What are the treatment options for performance anxiety?

Treatment Options for Performance Anxiety

Cognitive-behavioral therapy (CBT) should be the first-line treatment for performance anxiety due to its proven effectiveness in reducing anxiety symptoms and maintaining treatment gains over time. 1, 2

First-Line Treatment: Cognitive-Behavioral Therapy (CBT)

CBT is the psychological intervention with the highest level of evidence for treating anxiety disorders, including performance anxiety. It targets the three primary dimensions of anxiety:

• Cognitive components: Addresses cognitive distortions about the likelihood of harm or negative evaluation 1
• Behavioral components: Targets avoidance behaviors through graduated exposure 1
• Physiological components: Manages autonomic arousal and somatic symptoms 1

Key CBT Elements for Performance Anxiety:

• Education about anxiety to help understand the nature of performance anxiety 1
• Behavioral goal setting with contingent rewards 1
• Self-monitoring to identify connections between performance situations, thoughts, and behaviors 1
• Relaxation techniques including deep breathing, progressive muscle relaxation, and guided imagery 1, 3
• Cognitive restructuring to challenge distortions such as catastrophizing, over-generalization, negative predictions, and all-or-nothing thinking 1, 3
• Graduated exposure to feared performance situations, creating a fear hierarchy that is mastered in a stepwise manner 1
• Problem-solving and social skills training relevant to anxiety-provoking performance situations 1

CBT Delivery Formats:

• Individual face-to-face sessions (most common, 52.3% of interventions) 1
• Group therapy (20.5% of interventions) 1
• Computer-based interventions (9.1%) 1
• Self-help approaches (20.5%), either guided or unguided 1

CBT typically requires 12-20 sessions for meaningful symptomatic and functional improvement 1, though briefer interventions may also be effective in primary care settings 1.

Second-Line Treatment: Pharmacotherapy

When CBT alone is insufficient or when rapid symptom relief is needed, medication can be considered:

SSRIs/SNRIs (First-line medications):

• Selective Serotonin Reuptake Inhibitors (SSRIs) such as paroxetine have demonstrated efficacy for various anxiety disorders including social anxiety disorder (performance anxiety) 1, 4
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) 1
• These medications should be continued for 6-12 months after remission 5

Benzodiazepines (Limited use):

• Alprazolam and other benzodiazepines may be used for short-term management of acute performance anxiety 6
• Starting dose for alprazolam: 0.25 to 0.5 mg three times daily, with gradual increases as needed 6
• Not recommended for routine or long-term use due to risk of dependence 6, 5
• Gradual tapering is essential when discontinuing (no more than 0.5 mg reduction every 3 days) 6

Treatment Effectiveness

• Overall effectiveness: 65.9% of psychological interventions for anxiety in primary care settings demonstrated effectiveness in reducing anxiety symptoms 1
• Maintenance of gains: 77.8% of effective interventions maintained treatment gains at follow-up 1
• CBT vs. medication: Most primary care patients prefer psychological treatments for anxiety over medication 1

Special Considerations

• Performance-specific approach: Treatment should specifically target the performance context (public speaking, test-taking, musical performance, etc.) 3, 7
• Exposure hierarchy: Creating a graduated hierarchy of feared performance situations is essential for effective treatment 1, 3
• Combination therapy: For severe cases, combining CBT with appropriate medication may provide optimal outcomes 1, 5
• Systematic assessment: Using standardized anxiety rating scales can help track progress and optimize treatment 1

Common Pitfalls to Avoid

• Relying solely on medication without addressing underlying cognitive and behavioral patterns 1
• Prolonged benzodiazepine use which can lead to dependence and tolerance 6, 5
• Abrupt discontinuation of anxiety medications, especially benzodiazepines 6
• Insufficient exposure practice or allowing avoidance behaviors to persist 1, 3
• Focusing only on symptom reduction without addressing functional improvement 1