muscular
Intensity of the sport
tension, tightness in neck and shoulders, trembling,
Level of competition blushing, pacing up and down, distorted vision,
Motivational climate twitching, yawning, nausea, vomiting, diarrhea, loss
Perceived abilities of appetite, and loss of sleep. Behavioral signs and
Performance setting symptoms include biting fingernails, defensive man-
Pre-competition mood state
nerisms, inhibited posture, repetitive movements,
Significance of win or loss withdrawal, aggressive outbursts, fidgeting, avoiding
Social support eye contact, and covering face with hands. Some ath-
Sports context letes may choke or be debilitated to the point of be-
Team cohesion ing unable to participate in sports.
Team goal
Underlying anxiety traits
Sport-related performance anxiety in principle is
similar to social phobia; however, there are subtle dif-
ferences between the two, especially when it is debil-
itating. Social phobia is related to exposure to or
anticipation of certain social or performance situa-
Clinical Presentation tions in which evaluation or scrutiny by others is
Athletes who experience sport related performance likely. In social phobia the overall impairment is more
anxiety may present with a wide spectrum of symp- pervasive, focus of fears is most interactions with
toms and signs ranging from mild to debilita- others, expectations of self are low, fear of scrutiny
ting.4,6,8,78e80 Athletes often seek help because their by others is primary, anticipatory anxiety is high,
anxiety before and during an event causes them to and the commitment to feared task is low.22 In debil-
perform at a level well below their demonstrated ca- itating sport-related performance anxiety the impair-
pabilities.22 Deterioration of performance may be ment is limited to sport participation, focus of fears
sudden or insidious, lasting over several weeks or is limited to a specific performance situation, expecta-
months, referred to by some as a slump.80 tions of self are high, fear of scrutiny by others is

Table 4. Theories of Arousal-Athletic Performance Relationship

Theory Comments

Drive Theory70 Motivation to compete creates a state of heightened arousal which allows an athlete to perform at his or
her highest skill level during the competition in order to fulfill the motivation and achieve subjective
relaxation at the end of the competition.
Inverted-U Hypothesis76 Describes a continuous relationship between performance and arousal. The best performance occurs at
the midpoint of arousal. Either increased or decreased arousal relative to the peak causes decreased
Multi-Dimensional Anxiety Explores 2 components of anxiety: (1) Cognitive anxiety (negative thoughts, concerns about
Theory1 performance, disrupted concentration) that originates from a fear of evaluation, and (2) Somatic
anxiety (classically-conditioned physical reactions to competition including sweating, increased heart
rate, tremor, unsettled stomach).
Individual Zone of Optimal Hypothesizes that athletes are able to interpret emotions within a predetermined construct and regulate
Function Theory71 their psychological state to facilitate optimal performance.
Reversal Theory74 Postulates that an athlete can selectively perceive his or her level of arousal and physical reactions as
either positive or negative and subsequently perform well or poor, respectfully.
Catastrophe Theory72 Suggests that as an athlete becomes aroused above the peak level required for optimal performance, there
is a sudden and severe drop-off in performance.
328 Patel et al: Performance Anxiety in Young Female Athletes

Table 5. Differential Diagnosis of Anxiety Symptoms and Interestingly, family physicians were more likely to
Disorders discuss injury-related issues than orthopedic surgeons.
Mental Health Conditions
Although most cases of sport related anxiety are
straightforward, physicians should consider other con-
Agoraphobia ditions that can present with anxiety symptoms (Table
Acute stress disorder 5).2,9 Asthma and vocal cord dysfunction are the most
Adjustment disorder with anxious mood
Competitive anxiety in athletes
common medical conditions confused with anxiety
Generalized anxiety disorder disorders in athletes. Some of these athletes are
Hypochondriasis initially referred to pulmonologists and often get a di-
Obsessive compulsive disorder agnostic work-up for asthma and vocal cord dysfunc-
Panic attacks and panic disorder tion. Conditions comorbid with anxiety disorders
Posttraumatic stress disorder
Separation anxiety disorder
include mood disorders, learning disorders, and atten-
Social phobia tion deficit hyperactivity disorder.2
Somatization disorder Based on the initial clinical evaluation, some ath-
Specific phobia letes may need additional or formal psychological as-
Substance abuse sessment by a clinical psychologist with experience in
Medical Conditions
sport psychology. Several standardized instruments
that are used to evaluate athletes who experience anx-
Asthma iety symptoms related to their participation in sports
Epilepsy are summarized in Table 6.81e88
Hyperventilation syndrome Management
Mitral valve prolapse Behavioral Approaches
Athletes employ different strategies to cope with anx-
Vestibular dysfunction iety symptoms.89e91 Athletes who experience sport-
Vocal cord dysfunction related anxiety should be managed in consultation
with clinical psychologist or other similarly qualified
clinicians, depending on the local community re-
sources and available expertise.
Behavioral approaches remain the main stay of
secondary, anticipatory anxiety is variable, and com- treatment for athletes who experience anxiety symp-
mitment to sports is very high.22 toms.4,8,9,10 Evidence supports the long-term effec-
tiveness of many of these approaches. A detailed
Evaluation discussion of various behavioral treatment strategies
The diagnosis of sport-related performance anxiety is is beyond the scope of this review. Major behavioral
apparent in most cases based on the presenting his- approaches applied to treating athletes are summa-
tory. In few cases, criteria for a specific anxiety disor- rized in Table 7.92e107 Cognitive behavioral therapy
der may be met. A detailed history is the mainstay of (CBT) is the treatment of choice for the management
evaluation. Many athletes may not recognize the sig- of sport related anxiety symptoms and anxiety disor-
nificance of their symptoms and so never seek appro- ders.1,4,10,108,109 In this therapy, the individual works
priate professional advice. Physicians need to be with the therapist to target and address the negative
aware of psychosocial issues related to sport partici- thoughts and behaviors that underlie the anxiety signs
pation by young athletes and a thorough psychosocial and symptoms. Improvement following CBT is usu-
history should be obtained.78 ally long lasting; however, some individuals may need
Mann et al reported results of their survey of sports booster sessions for break-through symptoms.
medicine physicians regarding psychological issues in Albano and Kendale have described five compo-
patient-athletes.7 The extent to which physicians dis- nents of CBT for anxiety disorders, namely psycho-
cussed psychological issues with athletes varied by education about the illness and CBT, somatic
subspecialty and by specific issues assessed. The three management skills training (e.g., relaxation, diaphrag-
most frequent injury-related topics discussed were matic breathing, self-monitoring), cognitive restruc-
fears about reinjury, fears related to surgery, and lack turing (e.g., challenging negative expectations and
of patience with recovery or rehabilitation. The three modifying negative self talk), exposure methods
most common noneinjury-related topics discussed (e.g., imaginal and in vivo exposure with gradual de-
were stress or pressure, anxiety, and burnout. sensitization to feared stimuli), and relapse prevention
Patel et al: Performance Anxiety in Young Female Athletes 329

