Do you always get nervous when taking exams? This is definitely not something you want to deal with especially on the MCAT.
Dr. David Puder is a psychiatrist and today, he talks about test anxiety and how to reduce it. He also hosts his own podcast – the Psychiatry & Psychotherapy Podcast.
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[02:05] Interest in Medicine
It wasn’t until his senior year of high school that he decided to get into medicine. By college, he was focused on giving his best shot.
Basically, he did a year of internal medicine and later went on to take Psychiatry. He was fascinated by the mind and workings of human behavior. To him, the psychological part was always so much more fascinating to him.'It's one thing to be able to prescribe, it's another thing to be able to convince the person that they change the diet, the lifestyle.'Click To Tweet
His interest in helping students with overcoming text anxiety began when he as moonlighting at a local university, where he worked one day a week. This was something he did for about five years.
He noticed that a lot of the kids that would come to see him would have anxiety around test taking as well as depression, ADHD, and procrastination issues. David got interested in it and feels satisfied being able to treat it and see the response. They take the test and they do well.
[04:30] David’s Personal Journey with Text Anxiety
Not coming from a family of doctors, no one prepared him for what it would be like taking the MCAT. Until he showed up that day, he didn’t have any idea what a lifechanging exam it felt like.
He remembers having a dizzy feeling at the beginning of the test. It took him a while to ground himself. And he didn’t score well because of that.'It felt like a fight-or-flight, near death experience.'Click To Tweet
[05:45] The Science Behind Text Anxiety
David describes the symptoms of students with severe anxiety or anticipation during the exam. In fact, they do worse than their IQ would estimate. They may do well in the prep but then when the actual exam comes, their anxiety is high.
They have palpitations or shortness of breath. They feel derealization or depersonalization, where you feel out of body or the world is in a fog. Then as they look back to the test, they realize they totally knew it but they just had difficulty pulling information out of their brain.'You have this impaired attention... it's hard to focus. You overlook details to the questions.'Click To Tweet
These people can hear everything around them and it’s distracting them. You have increased obsessional thoughts. You get obsessed about one question and you spend a ton of time even if you probably should move on.
Another symptom is poor working memory, which is the ability to move pieces of knowledge around in your brain.
The people that have high anxiety before the actual test may procrastinate, may be disorganized, and have reduced effort. They may have failed the MCAT or some standardized test before.
They may have no evidence of other types of mood issues, no chronic anxiety, social anxiety, or depression. They may not binge on alcohol on the weekends or smoke marijuana, or have any secondary gain for failure. They don’t have ADHD or any learning disorder like dyslexia.
In fact, David says that some of his most interesting patients are those who fail because they don’t want to go to medical school because their parents are pushing them too hard.
[09:00] Test Anxiety vs Learning Disorder
David recalls being disappointed by his MCAT score and getting told by his mentor to get psychological testing. He felt an intense feeling of shame. So he never went to get tested.
But now, David actually recommends getting psychology testing done.
For instance, you get a referral from a psychiatrist or a learning disorder specialist. Then they test you for 4-6 hours. They can check whether you have ADHD. They can check your IQ. They can check for specific learning disorders.
Then you get this huge 40-page writeup about all of your strengths and areas where you may not be as strong. David believes this is a good place to start. You might also want to go see a psychiatrist who has seen a number of people in similar situations.
You know you have dyslexia or a learning disorder when for instance, you’re smart in math but reading is really hard. There’s a big step to different functions of your IQ.
There are benefits to getting tested and having a diagnosis. This means you can work around your deficits just in time before you take the MCAT.
[12:12] Knowing Your Learning Style
Part of developing a good learning plan for yourself is to understand where your strengths are and meeting those needs.
For some people, they may not go to lectures but they may spend time reading books. Others learn through auditory hearing. Once they get psychological testing, they can go through the Braille Institute and get every textbook on audio. So they just listen to the material.
For David, he finds auditory learning to be more effective than reading. (The same way for me.) This being said, it’s not impossible for somebody to have a diagnosis of a learning disability and still do well.
Regardless, you can still be a good doctor. You may have to put in more work. But keep going.'You can have all types of disabilities and still be a good doctor.'Click To Tweet
[15:08] Ruling Out Text Anxiety
Before we talk about the actual treatment, David outlines the things to be ruled out first.
For instance, when he sees a patient coming in, he figures out whether the person has a primary mood disorder.
Could they be struggling with depression or anxiety? Maybe they have difficulty motivating themselves. They may have lots of guilt or self-hatred. They may have panic disorders and have random panic attacks during the day.
They may have difficulty controlling their worry in most situations in life. For those with OCD, they may have obsessive thoughts that get in the way of study time or life in general.
They may be on substances. Marijuana can increase your anxiety long term and alcohol as well.'If you're on marijuana or alcohol, get off those things because those things can influence your anxiety.'Click To Tweet
They may have underlying medical issues that are not controlled such as hypothyroidism, hyperthyroidism, asthma attacks, seizures, etc. There may be medical issues that are not controlled that are affecting your ability to focus and concentrate.
Maybe they’re also on medication that decreases their cognitive function. There are drugs like Topamax for migraines. One of its side effects is a decreased ability to find words. Benadryl can cloud your thinking.'Are you on medications that are making it more difficult for you to focus and concentrate?'Click To Tweet
Once students have gone through this list, and none of these resonate for them. They can get ruled out by a doctor or a psychiatrist and that they only have text anxiety. Then we move on to the treatment.
