Managing Test Anxiety

“It’s all right to have butterflies in your stomach. Just get them to fly in formation.” – Dr. Rob Gilbert

To say there is pressure on WWAMI students to perform well might be the understatement of the century! Pressure can express itself in many different ways (not all of them bad – by the way) – but one of the most common manifestations is through test anxiety. Clearly, the ability to keep your emotions under control during important exams is crucial for high achievement in medical school.  But how do you do that?

Physiological Responses to Stress

When you are under pressure, you body will naturally activate your sympathetic nervous system. These responses include:butterflies_in_my_stomach_by_bee_ee

  • Dry mouth
  • Rapid breathing
  • Increased heart rate
  • Butterflies- digestion shuts down so energy can be redirected to the brain and muscles. There is less blood flow to the stomach, creating the sensation of butterflies.
  • Trembling hands and legs
  • Racing of thoughts
  • Dilation of pupils

These responses are the body’s way of preparing itself for the important upcoming event. All of these responses are good and necessary for top performance. They will help you operate at the highest level. Before an important exam, interview, or performance, you probably have experienced butterflies. Butterflies are normal… and they are good! Your body is preparing itself for an important situation.

Interpretation of Nerves

Stress (arousal) and anxiety are commonly used interchangeably, but they shouldn’t be. When the physiological responses to a stressor are interpreted as negative, cognitive anxiety will ensue. However, stress does not have to produce anxiety.

Our interpretation of our nerves is the most important aspect to consider while dealing with pre-performance stress!

You can benefit from the physiological responses to stress without the cognitive anxiety. Even the world’s top performers experience nerves before performances. It is not something we should attempt to decrease- it is something we should learn to view as positive and necessary to success.

  1. Embrace the nerves- welcome them. Understand they will help you perform at a higher level.
  2. Practice under pressure. Place yourself in situations where you must perform under stress. Start with less pressure and add stressors as you practice. Assess how the stress can benefit you and learn to enjoy the pressure!


Each performance situation you encounter requires a specific emotional arousal state. The optimal emotional (stress) arousal state differs depending on the task (i.e., interview vs. an exam) and on the individual. Picture2

The relationship between arousal and performance can be described using an inverted-u. Too low of an arousal level (e.g., bored or yawning before an exam) and too high of an arousal level (e.g., bouncing off the walls) are not ideal for successful performance. Rather, a moderate level of arousal is necessary for top performance. If you find yourself too aroused before an exam, relaxation techniques like deep breathing and progressive muscle relaxation (you can find these techniques in the coping with stress section) are useful tools to lower your arousal. If you find yourself under-aroused before an exam or performance, try the following technique:

Begin by taking regular, relaxed breaths. Consciously increase your breathing rhythm and with each inhalation imagine you are generating more energy. If you choose, with each inhalation say, “energy in” and each exhalation “fatigue out.” As you continue to increase your breathing rate, your level of energy generation should increase as well. You can also choose your own verbal cue to increase your energy. Words like “psych up” and “go” are examples. Choose a word that energizes you. Listening to music is helpful for both increasing and decreasing your arousal level, depending on the type of music.

Anxiety and Exam Preparation in Medical School

Recently, Encadela and colleagues (2014) conducted a qualitative study on medical students and test anxiety. The researchers identified common causes and effects of the anxiety, as well as typical strategies that the students used to cope with the anxiety.

  • Causes of Anxiety
    • Self-talk that focused on the ‘high stakes’ of the exam & how prior academic performance might influence the new exam.
    • Perceived time constraints for studying
    • Academic comparison with classmates
  • Effects of Anxiety
    • Stressors on emotional and mental well-being
    • Cognitive functions- Students explained that the anxiety affected their ability to concentrate and remember the material
    • Physical well-being- Anxiety due to exam preparation influenced sleep, appetite, and eating habits
  • Strategies used to Mediate Stress
    • Mindfulness & deliberate re-orientation of thinking
    • Using self-talk that brought perspective to the importance of the exam in the context with the rest of life
    • Focusing on prayer, mediation, yoga, and spirituality
    • Managing sleep & eating patterns
    • Maintaining well-planned study breaks
    • Balancing fun and physical activity
    • Maintaining an exercise regime

Coping with stress is not limited to exam preparation alone. View the coping with stress section to learn more.

Grounding- A Technique to Help

Before a test, it’s easy for your emotions and thoughts to run wild. You may become overwhelmed by anxious thoughts or fears of underachieving. These thoughts and feelings can be managed through a technique called grounding. Grounding is deliberate reorientation of thinking that helps you get out of your own head and return to reality. 5-4-3-2-1 is a specific grounding exercise. Try it out now to practice, and then use it before an exam when you are feeling anxious.

  • Take a few deep breaths.
  • Name 5 things you can see in the room
  • Name 4 things you can feel
  • Name 3 things you can hear right now
  • Name 2 things you can smell right now
  • Name 1 good thing about yourself

Test Anxiety Scale

Does your test anxiety hinder you? The Westside Test Anxiety Scale is a brief questionnaire designed to identify students with anxiety impairments.

Helpful Links

Learn more about performance anxiety

Test anxiety literature

Overcoming Test Anxiety Videos