Table 6. Instruments Used in Assessing Anxiety in Athletes

Sport Anxiety Scale86 Widely used by researchers. Twenty-one items, ranking short statements on a four-point
scale, ranging from, not at all to very much so. Three dimensional measure of
anxiety including somatic, cognitive, and concentration-disruption components.
Cognitive Appraisal Scale in Original version in Portuguese. Eight-item assessment of an athletes perception of the
Sport Competition e Threat demands of a competition that cause the athlete to feel anxious.
COPE Inventory82 Sixty item quantitative measure to categorize an athletes response to a stressful event. The
4-point scale ranges from I usually dont do this at all, to I usually do this a lot.
Brief COPE Inventory83 Widely used by researchers. Twenty-eight item revised edition of the COPE Inventory.
Competitive State Anxiety Widely used by researchers. Twenty-seven item questionnaire with responses on a 4-point
Inventory -21 scale, ranging from, not at all to very much so. Differentiates cognitive anxiety,
somatic anxiety, and self-confidence sub-scales.
Competitive State Anxiety Same as above, except modified for children rather than adults.
Inventory e Children1,84
State-Trait Anxiety Inventory87 Assessment of anxiety in adults and adolescents. Forty items total, ranked on a 4-point
scale. The state, or S-anxiety component asks the participants to rank their current
subjective emotional state, from not at all to very much so. The trait, or T-anxiety
component requires the participants to rank the frequency with which they generally tend
to feel, from almost never to almost always.
State Anxiety Inventory for Children88 Adapted version of the State-Trait Anxiety Inventory as above. Forty items total, ranked on
a three-point scale.
Sport Competition Anxiety Test84 Ten-item measurement of competitive trait anxiety, ranked on a three-point scale: often,
sometimes, and hardly ever.
Cognitive-Somatic Anxiety Fourteen-item questionnaire ranking from one, meaning not at all, to five, very much
Questionnaire75 so, the symptoms that the participant experiences when feeling anxious. Differentiates
both cognitive and somatic divisions of trait anxiety.

plans (e.g., booster sessions and coordination with imagery, cognition, interpersonal relationship, and
parents and school).104 drugs or biological factors (BASIC ID).
Lazarus and Abramovitz described a multimodal Anderson et al recently reviewed computer sup-
approach to CBT.102 A trimodal assessment frame- ported CBT of anxiety disorders.103 Computer-assis-
work of CBT comprises affect, behavior, and cogni- ted CBT typically consists of presenting aspects of
tive (ABC) components, whereas the multimodal CBT via computer, including rationale for treatment,
approach comprises seven discrete but interactive instructions in various anxiety management tech-
components, namely behavior, affect, sensation, niques, and instruction in exposure. Palmtop

Table 7. Selected Behavioral and Psychological Approaches to Treating Sport-related Anxiety

Biofeedback106 Method of learning to control autonomic nervous system responses. Initially, instruments are used
to monitor physiologic responses (e.g., heart rate, blood pressure) which allows the individual to
be conscious of his or her status. Then, individuals can be trained to control and adjust these
responses without the use of instrumentation.
Relaxation Techniques92,93 Somatic techniques to decrease arousal and avoid poor performance. One such method,
Progressive Muscle Relaxation, involves tensing specific muscle group, then relaxing them
sequentially. Others include deep breathing and counting.
Cognitive Behavior Therapy95,100 Psychological techniques to decrease anxiety including positive self-talk, thought-stopping, and
rational thinking. Other techniques include self-instructional training (developing specific
statement to repeat in ones head to reduce anxiety, increase focus, and improve concentration);
cognitive restructuring (identify irrational beliefs in response to a given situation, analyze the
events, and replace irrational beliefs with positive self-statements); and integrated coping
response (integrate relaxation and cognitive strategies into breathing cycle).
Stress Management Training96 Educational program used to encourage improved self-control of emotions.
Meditation Procedure93 Method of relaxation used during noncompetition states to reduce tension and pre-event stress.
Mental Toughness Training Imagining and recreating a stressful situation in order to practice the relaxation-coping technique
in a situation that approximates real-life.
Environmental Manipulation Adjusting sport milieu, including coaches, parents, referees, or administrators. Some strategies
may include reducing miscommunication errors, improving organization, developing clear and
advance instructions, ensuring consistent coaching and appropriate expectations, minimizing
media coverage.
330 Patel et al: Performance Anxiety in Young Female Athletes