[17:40] How to Treat Text Anxiety
David tries to get his patients on an exercise routine just to bring down their physiological system. He gets them off caffeine, tobacco, alcohol, or marijuana.
The next step would be some behavioral treatments – progressive muscle relaxation, systematic desensitization, and behavioral rehearsal. Yoga is another great way to calm your body systems down.'Progressive muscle relaxation, systematic desensitization, and behavioral rehearsal are the three behavioral things that you can do.'Click To Tweet
Behavioral rehearsal involves recreating every situation possible on what it’s going to look like on test day itself.
For instance, if your test day is on a Friday, so you do it on a Friday. Drive in the same way that you’re going to drive on test day. Eat the same food. (Get some slow-burning fuel in your system like avocado and oats.)
Create a pattern for how you’re going to start your day on the actual test day. Do it and rehearse it. Go and take a trial exam. Sit in the same room. Pretend you’re taking the real test.
When you get overly stimulated, practice muscle relaxation and calm breathing. If you do this enough, you can extinguish the level of fear you’ll feel on the day of the exam.
[20:24] Apps and Mindfulness Exercises
David doesn’t recommend particular apps but his patients have found this to be useful. What he generally does is walking mindfulness with patients. They walk together. They walk slowly and feel their feet on the bottom of the ground.
He would also do some chocolate mindfulness at times. They would sit and eat the chocolate for a minute or two. They chew on the chocolate, not swallowing. They’re tasting all the flavors.'Eat slowly, walk slowly, and breathe slowly.'Click To Tweet
When you slowly eat, walk, and breathe, you’re strengthening the part of your brain that is in connection with your body.
Derealization and depersonalization in an exam would refer to the feeling of floating away from your body. Come back to your body. Feel your butt on your seat. Feel your feet planted on to the ground. Walk around if you need to and feel your feet on the ground.
These things actually pull you out of that state of dissociation and can keep you in a state that lowers anxiety. So you can perform but not freak out.
[22:50] Dealing with Anxiety During Test Day
Come test day, David suggests some tips to help you deal with potential anxiety. Learn breathing techniques. Feel your body in the position it is. Feel your feet on the ground. Move your feet. Squeeze your toes.
You can also practice test-taking strategies. For instance, if you find a specific question to be really hard, just skip it and move ahead. Then come back to it if you have time.'There are different strategies you can take if you have anxiety at the moment.'Click To Tweet
When you regulate and calm your body, there is a bio-directional thing. That’s why parenting can be so hard because you can feel the chaotic dissociative energy of the kids.
So you breathe mindfully to calm your own body. Then when you look a child, the child takes in that energy and calms down. This is the same as what David does with his patients who are anxious.
[25:45] Dealing with Negative Self-Talk
Cognitive therapy is an effective way of dealing with negative thinking. We put our own thoughts on trial and judge the accuracy of the thoughts.
For example, one cognitive distortion is over generalization. You take one bad experience and extend it to all the experiences that will happen in the future. “I failed this test. Therefore, I will fail all tests.” And you know this is not true. So you try to move into a more truthful state.
Another example is black and white thinking. “I didn’t study 40 hours a week then I will not pass this test.” So you go all black or all white on things.
There’s also emotional reasoning – “I feel stupid, therefore, I am.” And this is the system that we live in.'There's a barrage of questioning that happens in medical school which is really tough. So you're left with this feeling that you don't really know anything.'Click To Tweet
Once you realize that your goal is to make other people not look stupid, you’ll do a lot better. There is no way you can know everything. You have to get used to the fact that you can’t be perfect. You can only work hard and continue to try to learn.
Ultimately, it just comes down to practice. People spend hundreds of hours learning stuff. Instead, spend 50 hours just learning on yourself. Learn some of this emotional stuff. Get into a place where you can counteract these negative thoughts that come into your brain. It really is a discipline of practice to be good at doing this.
[30:00] Use of Medications
David says that sometimes medications can help. He has treated some cases where he gives Propanolol. It’s a beta-blocker that decreases the physiologic experience of stress.
He recommends that you start with 10-20 mg Propanolol. Try it on a weekend when you’re studying just to see if there are any side effects. Some people feel lightheaded or really tired, but that’s rare.
Try this another time when you’re taking a trial test. See if this decreases your anxiety. Then take the same dose during the test.
The other class of medications would be antidepressants. They tend to decrease overall anxiety. But you have to be on them for six weeks for the anxiety to come down. It’s not something you want to take a week before the MCAT.
[31:53] Listen to the Psychiatry & Psychotherapy Podcast
Please take time to check out and listen to David’s podcast. He goes through a series on microexpression, where you learn how to read people’s facial expressions, and how to use that information.
Microexpression is that ellipse of emotion that flash on people’s faces. And most of the time, they people would score it 50% right and 50% wrong. Learn how to read it and use it! Once you can get that feedback, you can learn from your experiences.
So much of what we do in medicine is face-to-face human interaction. If you’re able to connect with people on a day-to-day basis, you will experience so much more gratitude from your patients because your patients will appreciate you. It’s one of the areas we can influence and decrease burnout actually.'If we just connected better with our colleagues and connected better with our patients, we would have less burnout.'Click To Tweet
Follow David on Instagram @dr.davidpuder