Performance Anxiety in Sport - An MD Perspective

'What exactly is sports performance anxiety?

“The twisties” in gymnastics, the “yips” in baseball… these are all common names for performance anxiety in sport.  It’s that feeling of “Oh (insert favorite curse word here)….” and suddenly becoming… well… self conscious of what you are doing.  Even the singer with one of the most beautiful voices in the world… Adele… threw up on an audience member in a concert one time due to performance anxiety.

But what is it, exactly, and what can you do about it?

Performance anxiety is what happens when you get really nervous about what you are about to perform, whether it’s a pitch, a gymnastic maneuver, singing, or even giving a speech in front of the classroom or a presentation to your coworkers.  Your heart starts to beat fast, you start to break out in a sweat, then you overthink things and doubt your abilities to do that one thing you have practiced hours, months, and even years for.  “Can I do this?  I can’t do this as well as I think.  What if I mess up….?  What if I don’t land it…” What if…?” The ”What ifs” and doubt from the pressure and stress you feel make you tense up and “get in your head” as your coaches might say.  Your mind goes blank, and you can’t remember what to say, what note to play next, or where your body is supposed to go.

Performance anxiety is a biological thing, so what is happening to your brain?

Your brain has hijacked your muscle memory, or your innate ability to do that thing you’re supposed to be able to do well… that thing you have done hundreds of times in practice without an issue.  The brain is just like a big electrical circuit board, but a complex one with many, many circuits.  When your brains engage its thinking and anxiety circuit, it uses higher level circuits (by that I mean literally located higher up in your brain) and engages the amygdala, which is the part of the brain you need to alert you to truly anxious things, such as a robber, a fire, etc.  We want these parts of the brain to be in the off position when we are performing. The part of the brain we want to engage is our muscle memory part, or our procedural memory.  This is the memory we use to automatically do movements we have practiced 100’s of times.  This are of the brain is located in the motor cortex (responsible for motor movement as the name sounds), and the lower parts of the brain, namely the basal ganglia and the cerebellum, which are responsible for our automatic movements, like breathing, walking.

How do we fix it?

The good news is, we can shut off our thinking circuit and re-engage our muscle memory circuit.  But how do we do that?

In order to get muscle memory to take over, we need to be relaxed.  When we are stressed, we have engaged our sympathetic nervous system,  which is what causes us to sweat, have a faster hear rate, and “freak out”.  We have to engage our relaxation, or parasympathetic nervous system to become relaxed again which will allow us to turn on our muscle memory.   We use breathing techniques to do this... but not just run of the mill “breath deeply” techniques.  These specialized breathing techniques were made to optimize relaxation and physiologically make your body relax. 

Why do we focus on breathing?  Because, as you breathe in through your nose, you create an increase in pressure in your nasal passages.  Near your nasal passages are sensors in your neck which will feel this pressure, like a filled balloon, that then tell your body to turn on the parasympathetic nervous system, or the relaxation system. If we inhale but then exhale long enough, those sensors have enough time to tell your relaxation system to engage because they keep sensing “too much pressure” from your inhalation.  If you exhale too quickly, you don’t give those sensors enough time to do that.  Once that system is engaged, your body automatically slows your heart rate and stops you from sweating.  Your tingling and numb hands and legs return to normal as your regulated breathing now provides more oxygen to those areas.  Your brain has to stop its overthinking as it is concentrating  on doing this specialized regulated breathing because it can’t do overthinking and this type of breathing at the same time. 

Everyone can learn this specialized breathing.  It’s not a secret.  Doctors even use this type of breathing in patients with lung disease, where an increased chronic stress response is always present, to activate their parasympathetic, or relaxation, system.  It is a matter of learning it, practicing, and inserting this skill into your daily training and then games/meets/tournaments/performances.  For every sport, it will be different, depending on what is making you anxious. 

What if I still have trouble with anxiety and can’t perform like I want to in my sport?

What if someone’s anxiety is so severe, the regulated, specialized breathing techniques are not helping enough?  

Sometimes, a person’s performance anxiety goes beyond just their sport or dance competition. Sometimes, they cannot perform anywhere… even that oral presentation they have to do in school or the talk they have to give at work.  Sometimes, they are anxious in lots of other areas of their life, asking “what if” questions apart from their sport.  “What if I can’t get to college?  What if I do badly on this project?  What if I wear the wrong thing tomorrow?  What if I choose the wrong major?”  The list can go on and on.  Other times, they will think a lot about past events in their life, usually things they think may have been mistakes.  “Maybe if I said this instead of that, this thing wouldn’t have happened… maybe I should have done this instead…“

When anxiety spills into daily life where it becomes difficult to complete the goals you have set, the treatment may involve other types of psychotherapy (e.g. cognitive behavioral therapy, acceptance and commitment therapy) and also, some medication. 

What parents of an athlete with performance anxiety can do:

Beyond not performing well in competitions or performances, children with performance anxiety can also appear frustrated, angry, sullen, or negative.  One of the important things to remember is to be supportive and remember that the lack of performance may not be due to an unwillingness to perform well or not want the outcome badly enough.  Keep an open dialogue, focus on process goals and not outcomes.  Goals should not be “Make state team”, but rather, “Cut 0.5 seconds off my time in my 100 fly” and list 3 practice mechanisms for achieving that goal.  Make goals achievable and reassess these goals every few weeks to make sure they are attainable, on track, and check in with their coaches to make sure their practice mechanisms don’t have to be adjusted. Make sure your child is resting well, actively recovering between training, and having proper caloric intake.  Easier said than done or your child is still having trouble? Negativity, frustration, or anger can be signs of other mental health issues and should be evaluated by a professional.

So the next time you see that person who performs so well in practice but doesn’t quite do as well in the actual game, competition, or race, consider performance anxiety, and realize it should not get in the way of any athlete’s progress.  Performance anxiety is common and treatable.

Donna Roybal, MD

For my athletes with performance anxiety, I teach everyone these specialized breathing techniques and make them relevant to your sport.  I then use other psychotherapy and medication management as necessary.  As an MD sports psychiatrist, I am board certified to diagnosis and treat mental health issues using psychotherapy, medication management, and breathing/mental skills training.  With youth sports, I often teach the parents the same specialized techniques, including regulated breathing, visualization, and learning how to focus in the moment.  Parent involved with the young athlete is encouraged to be able to guide your athletes towards success with these skills. 

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"Remember, you do the best with what you've been given and with what you know. When it isn't enough, you can't change what you've been given, but you can change what you know".

References

McDuff, David R., Sports Psychiatry - Strategies for Life Balance and Peak Performance, American Psychiatric Publishing, 2012.

Nguyen, John D, et al., Pursed lip breathing, StatPearls, Jan 25, 2025.