computers have also been used as adjunct to standard dysfunction both in males and females.9,108e112 Sex-
CBT. In virtual reality (VR), the individual actively ual side effects include delayed orgasm, anorgasmia,
participates within computer-generated, 3-dimen- and decreased libido. Most of these non-life threaten-
sional world. He or she wears a head-mounted display ing side effects tend to diminish with time. SSRIs can
(HMD) that consists of display screens for each eye, reduce the total duration of sleep and the duration of
earphones, and head-tracking device. The HMD pro- rapid-eye-movement sleep. Sleep disturbances are
vides the participants visual and auditory cues and al- common in patients taking SSRIs and include diffi-
lows the virtual environment to change in a natural culty falling or staying asleep, daytime drowsiness,
way with head and body motion.103 and vivid and frightening dreams.108,112
Some patients on SSRIs (and antidepressant medi-
cations in general) may experience behavioral activa-
tion.108,114 In contrast to activation in which the mood
In some cases use of anti-anxiety medications may be
state remains the same, switching (or bipolar switch-
indicated along with behavioral treatment. Pharmaco-
ing) is characterized by treatment-emergent change in
therapy may allow initial control of severe symptoms
to facilitate participation in behavioral therapy.107,108 mood state from depressed mood to mania or hypo-
mania in patients taking SSRIs (and other antidepres-
Long-term or intermittent use of medications to con-
sants). Some of the symptoms seen in behavioral
trol anxiety related symptoms limited to sport partic-
activation overlap those of discontinuation syndrome
ipation is controversial in the absence of a clear
and a careful history of adherence to medication reg-
diagnosis of a specific anxiety disorder.
imen should be ascertained to differentiate the two
conditions. Discontinuation syndrome has been de-
Selective Serotonin Re-uptake Inhibitors scribed with abrupt discontinuation of an SSRI agent
Selective serotonin re-uptake inhibitors (SSRIs, Table after several weeks of use, characterized by dysphoric
8) are the medications of choice for the treatment of mood, irritability, agitation, dizziness, sensory distur-
anxiety disorders.10,108 Several well controlled studies bances (e.g., electric shock-like sensations), anxiety,
have provided evidence of their safety and effective- tearfulness, confusion, nightmares, and sleep distur-
ness in the treatment of anxiety disorders in children bances.108,114 Apathy or amotivational syndrome, ex-
and adolescents.9,10,107e111 SSRIs block the reuptake trapyramidal symptoms, and increased bleeding
of serotonin into presynaptic neurons and enhance tendencies including gastrointestinal bleeding have
serotonergic neurotransmission.112 been reported in patients on SSRIs.
At least 12 months of use is recommended before A more serious adverse event associated with
trial off the medication; if there is a recurrence of SSRIs is the central serotonin syndrome (CSS), which
symptoms, the patient should be placed back on the is caused by excessive central nervous system seroto-
medication.110,112,113 Once treatment is initiated, the nergic activity.110,112,114 Although CSS can occur
agent should be continued for at least 4 weeks before when the patient is on a single SSRI agent at high
a decision is made either to increase the dose or to doses, it is potentially more likely to occur when
switch to a different SSRI. Dosage increase should the patient is on multiple SSRIs or other agents with
occur no less frequently than every 4 weeks. The serotonergic effects.
medication is increased until positive clinical re- CSS is characterized by agitation, confusion,
sponse is obtained, intolerable (or dangerous) side ef- tachycardia, hypo- or hypertension, resting tremors,
fects emerge, or a maximum dosage has been reached incoordination, muscular rigidity, myoclonus, hyper-
with no or inadequate clinical response. reflexia, fever, shivering, diaphoresis, and diar-
The common side effects of the SSRIs are nausea, rhea.112,114 CSS can result in seizures, metabolic
decreased appetite, dry mouth, increased sweating, acidosis, rhabdomyolysis, disseminated intravascular
insomnia, headaches, diarrhea, rash, nervousness, coagulation, respiratory failure, coma, and death.114
agitation, and akathisia. SSRIs also cause sexual When CSS is suspected, all serotonergic medications
must be discontinued and immediate general medical
Table 8. Selective Serotonin Re-uptake Inhibitors care must be initiated including inpatient care and ap-
propriate consultations.
Dosing Daily Range (mg) and In patients being treated with antidepressants such
Agent Initial (mg) Schedule as SSRIs, careful clinical monitoring is recommended
Citalopram 5e20 10e60 qd for potential increased risk for suicidal behav-
Escitalopram 1.25e5 2.5e20 qd iors.108,110,114 Although the current US FDA labeling
Fluvoxamine 12.5e50 50e300 qd-bid suggests that the patient who is started on an antide-
Fluoxetine 5e20 10e80 qd pressant be seen by the physician (face to face) once
Sertraline 12.5e25 50e200 qd-bid
a week for first four weeks of the treatment; biweekly
Patel et al: Performance Anxiety in Young Female Athletes 331

Table 9. Benzodiazepines periodic blood testing for complete blood count (to
check for neutropenia) and liver function tests (to
Dosing Daily Range (mg) and
Agent Initial (mg) Schedule check for elevated bilirubin or lactate dehydrogenase)
are suggested.108,112
Alprazolam 0.125 1e6 tid-qid
Chlordiazepoxide 2.5e5 15e40 tid-qid Buspirone
Clonazepam 0.125e0.5 0.125e3 qhs-bid
Diazepam 1e2 0.5e4 qhs-bid
Buspirone is an azapirone and a serotonin 1A partial
Lorazepam 0.125e0.5 0.125e4 qhs-bid agonist. The anxiolytic effects of buspirone are be-
lieved to be due to its postsynaptic partial agonist ac-
tions reducing serotonergic activity.112 Side effects of
buspirone are generally mild and include headache,
dizziness, nervousness, sedation, nausea, lightheaded-
for the second month of treatment; and at the end of ness, restlessness, and excitement.108,112 Buspirone
the 12th week on medication, most experts favor an has a high safety profile and may be considered as
individualized approach that takes into consideration one of the first line treatments for anxiety disorders
the unique needs and circumstances of the patient after SSRIs. Buspirone is not associated with depen-
and his or her family.108 dence or addiction risks and can be used as an aug-
menting agent to treat anxiety. The initial dose is
Benzodiazepines 2.5 mg that can be increased to a range of 5e60 mg
Benzodiazepines (BDZs, Table 9) can be used to treat bid or tid.108,112
the short-term effects and somatic symptoms before
a stage performance but because of their side effects, Beta-blockers
BDZs are not the medications of choice for sport- Propranolol is often used to reduce anxiety and
related anxiety.115,116 Their use is limited to short-term tremors associated with certain situations such as per-
treatment in patients with severe anxiety symptoms for formance anxiety and acute anxiety in athletes in
rapid effects before the effects of psychotherapy or competitive sports.108 Although propranolol and other
SSRIs can be achieved. BZDs are often used for proce- beta-blockers have been shown to be efficacious in
dure-related anxiety.108,115 ameliorating symptoms of anxiety in adults, espe-
BDZs bind to the benzodiazepine receptors in the cially somatic symptoms of anxiety, no controlled
central nervous system at the gamma aminobutyric studies support their use in the treatment of anxiety
acid-A (GABA-A) ligand-gated chloride channel disorders in children and adolescents
complex and enhance the inhibitory effects of GABA. Propranolol blocks the beta-adrenergic receptors,
BDZs facilitate the chloride conductance through effectively reducing sympathetic nervous system ac-
GABA-regulated channels.112 Their therapeutic ef- tivity.112 It is not known how beta-blockers exert their
fects in reducing anxiety symptoms are believed to effects on the central nervous system, as agents vary
be due to inhibition of amygdala-centered neuronal by degree and selectivity for beta 1 (mostly cardiac)
circuits. and beta 2 (noncardiac) receptors, and also vary in de-
Side effects of BZDs include sedation, cognitive gree of lipophilicity.112 Common side effects of pro-
blunting, dizziness, ataxia, nystagmus, bradycardia, pranolol include dizziness, fatigue, bradycardia,
transitory hallucinations, memory impairment (typi- mental status change, gastrointestinal upset, and vari-
cally anterograde amnesia), constipation, diplopia, ous skin rashes.108 Less common but more serious ad-
hypotension, urinary incontinence or retention, fa- verse events associated with propranolol use include
tigue, slurred speech, paradoxical hyperexcitability, bronchospasm and heart failure, both of which may
and nervousness.108,112,115 Higher dose and longer du- occur more readily in children.112 It is also associated
ration of treatment increase the risk of side effects. with Raynauds phenomenon in some patients.
BZDs are potentially habit forming and can lead to The major contraindications to propranolol use
addiction and dependence. Less common but signifi- pertain to the cardiovascular and respiratory systems.
cant and potentially life threatening side effects of The beta blockers should not be used in patients with
BDZs include respiratory depression, hepatotoxicity, sinus bradycardia and greater than first degree heart
renal dysfunction, and blood dyscrasias. block, asthma, sick sinus syndrome, significant pe-
BZDs should not be used in patients with narrow ripheral arterial disease, pheochromocytoma, insulin
angle glaucoma. Abuse or dependence potential may dependent diabetes mellitus, hyperthyroidism, and
exclude use in some patients.112 The safety and effi- right ventricular failure associated with pulmonary
cacy of BZDs in the long-term treatment of anxiety hypertension.108,112
disorders in children and adolescents have not been For patients on propranolol, blood pressure and
established. For patients on long term therapy, heart rate should be routinely monitored to detect
332 Patel et al: Performance Anxiety in Young Female Athletes

significant drop in heart from baseline. A baseline Acknowledgments: Authors thank Kim Douglas, Kalamazoo
ECG is also recommended to detect asymptomatic Center for Medical Studies, for assistance in the preparation
cardiac conduction abnormalities.108 Before starting of the manuscript, and Sandra Howe and Marge Kars, Bronson
propranolol, fasting blood glucose should be obtained. Methodist Hospital Health Sciences Library, for assistance
with search and retrieval of articles and books.
Propranolol can sometimes cause elevations in serum
potassium, liver transaminases, and alkaline phospha-
tase in hypertensive patients. The initial dose is
10e20 mg daily that is increased up to 40 mg daily.112 References
Other 1. Martens R, Vealey RS, Burton D: Competitive Anxiety in
Hydroxyzine is not useful for long term treatment of Sports. Champaign, Human Kinetic Books, 1990
anxiety disorders. Its main use is for short term effects 2. American Psychiatric Association: Diagnostic and
in special circumstances in patients with anxiety Statistical Manual of Mental Disorders, Fourth Edition
symptoms associated with organic diseases, pre-med- Text Revision (DSM-IV-TR). Washington, DC, APA,
ication for sedation, anxiety, and pruritus associated 2000. 429e484
with allergic conditions, acute hysteria, and anxiety 3. Spielberger CD, Sarason IG. In: Stress and emotion:
anxiety, anger, and curiosity, Vol 17. New York, NY,
associated with alcohol withdrawal.108 The initial
Routledge, Taylor, and Francis Group, 2005
dose is 12.5e25 mg daily that can be increased up 4. Smoll FL, Smith RE: Competitive anxiety: sources,
to 50e100 mg bid-qid.112 consequences and intervention strategies. In: Smoll FL,
Duloxetine and venlafaxine block both the serotonin Smith RE, editors. Children and Youth in Sport: A
and norepinephrine re-uptake and increase serotoner- Biopsychosocial Perspective. New York, McGraw Hill,
gic, noradrenergic and dopaminergic neurotransmis- 1996, pp 359e380
sion.112 Duloxetine and venlafaxine have largely 5. Gould D, Krane V: The arousal-athletic performance
similar side effects as those of SSRIs, in addition to relationship: current status and future directions. In:
more significant increase in systemic blood pressure.108 Horn TS, editor. Advances in Sport Psychology.
Hyponatremia and syndrome of inappropriate antidiu- Champaign, Human Kinetics, 1992, pp 119e142
retic hormone secretion are uncommon but significant 6. Maffulli N, Helms P: Controversies about intensive
training in young athletes. Arch Dis Child 1988; 63:1405
side effects reported with the use of venlafaxine.108,112
7. Mann BJ, Grana WA, Indelicato PA, et al: A survey of
Duloxetine and venlafaxine are not considered as first sports medicine physicians regarding psychological
line treatment for anxiety disorders. Venlafaxine has issues in patient-athletes. Am J Sports Med 2007; 35:
been used in some cases as a second choice in those 2140
who have failed adequate trial of SSRI. 8. Raglin JS: Anxiety and sport performance. Exerc Sport
Sci Rev 1992; 20:243
Conclusion 9. Varley CK, Smith CJ: Anxiety disorders in the child and
teen. Pediatr Clin North Am 2003; 50:1107
Sports-related performance anxiety is common, espe- 10. Connolly SD, Bernstein GA: Work Group on Quality
cially in young female athletes, and the severity and Issues: Practice parameter for the assessment and
persistence of its signs and symptoms is influenced treatment of children and adolescents with anxiety
disorders. J Am Acad Child Adolesc Psychiatry 2007;
by multiple factors. Diagnosis is apparent based on
a detailed history. In some cases additional assess- 11. DeMoja CA, DeMoja G: State-trait anxiety and
ment is done by a clinical psychologist and any of motocross performance. Percept Mot Skills 1986; 62:107
the several standardized instruments can be used. A 12. Filaire E, Sagnol M, Ferrand C, et al: Psychophysio-
multimodal treatment approach is recommended that logical stress in judo athletes during competitions.
integrates psychotherapy (especially exposure based Sports Med Phys Fitness 2001; 41:263
cognitive behavior therapy), family and patient educa- 13. Finkenberg ME, DiNucci JM, McCune ED, et al:
tion, and use of medication, if indicated. When med- Analysis of the effect of competitive trait anxiety on
ications are deemed necessary, SSRIs are the performance in Taekwondo competition. Percept Mot
treatment of choice. SSRIs should be considered in Skills 1992; 75:239
patients with moderate to severe symptoms that may 14. Haase AM, Prapavessis H: Social physique anxiety and
eating attitudes in female athletic and non-athletic
make participation in psychotherapy difficult or in pa-
groups. J Sci Med Sport 2001; 4:396
tients whose response to psychotherapy is considered 15. Hale BS, Koch KR, Raglin JS: State anxiety responses to
to be inadequate, especially in terms of improving 60 minutes of cross training. Br J Sports Med 2002; 36:
functional impairment. The response to treatment 105
varies depending up on the severity and specific type 16. Hammer WM: A comparison of differences in manifest
of the anxiety disorder and can range from 50% to anxiety in university athletes and non-athletes. J Sports
more than 70%. Med Phys Fitness 1967; 7:31
Patel et al: Performance Anxiety in Young Female Athletes 333

17. Hanna EA: Potential sources of anxiety and depression 37. Cerin E, Szabo A, Hunt N, et al: Temporal patterning of
associated with athletic competition. Can J Appl Sport competitive emotions: a critical review. J Sports Sci 2000;
Sci 1979; 4:199 18:605
18. Hannon B, Fitzgerald P: Anxiety and performance in elite 38. Cox LM, Lantz CD, Mayhew JL: The role of social
non-professional athletes. Ir Med J 2006; 99:238 physique anxiety and other variables in predicting
19. Kirkby RJ, Liu J: Precompetition anxiety in Chinese eating behaviors in college students. Int J Sport Nutr
athletes. Percept Mot Skills 1999; 88:297 1997; 7:310
20. McKelvie SJ, Huband DE: Locus of control and anxiety 39. Cresswell S, Hodge K: Coping skills: role of trait sport
in college athletes and non-athletes. Percept Mot Skills confidence and trait anxiety. Percept Mot Skills 2004;
1980; 50(3 Pt 1):819 98:433
21. Miller TW, Vaughn MP, Miller JM: Clinical issues and 40. Finkenberg ME, DiNucci JM, McCune SL, et al:
treatment strategies in stress-oriented athletes. Sports Commitment to physical activity and anxiety about
Med 1990; 9:370 physique among college women. Percept Mot Skills
22. Powell DH: Treating individuals with debilitating 1998; 87(3 Pt 2):1393
performance anxiety: An introduction. Clin Psychol 41. Hanton S, Cropley B, Lee S: Reflective practice,
2004; 60:801 experience, and the interpretation of anxiety symptoms.
23. Pratt HD: Principles of psychological management. In: J Sports Sci 2009; 27:517
Greydanus DE, Calles JL Jr, Pratt HD, editors. Pediatric 42. Hassmen P, Koivula N, Hansson T: Precompetitive mood
and Adolescent Psychopharmacology. New York, states and performance of elite male golfers: do trait
Cambridge University Press, 2008, pp 1e24 characteristics make a difference? Percept Mot Skills
24. Psychountaki M, Zervas Y: Competitive worries, sport 1998; 86(3 Pt 2):1443
confidence, and performance ratings for young 43. Kjrmo O, Halvari H: Two ways related to performance in
swimmers. Percept Mot Skills 2000; 91:87 elite sport: the path of self-confidence and competitive
25. Rouveix M, Bouget M, Pannafieux C, et al: Eating anxiety and the path of group cohesion and group goal-
attitudes, body esteem, perfectionism and anxiety of clarity. Percept Mot Skills 2002; 94(3 Pt 1):950
judo athletes and nonathletes. Int J Sports Med 2007; 44. Lorimer R, Westbury T: Physical self-presentation and
28:340 competitive anxiety in male master divers. Psychol Rep
26. Sanderson FH, Reilly T: Trait and state anxiety in male 2006; 99:773
and female cross-country runners. Br J Sports Med 45. Martinent G, Ferrand C: A cluster analysis of
1983; 17:24 perfectionism among competitive athletes. Psychol Rep
27. Tenenbaum G, Milgram RM: Trait and state anxiety in 2006; 99:723
Israeli student athletes. J Clin Psychol 1978; 34:691 46. Matheson H, Mathes S: Influence of performance setting,
28. Thirer J, ODonnell LA: Female intercollegiate athletes experience and difficulty of routine on precompetition
trait-anxiety level and performance in a game. Percept anxiety and self-confidence of high school female
Mot Skills 1980; 50:18 gymnasts. Percept Mot Skills 1991; 72(3 Pt 2):1099
29. Vardar E, Vardar SA, Kurt C: Anxiety of young female 47. Mellalieu SD, Neil R, Hanton S: Self-confidence as
athletes with disordered eating behaviors. Eat Behav a mediator of the relationship between competitive
2007; 8:143 anxiety intensity and interpretation. Res Q Exerc Sport
30. Wadey R, Hanton S: Basic psychological skills usage and 2006; 77:263
competitive anxiety responses: perceived underlying 48. Mullen R, Lane A, Hanton S: Anxiety symptom
mechanisms. Res Q Exerc Sport 2008; 79:363 interpretation in high-anxious, defensive high-anxious,
31. Wiggins MS, Lai C, Deiters JA: Anxiety and burnout in low-anxious and repressor sport performers. Anxiety
female collegiate ice hockey and soccer athletes. Stress Coping 2009; 22:91
Percept Mot Skills 2005; 101:519 49. Ntoumanis N, Biddle S: The relationship between
32. Wilson GS, Raglin JS: Optimal and predicted anxiety in competitive anxiety, achievement goals, and
9-12-year-old track and field athletes. Scand J Med Sci motivational climates. Res Q Exerc Sport 1998; 69:176
Sports 1997; 7:253 50. OBrien M, Hanton S, Mellalieu SD: Intensity and
33. Wong EH, Lox CL, Clark SE: Relation between sports direction of competitive anxiety as a function of goal
context, competitive trait anxiety, perceived ability, and attainment expectation and competition goal generation.
self-presentation confidence. Percept Mot Skills 1993; J Sci Med Sport 2005; 8:423
76(3 Pt 1):847 51. Ommundsen Y, Pedersen BH: The role of achievement
34. Abrahamsen FE, Roberts GC, Pensgaard AM, et al: goal orientations and perceived ability upon somatic
Perceived ability and social support as mediators of and cognitive indices of sport competition trait anxiety.
achievement motivation and performance anxiety. Scand A study of young athletes. Scand J Med Sci Sports
J Med Sci Sports 2008; 18:810 1999; 9:333
35. Baker J, Cote J, Hawes R: The relationship between 52. Peng H, Johanson RE: Career maturity and state anxiety of
coaching behaviours and sport anxiety in athletes. J Sci Taiwanese college student athletes given cognitive career-
Med Sport 2000; 3:110 oriented group counseling. Psychol Rep 2006; 99:805
36. Bekiari A, Patsiaouras A, Kokaridas D, et al: Verbal 53. Raglin JS: Psychological factors in sport performance:
aggressiveness and state anxiety of volleyball players the Mental Health Model revisited. Sports Med 2001;
and coaches. Psychol Rep 2006; 99:630 31:875
334 Patel et al: Performance Anxiety in Young Female Athletes

54. Robazza C, Bortoli L: Intensity, idiosyncratic content and 74. Kerr JH: Structural phenomenology and performance. J
functional impact of performance-related emotions in Human Mov Studies 1987; 13:211
athletes. J Sports Sci 2003; 21:171 75. Schwartz GE, Davidson RJ, Goleman DJ: Patterning of
55. Robazza C, Pellizzari M, Bertollo M, Hanin YL: cognitive and somatic processes in the self-regulation of
Functional impact of emotions on athletic performance: anxiety: Effects of meditation versus exercise.
comparing the IZOF model and the directional Psychosom Med 1978; 40:321
perception approach. J Sports Sci 2008; 26:1033 76. Yerkes RM, Dodson JD: The relation of strength of
56. Ryska TA: The relationship between trait and stimulus to rapidity of habit formation. J Comp Neurol
precompetitive state anxiety among high school Psych 1908; 18:459
athletes. Percept Mot Skills 1993; 76:413 77. McNally IM: Contrasting concepts of competitive state
57. Smith AM, Sim FH, Smith HC, et al: Psychologic, anxiety in sport: multidimensional anxiety and
situational, and physiologic variables and on-ice catastrophe theories. Athletic Insight 2002; 4:10
performance of youth hockey goalkeepers. Mayo Clin 78. Patel DR, Greydanus DE, Pratt HD: Psychosocial aspects
Proc 1998; 73:17 of youth sports. In: Patel DR, Greydanus DE, Baker RJ,
58. Smith RE, Smoll FL, Cumming SP: Effects of editors. Pediatric Practice: Sports Medicine. New York,
a motivational climate intervention for coaches on McGraw Hill Medical, 2009
young athletes sport performance anxiety. J Sport 79. Grossbard JR, Smith RE, Smol FL, et al: Competitive
Exerc Psychol 2007; 29:39 anxiety in young athletes: differentiating somatic
59. Storch EA, Storch JB, Adams BG: Intrinsic religiosity anxiety, worry, and concentration disruption. Anxiety
and social anxiety of intercollegiate athletes. Psychol Stress Coping 2009; 22:153
Rep 2002; 91:186 80. Grove JR, Eklund RC, Heard NP: Coping with
60. Swain A, Jones G: Intensity and frequency dimensions of performance slumps: factor analysis of the Ways of
competitive state anxiety. J Sports Sci 1993; 11:533 Coping in Sport Scale. Aust J Sci Med Sport 1997; 29:99
61. Terry PC, Walrond N, Carron AV: The influence of game 81. Abrahamsen FE, Roberts GC, Pensgaard AM: An
location on athletes psychological states. J Sci Med examination of the factorial structure of the Norwegian
Sport 1998; 1:29 version of the sport anxiety scale. Scand J Med Sci
62. Turner PE, Raglin JS: Variability in precompetition Sports 2006; 16:358
anxiety and performance in college track and field 82. Carver CS, Scheier MF, Weintraub JK: Assessing coping
athletes. Med Sci Sports Exerc 1996; 28:378 strategies: a theoretically based approach. J Pers Soc
63. Wang J, Marchant D, Morris T, et al: Self-consciousness Psychol 1989; 56:267
and trait anxiety as predictors of choking in sport. J Sci 83. Carver CS: You want to measure coping but your protocol
Med Sport 2004; 7:174 is too long: consider the brief COPE. Int J Behav Med
64. Wiggins MS, Brustad RJ: Perception of anxiety and 1997; 4:92
expectations of performance. Percept Mot Skills 1996; 84. Martens R: Sport Competitive Anxiety Test. Champaign,
83(3 Pt 1):1071 Human Kinetics, 1977
65. Wiggins MS, Cremades JG, Lai C, et al: 85. Wilson GS, Raglin JS, Harger GJ: A comparison of the
Multidimensional comparison of anxiety direction and STAI and CSAI-2 in five-day recalls of precompetition
burnout over time. Percept Mot Skills 2006; 102:788 anxiety in collegiate track and field athletes. Scand J
66. Jokela M, Hanin YL: Does the individual zones of Med Sci Sports 2000; 10:51
optimal functioning model discriminate between 86. Smith RE, Smoll FL, Schutz RW: Measurement and
successful and less successful athletes? A meta-analysis. correlates of sport-specific cognitive and somatic trait
J Sports Sci 1999; 17:873 anxiety: The sport anxiety scale. Anxiety Res 1990; 2:263
67. Pons D, Balaguer I, Garcia-Merita ML: Is the breadth of 87. Spielberger CD, Gorsuch RL, Lushene RE: Manual for
individualized ranges of optimal anxiety (IZOF) equal for the State-trait Anxiety Inventory. Palo Alto, CA,
all athletes? A graphical method for establishing IZOF. Consulting Psychologists Press, 1970
Span J Psychol 2001; 4:3 88. Spielberger CDPreliminary Manual for the State-Trait
68. Prapavessis H, Cox H, Brooks L: A test of Martens, Anxiety Inventory for Children: How I feel
Vealey and Burtons theory of competitive anxiety. Aust questionnaire. Palo Alto, CA, Consulting Psycho-
J Sci Med Sport 1996; 28:24 logists Press, 1973
69. Raglin JS, Morris MJ: Precompetition anxiety in women 89. Dias C, Cruz JF, Fonseca AM: Anxiety and coping
volleyball players: a test of ZOF theory in a team sport. strategies in sport contexts: a look at the psychometric
Br J Sports Med 1994; 28:47 properties of Portuguese instruments for their
70. Hull C: Principles of Behavior. New York, Appleton- assessment. Span J Psychol 2009; 12:338
Century-Crofts, 1943 90. Johnson U: Coping strategies among long-term injured
71. Hanin Y: Emotions in Sport. Champaign, Human competitive athletes. A study of 81 men and women in
Kinetics, 2000 team and individual sports. Scand J Med Sci Sports
72. Hardy L, Parfitt G: A catastrophe model of anxiety and 1997; 7:367
performance. Br J Psychol 1991; 82:163 91. Partridge JA, Wiggins MS: Coping styles for trait shame
73. Kerr JH: Motivations and Emotions in Sport: Research and anxiety intensity and direction in competitive
Theory. Hove, East Sussex, Psychology Press, 1997 athletes. Psychol Rep 2008; 103:703
Patel et al: Performance Anxiety in Young Female Athletes 335

92. Jacobson E: Progressive Relaxation. Chicago, University 106. Miller NE: Applications of learning and biofeedback to
of Chicago Press, 1938 psychiatry and medicine. In: Freddman AM, Kaplan HI,
93. Benson H: The Relaxation Response. New York, Avon Sadock BJ, editors. Comprehensive Textbook of
Books, 1975 Psychiatry/II. Baltimore, Williams & Wilkins, 1975, pp
94. Wilks B: Stress management for athletes. Sports Med 349e365
1991; 11:289 107. Baldwin DS, Anderson IM, Nutt DJ, et al: British
95. Meichenbaum D: Cognitive Behavior Modification: An Association for Psychopharmacology: Evidence-based
Integrative Approach. New York, Plenum Press, 1977 guidelines for the pharmacological treatment of anxiety
96. Smith RE: A cognitive-affective approach to stress disorders: recommendations from the British Association
management training for athletes. In: Nadeau CH, for Psychopharmacology. J Psychopharmacol 2005; 19:
Halliwell WR, Newell KM, Roberts GC, editors. 567
Psychology of Motor Behavior and Sport. Champaign, 108. Greydanus DE, Calles J, Patel DR: Pediatric and
Human Kinetics, 1980 Adolescent Psychopharmacology. New York, Cambridge
97. Goldfried MR, Linehan MM, Smith JL: Reduction of test University Press, 2008. 61e76.
anxiety through cognitive restructuring. J Consult Clin 109. Fisher PH, Tobkes JL, Kotcher L, et al: Psychosocial and
Psychol 1978; 46:32 pharmacological treatment for pediatric anxiety
98. Strosahl KD, Ascough JC: Clinical uses of mental imagery: disorders. Expert Rev Neurother 2006; 6:1707
experimental foundations, theoretical misconceptions, and 110. Hammerness PG, Vivas FM, Geller DA: Selective
research issues. Psychol Bull 1981; 89:422 serotonin reuptake inhibitors in pediatric psycho-
99. Conrad A, Roth WT: Muscle relaxation therapy for pharmacology: a review of the evidence. J Pediatr
anxiety disorders: it works but how? J Anxiety Dis 2005; 148:158
2007; 21:243 111. Kapczinski F, Lima MS, Souza JS, et al: Antidepressants
100. Goldfried MR, Davison GC: Clinical Behavior Therapy. for generalized anxiety disorder. Cochrane Database Syst
New York, Holt, Rinehart Winston, 1976 Rev 2003;CD003592
101. James AACJ, Soler A, Weatherall RW: Cognitive 112. Stahl SM: Essential Psychopharmacology: The
behavioural therapy for anxiety disorders in children Prescribers Guide. New York, Cambridge University
and adolescents. Cochrane Database System Rev 2005; Press, 2006
4. CD004690. 113. Waslick B: Psychopharmacology interventions for
102. Lazarus AA, Abramovitz A: A multimodal behavioral pediatric anxiety disorders: a research update. Child
approach to performance anxiety. J Clin Psychol 2004; Adolesc Psychiatr Clin N Am 2006; 15:51
60:831 114. Chiu S, Leonard HL, Antidepressants I: Selective sero-
103. Anderson P, Jacobs C, Rothbaum BO: Computer- tonin reuptake inhibitors. In: Pediatric Psycho-
supported cognitive behavioral treatment of anxiety pharmacology. Oxford, UK, Oxford University Press,
disorders. J Clin Psychol 2004; 60:253 2003, pp 274e283
104. Albano AM, Kendal PC: Cognitive behavioral therapy for 115. Witek MW, Rojas V, Alonso C, et al: Review of
children and adolescents with anxiety disorders; clinical benzodiazepine use in children and adolescents.
research advances. Int Rev Psychiatr 2002; 14:129 Psychiatr Q 2005; 76:283
105. Humara M: The relationship between anxiety and 116. Hoffman EJ, Mathew SJ: Anxiety disorders:
performance: a cognitive-behavioral perspective. Athletic a comprehensive review of pharmacotherapies. Mt Sinai
Insight 1999;2 J Med 2008; 75:248